Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Park Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical and psychiatric diagnoses had two active orders for Wellbutrin 300 mg daily on the MAR, creating an apparent total dose of 600 mg daily. Psychiatric notes reflected that 600 mg was being given and later adjusted to 450 mg, while multiple MAs and an LVN reported they actually administered only 300 mg but signed the MAR as if 600 mg had been given. The resident reported that staff were trying to give her 600 mg instead of 300 mg and that she refused when this occurred. The DON and ADON acknowledged the duplicate order and inaccurate MAR documentation, and the facility’s medication administration policy referenced the right medication and right dose, which were not correctly reflected in the MAR entries.
Improper food storage, labeling, and sink waste receptacle use. The kitchen had multiple food items in dry storage and the walk-in cooler that were exposed to air, missing item labels, and missing open or best-by dates, including cereal, bread, buns, cake confetti, pasta, and shredded cheese. The #1 handwashing sink waste receptacle also contained items other than disposable paper towels, such as cups, cans, foil, shrink wrap, and cartons. The DM and Dietary Aide gave conflicting explanations about the dating process, while the facility policy required opened foods to be labeled and dated.
Ineffective Pest Control Program With Gnats Throughout Facility: Gnats were observed in resident rooms, bathrooms, hallways, and on a medication cart across multiple halls, and residents reported the pest problem had continued despite prior treatment of drains. The pest control log showed limited documentation, while the Plant Ops Mgr and Admin acknowledged ongoing pest issues in resident areas.
Medication Refusals Not Reflected in Care Plan: A cognitively intact resident with CHF, CKD, COPD, and bilateral blindness repeatedly refused scheduled meds over about 2 months, including antibiotics and morning/evening doses. Nurses documented refusals and education attempts, but the comprehensive care plan did not address the pattern of refusals until it was identified by the surveyor; the MDS nurse, ADON, and DON acknowledged awareness of the issue.
A MA failed to disinfect a blood pressure cuff between use on two residents and did not perform hand hygiene before administering eye drops to one resident. The residents involved were cognitively intact and had orders for routine BP checks and BP medications. The MA acknowledged the missed cleaning and hand hygiene steps, and the DON stated staff must clean equipment after each resident and wash hands before giving eye drops.
A medication cart on one hall was observed unlocked and unattended in the corridor with the keys still in the lock. An MDS nurse secured the cart and identified it as belonging to an LVN, who later admitted she had just cleaned the cart and briefly went to the med room for blood sugar strips, forgetting to lock the cart and remove the keys. The LVN acknowledged the importance of keeping the cart locked and keys in the nurse’s possession, consistent with facility policy requiring medication carts to be locked unless under direct supervision and keys to remain on authorized staff.
A resident with severe cognitive impairment, chronic ankle ulcers, incontinence, and a G-tube was on Enhanced Barrier Precautions (EBP) requiring staff to wear gowns and gloves for high-contact care. Despite EBP signage and care plan interventions, an LVN and a CNA provided incontinence care without gowns, and the LVN did not change soiled gloves or perform hand hygiene before reconnecting the resident’s G-tube feeding. The LVN reported not realizing a G-tube was an indwelling medical device requiring EBP and believed gowns were only needed for bloody secretions, while the CNA followed the LVN’s example and was unsure of the risk. The DON stated that EBP required gown and glove use for such care and that gloves and hand hygiene should have been addressed before handling the G-tube, consistent with facility policies on Standard and Enhanced Precautions.
Surveyors found a second-floor medication cart at the nurse’s station unlocked and unattended, with the top drawer containing medications and biologicals easily opened. Security camera footage confirmed the cart was unlocked when accessed by the surveyor, after which an MDS coordinator closed the drawer and locked the cart. An LVN later denied the cart had been unlocked, though acknowledged that a resident could open an unlocked cart. The MDS coordinator, Administrator, and DON all stated that medication carts are expected to be locked whenever not in active use, and facility policy requires medications to be stored securely with carts locked when not attended by authorized staff.
A resident with severe cognitive impairment, multiple chronic conditions, and dependence for bed mobility and toileting was being turned in bed by two CNAs for incontinent/perineal care when she moved unpredictably and nearly fell off the bed. Although staff prevented a fall to the floor, they were unable to stop her from striking her head and face on a bedside table that was positioned very close to the bed, resulting in a right eyebrow laceration and significant bruising and swelling around the right eye. Nursing assessments, skin checks, and imaging confirmed the facial injury without fracture, and interviews with nursing, medical staff, and administration consistently identified the impact with the bedside table during the turn as the cause of the injury.
A resident with severe cognitive impairment and multiple medical conditions did not consistently receive prescribed medications, including phenytoin and PEG 3350, as ordered via G-tube and orally. Facility records and staff interviews revealed missed doses, refusals, and inconsistent documentation, while hospital findings showed subtherapeutic phenytoin levels and fecal impaction, indicating lapses in medication administration and pharmaceutical services.
A resident with severe cognitive and physical impairments was discharged to a homeless shelter without verification of the shelter's ability to meet care needs or guarantee admission. The facility did not document alternate placement referrals, failed to confirm the resident's representative's involvement, and did not ensure the resident's safe admission to the shelter. The resident was left without appropriate support, ultimately found by school security after leaving the shelter.
A resident with severe cognitive impairment and multiple comorbidities sustained a laceration and significant facial bruising after striking a bedside table during a two-person assist for incontinent care. The incident occurred when the resident moved unpredictably while being turned, and the bedside table was positioned too close to the bed, resulting in injury despite staff presence and assistance.
A resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed injuries, including a wrist fracture and facial bruising, due to inadequate supervision and insufficient staffing. The facility failed to ensure staff worked full shifts, did not provide consistent coverage in the memory care unit, and staff were at times found asleep during their shifts. These failures resulted in repeated falls and injuries for the resident, with staff often unaware of how the injuries occurred.
A facility failed to include interventions for combative behavior in the care plan of a resident with severe cognitive impairment and a history of aggression, despite multiple documented incidents of physical aggression towards staff and self-injury. Staff were aware of the resident's behavioral challenges, but the care plan only addressed fall risk and cognitive deficits, omitting strategies for managing aggression. Facility policies required care plans to be updated for behavioral changes, but this was not done.
A resident with severe cognitive impairment was found with a swollen and fractured wrist of unknown origin. Staff and the administrator did not report the injury to the state survey agency within the required timeframe, despite facility policy and regulatory requirements mandating immediate reporting of serious injuries of unknown source.
A resident with severe cognitive impairment was found with a swollen, fractured wrist of unknown origin. Staff were unable to determine how the injury occurred, and although immediate medical care was provided, there was no evidence of a thorough investigation or required reporting to the state agency, as mandated by facility policy.
A resident with End Stage Renal Disease and Essential Hypertension received Clonidine outside of the ordered blood pressure parameters on multiple occasions. The medication aide admitted to not following the prescribed parameters, but the resident did not experience any adverse effects. The facility's policy on reviewing vital sign parameters was not adhered to.
