Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Five Points Nursing & Rehabilitation Of College St during CMS and state inspections, most recent first.
A facility failed to provide ordered ostomy, trach, and bowel supplies for two residents. One resident with a urostomy was given colostomy bags instead of the correct urostomy bags, so the family purchased the proper supplies. Another resident with a trach and neurogenic bowel did not receive ordered inner cannulas or Enemeez, and the family had to buy those items after the facility lacked the needed supplies. Staff, including the CSC, DON, and ADM, acknowledged the facility was responsible for providing the ordered items.
Failure to assess and obtain wound care orders for a resident’s sacral pressure injury on admission led to a deficiency. The resident had quadriplegia, paralytic syndrome, and limited mobility, and the wound was documented as unstageable/deep tissue injury on admission. The record showed no wound assessment or orders until several days later, when the wound was described as stage 4 with necrosis and treatment orders were entered; the resident and family member voiced concern that staff had not been providing wound care.
A resident with dementia, severe cognitive impairment, reduced mobility, repeated falls, and dependence for ADLs was care planned to have a fall mat beside the bed and the bed kept in a low position when in bed. On a morning shift, staff found the resident on the floor next to the bed with bleeding from the head and mouth; documentation and hospital records confirmed scalp and lip lacerations. Multiple staff reported that at the time of the fall the bed was not in the lowest position, the resident was not on a fall mat, and the mats were rolled up against the wall, despite prior knowledge that the resident was a fall risk who required these interventions, and the night-shift CNA stated she was unaware he needed fall mats even though the Kardex contained this information.
A resident with significant mobility and medical needs was transferred from the toilet to a wheelchair by only one CNA, despite care plan and policy requiring a two-person assist and use of a mechanical lift. The resident fell and sustained a femur fracture, with interviews and records confirming that staffing shortages and lack of adherence to transfer protocols led to repeated one-person transfers for residents needing two-person assistance.
A resident with heart failure and other chronic conditions was given nearly double the prescribed amount of IV Sodium Chloride due to a breakdown in communication and handoff procedures among nursing staff. The error occurred when a 1000 ml IV bag was used instead of a 500 ml bag, and the infusion was not stopped at the correct volume, resulting in a medication error and subsequent hospital transfer for shortness of breath.
A resident with diabetes and a history of skin ulcers did not receive prescribed wound care for a skin tear on the lower leg due to incorrect order entry and documentation errors by nursing staff. The wound care treatments were missed over several days, and the issue was discovered after the resident's family raised concerns about an outdated bandage. Nursing staff and leadership confirmed the lapse in care, which was attributed to mistakes in the electronic medical record and failure to follow facility policy.
Medication Cart #1 was found unlocked on two separate occasions, once with an RN present who was unaware the cart was unsecured, and once with no nurse present for approximately ten minutes. The RN admitted to forgetting to lock the cart both times and could not recall the date of her in-service training on medication security. The ADON confirmed that staff had been in-serviced on this policy but did not remember when the last training occurred. Facility policy requires medications to be stored securely and accessible only to authorized personnel.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
The facility did not post daily nurse staffing information in a prominent and accessible location for several consecutive days. The DON, who was responsible for this task, acknowledged the lapse and stated that the information had not been updated. The ADM confirmed the expectation for daily posting and noted the absence of a facility policy on this requirement.
A resident with severe cognitive impairment and high dependence on staff was observed twice with his call light out of reach while seated in a recliner. Staff interviews confirmed that ensuring call lights are within reach is a shared responsibility, but the assigned CNA was not present and the replacement was unaware of the issue. The facility lacked a policy on call lights, resulting in the resident being unable to request assistance as required by his care plan.
Two residents who required staff assistance for bathing did not consistently receive showers or baths according to their scheduled care plans, as documented in the EMR and confirmed by resident interviews. Staff and leadership acknowledged responsibility for providing these services, and the facility's policy outlined the importance of regular bathing, but scheduled baths and showers were missed on multiple occasions.
A resident with a stage 4 pressure ulcer did not receive prescribed wound care treatments on three scheduled days, despite clear physician orders and care plan interventions. Documentation showed the treatments were missed, and staff interviews confirmed that wound care orders were expected to be followed and tracked in the electronic medical record. The wound physician noted no decline or infection in the ulcer following the missed treatments.
The facility did not submit required Payroll Based Journal (PBJ) staffing data to CMS for a full quarter, as confirmed by record review and staff interviews. The Administrator and Regional Clinical Nurse were aware of the missing submission but were unclear on the cause, citing recent receipt of a federal number and pending clarification from corporate staff. No policy on PBJ reporting was provided.
Several residents with significant medical needs did not receive scheduled showers or adequate assistance with activities of daily living, including bathing and hygiene. Residents and their representatives reported missed showers, long wait times for care, and inconsistent staff response. Observations confirmed that some residents remained unwashed and in the same clothes for days. Staff interviews revealed confusion about assignments, documentation, and equipment responsibilities, with chronic understaffing cited as a major barrier. Documentation of ADL care was inconsistent or missing, and supervisory staff were unaware of the extent of the deficiencies.
Multiple residents with complex medical needs did not receive timely assistance with ADLs such as bathing, toileting, transfers, and medication administration due to insufficient nursing staff. Residents and their families reported long waits for care, missed showers, and delayed medications, while staff confirmed frequent short staffing, especially on weekends, and difficulties providing two-person assistance. Documentation showed gaps in required care, and staff indicated that administration was aware of the ongoing staffing issues but had not resolved them.
