Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Galveston Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Improper Garbage and Refuse Disposal: A green dumpster was observed with its door open behind an open gate, trash was scattered around the area, and two uncovered blue barrels contained tied bags of linens. A second large dumpster was filled to the brim with boxes and debris, with a wheelchair, pallets, and a mattress nearby. The ADM and Maintenance Director acknowledged the area was not secured or kept clean, and the facility stated it did not have an official waste management policy.
A resident with a PEG tube, dysphagia, and anorexia was admitted on a pureed "pleasure" diet with orders for enteral feeds and oral Ensure, but staff did not administer tube feeding formula and documented repeated refusals of oral supplements and medications over multiple days without promptly notifying the NP/MD or the resident’s representative. The resident was observed alone with an uneaten pureed meal tray, reported only receiving water flushes through the PEG and difficulty swallowing, and described disliking the pureed food. Medication aides stated the resident had not taken oral meds or Ensure since admission due to swallowing problems and that they verbally informed charge nurses, while the RN and DON acknowledged they were unaware of the full extent of refusals and had not ensured timely provider notification. The NP and MD confirmed they had not been informed of the resident’s ongoing refusals or lack of a clear enteral feeding regimen, leading surveyors to cite the facility for failing to immediately inform and consult with the practitioner and representative when significant treatment changes were needed.
A resident with dysphagia, anorexia, and a newly placed PEG tube was admitted with hospital orders indicating that pureed oral intake was for comfort only and not sufficient for nutrition, and that she should otherwise remain NPO with tube feeding. The facility did not implement a specific enteral feeding formula order for the PEG, instead relying on a pureed diet and Ensure PO TID, which the resident frequently refused or did not receive as documented. Staff did not notify the NP or MD of the refusals, lack of tube feeding, or a documented 19% weight loss over 12 days, and weekly weights were not consistently obtained or accurately managed. The resident reported receiving only water through the PEG, and surveyors observed her seated alone with an uneaten pureed meal tray, stating she was hungry and needed help, while staff were unaware she had not eaten. The resident’s representative also reported multiple occasions where the resident was left with untouched trays and no feeding assistance, and an RN told the representative the resident needed to learn to feed herself with her non-dominant hand despite right-sided weakness.
A resident with dysphagia, anorexia, and a PEG tube placed in the hospital was admitted with orders for NPO status except for pureed food for comfort and active enteral tube flush orders. However, the admission MDS did not include an active diagnosis for gastrostomy status, and Section K reflected only a swallowing disorder with a mechanically altered diet. The resident’s EMR diagnosis list lacked a gastrostomy diagnosis at the time of the assessment, and the MDS nurse later acknowledged that the gastrostomy tube and related diagnosis should have been coded but were missed, despite relying on the RAI manual for MDS completion.
A resident admitted with dysphagia, anorexia, and a PEG tube placed in the hospital had orders for NPO status with pureed food for comfort and enteral feeding with scheduled water flushes, but the facility did not develop or implement a comprehensive, person-centered care plan addressing the G-tube, diet, or enteral feeding as required. The admission MDS documented a swallowing disorder and mechanically altered diet but omitted an active gastrostomy tube diagnosis, and care plan entries referencing the G-tube and mechanically altered diet were only added after surveyor inquiry. During observation, the resident sat with a pureed breakfast tray, reported needing help to eat, and later stated that staff only pushed water through the tube without providing medications or feeding formulas. The DON, Administrator, and MDS nurse acknowledged that care plans for the G-tube and diet should have been initiated on admission and that the lack of a comprehensive care plan could result in the resident not receiving appropriate care.
The facility failed to submit required follow-up investigation reports to the State Survey Agency within the mandated 5-day timeframe for two separate incidents involving two residents. Review of the state TULIP system showed no Provider Investigation Reports on file for these incidents, despite facility policy requiring the administrator to provide a follow-up report within five days. Interviews revealed that the former administrator had handled PIRs alone, current leadership and staff did not have TULIP access, and no one assumed responsibility for completing or locating the pending investigations during a change of ownership, resulting in noncompliance with state reporting requirements.
Nursing staff lacked adequate competency and training in controlled medication management, leading to multiple discrepancies and unsafe practices. For one resident with seizure disorder and severe cognitive impairment, an RN’s control count sheet for Lacosamide did not match the actual volume on the cart, and the RN reported no recent skill check‑off or training on medication administration or control counts. For another resident with dementia and pain management needs, a tramadol blister pack was found with a punched, half‑exposed tablet, and the same RN stated she did not know how to handle the situation and had not been trained on control counts. For a third resident receiving PRN acetaminophen‑codeine for pain, an LVN’s control sheet showed one more tablet than was present in the blister pack; the LVN admitted administering a dose without signing it out on the control sheet or MAR and indicated she had not received medication administration training beyond brief floor orientation, despite facility policy requiring nursing leadership to ensure staff competency.
Multiple failures in pharmacy services were identified, including inaccurate controlled drug counts, improper handling of damaged blister packs, and incomplete documentation. One resident receiving Lacosamide via G-tube had a control count sheet that did not match the actual volume in two bottles, and the RN who discovered the discrepancy reported no recent training on med administration or controlled counts. Another resident with PRN tramadol for pain had a blister pack with a punched-open seal and a half-exposed tablet, and the RN did not know the appropriate action. A third resident receiving PRN acetaminophen-codeine had a mismatch between the blister pack count and the control sheet because an LVN administered a dose but failed to sign it out on the control sheet or MAR. The DON reported limited time for comprehensive nurse training, the facility’s policy required MAR initials after each medication, and a requested drug diversion policy was not provided.
A resident with convulsions, hypertension, traumatic brain injury, severely impaired cognition (BIMS 3/15), and extensive to total ADL needs was found to have no active care plan after the existing plan was cancelled in the electronic record. The MDS Coordinator stated she did not cancel the plan and believed her supervisor did so, and she was unaware of the cancellation until the surveyor requested the care plan, despite having recently completed the quarterly MDS without reviewing it. The DON and Administrator reported they did not know why the plan was cancelled, confirmed that the care plan is used to guide care and communicate with providers and nursing staff, and acknowledged that every resident should have a current, quarterly-updated care plan, while also noting the facility had no specific care plan policy and followed the RAI manual instead.
A resident with multiple comorbidities, severe cognitive impairment, and on hospice care had PRN oral morphine ordered for pain. While counting the resident’s prefilled morphine syringes on the medication cart, an LVN dropped one syringe on the floor, then picked it up and placed it back with the other syringes instead of wasting it, thereby contaminating the entire group. In interviews, the LVN acknowledged the syringe was contaminated and should have been destroyed with another nurse, and the DON confirmed that the dropped syringe and the remaining syringes were considered contaminated, constituting a breach of the facility’s medication administration policy requiring adherence to infection control procedures. The requested infection control policy was not provided by administration at exit.
The facility did not include required staffing level information in its facility-wide assessment, and the assessment was not used to inform nursing staff schedules. Instead, staffing decisions were based on PPD, census, and national averages, without considering individual resident needs as outlined in facility policy.