A resident's Hydrocodone-Acetaminophen was misappropriated at an LTC facility. The medication was signed for and placed in a lock box by an LVN but later found missing. The resident, who was trialing Tylenol, was unaware of the issue until notified. The facility's investigation confirmed the medication's initial placement but did not capture subsequent events due to limited camera coverage. The missing medication went unnoticed during narcotic counts because the entire card and count sheet were removed.
A facility failed to accurately reconcile and account for controlled medications for a resident with chronic pain, leading to a deficiency in pharmaceutical services. The resident's Oxycodone was missing from the medication cart despite being delivered and signed for by an LVN. The absence of the narcotic count sheet and medication cards meant the missing medication went unnoticed during routine counts. The issue was discovered when an LVN noticed the medication was not on the cart, and an investigation was initiated by the DON.
A facility's kitchen was found to have deficiencies in food storage and labeling, including unlabeled and undated food items in the walk-in cooler and freezer, and personal food stored in the preparation cooler. The Dietary Manager and staff acknowledged the risks of cross-contamination and the importance of adhering to food safety standards.
The facility's kitchen failed to meet food safety standards, with issues including a dirty ice machine, improper storage of raw meat, and unlabeled food items. Staff interviews revealed inconsistencies in cleaning schedules and responsibilities, and the cleaning log was incomplete. These deficiencies could risk food-borne illnesses and cross-contamination.
The facility failed to respond to call lights promptly, impacting the dignity and care of residents. A resident with multiple health issues reported being ignored for an entire morning, while another was left waiting for over an hour for toileting assistance, resulting in an accident. Staff interviews revealed inadequate support from nurses, with CNAs often left to manage alone, leading to delays in care. The DON and Administrator acknowledged the issue, emphasizing the need for timely responses.
The facility failed to provide necessary bathing services to residents unable to perform ADLs, affecting their personal hygiene. A resident with moderate cognitive impairment and another with intact cognition did not receive scheduled showers, while a third resident with severe cognitive impairment was found in poor hygiene. The DON acknowledged missed showers due to time and staffing issues, but no refusals were documented. The Administrator noted inadequate documentation by CNAs, despite the facility's policy emphasizing cleanliness and comfort.
A resident with complex medical conditions experienced a significant decline in health, including low blood pressure and oxygen saturation. An LVN failed to notify the physician or document further vital signs, delaying the resident's transfer to the hospital. The resident was later diagnosed with septic shock and placed on a ventilator.
A resident with complex medical conditions experienced a decline in health due to the facility's failure to monitor and report changes in condition. LVN A did not follow the care plan or notify the DON about the resident's low blood pressure, while LVN B failed to document monitoring during her shift. This led to the resident's hospitalization with septic shock and the need for life support.
A resident with complex medical conditions received abnormal lab results indicating an elevated white blood cell count. The ADON failed to follow up with the PA/MD after faxing the results, assuming no response meant no new orders were needed. This oversight could have delayed addressing potential health issues.
A facility failed to maintain accurate medical records for a resident, as two LVNs did not document BP checks after a significant drop in BP. The resident's standing orders for a renal diet with fluid restrictions were also not included in the facility doctor's orders. This lack of documentation and communication led to a delay in addressing the resident's condition, resulting in hospitalization.
A resident's privacy was compromised when a nurse left a computer unattended with the resident's personal and medical information visible. The resident, who was cognitively intact and had a history of diabetes and hyperlipidemia, had their health records exposed at the nurses' station. The nurse admitted to not locking the computer screen, contrary to facility policy, which requires securing electronic health records to prevent unauthorized access.
A resident with moderate cognitive impairment and dependency on staff for ADLs did not receive scheduled showers or bed baths as required. Despite the facility's schedule, the resident had not been documented to have received a shower since a specific date. Interviews with staff revealed a lack of awareness and responsibility regarding the resident's care, leading to a deficiency in maintaining the resident's hygiene and well-being.
A resident with multiple pressure ulcers did not receive consistent wound care according to physician orders. Despite specific wound care instructions, the resident missed several days of treatment, and there was no documentation of refusal on those dates. Staff interviews revealed issues with the availability of the Wound Care Nurse and inconsistent care by other staff.
A resident with multiple medical conditions was found in a neglected state, lying in a wet bed with fecal matter on his body, after expressing discomfort and being left in this condition since the previous night. The facility's policy on providing dignified incontinent care was not followed, as a CNA delayed changing the resident, prioritizing other tasks. The administrator recognized the situation as a dignity issue and a risk for skin breakdown.
A resident with osteomyelitis, type 2 diabetes, and hypertension was not included in his Care Plan Conference due to being at dialysis. Despite being mildly cognitively intact and expressing a desire to participate, the resident was not contacted regarding attendance. The Social Worker admitted the oversight, and the Administrator and DON acknowledged the need for scheduling at convenient times.
A facility failed to ensure resident privacy during personal care when a caregiver did not close the door or pull the privacy curtain while assisting a resident in dressing, leaving the resident exposed to those in the hallway. The resident, who was cognitively intact, was found in the hallway without pants or underwear and required assistance to return to his room and get dressed. The facility's policy mandates staff to protect resident privacy during care.
The facility failed to update a resident's care plan to address his tendency to undress and leave his room undressed. Despite staff awareness of the behavior, it was not documented until after surveyor intervention, leading to inappropriate care.
A facility failed to update a resident's care plan to reflect his tendency to undress and leave his room, despite staff being aware of this behavior. The resident, who was cognitively intact, was found in the hallway without pants or underwear. The care plan was only updated after surveyor intervention, highlighting a lapse in the periodic review and revision of care plans as required by facility policy.
Duplicate Wellbutrin Orders and Inaccurate MAR Documentation
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for one resident by allowing a duplicate order for Wellbutrin 300 mg daily to remain on the Medication Administration Record (MAR), resulting in an apparent order for 600 mg daily from early to late March. The resident, a cognitively intact female with diagnoses including heart failure, end-stage kidney disease, blindness, generalized anxiety disorder, and major depressive disorder, had a care plan noting non-compliance with medication administration. Her March MAR showed two separate daily orders for Wellbutrin 300 mg, and psychiatric assessments documented that she was receiving Wellbutrin 600 mg daily, later changed to 450 mg daily. The NP stated that an outside NP might have ordered the additional 300 mg dose, and the physician did not know why there was an extra order. Medication aides and an LVN reported that they administered only 300 mg of Wellbutrin daily but signed the MAR as if 600 mg had been given, despite having been trained to sign only for medications actually administered. The resident reported she was not receiving her medications correctly, stating the facility was overdosing her by giving 600 mg instead of 300 mg daily, and that she would refuse the dose when 600 mg was offered. The DON and ADON acknowledged the presence of a 600 mg daily order on the MAR and that it was a duplicate order, and the DON stated she did not know if the resident had actually received 600 mg daily during the period in question. The facility’s undated medication administration policy referenced the right medication and right dose, but staff documentation on the MAR did not accurately reflect the dose administered.