Surveyors found that kitchen staff failed to discard an expired ham and did not properly seal, label, or date an opened bag of rolls in the freezer. Staff interviews confirmed a lack of awareness about these items, despite facility policy requiring regular checks and proper labeling of food to prevent spoilage and contamination.
A resident with significant physical and cognitive impairments was not provided the necessary assistance to get out of bed daily, despite repeated requests and a care plan requiring a mechanical lift with two staff. Observations and interviews confirmed the resident remained in bed for seven days, with staff citing shortages and equipment limitations as barriers to honoring the resident's choices, resulting in unmet needs for mobility and self-determination.
A deficiency was identified when an ADON left a computer screen displaying a resident's confidential medical information, including name and insulin order, open and visible in a hallway. The resident had severe cognitive impairment and Type 2 Diabetes. The ADON was aware of the expectation to close screens but could not recall receiving formal or HIPAA training. Facility leadership confirmed that this action violated confidentiality policies.
Two residents had care plans that incorrectly included anticoagulant therapy, despite only being prescribed antiplatelet medication. The care plans failed to reflect the actual physician orders and included interventions for anticoagulant complications, which were not relevant. Staff interviews confirmed that care plans are the basis for resident care and that such inaccuracies could lead to improper care.
A bottle of expired Glucosamine and Chondroitin was found in the medication storage room, and staff interviews revealed that monthly audits sometimes failed to catch expired medications. The staff responsible for audits, as well as the ADM and DON, confirmed that expired medications should be removed, but there was no specific policy in place for handling expired drugs.
A resident with multiple complex medical conditions was prescribed Quetiapine, and the pharmacy consultant recommended a gradual dose reduction. The facility did not document that this recommendation was communicated to the physician or acted upon, due to process discrepancies and staff turnover. Staff interviews confirmed the breakdown in communication and the responsibility of the DON to ensure pharmacy recommendations reach the physician.
A medication cart was left unlocked and unattended by a CMA during medication administration, contrary to facility policy and training. Facility leadership confirmed that medication carts must be locked when not attended, and the facility's pharmacy manual requires carts to be secured after use.
Staff failed to follow Enhanced Barrier Precautions during wound care for a resident with stage 4 pressure ulcers and an indwelling catheter. Despite facility policy and posted instructions requiring gowns and gloves for high-contact care, the wound care nurse, MDSC, and DON performed wound care without gowns, allowing their uniforms to come into contact with the resident and bedding, and acknowledged in interviews that this was not in compliance with infection control protocols.
The facility did not post daily nurse staffing information in a prominent location as required, with the designated notice holder found empty and staff confirming the omission. The ADON reported forgetting to post the information due to other duties, and the facility lacked a policy on staffing postings.
A long-term care facility failed to provide sufficient nursing staff, resulting in delayed care and unmet hygiene needs for several residents. One resident experienced prolonged exposure to diarrhea without assistance, while another was unable to receive timely help to the bathroom. The facility's outdated staffing assessment and poor scheduling practices contributed to these deficiencies, impacting the quality of care for 76 residents.
The facility failed to provide adequate staffing, resulting in residents experiencing prolonged exposure to incontinence and missed showers. One resident waited three hours for assistance after a diarrhea episode, while another was unable to use the bathroom due to a lack of CNAs. Multiple residents did not receive their scheduled showers, highlighting significant staffing shortages.
The facility failed to provide scheduled showers to residents, impacting their hygiene and well-being. Several residents, including those with cognitive impairments and physical disabilities, did not receive showers as per their care plans. Staffing shortages were cited as a reason for this deficiency, with staff acknowledging the inability to meet residents' needs. The facility's administration recognized the issue but had not fully addressed it.
Failure to Provide Ordered Ostomy, Tracheostomy, and Bowel Supplies
Penalty
Summary
The facility failed to provide the correct urostomy bags for a resident with quadriplegia and an artificial urinary opening. The resident’s physician order summary included a PRN order for urostomy bag changes, and the care plan directed staff to perform ostomy care as ordered and change the urostomy bag and ring as needed. During interview and observation, the resident stated his family had been purchasing urostomy bags because the bags provided by the facility were not the correct type. He reported that the bags obtained through the facility were colostomy bags and did not have the drain needed to connect to his Foley catheter bag. A box of colostomy bags was observed in the facility. The facility also failed to provide tracheostomy inner cannulas and Enemeez for another resident with quadriplegia, neurogenic bowel, neuromuscular bladder dysfunction, dysphagia, and tracheostomy status. The resident had physician orders for changing a size 4 Shiley inner cannula every shift and for Enemeez mini rectal enema daily, along with other bowel medications and a digital stimulation program. The resident’s family stated they had to purchase inner cannulas and Enemeez because the facility did not have the needed supplies. The family reported that the supplies were discussed in a care plan meeting with the ADM and DON, but the supplies were still not provided, prompting the family to purchase them for the resident. Facility staff confirmed the supply problems. The CSC stated she did not know the difference between urostomy and colostomy bags and acknowledged that the resident’s family had been purchasing the urostomy bags because the resident preferred a different bag than the one the facility provided. The DON and ADM both stated the facility was responsible for providing the correct urostomy bags and acknowledged that a colostomy bag was not the same as a urostomy bag. Regarding the second resident, the DON and ADM stated the facility was responsible for providing the inner cannulas and Enemeez, and both acknowledged that the quantities ordered by the facility would only have lasted a short period of time. The DON also stated the facility did not have tracheostomy inner cannulas in the building when the resident was admitted and that not having extra inner cannulas could cause breathing difficulties if the tracheostomy became dislodged.
