Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 resident with moderate cognitive impairment, bilateral lower extremity impairment, prior left femur fracture, sickle cell disease, and osteoporosis was transported from a medical appointment in a wheelchair using the facility van. While the van was parked, the resident began to slide from the wheelchair, and the CNA driver guided the resident to the floor of the van. Instead of obtaining immediate nursing assessment or emergency assistance at the appointment site, the CNA drove back to the facility with the resident unsecured on the van floor. Upon arrival, an LVN assessed the resident, who reported dull left thigh pain, and staff assisted her back into the wheelchair. Facility documentation and staff interviews showed that this sequence of actions did not follow the facility’s safe patient handling and fall procedures, leading to a cited deficiency for failure to ensure adequate supervision and proper use of assistance devices to prevent accidents.
The facility failed to ensure residents were treated with dignity and respect when staff did not respond promptly or appropriately to call lights. Several residents with conditions such as dementia, stroke with paralysis, malnutrition, diabetes, muscle weakness, and end-stage renal disease reported or were associated with long waits for assistance, sometimes up to an hour or more. Resident council minutes documented repeated complaints that staff would enter rooms, turn off call lights, and leave without meeting residents’ needs, and grievance logs reflected ongoing concerns about delayed call light response across multiple months.
The facility failed to accurately document physician-ordered wound care for three residents with pressure injuries or at risk for pressure injuries. Each resident had multiple comorbidities, incontinence, and care plans specifying skin integrity goals and interventions such as repositioning, incontinence care, and adherence to pressure injury prevention/treatment protocols. Review of TARs for a given month showed multiple missed entries for scheduled wound care for each resident. In interviews, the ADON, DON, and Administrator confirmed that staff are expected to document wound care at least once per shift and that undocumented care is considered not done, despite acknowledging that staff may sometimes perform treatments without charting. Facility policy required the treatment nurse or designee to sign off on treatment sheets for any completed wound care, which was not consistently reflected in the records.
A resident with severe cognitive impairment, incontinence, and multiple pressure ulcers required total assistance with toileting and repositioning. During observed incontinence care, a CNA reused the same soiled wipe multiple times on the perineal area and used a soiled, gloved hand to adjust his clothing before continuing care without changing gloves or performing hand hygiene. The DON later confirmed that staff were expected to discard wipes after a single use and perform hand hygiene after touching their clothing, consistent with the facility’s infection control policy emphasizing hand hygiene as the primary means of preventing infection transmission.
After the departure of the Activity Director, two residents with significant medical needs did not receive scheduled or individualized activities as required by their care plans. Staff and family interviews confirmed that regular activities like bingo and birthday parties had not occurred for over a month, and residents were mostly observed watching TV. The facility did not maintain an updated activity calendar or provide documentation of recent activity programming.
Multiple residents with complex medical needs reported receiving cold and unappetizing meals that were frequently served late. Observations confirmed that food was delivered to some halls well after scheduled mealtimes, with only one staff member distributing trays per hall and non-insulated carts used for delivery. Staff interviews and grievance records indicated ongoing issues with meal quality and timeliness, and management was aware of the problems but had not implemented effective interventions.
A resident with intellectual disability and severe cognitive impairment did not receive required day habilitation services because the facility failed to submit the necessary application within the required timeframe. Staff interviews revealed confusion about responsibility for completing the paperwork and a lack of follow-up with the resident's family, resulting in the resident missing out on specialized services as outlined in their care plan.
The facility failed to develop effective discharge plans for five residents, focusing on their specific needs and goals. Record reviews showed that care plans lacked discharge interventions, potentially affecting safe and orderly discharges. Interviews with staff revealed inconsistent discharge planning practices, with the social worker not completing plans for long-term residents and the DON unaware of protocols. The facility's policy emphasized regular re-evaluations and interdisciplinary planning, which were not followed.
A resident with dementia and other health issues experienced a fall, resulting in a dislocated shoulder. The facility failed to promptly notify the physician of the x-ray results, which were available two days before the physician was informed. The resident continued to receive pain medication during this period. Interviews revealed a lack of clear procedures for checking and communicating diagnostic test results.