Improper Food Storage, Labeling, and Sink Waste Receptacle Use
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its kitchen. During observation of the #1 handwashing sink, the garbage receptacle contained items other than disposable paper towels, including plastic cups, tin cans, insulated foil, plastic shrink wrap, a large empty tin can, styrofoam cups, and an empty apple juice carton. These observations were made on multiple dates and showed that the receptacle at the handwashing sink was being used for items beyond paper towels. In the dry storage room, several food items were found improperly stored and labeled. A clear plastic press-and-seal bag of colored circled-shaped cereal was exposed to air, had no item label, and had an open date of 02/12/2026 with a best-by date of 02/28/2026. A previously opened bag of sandwich bread had no item label and no open date, and a previously opened bag of hamburger buns had no open date. A large bag of edible cake confetti was exposed to air, had an open date of 10/30/2025, and had a best-by date of 01/30/2026. A large bag of spiral shaped pasta was exposed to air, had no item label, had an open date of 02/15/2026, and had no best-by date. Four unopened loaves of bread also had no item label and no best-by date, with only the manufacturer's name visible. In the walk-in refrigerator, a large clear plastic press-and-seal bag containing shredded cheese was exposed to air, had an open date of 02/10/2026, and had no best-by date. The Dietary Manager stated the two dates on food items reflected the date the product was opened and the best-by date, and that all kitchen staff were responsible for labeling and properly sealing food items after opening them. The Dietary Aide stated the two dates reflected the day the product was received and the best-by date, and that the best-by date was three days after opening. The facility's Food Labeling and Dating policy stated opened food items must be labeled with an open by date and use-by date or the manufacturer's recommended shelf-life, and the FDA Food Code section cited required food to be covered, labeled, and dated when stored.
Ineffective Pest Control Program With Gnats Throughout Facility
Penalty
Summary
The facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests. Gnats were observed in multiple areas of the building, including Hall A on the first floor, Hall B on the secured unit, and Hall C on the second floor. Observations documented gnats crawling in bathroom sinks, on a medication cart, on a bedside table, on walls near resident room doorways, and flying in resident rooms and hallways. During a confidential group meeting, eleven residents stated there was a pest control problem with gnats in their bathrooms and rooms, and that they had reported the issue to staff. Record review showed the pest control company came two times a week, but the pest control log contained only one mention of gnats and no further documentation beyond that entry. The Plant Operations Manager stated the pest control company said gnats would continue as long as residents had plants and food in their rooms, and he said he would call the company back out again. The Administrator stated he was aware of a pest problem in residents' rooms and other parts of the facility and said the problem would be addressed now that he was aware pests were still present.
Medication Refusals Not Reflected in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident that reflected repeated refusals of medications. The resident was admitted with diagnoses including congestive heart failure, chronic kidney disease, blindness in both eyes, chronic obstructive pulmonary disease, and chronic viral hepatitis C. Her most recent MDS showed a BIMS of 15, indicating she was cognitively intact and needed partial to moderate assistance with activities of daily living. Nurses’ notes documented multiple medication refusals over a period of about 2 months, including refusal of cefuroxime and other scheduled pills, refusal of morning medications that were later accepted from a nurse, refusal of all morning medications, refusal of all evening medications except amitriptyline 25 mg, and continued refusal of scheduled morning medications despite education and encouragement. The comprehensive care plan dated 12/15/2025 did not include a plan to address medication refusal until 02/19/2026, when it was brought to the facility’s attention by the surveyor. Interviews with the MDS nurse, ADON, and DON confirmed awareness of the refusals and that the issue had not been care planned during the period reviewed.
Infection Control Lapses During Vital Signs and Eye Drop Administration
Penalty
Summary
The facility failed to maintain its Infection Prevention and Control Program when a MA did not disinfect a blood pressure cuff between use on two residents and did not perform hand hygiene before administering eye drops to one resident. Resident #78 was a cognitively intact female with diagnoses including hypertension, diabetes, and heart failure, and had physician orders for blood pressure checks every shift and metoprolol twice daily. Resident #124 was a cognitively intact male with diagnoses including hypertension and end stage renal disease, and had physician orders for blood pressure checks every shift prior to blood pressure medications. During observation of medication administration, the MA used the blood pressure cuff on Resident #78 and then left the room without cleaning the cuff with germicidal wipes. The MA then returned to the medication cart, used hand sanitizer, prepared medications, and later used the same blood pressure cuff on Resident #124 without cleaning it before or after use. The MA stated she was supposed to clean all equipment used before and after each resident and acknowledged she did not clean the cuff in front of the surveyor because she got to talking and forgot. During the same observation with Resident #78, the MA administered oral medications and nasal spray, then gave eye drops to both eyes without cleansing her hands first. The MA later stated she should have cleaned her hands before giving the eye drops. The DON stated direct care staff must clean equipment, including blood pressure cuffs, after contact with each resident, and that staff should always wash their hands and put on gloves before administering eye drops. The facility policy identified blood pressure cuffs as non-critical equipment and stated hand hygiene is the primary means to prevent the spread of infections.
Unlocked and Unattended Medication Cart with Keys Left in Lock
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all drugs and biologicals were stored in locked compartments with access limited to authorized personnel. During an observation on Hall C, a medication cart was found unlocked and unattended in the middle of the hall between specified rooms, with the keys still in the lock mechanism. An MDS nurse approached the unattended cart, pushed in the lock mechanism to secure it, and removed the keys, stating that the cart should have been locked and that the nurse should not have left it unlocked when unattended. She identified the cart as belonging to an LVN assigned to Hall C. In a subsequent interview, the LVN acknowledged that the unattended, unlocked cart belonged to her and that it was a nurse cart. She reported that she had just finished cleaning the cart and had quickly gone into the medication room to get blood sugar strips, forgetting both to lock the cart and to take the keys with her. She stated that it was important to keep the medication cart locked and the keys safely removed and in the nurse’s possession, and she recognized that the risk was medication safety related to residents or others obtaining narcotic medications. The facility’s policy on Medication Storage, revised 01/2026, requires that medication carts remain locked and secured unless under direct and continuous supervision of authorized personnel, and that keys must always remain on the authorized staff member and not be left in or on the cart or unattended.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinence and G-Tube Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the care of one resident on Enhanced Barrier Precautions (EBP) for a G-tube and wounds. The resident was an elderly female with senile degeneration of the brain, gastrostomy status, and non-pressure chronic ulcers to both ankles, who was severely cognitively impaired, always incontinent of bowel and bladder, and dependent for toileting, showers, and transfers. Her care plan, initiated 07/18/24, documented that she was on EBP related to wounds and device care, with interventions requiring staff to wear clean gowns and gloves while performing high-contact care. On observation, a sign was posted outside her door indicating EBP, yet during incontinent care, an LVN and a CNA did not wear gowns as required. Further observation showed that after wiping the resident’s bottom during incontinence care, the LVN did not remove her soiled gloves or perform hand hygiene before reconnecting the resident’s G-tube feeding. In interviews, the LVN stated she had washed her hands before starting care and was not aware that a G-tube was considered an indwelling medical device requiring EBP, believing gowns were only needed if secretions were bloody and that EBP applied only to wounds and Foley catheters. She acknowledged the risk as contamination and stated she should have changed gloves before handling the feeding tube. The CNA reported she did not wear a gown because the nurse was not wearing one and she was unsure of the risk. The DON stated that EBP required staff to wear gloves and gowns while providing care and that the nurse should have changed gloves and performed hand hygiene before connecting the G-tube, identifying the risk as contamination and spread of infection. Facility policies on Standard and Enhanced Precautions and Implementation of Standard and Transmission-Based Precautions indicated that gowns and gloves are required for high-contact resident care activities for residents with wounds and/or indwelling medical devices, even if not known to be infected or colonized with MDROs.