The facility did not provide enough nursing staff to meet residents' needs, resulting in a resident remaining in a urine-soaked brief, another unable to get out of bed for an entire day, and a third experiencing long waits for incontinent care. Staffing assignments showed fewer CNAs present than scheduled, and staff interviews confirmed that care was delayed or missed due to inadequate staffing levels.
Multiple medication carts were found unattended and unlocked, with keys left accessible and a variety of prescription and OTC medications, including narcotics, stored inside. Nursing staff and the acting DON confirmed that facility policy requires all medication carts to be locked when not in use, but this was not followed, resulting in unsecured access to medications.
A resident with severe cognitive impairment and multiple medical conditions was not provided with a care plan that addressed her G-J tube feeding and pleasure feeding needs, despite clear physician orders and hospital discharge instructions. The care plan did not include protocols for pureed snacks with SLP or trained caregiver supervision, nor did it reflect the resident's tube feeding requirements.
Two residents were found to have roaches in their rooms, with one resident experiencing repeated infestations involving her bed, wheelchair, and personal items. Staff and maintenance confirmed ongoing pest issues despite regular pest control treatments, and food was often found left in the affected rooms, contributing to the problem. Housekeeping and maintenance staff acknowledged that pest control efforts had not been effective in eliminating the roaches.
Three residents were inaccurately assessed during the MDS process, including one whose bed grab bars were incorrectly coded as restraints, another who was documented as having a catheter that had already been removed, and a third who was assessed as having a catheter despite its prior discontinuation. Staff interviews, observations, and record reviews confirmed these inaccuracies, which resulted in incorrect documentation of the residents' actual conditions.
Two residents with complex medical needs did not have comprehensive care plans addressing their indwelling urinary catheter and oxygen therapy, despite clear documentation and physician orders indicating these interventions. Staff interviews and record reviews confirmed the absence of these care plans, which are required to guide care and ensure all needs are met.
A resident with multiple chronic conditions was sent to the hospital for altered mental status and tested positive for THC, but the physician was not notified of this significant change. Staff interviews revealed gaps in communication and review of hospital records, and the facility's policy requiring timely notification of clinical changes was not followed.
The facility did not update the care plans for two residents after they were hospitalized for altered mental status and tested positive for substances not prescribed to them, including benzodiazepines and THC. Despite these significant findings, care plans were not revised to address substance use, and staff interviews confirmed that this information was not incorporated into resident care planning.
Two residents experienced significant medication errors related to blood pressure management. One resident received Midodrine despite a high SBP, contrary to physician orders. Another resident was given Toprol X and Spironolactone when blood pressure readings indicated they should be held. The medication aide admitted to overlooking the orders, and the ADON acknowledged the incomplete documentation and potential health risks.
The facility failed to maintain accurate medication records for two residents, leading to improper administration of blood pressure medications. For one resident, the MAR did not consistently reflect whether Midodrine was given or held, and blood pressure logs were incomplete. Another resident received Spironolactone and Toprol X despite blood pressure readings indicating they should be held. Staff interviews revealed acknowledgment of these errors, highlighting the need for improved adherence to physician orders and documentation practices.
The facility failed to notify the physician and implement orders for a resident's G-tube care, leading to complications and hospital intervention. Staff were unaware of the physician's orders for an abdominal binder and did not properly manage the G-tube, resulting in pain and soiling at the site.
A facility failed to implement a physician's order for an abdominal binder and did not provide proper gastrostomy tube care for a resident, leading to hospitalization for G-Tube replacement. Additionally, medications were improperly administered via the G-Tube, placing the resident at risk for complications.
A facility failed to maintain a medication error rate below 5 percent, resulting in a 16 percent error rate. An LVN administered the wrong dose of Lactulose, used an incorrect volume of water for g-tube flushing, and did not elevate a resident's head during medication administration, contrary to physician orders and facility policy.
The facility, licensed for 150 beds, failed to employ a qualified full-time social worker for four months, despite job postings and interviews. An LVN was placed as acting social services, and residents expressed confusion over the delay in hiring a qualified social worker.
The facility failed to conduct a comprehensive and accurate assessment of a resident's functional capacity, missing critical information about hospice care and dental status. The resident, with multiple diagnoses including ovarian cancer and major depressive disorder, reported issues with her dentures that were not addressed in a timely manner. Staff interviews revealed gaps in MDS documentation and follow-up.
The facility failed to update a resident's MDS assessment within 14 days after the resident was discharged from hospice care. The resident, who had multiple diagnoses including diabetes and ovarian cancer, discharged herself from hospice due to restrictions on visiting her own physician. The facility did not reassess her condition following this significant change, as required by the RAI manual.
The facility failed to complete and transmit a Death in Facility MDS for a resident who passed away, due to the absence of a permanent MDS Coordinator and reliance on remote staff. The oversight led to the resident's assessment not being recorded in the EMR within the required timeframe.
The facility failed to ensure that a resident's Death in Facility assessment accurately reflected her date of death. The resident had severe cognitive impairments and multiple medical conditions. The Regional MDS RN acknowledged the need to review the resident's EMR to determine if a corrected or modified Death in Facility MDS was necessary.
A resident with COPD and other health issues was transported to a doctor's appointment without a portable oxygen tank, despite being on continuous oxygen therapy. Upon arrival, the resident's oxygen saturation was critically low, requiring immediate intervention. The facility's staff, including the ADON and the resident's nurse, acknowledged the oversight, which was due to a lack of communication and verification of the resident's needs before transport.
Improper Garbage and Refuse Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters reviewed. During observation, one green garbage dumpster was seen with its door open behind an open white and metal gate, with trash scattered on the ground in front of it. Two large blue plastic barrels were uncovered and contained tied clear plastic bags that appeared to hold linens. Nearby, there was a broken white PVC shower chair, and outside the gate there was a dilapidated red shed that was open in front, missing part of its roof, filled with what appeared to be water-damaged materials, and leaning to one side. A second dumpster, described as approximately 40 feet long, was observed filled to the brim with cardboard boxes piled behind it and in the grass behind it. A black wheelchair was folded in front of the dumpster, a stacked pile of wooden pallets was on the side, and there were white plastic bags, debris, and a gray and navy-blue mattress around it. The Administrator stated the waste management company had already come and was scheduled to return later in the week, could not recall the exact day, and did not know why the green dumpster door was open, why trash was on the ground, or why the blue barrels were uncovered. The Maintenance Director said the gate should have been closed, the barrels should have been covered or emptied, and the trash area needed to be kept clean. Record review showed the haul-off dumpster was last serviced on 06/01/2026, and the facility stated it did not have an official waste management policy.