Failure to Assess and Order Care for Sacral Pressure Injury
Penalty
Summary
The facility failed to provide wound care consistent with professional standards for Resident #2’s sacral pressure injury. Resident #2 was a female admitted with diagnoses including quadriplegia, paralytic syndrome, and reduced mobility, and her admission MDS reflected a BIMS score of 15 with no cognitive impairment. Her record showed a pressure ulcer/injury on the sacrum that was initially documented as unstageable/deep tissue injury, and the admission record and wound documentation reflected that the wound was present on admission. Review of the record showed that the sacral wound was not assessed and no wound care orders were acquired from admission until 04/08/2026. The order summary later reflected treatment for an unstageable sacral wound, including normal saline cleansing, packing with moistened gauze, skin prep to the periwound, and bordered foam, with additional orders dated 04/12/2026 for a stage 4 sacral wound and doxycycline for wound infection. The wound care provider note on 04/08/2026 described the sacral wound as stage 4, measuring 5 x 6 x 1.1 cm, and the care plan dated 04/12/2026 identified a stage 4 sacral pressure ulcer with interventions to follow facility policies and protocols for prevention and treatment of skin breakdown. During interviews, the resident and family member expressed concern about the wound worsening because staff were not providing care, and the wound care doctor stated he had evaluated and treated the wound twice and noted necrosis in the wound bed.
Failure to Maintain Fall Prevention Interventions Resulting in Resident Fall and Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s environment as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents. A male resident with severe cognitive impairment (BIMS score of 3), dementia, reduced mobility, repeated falls, gait and mobility abnormalities, history of TIA and cerebral infarction, and lack of coordination was care planned as being at risk for injury from falls. His comprehensive care plan, revised in January 2026, specified that he required a fall mat beside the bed whenever he was lying in bed and that his bed should be kept in the low position at night. The care plan also documented that he was dependent or required significant assistance for ADLs and transfers, used a wheelchair, and was totally dependent on staff for locomotion. On the morning of 02/12/2026, the resident was found on the floor beside his bed with bleeding from his head and mouth. An activity note documented that staff were called to the room, found that he had fallen from bed onto the floor, and that he stated he had been trying to get up. Nursing documentation and hospital records showed that he sustained a laceration to the scalp requiring three staples and a laceration to the lower lip closed with skin glue. A weekly skin assessment recorded abrasions to the right side of the lip and inside the mouth, and a laceration on the top right side of the head with three staples, though no measurements were documented. A neuro assessment later that day showed vital signs within normal limits, confused but coherent verbal responses at his baseline, and no new neurological changes requiring physician notification. Multiple staff interviews and observations established that the resident’s fall prevention interventions were not in place at the time of the fall. A CNA who discovered the resident on the floor around the beginning of the day shift reported that his bed was in a high position, he was not on a fall mat, and the fall mats were rolled up and leaning against the wall near the window, despite her understanding that he was a fall risk who was required to have his bed in low position with fall mats beside the bed whenever he was in bed. Another CNA who responded to the incident also stated that there were no floor mats beside the bed, that the mats were rolled up against the wall, and that the bed was in a high position. The LVN who assessed the resident after the fall confirmed that he was lying on the floor without fall mats beside the bed and that the bed was not in the lowest position, estimating it to be mid-position. The night-shift CNA who had put the resident to bed the evening before stated she did not see any fall mats in the room and was not aware he required them, although she acknowledged that the Kardex was available for CNAs to review resident care needs. Other CNAs interviewed stated that, prior to this incident, the resident was known as a fall risk who required fall mats and a low bed per the Kardex. The administrator stated that all staff were expected to follow care plan interventions and that nurses were responsible for ensuring CNAs followed residents’ care plans.
Failure to Provide Required Two-Person Assistance During Resident Transfer Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident, a 93-year-old woman with a history of left femur fracture, peripheral vascular disease, and congestive heart failure, was not provided with the required level of assistance during a transfer from the toilet to her wheelchair. The resident's care plan and clinical assessments specified that she required a two-person assist and the use of a mechanical lift for transfers. On the date of the incident, only one CNA assisted the resident off the toilet, despite the care plan requirements. The resident's knee gave out during the transfer, causing her to fall and hit her knee on the toilet paper dispenser. She complained of pain, and subsequent x-rays revealed a broken femur, necessitating hospitalization and surgery. Interviews and record reviews revealed that the facility had ongoing staffing shortages, which led to frequent instances where only one staff member performed transfers that required two people. Multiple staff members, including CNAs and the ADON, acknowledged that one-person transfers for residents requiring two-person assistance were common due to inadequate staffing. Video evidence provided by the resident's representative also showed several instances where the resident was transferred by one staff member, both with and without a mechanical lift, in violation of facility policy and the resident's care plan. Further investigation indicated that some staff were unaware of how to access the resident's transfer requirements in the electronic Kardex, and communication lapses contributed to the failure to provide adequate assistance. The facility's own policies required two staff members for mechanical lift transfers and for residents assessed as needing two-person assistance. Despite these requirements, staff routinely performed one-person transfers, and the incident in question was directly linked to these practices. The deficiency was identified as Immediate Jeopardy due to the risk and actual harm caused to the resident.