Unlocked and Unattended Medication Cart at Nurse’s Station
Penalty
Summary
The deficiency involves the facility’s failure to keep a second-floor medication cart locked and secured when unattended. During an observation and interview on 01/13/2026 at 2:30 p.m., the surveyor found the medication cart at the second-floor nurse’s station unlocked and unattended, and was able to open the top drawer, which contained medications and biologicals for residents. A security camera review from 2:29:04 p.m. confirmed that the cart was unlocked when the surveyor opened the drawer. At 2:29:07 p.m., the MDS Coordinator approached, closed the drawer, locked the cart, and then walked behind the nurse’s station. At 2:30:05 p.m., LVN A approached the cart, pushed on the lock, and stated it was locked, and during interview at 2:35 p.m., LVN A denied that the cart had been observed unlocked, though acknowledged that a resident could open an unlocked cart. In contrast, during an interview at 3:10 p.m., the MDS Coordinator stated she locked the cart because it was unlocked, unattended, and could be opened by someone other than the nurse responsible for it, and that a medication cart should be locked when the responsible person is not standing in front of it. In separate interviews, the Administrator and DON both stated the expectation that medication carts are to be locked when not in use or whenever the nurse turns away from the cart, and that residents could access medications if the cart is left unlocked. A review of the facility’s “Storage of Medications” policy (revision date 08-2020) showed that medications and biologicals are to be stored safely and securely, and that only licensed nurses, pharmacy personnel, and others lawfully authorized to administer medications may access medications, with medication carts and supplies to be locked when not attended by authorized personnel. The observed unlocked and unattended medication cart was therefore inconsistent with the facility’s stated policy and expectations.
Inadequate Supervision and Environmental Hazard During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment during incontinent care, resulting in a resident striking her head on a bedside table. The resident was an elderly female with severe cognitive impairment (BIMS score 00) and multiple diagnoses including dementia, Alzheimer’s disease, hypertension, chronic kidney disease, osteoarthritis, neuropathy, depression, anxiety disorder, muscle weakness, and cognitive communication deficit. Her care plan documented that she required two‑person assistance, was dependent for toileting hygiene and rolling left and right, and needed substantial to maximum assistance with bed mobility and personal hygiene. She was also bowel and bladder incontinent related to Alzheimer’s disease and dementia. During a routine incontinent/perineal care episode, two CNAs were turning the resident in bed when the incident occurred. According to CNA witness statements and nursing interviews, the resident began to move unpredictably or pushed with her upper body in the middle of the turn, almost falling off the bed. Although the CNAs were able to prevent her from falling to the floor by keeping her on the bed, they were unable to prevent her from hitting her head and face on the bedside table, which was positioned very close to the bed. Staff reported that the resident leaned or moved toward the side where the bedside table was located and struck the table with the side of her face, causing a laceration above the right eyebrow and subsequent bruising and swelling around the right eye. Post‑incident assessments and documentation confirmed the injuries and the circumstances of the event. A weekly skin check documented a bruise to the right eye and a laceration to the right eyebrow. The incident report completed by an LVN described a straight‑line injury above the right eyebrow, a swollen black eye, and bleeding that required cleansing and dressing, with vital signs within normal limits. Subsequent imaging of the facial bones showed no fracture, and neuro checks documented the resident as alert and oriented with normal vital signs. Observations later noted a large yellow discoloration bruise on the upper right side of the resident’s face. Interviews with the DON, ADON, physician, nurse practitioner, CNAs, LVN, and administrator consistently attributed the injury to the resident hitting her head on the bedside table during the turn for incontinent care, with the table described as being very close to the bed at the time of the incident.
Failure to Ensure Accurate Medication Administration and Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquisition, receipt, dispensing, and administration of all drugs and biologicals for a resident with complex medical needs. The resident, a female with diagnoses including Type 1 diabetes mellitus with ketoacidosis, altered mental status, urinary tract infection, and severe cognitive impairment, was prescribed multiple medications to be administered via G-tube and orally. Record reviews revealed inconsistencies in the administration of medications, particularly phenytoin and PEG 3350, with documentation showing missed doses and refusals. Hospital records indicated the resident had extremely low phenytoin levels, and imaging showed significant fecal impaction, suggesting that prescribed medications for seizure control and constipation were not consistently administered as ordered. Interviews with facility staff, including nurses and certified medication aides, revealed that the resident sometimes refused medications, and staff would attempt re-administration, notify charge nurses, and document refusals. However, hospital physicians noted that the resident's phenytoin levels were subtherapeutic, and imaging findings were consistent with a lack of regular administration of prescribed laxatives. The facility's medication administration records did not consistently reflect that all medications were given as ordered, and there were discrepancies between staff statements and documented administration. Further review of the facility's policies indicated that licensed nurses are required to know the indications, dosages, and documentation requirements for all medications administered. Despite this, the resident's medication records showed missed doses and lack of administration for certain medications, particularly during periods when the resident was not hospitalized. The failure to ensure accurate and consistent medication administration was corroborated by both facility documentation and hospital findings.
Failure to Ensure Safe and Orderly Discharge for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure safe and orderly discharge for a resident with significant medical and cognitive needs. The resident, who had diagnoses including anoxic brain damage, major depressive disorder, anxiety disorder, seizures, impaired mobility, severe malnutrition, and other chronic conditions, required supervision for all activities of daily living and medication management. Despite these needs, the facility discharged the resident to a homeless shelter without verifying that the shelter could meet his care requirements or that a bed was available. The shelter did not provide 24-hour medical staff, medication management, or guaranteed admission, and the resident was left standing in line without being checked in. There was no documentation in the resident's records of referrals for alternate placement, no evidence of a verbal or written notice of intent to leave the facility, and no documentation that the resident's representative refused to pick him up. The facility's social worker and administrator did not confirm the shelter's ability to provide necessary care or verify bed availability. The interdisciplinary team (IDT) did not consistently oversee the discharge decision, and there was inadequate documentation verifying safe placement and discharge readiness. The resident ultimately left the shelter, walked a significant distance, and was found by school security several days later, having apparently slept on the streets. Interviews with facility staff revealed a lack of communication and coordination regarding the discharge plan. The DON was unaware that the resident had not been discharged to his family as planned, and the administrator did not verify the shelter's services or admission process. The facility's discharge policy required IDT involvement, education, and documentation to ensure safe discharge, but these procedures were not followed in this case. The failure to provide and document sufficient preparation and orientation for discharge resulted in an unsafe situation for the resident.