The facility failed to provide activities to meet the interests and support the well-being of residents due to the absence of an Activity Director. Four residents reported missing group activities, musical programs, and other events, leading to increased boredom and isolation.
The facility failed to follow enteral feeding protocols for two residents, including not checking for residual volume, not flushing the G-tube between and after medication administration, and not maintaining the head of the bed at 30 degrees elevation during medication administration. Medications were also not administered through the gravity method as required.
A resident with a history of cerebral infarction, multiple sclerosis, and muscle weakness was left unattended during breakfast, leading to a coffee spill. Despite requiring supervision for eating, the resident did not receive the necessary assistance, as indicated in his care plan. Interviews and observations confirmed the lack of staff presence and adherence to the care plan, resulting in the incident.
The facility had a medication error rate of 22% due to a nurse improperly administering medications via G-tube by combining them and not flushing with water between each medication, contrary to physician orders and facility policy. The resident involved had multiple diagnoses, including intracranial injury and GERD.
The facility failed to provide food that accommodated residents' preferences, leading to dissatisfaction with meals and potential weight loss. Two residents reported not being informed about alternate meal options and receiving meals they did not like. Staff interviews revealed inconsistencies in how meal preferences were communicated, and an anonymous group interview confirmed that residents were often not informed about alternate meals.
A facility failed to maintain an infection control program when a CNA did not perform proper hand hygiene during incontinence care for a resident. The CNA did not change gloves or wash hands after cleaning the resident, which was against the facility's infection control policy and training. The DON confirmed the expectations for hand hygiene and glove changes to prevent infection spread.
Failure to Provide Adequate Supervision and Safe Transport After Resident Slid From Wheelchair in Van
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper fall procedures for a resident during transportation in the facility van. The resident was an older female with multiple significant diagnoses, including a displaced supracondylar fracture of the left femur, sequelae of cerebral infarction, muscle weakness, lack of coordination, sickle cell anemia, age-related osteoporosis, and a cognitive communication deficit. Her admission MDS documented moderate cognitive impairment (BIMS 11), use of a wheelchair and a manual lift for transportation, need for assistance with self-care and mobility, and bilateral lower extremity impairment. Her care plan identified her as being at risk for falls due to decreased mobility and unstable balance, and noted a potential for uncontrolled pain related to sickle cell disease and a history of fracture. On the date of the incident, the resident was being transported back from a medical appointment by a CNA who was driving the facility van. According to the facility’s Provider Investigation Report and witness statements, the CNA loaded the resident into the van in her wheelchair using the lift. While the van was parked, the resident began to slide out of her wheelchair. The CNA reported that as the resident began to slide, she guided the resident to the floor of the van. The CNA’s witness statement indicated that after assisting the resident to the floor, she then transported the resident back to the facility with the resident remaining on the floor of the van. The administrator’s statement confirmed that the CNA acknowledged the resident was a two-person lift, that she knew she should have called for help, and that she nonetheless drove back to the facility with the resident on the floor. Nursing documentation and interviews further described the sequence of events once the van returned to the facility. A LVN stated that the van driver came into the building and said she needed help getting a resident up who had slid out of her chair and was on the floor of the van. The LVN assessed the resident, documented that the resident had slid out of the wheelchair and been assisted to the floor by staff, and that staff assisted her back into the wheelchair. The LVN’s progress note recorded that the resident appeared and/or stated she was in pain, describing it as dull pain in the left thigh, and that PRN pain medication was given. The resident later reported in interview that she started to slip while in the van, that the driver helped her to the floor, then left her on the floor and drove back to the facility, and that her leg hurt but had been broken before the incident. Subsequent documentation showed that x‑rays were obtained, a possible fracture was reported, and the resident was sent to the hospital, where no new fractures were found. The facility’s own policies on safe patient handling and fall risk required staff to report inability to safely complete lifting or transfers and to ensure immediate assessment after a fall, but the CNA did not contact a nurse for immediate assessment at the time of the incident and transported the resident unsecured on the van floor, leading to the cited deficiency for failure to provide adequate supervision and assistance devices to prevent accidents. Additional staff interviews highlighted the expectations for handling such situations. An RN stated that if a CNA found a resident on the floor, the CNA should get a nurse immediately so the nurse could assess whether the resident could be safely assisted up or if 911 should be called, and that the MD and family member would then be informed. Another CNA, who had received transportation training, described the proper loading procedure as pushing the resident up the ramp, latching the wheelchair, and applying a seat belt, and stated that if a resident began to slide, she would have gone back