Failure to Notify Practitioner and Representative of Resident’s Refusals and Enteral Feeding Needs
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s practitioner and resident representative of significant changes in condition and treatment needs, including persistent refusals of medications, nutritional supplements, and meals, as well as issues related to swallowing and enteral feeding. A female resident with Wernicke’s encephalopathy, carotid aneurysm, dysphagia, and anorexia was admitted with a PEG tube placed in the hospital for long‑term nutrition, hydration, and medication administration. Her hospital discharge summary specified that pureed food was for comfort only and not sufficient for nutrition, and that she should otherwise remain NPO with PEG feeding. However, the facility’s admission documentation did not include an active diagnosis for a gastrostomy tube on the MDS, and an undated, unsigned note in the EMR referenced PEG use and Jevity via NG tube, even though the NG tube had been removed and replaced with a PEG. Physician orders in the facility record included a regular pureed diet “for pleasure food,” an enteral feed order every shift with water flushes, and an oral Ensure Plus supplement three times daily. The MAR showed that the resident refused all three scheduled Ensure doses on multiple days, had no documentation of administration on several days, and was noted as nauseated/vomiting or asleep on others. During surveyor observation, the resident was found seated alone in front of an uncovered, uneaten pureed breakfast tray, stating she was hungry and needed help to eat but no one had assisted her. In a later interview, she reported that staff only flushed her PEG tube with water and that she had not received medications or feeding formula through the tube since admission. She also described difficulty with food sometimes feeling like it got stuck, dislike of the pureed food’s appearance and taste, and selective eating based on her preferences. Interviews with staff revealed that the resident’s refusals and swallowing difficulties were not promptly or consistently communicated to the NP/MD or to facility leadership. RN A stated he had notified the NP at some point that there was no enteral feeding formula order but could not recall when or where it was documented, and he only learned on the survey date that the resident had been refusing Ensure. He acknowledged that refusals of medications and nutritional supplements would be considered a change in condition that should be reported immediately, but he had not reported them, assuming others had done so and indicating he had not been clearly trained on reporting expectations. Medication aides reported that the resident had not been taking medications or Ensure since admission due to inability to swallow, that they tried various methods (crushing meds in pudding, jelly, applesauce) without success, and that they verbally and via handwritten notes informed charge nurses of ongoing refusals, but were unsure whether this was documented in the EMR or escalated further. The DON stated she was unaware that the resident had no enteral feeding formula order, was refusing medications, supplements, and meals, and attributed missed order verification and change‑in‑condition follow‑up to workload and role strain. The resident’s representative reported finding the resident multiple times in front of untouched meal trays without staff assistance and stated they had not been informed of the resident’s medication and supplement refusals. The NP and MD both confirmed they had not been notified of the resident’s refusals or lack of enteral feeding orders and indicated these issues constituted changes in condition that should have been reported. These failures led surveyors to identify an Immediate Jeopardy related to the lack of timely notification and consultation when there was a need to alter treatment significantly.
Failure to Provide Ordered PEG Nutrition, Monitor Weight Loss, and Assist With Feeding
Penalty
Summary
The deficiency involves the facility’s failure to maintain acceptable nutritional status and follow physician and hospital discharge orders for a cognitively intact female resident with Wernicke’s encephalopathy, aneurysm, dysphagia, anorexia, and a newly placed PEG tube. On admission from the hospital, her discharge summary specified a regular diet with pureed texture for comfort only, explicitly stating that this oral intake was not sufficient for nutrition and that she had a PEG and should otherwise remain NPO. Despite this, the facility did not have an active, specific enteral feeding formula order in place for her PEG tube from admission through the date of the state survey entrance, and there was no active diagnosis for a gastrostomy tube documented on her admission MDS. An undated, unsigned handwritten note in the EMR referenced PEG use and Jevity 1.5 via NG tube, but this was not translated into a clear, implemented PEG feeding order. Instead of initiating PEG feedings, the facility obtained an order several days after admission for Ensure Plus PO TID and continued a regular pureed diet for “pleasure food.” Medication administration records showed that the resident refused all three daily Ensure doses on multiple days, had days with no documentation at all, and on some days was noted as nauseated, vomiting, or asleep at the time of administration. Nursing staff, including medication aides, reported that the resident had not really been taking her Ensure since admission because she could not swallow and that she regularly refused medications and supplements. The NP and MD both stated they were not notified of the resident’s refusals, lack of enteral feeding orders, or any significant weight loss, and believed she was tolerating a pureed diet based on information from facility staff. The resident herself reported that while in the hospital she had received a milk-like formula through a tube, that the tube was later placed directly into her stomach, and that since admission to the facility she only received water through the tube and no medications or feeding formulas. The facility also failed to obtain and monitor weekly weights as ordered and per policy. The only documented weight after admission was 120 lbs recorded seven days post-admission, which the DON later crossed out as inaccurate without knowing the resident’s true admission or current weight. A subsequent weight entry showed 96.5 lbs, reflecting a 23.5 lb loss and a 19% weight reduction in 12 days, but this significant change was not reported to the NP or MD. The DON acknowledged that weekly weights had not been done due to changes and inconsistency among CNAs and that she did not know who was responsible for obtaining weights. A CNA reported having no formal training on how to weigh residents and was unable to obtain an accurate weight for the resident due to lack of wheelchair tare weight and the resident’s refusal to transfer. Additionally, the resident’s risk of impaired nutrition related to her PEG tube and therapeutic diet orders was not addressed in a timely manner, and dietary recommendations were not in place from admission until the surveyor’s entrance. Direct observation by the surveyor further demonstrated failures in providing adequate assistance with meals. On the survey date, the resident was observed seated alone in a wheelchair with an uncovered, uneaten pureed breakfast tray in front of her; she stated she was hungry and needed help eating, but no staff had assisted her. The DON and RN assigned to her were initially unaware that she had not eaten. A receptionist, not clinical staff, ultimately reheated the tray and offered to assist before the RN took over. The resident’s representative reported having found her on at least two separate occasions in front of untouched meal trays without staff assistance and stated that when they raised concerns, an RN responded that the resident needed to learn to use her left hand to feed herself despite her right-sided weakness and prior right-hand dominance. These combined inactions and failures to follow orders, monitor intake and weight, and provide necessary feeding assistance led to the identified deficiency and were determined by surveyors to constitute Immediate Jeopardy until corrected.
Failure to Accurately Code Gastrostomy Tube Status on Admission MDS
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s admission MDS assessment accurately reflected her gastrostomy tube status. The resident, an adult female admitted with diagnoses including Wernicke’s encephalopathy, carotid artery aneurysm, dysphagia, and anorexia, had a PEG tube placed in the hospital and was ordered to remain NPO except for pureed food for comfort, which was not sufficient for nutrition. Despite this, her admission MDS dated 03/30/2026 did not include an active diagnosis for gastrostomy tube status in Section I, and Section K coded her as having a swallowing disorder with a mechanically altered diet, without reflecting her PEG-dependent nutritional status. Record review showed hospital discharge orders specifying a regular diet with pureed texture for comfort only and that the resident had a PEG and should remain NPO otherwise. The facility’s physician orders included a pureed diet for pleasure food and an enteral feed order with scheduled water flushes through the enteral tube every shift, indicating that the PEG tube was in use for hydration and enteral care. However, the resident’s diagnosis list in the EMR did not include gastrostomy status at the time of the admission MDS, and this omission carried through to the MDS coding, which failed to capture the presence of the gastrostomy tube. During observation, the resident was seen seated in a wheelchair with a breakfast tray containing pureed foods and liquids, stating she needed help eating and that no one had assisted her. In a subsequent interview in her room, she reported having had a tube placed in her stomach in the hospital and stated that staff pushed water through the tube daily but did not administer medications or feeding formulas through it. Interviews with the DON and the MDS nurse confirmed that the admitting nurse was responsible for entering diagnoses, that the MDS nurse was responsible for ensuring accurate diagnoses and coding, and that the resident should have had a diagnosis for gastrostomy status. The MDS nurse acknowledged that the omission of the gastrostomy diagnosis and failure to code the gastrostomy tube on the admission MDS was an oversight, despite using the RAI manual as guidance for accurate completion of the MDS.