Injury During Incontinent Care Due to Inadequate Environmental Safety and Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including dementia, Alzheimer's disease, and muscle weakness, did not receive adequate supervision and environmental safety during a routine incontinent care procedure. The resident required a two-person assist for activities of daily living and was dependent for toileting hygiene and bed mobility. During the care event, two CNAs were turning the resident when she made an unpredictable movement, resulting in her head striking a bedside table that was positioned close to the bed. The incident led to a laceration above the resident's right eyebrow and significant bruising around the right eye. Documentation and staff interviews confirmed that the resident did not fall from the bed, but the proximity of the bedside table contributed to the injury when the resident moved unexpectedly during the turn. The injury was immediately reported, and assessments were conducted, including a neuro check and imaging, which showed no fractures but confirmed soft tissue injury. The care plan for the resident indicated the need for substantial assistance and proper alignment during repositioning, but the environmental setup—specifically the placement of the bedside table—was not adequately managed to prevent accidental injury. Staff statements and medical records consistently described the sequence of events leading to the resident's injury, highlighting a lapse in ensuring a hazard-free environment and sufficient supervision during care for a resident with significant physical and cognitive limitations.
Failure to Provide Adequate Supervision and Prevent Accident Hazards
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision and assistance to prevent accidents for a resident with severe cognitive impairment and a history of falls. The resident, who had diagnoses including non-Alzheimer's dementia, encephalopathy, muscle weakness, and difficulty walking, experienced multiple unwitnessed falls and injuries over a period of several days. These included a left wrist fracture of unknown origin, a fall resulting in a lip bleed, and subsequent facial bruising and swelling. The care plan and assessments documented the resident's high risk for falls, unsteady gait, and combative behaviors, but interventions did not sufficiently address these risks, particularly her combative behaviors and need for increased supervision. Staffing records and interviews revealed that the facility did not consistently provide adequate staff coverage or supervision in the memory care unit. There were instances where only one staff member was scheduled or present for shifts, and staff were found to have clocked in late or out early, with no documentation of who covered for absent staff. On one occasion, two CNAs were found asleep at the nurses' station with the lights off, further reducing supervision. The lack of consistent and adequate staffing contributed to the resident's repeated falls and injuries, as staff were not always available to anticipate or respond to her needs. Documentation and interviews also indicated that staff were often unaware of how the resident sustained her injuries, and there was confusion regarding the timing and cause of her wrist fracture. The facility's failure to ensure staff worked their full shifts and to maintain proper supervision in the memory care unit directly led to the resident's injuries and placed other residents at risk. The deficiency was identified as Immediate Jeopardy, and although the Immediate Jeopardy was later removed, the facility remained out of compliance due to incomplete staff training and ongoing monitoring.
Failure to Address Combative Behavior in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting interventions for combative behavior. Despite multiple documented incidents of aggressive and combative actions by the resident, including physical aggression towards staff during care and after falls, the care plan did not include strategies or interventions to manage these behaviors. Progress notes and incident reports detailed episodes where the resident became combative, resulting in injury to herself and staff, yet these behaviors were not reflected or addressed in the care planning documentation. The resident in question had a complex medical history, including severe cognitive impairment, dementia, a history of falls, and recent musculoskeletal injury. She required partial to moderate assistance with activities of daily living and was noted to be resistive and combative during care, particularly when staff attempted to assist her. Staff interviews confirmed that the resident's combative behavior was known and associated with care provision, but this information was not incorporated into her care plan. The care plan focused on fall risk, cognitive impairment, and activity participation, but did not address the behavioral challenges that were repeatedly observed and documented. Interviews with facility staff, including the MDS Coordinator, ADON, and DON, revealed a lack of clarity and communication regarding responsibility for updating care plans to reflect behavioral issues. Staff acknowledged the resident's combative behavior but did not revise the care plan to include interventions for managing aggression. The facility's own policies required care plans to be updated for changes in behavior, but this was not done, resulting in a failure to provide a comprehensive plan of care tailored to the resident's identified needs.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown source were reported immediately, but not later than two hours after the allegation was made, as required by federal and state regulations. Specifically, the incident involved a resident with severe cognitive impairment who was found to have a swollen left wrist, later diagnosed as a fracture, and the cause of the injury was unknown. Despite the seriousness of the injury, the event was not reported to the state survey agency (HHSC) within the required timeframe. The resident in question had a history of cognitive deficits, impaired mobility, and was at risk for falls. On the day of the incident, staff observed swelling in the resident's left wrist, which was unwitnessed and could not be explained by the resident or staff. The resident's family member noticed the swelling, and subsequent assessment and imaging confirmed a fracture. The resident was sent to the hospital for further evaluation and treatment. Interviews with staff indicated uncertainty about how the injury occurred, and there was no documentation or witness to a fall or other event that could have caused the fracture. Despite the facility's policy requiring immediate reporting of injuries of unknown source resulting in serious bodily injury, the administrator and staff did not report the incident to the state survey agency as required. The administrator stated that they relied on the resident's statement about falling, despite her severe cognitive impairment, and did not consider the injury as an unknown source that required reporting. This failure to report was contrary to both facility policy and regulatory requirements.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate and report an injury of unknown origin for a resident with severe cognitive impairment. The resident, who had multiple diagnoses including non-Alzheimer's dementia, malnutrition, encephalopathy, and a history of falls, was found to have a swollen left wrist that was later diagnosed as a fracture. The injury was unwitnessed, and the resident was unable to specify how it occurred. Staff noted the swelling after a family member pointed it out, and immediate actions such as pain management and obtaining an x-ray were taken. However, there was no evidence that a thorough investigation into the cause of the injury was conducted, nor was the incident reported to the appropriate state agency as required by facility policy and regulation. Interviews with staff revealed uncertainty about how the injury occurred. The LVN who assessed the resident stated that the resident had no swelling in the morning but was found with a swollen wrist later in the day. The resident herself could not recall any fall or incident that would explain the injury, and staff could not determine if she was able to get up without assistance after a possible fall. The administrator confirmed that, despite the resident's low cognitive score and inability to provide a clear account, the facility did not initiate a formal investigation or report the incident to the state, relying instead on the assumption that the resident had fallen. The facility's own abuse and neglect policy requires prompt and thorough investigation of injuries of unknown source and mandates reporting to the administrator and state officials. In this case, the policy was not followed, as the injury was not investigated as an unexplained injury and was not reported to the state survey agency. This lapse in procedure left the cause of the injury undetermined and failed to ensure that all potential abuse, neglect, or mistreatment was ruled out.