into the doctor’s office for help or called 911. These accounts contrasted with the actions taken by the CNA driver, who did not seek immediate assistance at the appointment site or call for emergency help, but instead drove back to the facility with the resident on the floor of the van. This sequence of actions and inactions formed the basis of the survey finding that the facility failed to ensure adequate supervision and proper use of assistance devices to prevent accidents for this resident. The facility’s incident log recorded the event as a fall incident, and progress notes and investigation documents consistently described the resident as having slid from her wheelchair and been assisted to the floor. The administrator’s differing descriptions in interviews—first stating that the CNA got a nurse to assess and get the resident back into the wheelchair, and later stating that the aide helped the resident back into the wheelchair while going up into the van—were inconsistent with the CNA’s written statement and the LVN’s account that the resident was on the floor of the van upon return to the facility. The documented facts in the PIR, witness statements, and nursing notes collectively demonstrate that the resident, who had known fall risk factors and significant musculoskeletal and neurological conditions, was not provided with adequate supervision and proper fall procedures during transport, resulting in her sliding from the wheelchair, being placed on the van floor, and being transported back to the facility unsecured, without immediate nursing assessment at the time of the incident.
Failure to Respond Promptly and Appropriately to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to dignity, respect, and timely response to call lights. Multiple residents with varying levels of cognitive and physical impairment reported or were associated with delayed call light responses. One resident, an elderly female with severe cognitive impairment, dementia, stroke with left-sided paralysis, and protein-calorie malnutrition, was dependent on staff for repositioning and had no skin conditions on admission; her family member reported that staff took 45 minutes to answer call lights and over two hours to attend to her during rounding. Another resident, an elderly female with intact cognition and diagnoses including malnutrition, difficulty walking, and lack of coordination, stated that it could take staff up to an hour to respond to her call bell, occurring on all shifts depending on which staff were working. Additional residents with intact or moderately impaired cognition and diagnoses such as type 2 diabetes, muscle wasting, lack of coordination, muscle weakness, cerebral infarction, vascular dementia, and end-stage renal disease were included in the review for resident rights. Resident council meeting minutes from two consecutive months documented complaints about call light response times, including reports that staff would enter rooms, turn off call lights, and leave without assisting with residents’ needs. The facility grievance logs for January and February recorded concerns related to call light response times. These interviews, resident council minutes, and grievance records collectively showed that residents’ call lights were not answered promptly and that staff sometimes silenced call lights without providing assistance, resulting in residents not being treated with respect and dignity as required.
Failure to Accurately Document Physician-Ordered Wound Care Treatments
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records and document wound care treatments as ordered for three residents with pressure injuries or risk for pressure injuries. For one resident, an elderly female with severe cognitive impairment, dementia, Alzheimer’s disease, stroke, and malnutrition, the MDS and care plan showed she was dependent on staff for repositioning and incontinent care, with identified risk for pressure ulcers. Her care plan interventions included heel offloading, turning and repositioning at least every two hours, and assistance with bed mobility, dressing, and toileting. However, review of her Treatment Administration Record (TAR) for a specified month showed multiple dates on which her scheduled wound care was not documented as given. A second resident, an elderly male with moderately impaired decision-making, heart failure, malnutrition, muscle weakness, difficulty walking, and end-stage renal disease, was also always incontinent and required maximal assistance with toileting hygiene. His care plan documented that he had a pressure ulcer or risk for pressure ulcer development, with goals for intact skin and interventions including administering medications as ordered, following facility skin breakdown protocols, providing incontinence care after each episode with moisture barrier, and notifying nursing of any new skin issues. His February TAR similarly showed numerous dates where his scheduled wound care was not documented as completed. A third resident, an elderly female with intact cognition and diagnoses including type 2 diabetes, difficulty walking, muscle weakness, heart failure, and protein-calorie malnutrition, was always incontinent and dependent on staff for toileting. Her care plan identified potential for pressure ulcer development and decreased mobility, with goals for intact skin and interventions including following facility skin breakdown prevention protocols and assisting with turning and repositioning at least every two hours. Her February TAR also showed several dates with no documentation of scheduled wound care. In interviews, the ADON, DON, and Administrator each stated that the expectation was that staff document completed wound care at least once per shift, and that if wound care was not documented in the electronic health record, it was considered not done, even though staff might have performed the care and forgotten to chart it. The facility’s pressure injury policy required the treatment nurse or designee to sign off on the treatment sheet for any treatment completed, which was not consistently reflected in the records reviewed.