Failure to Develop and Implement Care Plan for G-Tube and Diet Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s gastrostomy tube status and diet, despite these needs being identified in admission and hospital records. The resident, an adult female admitted with diagnoses including Wernicke’s encephalopathy, aneurysm, dysphagia, and anorexia, had a PEG tube placed in the hospital and was ordered to remain NPO except for pureed food for comfort, which was not sufficient for nutrition. Her admission MDS showed intact cognition (BIMS 14), a swallowing disorder, and a mechanically altered diet, but did not list an active diagnosis for a gastrostomy tube. The physician orders included a regular pureed diet for pleasure and an enteral feed order with scheduled water flushes, yet there was no corresponding care plan for the gastrostomy tube, diet, or enteral feeding status upon admission. When the comprehensive care plan was reviewed, it contained an entry dated after admission stating that the resident had a G-tube related to oropharyngeal dysphagia and severe protein-calorie malnutrition, was receiving a puree diet for pleasure feeds with refusals to eat at times, and was NPO for her main source of nutrition. Another entry documented that she was receiving a mechanically altered diet due to oropharyngeal dysphagia. However, interviews and record review established that there had been no care plan specifically addressing the gastrostomy tube status, diet, or enteral feeding at the time they should have been initiated, and that these elements were only added after the state surveyor began asking questions. The facility’s own policy required a comprehensive, person-centered care plan with measurable objectives and timeframes to be developed and implemented for each resident within specified time limits after admission and MDS completion. During observation, the resident was seen seated in a wheelchair with a breakfast tray containing pureed foods and liquids; she stated that she needed help eating and that no one had come to assist her. Later, in her room, she reported having had no appetite for about a month, confirmed that she had a tube placed in her stomach in the hospital, and stated that staff pushed water through the tube daily but did not administer medications or feeding formulas through it. The DON, Administrator, and MDS nurse each acknowledged in interviews that the resident should have had care plans for her gastrostomy tube status and diet from admission, that the admitting nurse was responsible for initiating care plans, and that the MDS nurse was responsible for comprehensive care plans. They also acknowledged that the absence of a comprehensive person-centered care plan could result in a resident not receiving appropriate care, and that recent ownership and staff changes had disrupted IDT meetings and care plan reviews.
Failure to Submit Required Investigation Results to State Agency Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to report the results of abuse/neglect/theft-related investigations to the State Survey Agency within five working days as required by state law and facility policy for two separate incidents involving two residents. Record review of the TULIP system on 03/31/2026 showed that a Provider Investigation Report (PIR), Form 3613-A, was not filed in the system for two incidents that had been reported by the facility to Complaint and Incident Intake on 03/18/2026. The facility’s written policy, “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating- F609,” revised in September 2022, states that within five calendar days of the incident, the administrator will provide a follow-up investigation report, but this did not occur for the two incidents. Interviews with multiple staff members revealed that no one currently in the building had submitted or could locate the required PIRs, and that responsibility for PIRs had been handled solely by the former administrator. The Director of Operations reported that his team was trying to locate the PIRs and that the former administrator may have shredded them. The new Administrator, whose first day was 04/01/2026 and who did not yet have access to TULIP, stated she was unaware of incomplete investigations pending a provider investigation and that there was no process in place to locate pending investigations during the facility’s recent change of ownership. The DON stated she did not have access to TULIP and was not responsible for PIRs, and other staff, including the Regional NHA, Social Worker, and RNs, each stated they were not responsible for submitting PIRs and did not have access or assistance from the former administrator. As a result of these actions and inactions, the required follow-up investigation reports for the two incidents were not submitted to the State Survey Agency within the mandated timeframe.
Inadequate Nursing Competency and Medication Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff had appropriate competencies and skills to manage controlled and other high‑risk medications for multiple residents. For one male resident with convulsions, hypertension, traumatic brain injury, severely impaired cognition, and extensive to total ADL needs, surveyors found a discrepancy between the control count sheet and the actual volume of Lacosamide oral solution on the medication cart. The control sheet documented 480 mL, while two bottles on the cart contained a total of 510 mL (one unopened 400 mL bottle and one 110 mL bottle). The RN responsible for the cart stated she did not know what to do about the discrepancy, suggested it might be a documentation or measurement error, reported she had not received any skill check‑off on medication administration or control counts since starting three weeks earlier, and did not respond when asked what could have happened if the resident did not receive the prescribed seizure medication dose. A second male resident with dementia, hypertension, diabetes, moderately impaired cognition, and supervision to partial assistance with ADLs had an active care plan for pain management and an order for PRN tramadol. During a controlled substance count on the same medication cart, surveyors observed that one tramadol blister in the resident’s card had a punched seal with the tablet half exposed. The RN stated the seal was punched and she did not know what to do, and also reported she had not received training on medication administration or control counts. The DON later stated that if a tramadol blister pack seal was broken, the nurse should waste the medication with another nurse and sign the control sheet, and that if the medication in the opened blister was not taken out and destroyed, it could have gone missing and would have been reportable for drug diversion. A third female resident with obesity, hypertension, diabetes, intact cognition, and independence to supervision with ADLs had a care plan for pain medication therapy and an order for PRN acetaminophen‑codeine. Review of the control count sheet showed 16 tablets documented, but surveyors found only 15 tablets in the blister pack on a different medication cart. The LVN assigned to that cart stated she had administered one tablet earlier that afternoon and forgot to sign it out on the control sheet or the MAR, and when asked when she should have signed the control book and MAR, she shrugged her shoulders. She reported having no medication administration training since starting three weeks earlier, aside from three days of floor orientation. The DON acknowledged that the LVN should have signed out the medication immediately when it was pulled and administered, and also stated that comprehensive nursing training had not been completed due to ongoing staffing needs, despite the facility’s written policy requiring nursing leadership to establish and monitor competency requirements and training for nursing staff.