Medication Error: Clonidine Administered Outside Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by administering Clonidine outside of the ordered blood pressure parameters. The resident, a male with End Stage Renal Disease and Essential Hypertension, was prescribed Clonidine to be administered only if his systolic blood pressure was greater than 170 and diastolic blood pressure was greater than 100. However, the medication was given on multiple occasions when the resident's blood pressure was below these parameters, specifically 68 times in December 2024, 49 times in January 2025, and twice in February 2025. The medication aide responsible for administering the medication admitted to not adhering to the ordered parameters, attributing the error to human oversight. Despite the medication being given outside the prescribed parameters, the resident did not experience any episodes of hypotension or other adverse effects. The facility's Director of Nursing and the Nurse Practitioner were informed of the error, and the resident was evaluated, with no negative impact found. The facility's policy requires that medication administration records be reviewed for vital sign parameters, which was not followed in this instance.
Misappropriation of Resident's Pain Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of his prescribed medication, specifically Hydrocodone-Acetaminophen, which was intended for pain management. The resident, a male with a history of depression, difficulty in walking, phantom limb syndrome with pain, polyneuropathy, and chronic pain syndrome, was admitted to the facility and required pain management as per his care plan. The medication was delivered to the facility and signed for by an LVN, who placed it in a lock box and recorded it in the narcotic count sheet. However, the medication was later found to be missing from the medication cart. The discrepancy was discovered when another LVN returned to work and noticed the absence of the medication, which she had ordered the previous week. Despite the medication being delivered and signed for, it was not present on the medication cart, and the narcotic count sheet was also missing. The resident did not request the medication over the weekend, as he was trialing Tylenol, and was unaware of the issue until notified by the facility. The facility's investigation included reviewing security footage, which confirmed the medication's initial placement but did not capture subsequent events due to limited camera coverage. Interviews with staff revealed that the narcotic count was conducted each shift, but the missing medication went unnoticed because the entire card and count sheet were removed. The facility's policy on abuse prevention and prohibition was in place, but the incident highlighted a gap in the process of securing and accounting for narcotic medications. The facility initiated an investigation and reported the incident to the police, but the report does not detail any immediate corrective actions taken to address the deficiency.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to maintain accurate reconciliation and accounting of controlled medications for one resident, leading to a deficiency in pharmaceutical services. The resident, a male with a history of depression, difficulty in walking, phantom limb syndrome with pain, polyneuropathy, and chronic pain syndrome, was admitted to the facility and required pain management. The issue arose when the resident's prescribed Oxycodone was not available on the medication cart, despite being delivered and signed for by an LVN. The narcotic count sheet and medication cards were missing, preventing staff from realizing the medication was absent during routine narcotic counts. The deficiency was identified when an LVN, who had ordered the medication, noticed its absence upon returning to work. The resident did not request the medication over the weekend, opting to try Tylenol instead, and was unaware of the missing medication until informed by the facility. Interviews with staff revealed that the medication was delivered and placed on the cart, but the absence of the narcotic count sheet and medication cards meant the missing medication went unnoticed during shift changes. The facility's Director of Nursing (DON) confirmed the delivery of the medication and initiated an investigation, including reviewing security footage and filing a police report. However, the investigation was hampered by the lack of comprehensive camera coverage and the inability to contact the LVN who initially received the medication. The facility's policy on abuse prevention and prohibition was in place, but the incident highlighted a gap in the reconciliation process for controlled medications.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. The deficiencies included improper labeling and dating of food items stored in the walk-in cooler and freezer. Specifically, a Ziploc bag containing opened bread wraps and a bag of lettuce in the walk-in cooler were not labeled or dated. Additionally, a large container of dark brown liquid, identified as freshly brewed tea, was covered with cling wrap but lacked labeling and dating. In the walk-in freezer, an opened bag of frozen dough balls was also found without proper labeling or dating. Further observations revealed that personal food items were improperly stored in the facility's preparation cooler. A half-filled water bottle labeled with a staff member's name was found on the second shelf of the preparation cooler. This was confirmed by the Dietary Manager (DM), who stated that personal food items should not be stored in the facility's kitchen and that there was a designated cooler in the staff area for such items. The DM acknowledged that improper food storage could lead to cross-contamination, posing a risk to residents. Interviews with staff, including the Dietary Manager and a dietary aide, confirmed awareness of the facility's food storage policies. The dietary aide admitted to storing personal food in the preparation cooler due to a broken staff refrigerator and acknowledged the potential contamination risk. The facility administrator reiterated that only food items for resident consumption should be stored in the kitchen and emphasized the importance of proper sealing, labeling, and dating of all food items to prevent serving expired or compromised foods to residents.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The ice machine was found to have black buildup along the top of the inner guard, indicating it was not clean. Interviews with staff revealed inconsistencies in the cleaning schedule and responsibilities for the ice machine, with some staff stating it was cleaned daily, while others mentioned weekly cleaning. The cleaning log for the ice machine was not initialed for the day of the observation, further highlighting a lack of adherence to the facility's cleaning policy. In the walk-in refrigerator, a 30 lb box of bacon was found exposed to the air, with an uncooked egg inside the box, suggesting improper storage practices. The facility's food storage policy requires raw meat to be stored separately from other foods and in airtight containers, which was not followed in this instance. Additionally, in the dry storage area, a 6 lb carton of sprinkles was opened without an open date or expiration date, violating the facility's policy on labeling and dating food items. Interviews with staff confirmed that food should be covered or sealed and stored separately to prevent cross-contamination and bacterial growth. The facility's policies on food storage and ice machine cleaning were not consistently implemented, as evidenced by the observations and staff interviews. These failures in food safety practices could potentially place residents at risk for food-borne illnesses and cross-contamination.