Improper Hand Hygiene and Wipe Use During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during incontinence care for one resident. The resident was an elderly female with severe cognitive impairment due to dementia, Alzheimer’s disease, stroke, and malnutrition, who was always urinary and bowel incontinent and dependent on staff for toileting hygiene and repositioning. Her care plan identified existing or potential pressure ulcers with a goal that ulcers show signs of healing and remain free from infection, and interventions included following facility policies for prevention and treatment of skin breakdown. Skin assessments documented intact skin initially, followed by multiple new pressure ulcers on the feet, toes, heels, and sacral area over time, and the resident was assessed as having a moderate/high risk for skin breakdown due to incontinence of urine and stool. During an observation of incontinence care, a CNA washed his hands and donned gloves, then removed the resident’s brief and cleaned the perineal area. While doing so, he used the same soiled wipe multiple times on the perineal area instead of discarding it after a single use, and he used his soiled, gloved hand to pull up his own sleeve before continuing incontinence care without changing gloves or performing hand hygiene. In a subsequent interview, the CNA stated he was unaware he had reused the same wipe and had adjusted his sleeve with a soiled glove, and he acknowledged this was not the facility’s standard practice. The DON stated staff were supposed to use one wipe and discard it before obtaining a new one, and that staff should perform hand hygiene after touching any part of their clothing. The facility’s infection control policy identified hand hygiene as the primary means of preventing transmission of infection and required hand hygiene after handling soiled or used linens and dressings.
Failure to Provide Ongoing Resident Activity Program After Loss of Activity Director
Penalty
Summary
The facility failed to provide an ongoing program of activities based on comprehensive assessments, care plans, and resident preferences for at least two residents. After the Activity Director (AD) left the facility at the end of October, there was no replacement, and scheduled activities were not consistently provided. Multiple interviews with residents, family members, and staff confirmed that regular activities such as bingo, movie matinees, and birthday parties had not occurred for over a month. Residents were observed spending time watching TV in their rooms or in common areas, with limited engagement in group or individual activities. One resident with severe cognitive impairment and multiple medical conditions, including a history of stroke and dementia, was found lying in bed watching TV and had not participated in preferred activities like dominoes or bingo in recent weeks. Another resident, who was cognitively intact but medically complex, also reported not seeing any activities offered and spent most of her time watching TV. Family members and other residents corroborated the lack of activities, noting that previously scheduled events had not taken place and that the activity calendar was outdated. Staff interviews revealed that, in the absence of an AD, some group therapy sessions and occasional music or church services were provided, but these did not follow the established activity calendar or meet the individualized needs and interests of all residents. The facility's own policy required ongoing activity programming tailored to resident assessments and preferences, but this was not maintained. Documentation for recent months, such as resident council meeting minutes and updated activity calendars, was missing or unavailable, further indicating a lapse in the facility's activity program.