Medication Control, Documentation, and Packaging Failures in Pharmacy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, administering, and accounting of medications for multiple residents. For one resident with convulsions, hypertension, and traumatic brain injury, the control count sheet for Lacosamide oral solution (10 mg/mL, 20 mL via G-tube twice daily) documented 480 mL, while two bottles on the medication cart contained a total of 510 mL (one unopened 400 mL bottle and one 110 mL bottle). The RN conducting the count identified the discrepancy but stated she did not know what to do, suggested it might be a documentation or measurement error, and reported she had not received any skill check-off on medication administration or controlled drug counts since starting work three weeks earlier. The resident’s quarterly MDS showed severely impaired cognition and extensive to total assistance needs, and the resident had no current care plan after the prior plan was canceled. For a second resident with dementia, hypertension, and diabetes mellitus, who had a care plan identifying risk for pain and an order for tramadol 50 mg by mouth every six hours as needed for pain, surveyors observed that one tramadol blister pack on the medication cart had a punched-open seal with the tablet half exposed. The RN present stated she did not know what to do about the partially opened blister and reported she had not received training on medication administration or controlled drug counts. The DON later stated that if a tramadol blister pack seal was broken, the medication should be wasted with another nurse and documented on the control sheet, and also stated they were not sure if the medication in the opened blister was the original medication and that if not destroyed, the medication could come up missing and would be reportable for drug diversion. For a third resident with obesity, hypertension, and diabetes mellitus, who had intact cognition and a care plan for pain management with analgesic medications, the order summary showed acetaminophen-codeine 300-30 mg, one tablet by mouth every four hours as needed for pain. The control count sheet for this controlled medication showed 16 tablets, but the blister pack contained only 15 tablets. The LVN stated she had administered one tablet at 1:30 p.m. and forgot to sign it out on the control sheet or the MAR, and when asked when she should sign the control book and MAR, she shrugged her shoulders and reported she had not had any training on medication administration since starting at the facility, aside from three days of floor orientation. The facility’s written policy required the individual administering medication to initial the MAR after giving each medication and before administering the next one, and the surveyor’s request for a drug diversion policy was not fulfilled. The DON acknowledged that if controlled medications are not signed out when pulled, it would look like drug diversion and stated she had not had time for comprehensive nursing training while covering multiple roles.
Cancelled Care Plan Leaves Resident Without Comprehensive Person-Centered Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical and cognitive needs. The resident was an adult male with diagnoses including convulsions, hypertension, and traumatic brain injury, and a Quarterly MDS showed a BIMS score of 3/15, indicating severely impaired cognition, with extensive to total assistance required for ADLs. Record review showed that this resident’s care plan was cancelled on 01/19/26, leaving him with no current care plan in place. The MDS Coordinator reported that she did not cancel the care plan and stated it had been cancelled by her supervisor, the MDS Supervisor, and that she was unaware it had been cancelled until the surveyor requested the care plan. The MDS Coordinator stated that care plans were reviewed quarterly in conjunction with MDS completion and acknowledged she had completed the quarterly MDS earlier in the month but had not reviewed the care plan. She did not provide an explanation of how care would be provided without a care plan. The surveyor was unable to reach the MDS Supervisor by telephone. In an interview, the DON stated that care plans were the responsibility of the MDS Coordinator and that she did not know why the care plan had been cancelled, while acknowledging that the care plan was used to provide care for residents and that its absence could have affected this resident’s care. The Administrator similarly stated that the resident should have had a current care plan and that it was used to communicate with providers and nursing staff. The DON also reported that the facility did not have a care plan policy and followed the RAI manual, and that every resident should have had a care plan updated quarterly.
Improper Handling of Prefilled Morphine Syringes Breaches Infection Control
Penalty
Summary
The deficiency involves a failure to maintain an infection prevention and control program when handling a resident’s prefilled morphine syringes. The resident was an elderly female with diabetes mellitus, hypertension, and a history of cerebral infarction, with a BIMS score of 8/15 indicating severely impaired cognition, requiring extensive to total assistance with ADLs, and on hospice care with a terminal prognosis related to CVA. Her care plan included close observation for pain and administration of pain medication as ordered, and her orders included PRN oral morphine sulfate concentrate. During observation of the medication cart, an LVN was counting the resident’s prefilled morphine syringes when one syringe fell to the floor. The LVN picked up the fallen syringe and placed it back with the other nine syringes instead of wiping or destroying it, thereby contaminating the remaining syringes. In interview, the LVN acknowledged the syringe that fell became contaminated and that she should have wasted it with another nurse. The DON stated the syringe that fell should have been wasted and that placing it back with the others contaminated all of them, identifying this as an infection control issue. The facility’s medication administration policy required staff to follow established infection control procedures, and when the infection control policy was requested from the administrator, it was not provided upon exit.
Facility Assessment Lacks Staffing Level Information
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included information regarding the level of staff needed to meet the needs of each resident during both day-to-day operations and emergencies. Record review of the facility assessment dated 4/30/25 revealed that it did not contain details about staffing levels required to provide competent care for residents. The facility's policy states that the assessment should inform staffing decisions and consider staffing needs for each shift, but this was not reflected in the actual assessment document. During an interview, the Administrator acknowledged uncertainty about whether the facility assessment included staffing level information and confirmed that the assessment was not used when creating the nursing staff schedule. Instead, staffing decisions were based on the facility's PPD (per patient day) and census, with a CNA-to-resident ratio of 1:15. The Administrator also referenced the facility's star rating and national staffing averages but did not indicate that individual resident needs or the facility assessment were used to determine staffing levels.
Insufficient Nursing Staff Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple incidents involving three residents. One resident, who was legally blind, had dementia, and was dependent on staff for personal and toileting hygiene, was found by a family member in the evening with her hair, gown, and bed soaked in urine, and her room had a strong odor. Documentation showed that incontinent care was only provided once earlier in the day, and staff assignments indicated fewer CNAs present than scheduled. Interviews with staff could not clarify the care provided during the shift in question. Another resident, who had hemiplegia, hemiparesis, and required a two-person assist with a mechanical lift for transfers, reported that he was unable to get out of bed for 24 hours due to insufficient staff. Staffing records confirmed that fewer CNAs were present than scheduled, and a nurse was working as a CNA. The resident stated that delays in getting out of bed occurred when the facility was short-staffed, and a CNA confirmed that staffing ratios made it difficult to meet residents' preferences for getting up. A third resident, who was dependent on staff for transfers and toileting hygiene, reported waiting more than two hours for assistance with incontinent care during the evening shift, leading him to remove his own brief to prevent skin breakdown. Resident council records and staff interviews indicated ongoing concerns about insufficient staff, particularly at night, with residents reporting infrequent care and long wait times. The facility's assessment did not include information on the level of staff needed to meet each resident's needs, and scheduling was based primarily on census and PPD, without clear consideration of resident acuity.
Failure to Secure Medication Carts and Store Drugs in Locked Compartments
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments as required, as observed during medication storage inspections of four out of six medication carts. On multiple occasions, medication carts were found unattended and unlocked, with residents, visitors, and staff in close proximity. Specifically, Medication Cart #1 was left unlocked on hall 100 while the assigned nurse was on break, and the ADON confirmed that the cart should have been locked at all times when unattended. The nurse responsible for the cart acknowledged the oversight and stated that the cart contained various prescription and over-the-counter medications, including PRNs, insulin, blood pressure medications, pain and anxiety medications, antiepileptics, and OTC drugs. Although narcotics were said to be locked, the nurse admitted that they should have been secured under two locks, not one. Further observations revealed that Medication Carts #2, #3, and #4 were also left unlocked and unattended, with the keys placed on top of each cart and visible to anyone nearby. These carts contained a range of prescription medications, including heart, depression, diuretic, antinausea, diabetes, inhalation, anti-yeast, and OTC medications, as well as narcotics. At another time, Medication Cart #1 was again found unlocked, with several drawers open and no staff in sight. The cart contained a laptop, a cell phone, and keys hidden under the phone, along with a variety of prescription and OTC medications, insulin syringes, and lancets. Interviews with nursing staff and the acting DON confirmed that facility policy required medication carts to be locked at all times when unattended or out of direct sight of nurses. Staff acknowledged responsibility for ensuring the carts were secured and recognized that the failure to do so could result in medications being accessed by unauthorized individuals. The acting DON stated that the nurses had not followed the facility's medication storage policy, which mandates that all medications and biologicals be stored in locked compartments, with controlled substances separately locked.