Removal Plan
- Assess all residents requiring 2 person assist during transfer for any injuries.
- Provide 1:1 in-service to the CNA involved on Abuse and Neglect Policy, Mechanical Lifts Transfer, and use of the Electronic Medical Record for ADL Care Plan.
- Provide CNA retention checks, including written in-service cheat sheets for quick reference, obtain signature and verbal acknowledgements, and require return demonstration from CNA with all transfers with rehab director.
- Provide 1:1 in-service to the administrator, DON, and ADONs by the Regional Compliance Nurse and ADO on Abuse and Neglect Policy, Mechanical Lift Transfers, and use of the Electronic Medical Record for ADL Care Plan, and determine competency by post test.
- Assess and determine staffing levels daily in accordance with the census and facility assessment, offer extra shift bonuses to staff as needed, provide sign on bonuses to attract new employees, contact company sister facilities for staffing assistance as needed, and build out the schedule at least 1 week in advance.
- Provide employee retention checks to Administrator and DON, including written in-service cheat sheets for quick reference, obtain signature and verbal acknowledgements.
- In-service all certified and licensed staff on Abuse and Neglect Policy, Mechanical Lift Transfers, and use of the Electronic Medical Record for ADL Care Plan, require all staff not present for the in-services to complete them before working, in-service all new hires during orientation, require staff to sign the in-service sheet, in-service all agency staff before scheduled shift, provide a posttest to confirm understanding, and require return demonstration for mechanical transfer check-off.
- Notify the Medical Director of the immediate jeopardy citation.
- Conduct ADHOC QAPI meeting with the IDT Team and the Medical Director to review the immediate jeopardy citation and plan of removal.
Medication Error: Excess IV Fluid Administration Due to Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident with a history of congestive heart failure, chronic obstructive pulmonary disease, and morbid obesity was administered approximately 900 ml of Sodium Chloride 0.9% intravenously, instead of the prescribed one-time dose of 500 ml. The order specified that the infusion should be run at 75 ml/hour and reassessed at both 250 ml and 500 ml. The facility did not have a 500 ml IV bag available and used a 1000 ml bag, with a mark made at the 500 ml level to indicate where to stop the infusion. However, the infusion was not stopped at the correct volume, resulting in the resident receiving nearly double the ordered amount. The error was precipitated by a breakdown in communication and handoff procedures between nursing staff. The nurse who hung the IV bag reported the order and treatment plan to another nurse, who was assigned to a different hall and did not directly communicate with the nurse responsible for the resident. The oncoming nurse did not receive a verbal or written report about the IV order and did not check the resident's IV during her shift. Multiple staff interviews confirmed that the order was not properly communicated, and the nurse responsible for the resident did not review new orders or verify the IV status. As a result, the infusion continued beyond the prescribed amount. The resident subsequently developed shortness of breath and was transferred to the hospital, where she was diagnosed with pneumonia. The facility's documentation and staff interviews acknowledged that the administration of excess IV fluids constituted a medication error. The facility's policy required medications to be administered in accordance with written physician orders, which was not followed in this instance.
Missed Wound Care Treatments Due to Documentation and Order Entry Errors
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including diabetes, dementia, heart failure, and a history of skin ulcers, did not receive prescribed wound care for a skin tear on the right shin over a period of several days. The resident was dependent on staff for several activities of daily living and was identified as being at risk for pressure ulcers and skin injuries. Physician orders specified that the skin tear should be cleansed and dressed on a set schedule, but these treatments were not administered as ordered between 10/03/2025 and 10/09/2025. The failure to provide wound care was due to a combination of documentation errors and incorrect order entry in the electronic medical record. The treatment nurse entered the order with the wrong timing, specifying treatments at night rather than once daily, which led to missed treatments. Additionally, another nurse mistakenly documented that treatments had been completed on certain dates when they had not been performed. These errors were discovered after the resident's family noticed an outdated bandage and contacted the facility, prompting a review of the medical record and identification of the missed treatments. Interviews with nursing staff and facility leadership confirmed that the resident did not receive the required wound care during the specified period. The treatment nurse acknowledged responsibility for entering the incorrect order and failing to ensure treatments were completed, while the ADON and DON were identified as responsible for monitoring treatments. The facility's policy required prompt treatment of skin concerns, but this was not followed in this instance, resulting in a lapse in care for the resident.