Failure to Provide Palatable, Timely, and Safe-Temperature Meals
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at safe and appetizing temperatures. Multiple residents reported that their meals were consistently cold and served late, with some stating that they did not like the taste or quality of the food. Observations confirmed that meal trays were often delivered to certain halls significantly later than scheduled mealtimes, and that only one staff member was distributing trays per hall, resulting in further delays. The facility used non-insulated metal carts for meal delivery, which contributed to the food cooling before reaching residents, especially those served last. Several residents with complex medical histories, including malnutrition, diabetes, and cardiovascular conditions, were affected by these deficiencies. One resident with paraplegia and protein-calorie malnutrition reported always receiving cold food and not informing management, while another resident with severe cognitive impairment was noted by family to have ongoing complaints about late and cold meals. A third resident with multiple chronic illnesses stated that her food was usually cold and not to her liking, and that staff refused to reheat meals due to concerns about cross-contamination. Staff interviews corroborated these complaints, with dietary aides and CNAs acknowledging that meals were frequently late and cold, and that there was a shortage of dietary aides, particularly on certain shifts. Documentation review revealed a pattern of grievances related to cold and unappetizing food, with several residents reporting cold or burnt meals over multiple months. Resident council minutes also reflected ongoing concerns about meal timeliness, with no documented follow-up. Staff interviews indicated that management was aware of the issues, but there were no effective interventions in place to address delays in meal service or to ensure that food was served at appropriate temperatures. The facility's food temperature control policy required hot foods to be held at 140°F or above, but observations and interviews indicated that this standard was not consistently met due to operational and staffing challenges.
Failure to Provide Required Specialized Rehabilitative Services Due to Missed Application Deadline
Penalty
Summary
The facility failed to provide required specialized rehabilitative services, specifically day habilitation, for a resident with a PASRR positive status for mental illness and intellectual disability. The resident's care plan included a goal for specialized services as recommended by the local authority, and the resident had expressed interest in attending day habilitation. Documentation showed that the resident and their family had selected a day habilitation facility, and the need for these services was discussed in care plan and interdisciplinary team meetings. Despite these documented needs and expressed preferences, the facility did not submit the required day habilitation application within the 20-day timeframe. Interviews with staff revealed confusion regarding responsibility for completing and submitting the admission paperwork, with both the social worker and MDS nurse unsure of the process and timeline. The family was given the paperwork but did not return it, and there was no documented follow-up by facility staff to ensure the paperwork was completed and submitted on time. As a result, the resident was unable to access day habilitation services and would have to wait until the next quarterly meeting to reapply. The resident, who had severe cognitive impairment and was dependent on staff for most activities of daily living, confirmed interest in participating in day habilitation activities. Staff interviews acknowledged that the failure to secure these services was due to lack of clarity and follow-up regarding the application process. The administrator was unable to provide a PASRR policy when requested.
Failure in Discharge Planning for Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for five residents, focusing on their specific needs and goals. The deficiency was identified through interviews and record reviews, which revealed that the facility did not include discharge plans or interventions in the residents' care plans. This lack of planning could affect the residents' ability to discharge safely and orderly, ensuring all discharge needs were identified and addressed. Resident #1, a male with aphasia and chronic obstructive pulmonary disease, did not have a discharge plan or interventions in his care plan. Similarly, Resident #2, a female with dementia, malnutrition, and lack of coordination, also lacked a discharge plan. Resident #3, a female with no cognitive impairment, and Resident #4, a female with Alzheimer's Disease and hypertension, both had care plans without discharge plans or interventions. Resident #5, a male with a cerebrovascular accident and dementia, also did not have a discharge plan included in his care plan. Interviews with facility staff, including the social worker (SW), Director of Nursing (DON), and Administrator (ADM), revealed a lack of consistent discharge planning practices. The SW reported not completing discharge care plans for every admission, especially for long-term residents. The DON was unaware of the company's protocol for discharge planning, and the ADM stated that discharge planning should start upon a resident's arrival. The facility's policy on discharge planning emphasized regular re-evaluations and interdisciplinary team planning, which were not followed in these cases.