Failure to Develop and Implement Person-Centered Care Plan for Tube Feeding
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed all identified needs for a resident with complex medical conditions. Specifically, the care plan did not include the resident's requirement for G-J tube feeding with small amounts of pureed textured snacks for pleasure, to be administered under the supervision of a Speech-Language Pathologist (SLP) or a trained caregiver. This omission was identified despite the resident's comprehensive assessment and physician orders clearly indicating the need for such interventions. The care plan also did not reflect the resident's G-J tube status or the specific feeding protocols outlined in the hospital discharge summary and physician orders. The resident in question was an elderly female with multiple diagnoses, including gastronomy status, dyskinesia of the esophagus, dysphagia (pharyngeal phase), metabolic encephalopathy, and acute pulmonary edema. Her admission Minimum Data Set (MDS) assessment indicated severe cognitive impairment and that eating was not attempted due to medical or safety concerns. Although the Care Area Assessment (CAA) triggered the need for care planning related to feeding tube care, the actual care plan failed to address the resident's specific nutritional and feeding needs as documented in her medical records and physician orders.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the rooms of two residents. One resident, a female with cerebral palsy, congenital ear malformation, and a mood disorder, was found by a nurse to have roaches crawling on her bedroom floor, bed, and wheelchair while she was sitting in her wheelchair. The nurse and a CNA observed roaches on the blanket the resident was sitting on and on her wheelchair, prompting them to remove her from the room for cleaning. The resident's care plan indicated she was dependent on staff for meeting her needs and had communication difficulties due to a hearing deficit and unclear speech. Progress notes and staff interviews confirmed repeated sightings of roaches in her room, with food crumbs frequently found on the floor and bed, and the resident often refusing to allow staff to remove her meal trays. Another resident was observed to have a small live roach on the floor near the doorway of his bedroom. During interviews, housekeeping staff confirmed the presence of roaches and stated that despite regular spraying, the pests continued to return. The Director of Maintenance reported treating the affected room on several occasions and consistently finding German roaches, especially when moving furniture and checking outlets. Pest control invoices and records showed that the facility had pest control services performed monthly and additional treatments were requested for the affected rooms, but the problem persisted, particularly in the room of the first resident. Staff interviews revealed that the pest control measures in place were not effective in eliminating the infestation, especially in rooms where food was present and not promptly removed. The ongoing presence of roaches was documented through observations, staff reports, and pest control invoices, indicating a failure to ensure the facility was free of pests and rodents as required.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to accurately assess the status of three residents during the Minimum Data Set (MDS) process, resulting in incorrect documentation of their conditions. For one resident with a history of hemiplegia, chronic kidney disease, and above-the-knee amputation, the MDS incorrectly coded the use of bed grab bars as restraints, despite observations and interviews confirming the bars were used to assist with bed mobility and did not restrict movement. The care plan also indicated the grab bars were for safe repositioning, and staff confirmed the coding was inaccurate. Another resident with schizoaffective disorder, hypertension, and a history of traumatic brain injury was incorrectly documented on the MDS as having an indwelling catheter. Progress notes and staff interviews revealed the resident had removed the catheter prior to the assessment and refused reinsertion, with no physician order for a catheter present at the time of the MDS. Observations confirmed the absence of a catheter or drainage bag, and staff familiar with the resident's care verified he did not have a catheter during the assessment period. A third resident, admitted with diagnoses including intracranial hemorrhage, chronic kidney disease, and urinary retention, was assessed on the admission MDS as having a catheter, although observations and staff interviews confirmed she did not have one upon return from the hospital. Documentation showed the catheter had been discontinued prior to readmission, and no evidence of a catheter was found during the assessment. The MDS coordinator relied on nurse documentation and resident observation but failed to accurately reflect the resident's current status.
Failure to Develop and Implement Comprehensive Care Plans for Indwelling Catheter and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the management of an indwelling urinary catheter and oxygen therapy. For one male resident with multiple diagnoses, including metabolic encephalopathy, peripheral vascular disease, osteoporosis, atrial fibrillation, and acute urinary retention, there was no care plan addressing his indwelling urinary catheter following a recent hospitalization and procedure. Despite clear documentation in hospital records, physician orders, and nursing notes regarding the presence and management of the catheter, the resident's care plan did not include this information at the time of review. Interviews with facility staff confirmed the absence of a care plan for the catheter, and staff acknowledged that such a plan was necessary to guide care. Another female resident with complex medical needs, including a tracheostomy, chronic kidney disease, pressure ulcer, hypertension, encephalopathy, urinary retention, gastrostomy, muscle weakness, dysphagia, diabetes, chronic pain, and chronic respiratory failure, was also found to have an incomplete care plan. Although physician orders and the Minimum Data Set (MDS) assessment indicated that she was receiving continuous oxygen therapy via tracheostomy, her care plan did not address this intervention. Observations confirmed the resident was on oxygen, and staff interviews revealed awareness of her oxygen use but also acknowledged the lack of a corresponding care plan. The facility's policy requires the interdisciplinary team to develop comprehensive, person-centered care plans based on resident assessments. In both cases, the care plans failed to include measurable objectives and time frames for the identified needs, specifically the indwelling urinary catheter and oxygen therapy. This omission was confirmed through record review, staff interviews, and direct observation, demonstrating a failure to ensure that care plans accurately reflected the residents' current conditions and required interventions.
Failure to Notify Physician of Positive THC Test After Hospitalization
Penalty
Summary
The facility failed to notify a resident's physician following a significant change in condition, specifically after the resident tested positive for THC at the hospital. The resident, an adult female with a history of lumbar fracture, paraplegia, asthma, and COPD, was sent to the hospital for altered mental status. Hospital records indicated a positive THC drug screen and a diagnosis of THC overdose, with additional documentation of a history of marijuana use. The resident did not have a physician order for THC, and her care plan did not address substance abuse. Interviews with facility staff revealed that while some staff were aware of the resident's altered mental status and suspected drug ingestion, there was no evidence that the physician was notified of the positive THC result. The DON at the time was not employed during the incident, and the Interim DON stated she was not verbally notified by the hospital nor did she review the hospital report. The admissions nurse was identified as responsible for reviewing hospital records, but there was no confirmation that this occurred. Nursing staff reported inconsistent access to hospital discharge paperwork, and the physician confirmed she was not made aware of the positive drug test. Facility policy required timely communication of significant changes in resident status to the medical staff, including pertinent information from recent hospitalizations. Despite this, the positive drug test and related hospital findings were not communicated to the resident's physician, resulting in a failure to ensure the physician was informed of a significant clinical change.