Failure to Secure Medication Cart and Restrict Access to Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys for medication storage. Specifically, Medication Cart #1 was observed unlocked on two separate occasions in front of the nurses' station. During the first observation, a registered nurse (RN) was present behind the nurses' station but did not realize the cart was unlocked. The RN acknowledged that all medication carts were supposed to be locked except when a nurse was obtaining medications and confirmed she had received in-service training on this requirement, though she could not recall when. On the second occasion, the same medication cart was found unlocked with no nurse present in the area. The RN returned approximately ten minutes later and admitted she had walked away to assist a resident, mistakenly believing she had locked the cart. She acknowledged this was the second time that day she had forgotten to lock the cart and could not provide an explanation for her oversight. The Assistant Director of Nursing (ADON) confirmed that staff had been in-serviced on securing medication carts but could not recall the last in-service date. Facility policy requires that medications and biologicals be stored safely and securely, accessible only to licensed nursing personnel or staff authorized to administer medications.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily and readily accessible to residents and visitors, as required. Observations revealed that the posted nursing staffing information outside the DON's office was outdated, displaying information from 08/25/2025, and was not updated for the following three days reviewed. During interviews, the DON acknowledged responsibility for posting the staffing information and admitted it had not been updated since 08/25/2025. The DON also stated that the purpose of posting was to show transparency regarding staff presence for each shift. The ADM confirmed that posting the staffing information daily was the responsibility of the DON or ADON and that the facility did not have a policy regarding this requirement.
Failure to Ensure Call Light Accessibility for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility expectations. On two separate observations during the same day, the resident was seen sitting in a recliner with the call light on the ground approximately two feet away, making it inaccessible. The resident, who had severe cognitive impairment and was dependent on staff for several activities of daily living, was unable to be interviewed due to his condition. The care plan specifically included an intervention to keep the call light within reach and encourage its use for assistance. Interviews with staff, including a CNA, the DON, and the ADM, confirmed that it was the responsibility of all staff to ensure call lights were within reach at all times. The CNA assigned to the resident during the observed times was not present, and the replacement CNA was unaware of the call light's position. The facility did not have a policy regarding call lights. This inaction resulted in the resident not having reasonable accommodation for his needs and preferences, as he was unable to call for assistance when needed.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, for two residents who were unable to perform these tasks independently. Both residents were care planned to receive staff assistance with bathing according to individualized schedules documented in their electronic medical records (EMR). However, record reviews revealed that scheduled baths and showers were missed on multiple occasions for both residents, with no documentation to explain the omissions. Resident #1, an elderly female with multiple chronic conditions including COPD, heart failure, and osteoarthritis, was scheduled to receive baths on Monday, Wednesday, and Friday evenings. The EMR showed missed baths on several scheduled days, and the resident confirmed during interview that she did not receive a bath the previous week except when provided by her hospice provider. Resident #2, an elderly male with diabetes, muscle weakness, and mobility issues, was scheduled for showers on Tuesday, Thursday, and Saturday day shifts. His EMR also reflected missed showers on several scheduled days, and he reported dissatisfaction with the facility's adherence to his shower schedule. Interviews with CNAs and facility leadership confirmed that staff were responsible for providing scheduled baths and showers, and that failure to do so could result in residents developing odor or skin issues. Both the Director of Nursing and the Administrator stated their expectation that residents receive bathing as scheduled. The facility's own policy emphasized the importance of regular bathing for comfort, cleanliness, and skin integrity, but the documented care and staff interviews demonstrated that this standard was not consistently met for the two residents reviewed.
Failure to Provide Ordered Pressure Ulcer Treatments
Penalty
Summary
A deficiency occurred when the facility failed to provide pressure ulcer treatments as ordered for a resident with a stage 4 pressure ulcer on the left heel. The resident, who had multiple diagnoses including cellulitis, diabetes with neuropathy, and sepsis, was dependent on staff for most activities of daily living. The care plan and physician orders required wound care treatments three times per week, including cleansing, application of methylene blue, and appropriate dressings, as well as the use of pressure-reducing devices such as an air mattress, pillows to float heels, and a podus boot. Despite these orders, documentation revealed that the resident did not receive the prescribed wound care treatments on three specific dates. The Treatment Administration Record (TAR) for April and May showed missed treatments on two consecutive scheduled days and one additional day. Weekly wound assessments indicated the presence of a stage 4 ulcer with slough, granulation tissue, and moderate exudate, but no signs of infection or pain were noted. The wound physician confirmed that the wound had not declined after the missed treatments and that there was no infection present. Interviews with facility staff, including the Administrator and Director of Operations, confirmed that the expectation was for nurses to follow physician orders and that wound treatments due each day were visible in the electronic medical record system. The treatment nurse was responsible for executing orders, and oversight was provided by the DON and other managers. The facility had regular meetings to discuss wound care, but the missed treatments were not addressed prior to the survey. The facility's checklist for treatment dressing changes referenced verifying orders from the TAR and chart.
Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the first quarter of fiscal year 2025, specifically for the period from October 1, 2024, to December 31, 2024. This included a failure to report Payroll Based Journal (PBJ) data, which encompasses information for agency and contract staff, as required by CMS specifications. Record review confirmed that no PBJ data was submitted for the specified quarter. During interviews, the Administrator (ADM) and Regional Clinical Nurse (RCN) acknowledged awareness of the missing PBJ submission but were initially unsure of the reason for the failure. The ADM indicated that responsibility for submission lay with the corporate office and was awaiting further clarification from corporate staff. The ADM later reported that the facility had only recently received its federal number from CMS in mid-October, and the next scheduled reporting date had not yet occurred since receiving the number. No policy regarding PBJ data reporting was provided by the facility prior to the survey exit.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) independently received the necessary services to maintain grooming, personal, and oral hygiene. Specifically, nine residents reviewed for ADL care did not receive scheduled showers or adequate assistance with hygiene. Documentation and interviews revealed that showers were missed or not provided as scheduled, and in several cases, residents went a week or more without a bath. Residents and their representatives reported long wait times for assistance, lack of staff availability, and instances where staff did not return to provide care after initially responding to call lights. Multiple residents with significant medical conditions, such as acute respiratory failure, diabetes, cognitive deficits, paralysis, and pressure ulcers, were affected by these lapses. For example, one resident with total dependence for toileting and bathing reported only receiving one shower per week instead of the scheduled three, and another resident with quadriplegia and a stage 4 pressure ulcer stated that he had not received a bath in a week. Observations confirmed that some residents remained in the same clothes for several days, had unkempt hair, and appeared unwashed. Staff interviews indicated confusion about shower assignments, documentation procedures, and responsibility for equipment maintenance, such as charging mechanical lifts. Record reviews showed inconsistent or missing documentation of ADL care, including bathing, toileting, and repositioning. Staff interviews further revealed that CNAs were often unsure of their duties, lacked supervision, and cited chronic understaffing as a barrier to providing scheduled care. The Director of Nursing and other supervisory staff acknowledged that showers and baths were to be documented and monitored but were unaware of the extent of missed care and documentation lapses. No ADL policy was provided upon request during the survey.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of multiple residents, as evidenced by observations, interviews, and record reviews. Several residents with significant medical conditions, such as acute respiratory failure, dementia, chronic kidney disease, quadriplegia, and severe mobility impairments, did not receive timely assistance with activities of daily living (ADLs) including bathing, toileting, transfers, and medication administration. Documentation showed missed or delayed showers and bed baths, with some residents receiving only one bath per week despite being scheduled for more frequent care. There were also instances where residents waited extended periods for assistance with toileting and transfers, and medication administration was delayed until late in the day or night. Residents and their representatives reported concerns about inadequate staffing, particularly on weekends and holidays, leading to delays in care and unmet needs. Some residents described waiting several hours for call lights to be answered, not being assisted out of bed as requested, and not receiving scheduled showers or baths. Family members corroborated these concerns, noting that they or other families stayed late to ensure care was provided, and that medication administration was sometimes delayed until a DON intervened. Staff interviews confirmed frequent short staffing, with only one CNA per hall instead of the scheduled two, and difficulties in providing two-person assist for residents requiring mechanical lifts. Staff also reported confusion about shower assignments, lack of training, and unclear supervisory structures. Documentation in the facility's electronic record system often lacked entries for required ADL care on multiple days, and there were no documented refusals from residents to explain these omissions. Staff consistently reported that administration was aware of the staffing shortages but only responded that they were working on the issue, with no resolution provided. The lack of sufficient staff directly resulted in delayed or missed care for residents, as confirmed by both staff and resident interviews, as well as gaps in care documentation.
Failure to Properly Store, Label, and Discard Expired Food Items
Penalty
Summary
Surveyors observed that the facility failed to properly store, label, and discard food items in accordance with professional standards for food service safety. Specifically, a ham that had expired and was stored in a freezer bag with ice particles was not discarded, and an opened bag of rolls in the freezer was found unsealed and without a label. These issues were identified during a kitchen inspection, where it was noted that the ham was not in its original packaging and the rolls were not properly sealed or dated. Interviews with dietary staff and the dietary manager revealed a lack of awareness regarding the expired ham and improperly stored rolls. Staff stated that it was their responsibility to check for and discard expired or unlabeled food items, and that food should be labeled and dated when received. The facility's policy and FDA guidelines require proper labeling and storage of food to prevent spoilage and contamination, but these procedures were not followed in this instance.
Failure to Support Resident Self-Determination in Daily Mobility
Penalty
Summary
The facility failed to promote and facilitate a resident's right to self-determination by not providing the necessary support for the resident to get out of bed daily. The resident, an elderly female with a history of cerebral infarction, muscle weakness, abnormal posture, anemia, muscle wasting, hyperlipidemia, depression, anxiety, and hemiparesis, was assessed as having moderately impaired cognition and required substantial to maximal assistance for self-care, including the use of a mechanical lift with two staff for all transfers. Despite her care plan indicating these needs, the resident reported not being assisted out of bed for seven consecutive days, despite making daily requests to staff. Observations over two days confirmed the resident remained in bed, wearing the same pajamas and in the same position, and staff interviews corroborated that staffing shortages and equipment limitations contributed to delays or failures in meeting resident requests for assistance with mobility. The resident expressed dissatisfaction with the care received, specifically noting that her requests to get out of bed were acknowledged but not acted upon in a timely manner, often only being addressed late in the day when it was nearly time to return to bed for dinner and nightly care. Staff interviews further revealed an awareness of resident rights and the importance of self-determination, but also acknowledged that staffing and equipment constraints impeded their ability to honor resident choices consistently. The facility's policy on resident rights emphasized the importance of dignity, respect, and participation in care, including the right to receive necessary care to achieve the highest possible level of health. However, the failure to provide timely assistance for the resident to get out of bed as requested demonstrated a lack of support for resident choice and self-determination, as required by both facility policy and regulatory standards.
Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
A deficiency occurred when the Assistant Director of Nursing (ADON) left a computer screen displaying a resident's confidential medical information open and facing the hallway while she entered the resident's room. The exposed information included the resident's name and insulin order, and the ADON could not recall if the diagnosis was also visible. The resident involved was a male with Type 2 Diabetes and severe cognitive impairment, as indicated by a BIMS score of 5. The ADON acknowledged that she had received on-the-floor training regarding medication pass and was aware that computer screens should be closed when unattended, but she could not remember receiving formal or HIPAA-specific training since starting at the facility two months prior. Interviews with facility leadership, including the Administrator (ADM) and Director of Nursing (DON), confirmed that the expectation was for resident information to be kept confidential and that leaving such information exposed could constitute a HIPAA violation. Review of facility policy also reflected the requirement for privacy and confidentiality of residents' personal and medical records. The incident was identified through observation, interview, and record review, and it was determined that the facility failed to ensure the confidentiality of the resident's medical information.
Inaccurate Care Plans for Anticoagulant and Antiplatelet Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents reviewed. Specifically, the care plans for both residents inaccurately included anticoagulant therapy, despite there being no physician order or recommendation for such therapy. Instead, both residents were prescribed and receiving antiplatelet therapy (Aspirin), which was not reflected in their care plans. The care plans also included interventions related to monitoring for anticoagulant complications, which were not relevant to the residents' actual medication regimens. For one resident, a female with multiple complex diagnoses including senile degeneration of the brain, atrial fibrillation, and polycythemia vera, the care plan was initiated and revised to state she was on anticoagulant therapy, with goals and interventions related to anticoagulant use. However, review of her medical orders and assessments confirmed she was only receiving antiplatelet therapy and had no orders for anticoagulants. The resident was observed to have severe cognitive impairment and was unable to participate in conversation or confirm her care plan details. A second resident, also a female with a history of cerebral infarction, muscle weakness, and other chronic conditions, had a care plan similarly indicating anticoagulant therapy, with associated goals and interventions. Her medical records showed she was only prescribed antiplatelet therapy, with no anticoagulant orders. Staff interviews confirmed that care plans are used as the basis for resident care, and that inaccuracies or contradictions in care plans, physician orders, or assessments should be cross-referenced and corrected. The deficiency was attributed to incorrect focus areas being triggered in the care planning process, resulting in care plans that did not accurately reflect the residents' current medication regimens.
Expired Medication Not Removed from Storage Room
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the removal of expired medications from the medication storage room. During an observation, a bottle of Glucosamine and Chondroitin with an expiration date of 3/2025 was found in the medication storage room. Interviews with staff revealed that the responsibility for removing expired medications belonged to a staff member who performed monthly audits, but acknowledged that expired medications could sometimes be missed. The staff member confirmed that expired medications should be disposed of and that administering expired medications could potentially cause harm. Further interviews with the Administrator (ADM) and Director of Nursing (DON) confirmed that nursing staff are expected to check expiration dates before administering medications and that expired medications should be discarded and replaced. However, the ADM stated there was no specific policy or procedure in place regarding the handling of expired medications. The failure to remove expired medications from storage was directly observed and acknowledged by multiple staff members.
Failure to Act on Pharmacy Consultant's Psychotropic Medication Recommendation
Penalty
Summary
The facility failed to ensure that pharmacy consultant recommendations regarding a gradual dose reduction (GDR) for a psychotropic medication were received and acted upon for a resident. Specifically, the pharmacy made a recommendation on 1/28/25 for a GDR of Quetiapine, but there was no documentation that this recommendation was communicated to the physician for review. The resident's medical record, including progress notes and medication administration records, did not reflect any physician notification or action taken in response to the pharmacy's recommendation. The resident involved was an older female with multiple complex diagnoses, including dementia, type 2 diabetes, atrial fibrillation, cognitive communication deficit, chronic pain, Parkinson's disease, and other significant health conditions. She was receiving Quetiapine 50 mg at bedtime as part of her treatment plan. The care plan indicated the need for regular monitoring of psychotropic medications, consultation with pharmacy and physician, and consideration of dose reduction when appropriate. However, the process for reviewing and acting on pharmacy recommendations was not followed in this case. Interviews with facility staff revealed that the failure to communicate the pharmacy's recommendation was due to staff turnover and discrepancies in the process of uploading recommendations for physician review. The responsibility for ensuring pharmacy recommendations were communicated to the physician was identified as belonging to the DON. Both the RCN and ADM acknowledged that the lack of communication could negatively affect residents, but there was no evidence that the required actions were taken for this resident.