Delayed Notification of X-Ray Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of x-ray results for a resident, which revealed a left shoulder dislocation. The resident, an elderly female with dementia, malnutrition, and lack of coordination, was found on the floor in her bedroom and complained of pain on the left side of her body. Although pain medication was administered, the x-ray results indicating a dislocated shoulder were not communicated to the physician until two days later. The x-ray was ordered on the day of the fall, and the results were available in the computer system and faxed to the facility the same day. However, the results were not viewed by the facility until two days later, and the physician was not notified until the morning of the second day. During this time, the resident continued to receive pain medication as needed. Interviews with facility staff revealed a lack of clear procedures for checking and communicating diagnostic test results. The Licensed Vocational Nurse (LVN) responsible for the resident's care did not recall seeing the faxed results and only checked the computer system intermittently. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were not aware of specific requirements for checking results, and the Administrator (ADM) expected results to be checked every shift but was unsure of the facility's process.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide activities designed to meet the interests and support the physical, mental, and psychosocial well-being of residents. This deficiency was observed in four residents who were not provided activities since the Activity Director's (AD) last day of employment. The facility did not have an AD on staff, which could result in a decline in social and mental well-being for all residents requiring activities. Resident #49, who was cognitively intact and enjoyed group activities and musical programs, reported missing birthday parties and other activities. The resident mentioned that the facility could not retain an AD due to budget constraints. Similarly, Resident #26, who also enjoyed group activities and church services, stated that she stayed in her room most of the time due to the lack of activities. She used her iPad to pass the time. Resident #20, who had a history of participating in bingo and church programs, revealed that the facility had several ADs in the past two years, but the last AD left in March and did not return. The resident mentioned that the bingo store for prizes was taken away. Resident #45, who had severe vision impairment and required substantial assistance with daily activities, reported that she used to be taken to various activities but had not been asked to participate in any activities recently. The facility did not have an activity policy and followed CMS guidelines for the activity program.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to ensure that residents who were fed by enteral means received appropriate treatment and services to prevent complications. Specifically, the facility did not check for residual volume prior to medication administration for two residents. Additionally, the facility did not flush the G-tube between and after medication administration for one resident, and did not maintain the head of the bed at 30 degrees elevated during medication administration for the same resident. Medications were also not administered through the gravity method for both residents, contrary to the facility's policy and physician orders. For Resident #6, the Licensed Vocational Nurse (LVN) administered medications via the feeding tube without checking for residual volume, despite the physician's order to do so. The LVN also pushed fluids with a syringe instead of using the gravity method. The LVN admitted to not being aware of the facility's policy regarding pushing medication and water flushes via a feeding tube. This resident had severe cognitive impairment and required extensive assistance with activities of daily living. For Resident #36, the Registered Nurse (RN) also failed to check for residual volume before administering medications via the G-tube. The RN did not flush the G-tube after medication administration and did not maintain the head of the bed at the required 30 degrees elevation. The Director of Nursing (DON) confirmed that medications should not be mixed and should be administered one at a time with appropriate flushing in between. The DON also stated that medications should be given through gravity to avoid complications such as increased peristalsis and diarrhea. This resident had multiple diagnoses, including brain injury and dysphagia, and required enteral feeding and medication administration through a G-tube.
Failure to Provide Adequate Assistance During Meal Consumption
Penalty
Summary
The facility failed to ensure the safety of a resident by not providing adequate assistance during meal consumption, leading to the resident spilling coffee on himself. The resident, who had a history of cerebral infarction, multiple sclerosis, tremors, and muscle weakness, required supervision or touching assistance for eating, as indicated in his care plan. Despite these needs, the resident was left unattended during breakfast, resulting in the coffee spill incident. The coffee was observed to be warm, not hot, and the resident did not sustain burns or indicate pain from the spill. Interviews with the Director of Nursing (DON) and the resident's family revealed that the resident frequently experienced similar issues due to a lack of assistance, which the family attributed to staffing problems. The resident's family had repeatedly requested assistance for him, especially since he struggled with using his right hand after a stroke. The resident's care plan and assessments indicated that he could not consume hot liquids without special interventions, such as lids on cups and staff assistance, which were not provided during the incident. Further observations and interviews with staff confirmed that the resident needed assistance with meals and that the coffee served was at a safe temperature. However, the lack of staff presence and failure to follow the care plan's interventions led to the incident. The facility's policy on food temperature control and hot liquid/food spills was reviewed, highlighting the need for proper supervision and assistance to prevent such accidents.