Failure to Revise Care Plans After Positive Drug Screens
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents after significant changes in their condition were identified. Both residents were sent to the hospital for altered mental status and subsequently tested positive for substances not prescribed to them. Despite these findings, neither resident had their care plan updated to address substance abuse or the new information from their hospitalizations. One resident, a male with hepatic encephalopathy, alcohol cirrhosis, and other significant diagnoses, was admitted with moderate cognitive impairment. He was sent to the hospital for altered mental status, where a urine drug screen was positive for benzodiazepines and THC, neither of which were prescribed. The care plan did not reflect any interventions or monitoring related to substance abuse, and staff interviews confirmed that this information was not incorporated into his care planning. The second resident, a female with paraplegia and chronic respiratory conditions, was also sent to the hospital for altered mental status. Hospital records indicated a THC overdose, with a positive urine drug screen for THC. Like the first resident, her care plan did not address substance use, and staff interviews revealed that the hospital report was not reviewed or acted upon in terms of care planning. The lack of care plan revision was acknowledged by facility leadership and nursing staff.
Medication Errors in Blood Pressure Management
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. For one resident, the facility did not hold the medication Midodrine as ordered by the physician when the resident's systolic blood pressure (SBP) was above 100. Despite the blood pressure reading being 145/88, the medication was administered, contrary to the physician's instructions. This oversight was acknowledged by the medication aide, who admitted to overlooking the order and recognized the potential for adverse effects on the resident's health. Another resident was affected by the improper administration of blood pressure medications, Toprol X and Spironolactone. These medications were given even when the resident's blood pressure readings were within the parameters that required the medications to be held. Specifically, the medications were administered when the diastolic blood pressure (DBP) was 58 and the SBP was 105, both of which were below the threshold for administration. The medication aide admitted to possibly overlooking the parameters and acknowledged the potential consequences of such errors. The facility's policy on pharmacy services emphasizes the accurate and safe administration of medications, yet these incidents highlight a failure to adhere to physician orders and established protocols. The Assistant Director of Nursing (ADON) confirmed the expectations for staff to follow physician orders and acknowledged the incomplete documentation in the blood pressure log. The ADON also recognized the potential risks associated with these medication errors, including the possibility of adverse health effects for the residents involved.
Deficient Medication Documentation and Administration
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in the documentation of medication administration for two residents. For Resident #1, the Medication Administration Record (MAR) for May 2024 did not consistently reflect whether the medication Midodrine was given or held, despite specific physician orders to hold the medication if systolic blood pressure (SBP) was above 100. Additionally, there was a lack of documentation in the blood pressure log for several dates, and no explanation was provided in the nurse's notes for why blood pressure readings were not recorded or why the medication was not held when required. Resident #2's MAR also showed discrepancies in medication administration. The medications Spironolactone and Toprol X were administered on specific dates when the blood pressure readings indicated they should have been held according to physician orders. The nurse's notes lacked documentation explaining why these medications were given despite the blood pressure parameters indicating they should be held. This oversight in documentation and adherence to physician orders could potentially lead to adverse effects on the residents' health. Interviews with staff, including a medication aide and the Assistant Director of Nursing (ADON), revealed acknowledgment of the errors in medication administration and documentation. The medication aide admitted to possibly overlooking orders, which could result in incorrect medication administration, potentially causing residents' blood pressure to drop or rise inappropriately. The ADON confirmed that medications should not be given when blood pressure readings are within the parameters to hold them and emphasized the importance of documenting reasons for holding medications in the progress notes or MAR.
Failure to Notify Physician and Implement Orders for G-Tube Care
Penalty
Summary
The facility failed to immediately consult with the resident's physician regarding the dysfunction or malfunction of a gastrostomy tube (G-tube) for a resident. The resident had a diagnosis of Gastrostomy Status and Gastro-Esophageal Reflux Disease (GERD). The facility did not implement the physician's order for an abdominal binder to protect the G-tube and its site due to an inadequate supply. This failure resulted in the resident requiring discharge to the hospital for G-tube replacement. The facility also failed to notify the physician of complications related to the resident's G-tube site pain and the administration of medications via the G-tube. An LVN administered medications by forcefully pushing them into the G-tube instead of allowing them to flow by gravity, placing the resident at immediate risk for potential harms such as G-tube blockage and aspiration. The resident was observed not wearing the prescribed abdominal binder, and the G-tube site was found to be soiled and painful. Interviews with facility staff revealed a lack of awareness and communication regarding the physician's orders for the abdominal binder and the proper care of the G-tube. The staff did not routinely check the resident's orders each shift, and there was a failure to notify the physician of the complications and the inability to implement the prescribed abdominal binder. The facility's failure to follow physician orders and properly manage the resident's G-tube care led to significant complications and the need for hospital intervention.
Failure to Implement Physician's Orders and Proper G-Tube Care
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not implement the physician's order for an abdominal binder, which was indicated to prevent complications of the gastrostomy tube. This failure resulted in the resident requiring discharge to the hospital for G-Tube replacement. Additionally, the facility did not provide proper gastrostomy tube site care, leading to the resident experiencing pain and a visibly soiled dressing with dark red substance at the gastrostomy tube site. The resident was often seen pulling on the gastrostomy tube, and the staff was unaware of the abdominal binder order, which was not implemented due to the facility not having the proper size available. The facility also failed to use the proper technique and safety precautions for administering medications via the G-Tube. An LVN administered medications by plunger pushing them into the gastrostomy tube instead of administering to gravity, placing the resident at immediate risk for potential harms such as G-Tube blockage and aspiration. The LVN did not check the tube placement by auscultating for bowel sounds or visualizing the site to ensure the tube had not become dislodged or infected. The LVN also did not follow the physician's order to flush the feeding tube with water before and after administering medications. Furthermore, the facility did not notify the physician of the complications related to the G-Tube and the failure to implement the abdominal binder. The staff, including the DON and Administrator, were aware of the physician's order but did not take appropriate actions to ensure the resident received the necessary care. The facility's failure to implement the physician's orders and provide proper care placed the resident at immediate risk for complications, including infection and hospitalization. The facility's deficiencies were identified during a survey, and an Immediate Jeopardy was declared, indicating the severity of the situation.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate below 5 percent, resulting in a 16 percent error rate. This was observed during a medication administration pass involving one resident and one LVN. The LVN administered the wrong dose of Lactulose and flushed the resident's g-tube with an incorrect volume of water. Additionally, the LVN did not elevate the resident's head during medication administration, increasing the risk of aspiration. These actions were not in accordance with the physician's orders and the facility's policy for administering medications through an enteral tube. The resident involved had a diagnosis of Gastrostomy Status and Gastro-Esophageal Reflux Disease (GERD) and required an abdominal feeding tube. The resident's care plan specified the need for proper g-tube care, including checking tube placement and flushing with the correct volume of water. However, the LVN failed to follow these protocols, leading to the resident experiencing pain and discomfort during the medication administration process. Interviews with the LVN and the DON revealed that the LVN had been trained but did not follow the correct procedures for g-tube medication administration. The LVN admitted to pushing medications with force instead of using gravity flow and did not report complications related to the g-tube. The DON confirmed that the head of the bed should have been elevated and that pushing medications with force could cause harm to the resident. The facility's policy and training records were reviewed, and it was noted that additional training would be provided to address these deficiencies.