Medication Cart Left Unlocked and Unattended During Administration
Penalty
Summary
A medication cart on A Hall was observed to be intermittently left unlocked and unattended by a certified medication aide (CMA) during medication administration rounds. The cart was left facing the hallway and unattended from 7:15 AM to 7:43 AM while the CMA entered resident rooms to dispense medications. The CMA, who was a prn employee and had not worked at the facility for a month, stated this was her third time passing medications alone at the facility. She acknowledged being trained to lock the medication cart and recognized the risks associated with leaving it unlocked. Interviews with facility leadership, including the ADON, DON, and Administrator, confirmed that facility policy requires medication carts to be locked whenever unattended. They each stated that an unlocked cart could allow residents, visitors, or staff to access medications, which could result in ingestion of medications without supervision. Review of the facility's Pharmacy Policy and Procedure Manual also indicated that the medication cart must always be in full view of the nurse during administration and must be completely locked after the process is completed.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) during wound care for a resident with multiple risk factors. The resident in question was an older male with multiple sclerosis, two stage 4 pressure ulcers, and an indwelling catheter, all of which required EBP according to facility policy and posted signage. Despite clear care plan interventions and posted instructions at the resident's room, staff did not adhere to required infection control measures. During wound care, three staff members, including the wound care nurse, MDSC, and DON, entered the resident's room and performed high-contact care activities without donning gowns as required by EBP protocols. Their uniforms came into direct contact with the resident's bedding and gown, and at times, soiled gloves were used to touch room surfaces. The wound care nurse and other staff acknowledged in interviews that they should have worn gowns to prevent cross-contamination, and that failure to do so could result in the spread of infection. Record reviews confirmed that the facility's infection control and EBP policies required the use of gowns and gloves during high-contact care for residents with wounds or indwelling devices. Despite these policies and staff training, the required precautions were not followed during the observed wound care, as staff failed to don gowns and allowed their uniforms to become contaminated during the procedure.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information at the beginning of each shift in a prominent and accessible location for residents and visitors. On the day reviewed, the designated notice holder outside the DON office was found empty, and the daily staffing data was not posted. Interviews with the ADM, DON, and ADON confirmed that the posting was not completed, with the ADON stating she had forgotten to do so due to working as a floor nurse. The ADM acknowledged that posting staffing information was expected and important for staff and family awareness. Additionally, the facility did not have a policy or procedure regarding daily nurse staffing postings when requested by the surveyor.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the necessary competencies and skills to ensure resident safety and well-being. This deficiency was evident in the care of nine residents, where the lack of adequate staffing led to significant delays in providing essential care. For instance, one resident experienced prolonged exposure to diarrhea for three hours without assistance, leading to feelings of helplessness and discomfort. Another resident was unable to receive timely assistance to the bathroom, resulting in discomfort and distress. The facility also failed to adhere to the shower schedules for multiple residents, with several residents not receiving the scheduled number of showers over a month-long period. This lack of adherence to personal hygiene schedules was attributed to insufficient staffing, as staff members were unable to provide the necessary assistance due to being overburdened with other tasks. Interviews with residents and their family members revealed dissatisfaction with the care provided, highlighting the impact of staffing shortages on the quality of care. The facility's staffing issues were further compounded by inadequate scheduling practices and a lack of communication among staff. The acting Director of Nursing and the facility Administrator were unaware of the staffing shortages on specific shifts, which led to situations where only two nurses were available to care for 76 residents. This inadequate staffing level raised concerns about the facility's ability to provide safe and effective care, as well as its capacity to respond to emergencies. The facility's assessment tool, which was outdated and did not reflect the current resident population or staffing needs, contributed to the deficiency.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in inadequate staffing and care for residents. On one occasion, a resident experienced prolonged exposure to diarrhea for three hours due to insufficient staff to respond to her call light. This resident, who had a history of knee issues and hypertension, was unable to get out of bed independently and felt helpless and in pain. The situation escalated to the point where the resident called the non-emergency 911 for assistance, leading to the arrival of firefighters and police at the facility. Another incident involved a resident who was unable to receive assistance to use the bathroom due to a lack of CNAs on duty. The resident's family member had to intervene, and upon arrival, found that many call lights were on, indicating a widespread issue of unmet needs. The facility's staffing records confirmed that there were only two nurses and one CNA scheduled for a shift that typically required more staff, leading to significant delays in care and unmet resident needs. Additionally, the facility failed to adhere to residents' shower schedules, with multiple residents not receiving the scheduled number of showers over a month-long period. This was attributed to staffing shortages, with CNAs and nurses prioritizing other care tasks over showers. Interviews with staff and residents confirmed that the lack of adequate staffing led to residents not receiving showers as scheduled, contributing to concerns about hygiene and resident comfort.
Facility Fails to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene, nutrition, grooming, and personal and oral hygiene. This deficiency was identified for nine out of eleven residents reviewed for activities of daily living (ADLs). The facility did not provide showers to these residents in compliance with their scheduled shower times, which could place them at risk of a decline in hygiene, skin breakdown, and affect their level of satisfaction with life and feelings of self-worth. Resident #1, a female with chronic kidney disease and moderate cognitive impairment, was scheduled to receive showers three times a week but had no showers documented over a month. She expressed that there was not enough staff to assist her with showering. Similarly, Resident #2, a male with mild dementia and anxiety, was dependent on staff for showering but only received five out of thirteen scheduled showers. Resident #3, with dementia and heart failure, had four showers documented and four refusals, indicating a lack of consistent care. The report also highlights the experiences of other residents, such as Resident #4, who received only six out of thirteen scheduled showers, and Resident #5, who had four showers documented. Resident #6, who had intact cognition, reported not having a shower since admission, and Resident #7 expressed discomfort due to not receiving showers as promised. The facility's staff, including CNAs and nurses, acknowledged the issue, citing staffing shortages as a reason for not providing showers as scheduled. The facility's administrator and DON recognized the concern but had not fully addressed the issue at the time of the report.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 59 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 College Station
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accel At College Station | 1.5 mi | ★★★★★ | 8 | 1 |
| Fortress Nursing And Rehabilitation | 1.7 mi | ★★★★★ | 3 | 0 |
| Legacy Nursing And Rehabilitation | 5.1 mi | ★★★★★ | 5 | 0 |
| Crestview Retirement Community | 5.5 mi | ★★★★★ | 0 | 0 |
| St. Joseph Manor | 5.6 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.