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that it was free of a medication error rate of 5 percent or greater, resulting in a medication error rate of 22%. This was based on 6 out of 27 opportunities involving one resident observed for medication administration. Specifically, the facility failed to ensure that RN D administered medications to a resident via G-tube according to the physician's orders and standard practice. RN D crushed six different medications, combined them into one mixture, and pushed them through the G-tube instead of administering them by gravity and flushing with water between each medication as required by the physician's orders and facility policy. The resident involved was a male with multiple diagnoses, including unspecified intracranial injury, protein-calorie malnutrition, aphasia, and GERD. The resident's care plan included specific interventions to administer medications as ordered, which were not followed. During the medication pass, RN D prepared and administered the medications incorrectly by combining them and not flushing the G-tube with water between each medication. This was contrary to the physician's orders and the facility's policy on enteral medication administration. Interviews with RN D and the DON revealed a lack of adherence to proper medication administration protocols. RN D acknowledged that medications should be crushed separately but believed it was acceptable to combine them for administration. The DON confirmed that medications should not be mixed and should be administered through gravity, with appropriate flushing before, between, and after each medication. The facility's policy also specified these procedures, which were not followed during the observed medication pass.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodated residents' preferences for two residents, leading to dissatisfaction with meals and potential weight loss. Resident #45, a [AGE] year-old female with multiple diagnoses including stroke, diabetes, and heart failure, reported that she was not informed about alternate meal options and was only offered a grilled cheese sandwich as an alternative. Her family member corroborated this, stating that staff used to ask about meal preferences but had stopped doing so. Resident #45 expressed a preference for fish, which she was unaware was available as an alternate meal option. Resident #53, a [AGE] year-old female with severe cognitive impairment and a history of significant weight loss, also reported dissatisfaction with the facility's food. She mentioned that the food was often too salty or spicy and that she was not informed about alternate meal options. Despite discussing her food preferences with the dietician, she continued to receive meals she did not like. She expressed a preference for fish and tuna salad but was not aware that fish was available as an alternate meal option. Interviews with staff revealed inconsistencies in how meal preferences were communicated to residents. Some staff members stated that they no longer asked residents about their meal preferences before serving meals, while others mentioned that residents could request alternates if they did not like the meal provided. The facility's dietary manager and dietician were not fully aware of the residents' preferences, leading to a lack of appropriate meal options being offered. An anonymous group interview with residents confirmed that they were often not informed about alternate meals or that the facility ran out of alternate food options.
Failure to Maintain Proper Infection Control During Incontinence Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for a resident observed for infection control. During an observation, CNA A was seen providing incontinence care to a resident without performing proper hand hygiene. Although CNA A completed hand hygiene and gloved before starting the care, she did not change gloves or perform hand hygiene after cleaning the resident's soiled areas. Instead, she continued to apply a clean brief and barrier cream, and touched the resident's clean linen and bedside table with the same gloves. This action was contrary to the facility's infection control policy and the training CNA A had received the previous day. CNA A admitted in an interview that she forgot to change gloves during care and was aware of the requirement to perform hand hygiene and change gloves to prevent cross-contamination. The Director of Nursing (DON) confirmed that staff are expected to complete hand hygiene before and after care, and to change gloves during incontinence care to prevent the spread of infection. The facility's policy on infection control emphasizes the importance of hand hygiene, stating that it is the primary means of preventing infection transmission. The policy also notes that wearing gloves does not replace the need for hand washing, as gloves can have defects or become contaminated during use. Despite being in-serviced on infection control, CNA A failed to adhere to these guidelines, leading to a potential risk of infection for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Desoto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desoto Nursing & Rehabilitation Center | 1.4 mi | ★★★★★ | 15 | 1 |
| Williamsburg Village Healthcare Campus | 1.7 mi | ★★★★★ | 36 | 5 |
| The Lennwood Nursing And Rehabilitation | 2 mi | ★★★★★ | 4 | 0 |
| Methodist Transitional Care Center-desoto Llc | 2.2 mi | ★★★★★ | 5 | 0 |
| Duncanville Healthcare And Rehabilitation Center | 2.5 mi | ★★★★★ | 18 | 0 |
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