Failure to Employ a Full-Time Social Worker
Penalty
Summary
The facility, licensed for 150 beds, failed to employ a qualified full-time social worker despite having a capacity of more than 120 beds. The facility had been without a social worker for four months since the last social worker's employment ended on 11/23/23. The job description for the social worker position required a high school diploma or a bachelor's degree in social work along with an LCSW or LMSW. Despite job postings from 1/18/24 to 3/28/24 and a reposting from 3/11/24 to 4/10/24, the position remained vacant. The HR representative confirmed that an LVN was placed as acting social services in the interim. The Administrator, who joined on 1/16/24, acknowledged the vacancy and stated that several interviews had been conducted, but the candidates were not licensed. The Administrator also mentioned that they were waiting for corporate approval to have a social worker from a sister facility assist for 2-3 days. During a resident council meeting, four residents confirmed that the facility had not had a social worker for the last five months and that a nurse was acting in that capacity. The residents expressed confusion over the delay in hiring a qualified social worker.
Failure to Conduct Comprehensive Assessments
Penalty
Summary
The facility failed to conduct a comprehensive, accurate, and standardized assessment of Resident #27's functional capacity upon admission and periodically thereafter. Specifically, the facility did not assess the resident for hospice care and the lack of natural teeth in her oral cavity. Resident #27, a female with multiple diagnoses including diabetes, ovarian cancer, and major depressive disorder, was admitted on hospice with a DNR status. However, her Admission MDS did not reflect her hospice status, and her oral/dental status was marked as unable to examine. The resident later discharged herself from hospice services and reported issues with her dentures, which were not addressed by the facility in a timely manner. Interviews with staff revealed that the facility had been without a full-time MDS coordinator for some time, and the newly hired MDS coordinator was still in training. The Regional MDS Coordinator and a remote MDS coordinator had been assisting with assessments, but there were gaps in the documentation and follow-up. The resident's care plan did not reflect her current needs, and there was no significant change MDS assessment completed. The facility's policy on MDS accuracy was not specific, and the staff relied on the RAI manual. This lack of comprehensive assessment and follow-up could lead to unmet medical needs for the residents.
Failure to Update MDS Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to conduct a comprehensive, accurate, standardized, and reproducible assessment of Resident #27's functional capacity within 14 days after a significant change in the resident's condition. Specifically, the facility did not update Resident #27's MDS assessment within 14 days of the resident being discharged from hospice care. This oversight was identified through observation, interview, and record review. Resident #27, a female with multiple diagnoses including diabetes, ovarian cancer, major depressive disorder, and mobility issues, had a care plan indicating she was on hospice for a terminal prognosis. However, she discharged herself from hospice because the hospice company restricted her from visiting her own physician, and the facility did not reassess her condition following this significant change. Interviews with the MDS Coordinator and the Regional MDS Coordinator revealed that the resident should have been assessed for a significant change in status after being discharged from hospice. The Regional MDS Coordinator acknowledged the oversight and indicated that a modification would be made. The facility's policy on the accuracy of MDS assessments was requested but not provided, with the Administrator and Regional MDS Coordinator stating that the facility followed the RAI manual. According to the Long-Term Care Facility RAI Manual, a Significant Change in Status Assessment (SCSA) must be completed within 14 days from the determination date of the significant change in status, which was not done in this case.
Failure to Complete and Transmit Death in Facility MDS
Penalty
Summary
The facility failed to ensure resident assessments were completed within the required 7 to 14 days and transmitted to the CMS system for a resident who had passed away. Specifically, the facility did not complete a Death in Facility MDS for the resident, who had been admitted with diagnoses including dementia, drug-induced systemic lupus, hypertension, hyperlipidemia, and chronic hepatitis C. The resident expired at the facility, but no death in facility or discharge MDS was recorded in the electronic medical record (EMR) within the required timeframe. Interviews with the Regional MDS RN and MDS Coordinator B revealed that the facility had been without a permanent MDS Coordinator, and the assessments were being completed remotely. The Regional MDS RN, who was responsible for oversight, admitted that they did not know why the death in facility MDS had not been completed or initiated. MDS Coordinator B, who worked remotely, also did not know why the death in facility MDS was missed and depended on the information in the facility's EMR, which was found to be incorrect. The review of the resident's records confirmed that the Death in Facility MDS was not completed or transmitted within the required timeframe. The Regional MDS RN acknowledged that the assessment should have been completed within 14 days of the resident's death. The lack of a permanent MDS Coordinator and reliance on remote staff contributed to the oversight and failure to meet regulatory requirements for timely and accurate resident assessments.
Inaccurate Death in Facility Assessment
Penalty
Summary
The facility failed to ensure that a resident's Death in Facility assessment accurately reflected her date of death. The resident, an elderly female with severe cognitive impairments and multiple medical conditions including hyperlipidemia, dementia, dysphagia, peripheral vascular disease, and combined systolic and diastolic heart failure, was readmitted to the facility and later expired. The nursing clinical progress notes documented her death and the pronouncement by a hospice RN, but the Death in Facility MDS did not accurately reflect the date of death. The Regional MDS RN acknowledged that the MDS assessments were completed based on the census line provided by the facility and that there had not been an in-house, in-person MDS person at the facility. The Regional MDS RN indicated that they would need to review the resident's electronic medical record (EMR) to determine if a corrected or modified Death in Facility MDS was necessary. The facility's failure to ensure the accuracy of the resident's assessment could place residents at risk for inadequate care, services, and dignity in death.
Failure to Provide Continuous Oxygen During Resident Transport
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy. The resident, who had a history of Chronic Obstructive Pulmonary Disease (COPD) and other serious health conditions, was transported to a doctor's appointment without a portable oxygen tank. Upon arrival at the appointment, the resident's oxygen saturation level was critically low at 73%, and he experienced difficulty breathing. The clinic nurse had to administer oxygen to stabilize the resident's condition. Interviews and record reviews revealed that the resident was on continuous oxygen therapy as per physician orders, which required oxygen to be administered at 5L/min via nasal cannula. Despite this, the resident was transported without the necessary oxygen support. The Assistant Director of Nursing (ADON) and the resident's nurse, LVN A, acknowledged that the resident should have been transported with a portable oxygen tank, as he was oxygen-dependent. However, due to a lack of communication and oversight, the resident left the facility without the required oxygen support. The transporter, who was responsible for taking the resident to the appointment, assumed the resident was ready for transport and did not verify the need for a portable oxygen tank. The transporter stated that it was the nurse's responsibility to ensure all necessary items were provided before transport. The facility's administrator was unaware of the resident's continuous oxygen requirement and the oversight that led to the resident being transported without oxygen. This incident highlighted a significant lapse in the facility's procedures for ensuring residents receive necessary medical support during transport.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Galveston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Meridian | 5.7 mi | ★★★★★ | 0 | 0 |
| The Phoenix Post-acute | 10 mi | ★★★★★ | 4 | 0 |
| Harbor Point Skilled Nursing | 11.1 mi | ★★★★★ | 9 | 0 |
| The Shoal | 11.7 mi | ★★★★★ | 5 | 0 |
| Seabreeze Nursing And Rehabilitation | 12 mi | ★★★★★ | 8 | 0 |
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