Delayed Call Light Response Affects Resident Dignity and Care
Penalty
Summary
The facility failed to treat residents with respect and dignity by not responding to call lights in a timely manner, affecting the quality of life for three residents. Resident #1, a female with multiple health issues including monoplegia and diabetes, reported that her call light was ignored for an entire morning, leaving her without necessary care until the second shift. She expressed that staff would enter her room, turn off the call light without addressing her needs, and she had not filed a grievance since April 2024. Resident #2, also with significant health conditions, was observed in her wheelchair in the hallway for over an hour waiting for toileting assistance. She eventually had an accident and was left in an uncomfortable situation until the Admissions Director arrived to assist. Resident #2 mentioned that call lights often took hours to be answered, particularly during the overnight and 2-10 pm shifts, where staffing was inadequate, with only one CNA available and nurses refusing to help. Interviews with staff, including LVNs and CNAs, revealed inconsistencies in call light response times and a lack of support from nurses on the floor. The DON and Administrator acknowledged the issue, with the DON stating that response times should not exceed 15 minutes and that all staff were responsible for answering call lights. Despite efforts to educate staff on the importance of timely responses, the problem persisted, with CNAs reporting that nurses did not assist with resident duties, leading to delays in care.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received necessary services to maintain personal hygiene. This deficiency was identified for three residents who required assistance with bathing and hygiene. Resident #1, who had moderate cognitive impairment and required dependent assistance for bathing, reported not receiving a scheduled shower or bed bath on her designated days. Similarly, Resident #2, with intact cognition but requiring substantial assistance, also did not receive her scheduled shower or bed bath. Both residents expressed concerns about not being informed of the reasons for missed showers. The facility's grievance log revealed multiple complaints from residents about not receiving showers, including a grievance submitted by an Occupational Therapist on behalf of Resident #3. This resident, with severe cognitive impairment, was found in a state of poor hygiene, necessitating immediate intervention by the therapist. The Director of Nursing (DON) acknowledged awareness of missed showers, attributing them to time constraints and staffing issues, but no refusals were documented in the facility's online charting system. Interviews with the DON and the Administrator highlighted a lack of proper documentation and follow-up by the staff. The Administrator noted that CNAs were expected to document any abnormalities and refusals, but this was not consistently done. The facility's policy on showering residents emphasized the importance of maintaining cleanliness and comfort, yet the failure to adhere to scheduled bathing routines and inadequate documentation contributed to the deficiency in care provided to the residents.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant need to alter treatment due to a drastic change in the resident's condition. Specifically, a Licensed Vocational Nurse (LVN) did not contact the resident's doctor after observing a significant drop in blood pressure and other concerning symptoms such as weakness, vomiting, and poor eating. The resident, who had a history of complex medical conditions including hypertension, diabetes, and renal insufficiency, was not transferred to the hospital until the following day, where he was diagnosed with septic shock and placed on a ventilator. The resident's medical records indicated that he had a history of chronic kidney disease, respiratory issues, and cognitive impairment, among other conditions. On the day of the incident, the LVN noted abnormal vital signs, including a blood pressure reading of 93/44 and oxygen saturation of 88%. Despite these findings, the LVN did not document any further blood pressure checks or notify the physician about the resident's deteriorating condition. The LVN later admitted to not documenting subsequent vital signs and failing to contact the physician, believing the resident's condition had stabilized by the end of the shift. Interviews with other staff members revealed that the night shift nurse was not informed of the resident's change in condition, and no further monitoring or physician notification occurred during the night. The following morning, the resident's condition worsened, prompting the LVN to contact the physician's assistant, who then ordered the resident to be sent to the hospital. The delay in notifying the physician and transferring the resident to the hospital contributed to the resident's critical condition upon arrival at the emergency department.
Failure to Monitor and Report Resident's Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to a deficiency in quality of care. The resident, who had a history of complex medical conditions including hypertension, renal insufficiency, and diabetes, experienced a significant change in condition. On one occasion, LVN A did not monitor the resident's blood pressure after a low reading and failed to notify the Director of Nursing (DON) or another nurse about the resident's condition and the need for continued monitoring. This lack of action was contrary to the resident's care plan and the nephrologist's orders, which aimed to prevent fluid overload. Additionally, LVN B, who was responsible for the resident during the night shift, did not document any blood pressure checks or monitoring throughout her shift. Although she claimed to have checked the resident's blood pressure at 5:00 am, this was not recorded in the electronic medical records. The resident's condition deteriorated, resulting in hospitalization with septic shock and the need for life support. The facility's failure to adhere to professional standards of practice and the resident's care plan placed the resident at risk of harm. The lack of documentation and communication between staff members contributed to the resident's decline, highlighting deficiencies in monitoring and reporting changes in the resident's condition.
Failure to Ensure Timely Review of Abnormal Lab Results
Penalty
Summary
The facility failed to provide or obtain timely laboratory services for a resident, leading to a deficiency in care. The resident, who had a history of complex medical conditions including anemia, hypertension, peripheral vascular disease, renal insufficiency, diabetes mellitus, hyperlipidemia, malnutrition, depression, and generalized muscle weakness, received abnormal lab results on a specified date. These results indicated an elevated white blood cell count, which was flagged as abnormal. However, the Assistant Director of Nursing (ADON) did not follow up with the resident's Physician Assistant (PA) or Medical Doctor (MD) after receiving these results. The ADON faxed the lab results for three residents to the PA, but only received responses for two, excluding the resident in question. Despite recognizing the abnormality in the lab results, the ADON did not take further action to ensure the PA/MD reviewed the results, assuming that no response meant no new orders were needed. This lack of follow-up could have led to a delay in addressing potential health issues for the resident. Interviews with facility staff revealed that the PA was temporarily covering for the main PA and was not aware of the resident's lab results until much later. The Director of Nursing (DON) acknowledged that the ADON should have confirmed whether there were new orders and, if necessary, escalated the issue to the Medical Director. The failure to ensure the lab results were reviewed and acted upon could have placed the resident at risk of health deterioration.
Failure to Document Vital Signs and Orders
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident #1, who was reviewed for medical records. The deficiency involved the failure of two Licensed Vocational Nurses (LVN A and LVN B) to document blood pressure (BP) checks and monitoring after Resident #1's BP dropped significantly on two consecutive days. Additionally, the facility did not ensure that the resident's standing orders from his nephrologist for a renal diet with fluid restrictions were included in the facility doctor's orders. Resident #1, who had a moderate cognitive impairment and multiple complex medical conditions, experienced a drop in BP to 83/44. Despite this, there was no documentation of BP monitoring or notification to the Director of Nursing (DON) by LVN A on the first day. Similarly, LVN B did not document any BP checks or fluid intake during her shift. The lack of documentation and communication between the nurses led to a delay in addressing the resident's change in condition, which eventually resulted in the resident being sent to the hospital. The facility's policies on physician orders and medical records require accurate and timely documentation to ensure continuity of care. However, the failure to document vital signs and standing orders for a renal diet with fluid restrictions could potentially affect all residents, leading to errors in care, treatments, and diets. This deficiency highlights the importance of adhering to documentation protocols to prevent delays in care and potential health declines.
Resident Privacy Breach Due to Unattended Computer
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records, as observed during a survey. A registered nurse (RN A) left a laptop computer unattended at the second-floor nurses' station, with the screen displaying a resident's personal information, including medication and monitoring tasks. This incident involved a cognitively intact female resident with a history of a lower leg fracture, type 2 diabetes, and hyperlipidemia. The resident's electronic health records, including active medication orders, were visible on the screen. Interviews with RN A and the Director of Nursing (DON) revealed that the nurse did not lock the computer screen before stepping away, despite being trained to do so. The DON confirmed that it was the facility's policy for staff to secure electronic health records by logging out or locking the screen when away from the computer. The failure to secure the resident's information could potentially allow unauthorized access to protected health information, violating the resident's right to privacy.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, the facility did not provide showers or bed baths to a resident as per their scheduled routine. The resident, who had a moderate cognitive impairment and was dependent on staff for ADLs, had not received a documented shower or bed bath since a specific date, despite the facility's schedule indicating showers should be provided three times a week. Interviews with the resident and staff revealed inconsistencies in the provision of showers. The resident expressed dissatisfaction with the frequency of showers, stating he had not received them as often as desired. Staff interviews indicated a lack of awareness regarding the resident's last documented shower and a reliance on aides to provide and document showers. The assigned nurse and aides did not receive any complaints from the resident about missed showers, and there was confusion about which staff member was responsible for the resident's care during the previous week. The Director of Nursing (DON) and the Administrator acknowledged the deficiency, noting that showers should be provided according to the schedule and upon request. They emphasized the responsibility of all nursing staff to ensure showers were given and documented. The facility's policy on care and services highlighted the importance of providing necessary care to maintain residents' well-being, but the failure to adhere to the shower schedule posed a risk of infection and skin breakdown for the resident.
Failure to Provide Consistent Wound Care
Penalty
Summary
The facility failed to ensure a resident with pressure ulcers received necessary treatment and services according to physician orders. The resident, a cognitively intact [AGE]-year-old female with a history of paralysis, chronic non-pressure ulcers, and a bone infection, had multiple pressure ulcers at various stages. Despite having specific wound care orders, the resident did not receive wound care on several documented dates, and there was no indication that the resident had refused care on those dates. The resident reported that her wound care was frequently not done, and her last wound care was on 04/02/24, despite orders for daily care. Interviews with staff revealed that the facility's Wound Care Nurse was frequently unavailable due to a medical condition, and other staff were responsible for wound care in her absence. The facility's Regional Nurse Consultant acknowledged that one refusal should not mean the resident would not be seen again by the Wound Care Physician. The facility's Wound Management policy indicated that residents with wounds should receive necessary treatment and services to promote healing and prevent infection, but this was not consistently followed for this resident.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for a resident who was unable to perform them independently. The resident, a male with multiple medical conditions including obesity, osteomyelitis, and schizophrenia, was found in a state of neglect. On the day of the observation, the resident's room had a strong odor of urine and feces, and he was found lying in a wet bed with dried stains and fecal matter on his body and fingers. The resident expressed discomfort and stated he had been left in this condition since the previous night, despite having informed a staff member. The facility's policy mandates that residents receive incontinent care in a manner that ensures privacy and dignity, yet this was not adhered to in the case of the resident. A CNA admitted to noticing the resident was wet upon her arrival at work but did not change him immediately, prioritizing other tasks instead. The administrator acknowledged the situation as a dignity issue and a risk for skin breakdown. The facility's policies emphasize the importance of maintaining residents' dignity and quality of life, which was compromised in this instance.
Failure to Include Resident in Care Plan Conference
Penalty
Summary
The facility failed to ensure that a resident had the right to participate in the development and implementation of his person-centered plan of care. Specifically, the facility did not include the resident in his Care Plan Conference. The resident, a [AGE] year-old male with diagnoses including osteomyelitis, type 2 diabetes, and hypertension, was mildly cognitively intact with a BIMS score of 10. Despite this, the resident was not present at the care plan conference due to being at dialysis, and he was not aware of the goals or services being provided for his care. The resident expressed a desire to be part of his care plan conference but was not contacted regarding attendance. The Social Worker admitted that the resident was not involved in the previous care plan conference and that the next conference would be rescheduled to include him. However, there was no documentation of the attempt to involve the resident in the previous conference. The Administrator and Director of Nursing acknowledged that the care conference should have been scheduled at a time convenient for the resident and that it was the responsibility of the interdisciplinary team to ensure the resident's participation. The facility's policy stated that the resident and their family should be invited to care planning meetings and that efforts should be made to schedule these meetings at convenient times.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure residents had a right to personal privacy for one of three residents reviewed for personal privacy. Caregiver A did not close the door to Resident #2's room while assisting in dressing the resident, leaving the resident's bottom exposed to those in the hallway. This incident was observed by surveyors, and it was noted that maintenance staff and housekeeping passed by the door during this time. Caregiver A acknowledged that the privacy curtain was not pulled because the roommate was not present, and admitted that not closing the door or pulling the privacy curtain could violate the resident's rights. Resident #2, who was cognitively intact with a BIMS score of 15, was found in the hallway in a wheelchair with no pants or underwear on, covered only by a small blanket. The resident required assistance to return to his room and get dressed. The facility's policy on resident rights and quality of life, revised in August 2020, mandates that staff promote, maintain, and protect resident privacy during personal care and treatment procedures. Interviews with the Administrator and Director of Nursing confirmed that the door should be closed and the privacy curtain pulled when providing resident care.
Failure to Update Care Plan for Resident's Undressing Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #2, who had a tendency to undress himself and leave his room undressed. Despite being cognitively intact with a BIMS score of 15, Resident #2 was observed in the hallway without pants or underwear, covered only by a small blanket. Interviews with staff revealed that this behavior was known but had not been documented in the care plan until after surveyor intervention. The MDS regional nurse updated the care plan only after being informed of the incident by the surveyor, indicating a lapse in the facility's care planning process. Further interviews with the MDS regional nurse, Administrator, and Director of Nursing confirmed that Resident #2's behavior had been ongoing but was not reflected in the care plan. The facility's policy required care plans to be revised as needed, but this was not adhered to in Resident #2's case. The lack of an updated care plan meant that Resident #2 did not receive appropriate care for his behavior, highlighting a significant deficiency in the facility's care planning and documentation processes.
Failure to Update Care Plan for Resident with Undressing Behavior
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for a resident who had a tendency to undress himself and leave his room undressed. This deficiency was identified during a survey when Resident #2 was found in the hallway in his wheelchair without pants or underwear, covered only by a small blanket. The resident, who was cognitively intact with a BIMS score of 15, required assistance to return to his room and put his clothes on. Despite this behavior being known to staff, it was not reflected in the resident's care plan until after surveyor intervention. Interviews with staff revealed that the resident had a history of undressing and leaving his room, but this behavior had not been documented in his care plan. The MDS regional nurse, who had been working at the facility for two days due to the absence of a permanent MDS coordinator, updated the care plan only after being informed of the incident by the surveyor. The social worker and other staff confirmed that the resident had not been involved in the previous care plan conference due to being at dialysis, and the next conference was scheduled without ensuring the resident's participation. The facility's policy required care plans to be reviewed and revised periodically, including after each comprehensive and quarterly assessment. However, the care plan for Resident #2 had not been updated to address his known behavior, leading to a risk of inappropriate care. The administrator and director of nursing, both new to the facility, acknowledged the oversight and the potential risk of not providing accurate care due to the outdated care plan.
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Illustrative
What surveyors actually found near you
We read the 1,337 citations issued within 25 miles in the last 12 months — including the 55 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Traymore Nursing Center | 1.9 mi | ★★★★★ | 2 | 0 |
| Lakewest Rehabilitation And Skilled Care | 2.6 mi | ★★★★★ | 25 | 1 |
| The Plaza At Edgemere | 4.4 mi | ★★★★★ | 16 | 0 |
| Ventana By Buckner | 4.5 mi | ★★★★★ | 3 | 0 |
| Avir At Dallas | 4.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.