Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Estates Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was administered Alprazolam for anxiety without prior consent from the responsible party, despite clear orders and facility policy requiring notification and consent before administration. Staff interviews and record review confirmed that the responsible party was not informed of the risks or side effects, and the medication was given before the consent form was signed.
A resident with multiple diagnoses, including Schizophrenia, did not have all relevant conditions and medications accurately coded on the MDS assessment. The MDS omitted the psychiatric diagnosis, use of a lidocaine patch for pain, and recent antibiotic administration, despite documentation in the medical record and MAR. The MDS Nurse acknowledged these omissions and confirmed that the required look-back periods and coding procedures were not properly followed.
A resident admitted for hospice respite care with severe cognitive impairment had a hospice order requiring notification of her responsible party prior to administration of Alprazolam. This instruction was not transcribed into the resident's physician orders or MAR, resulting in the medication being administered without the required notification. Staff interviews confirmed the omission and acknowledged the importance of accurate order transcription.
The facility did not post the required daily nurse staffing information for two days, leaving an outdated staffing poster in the front lobby despite having scheduled nursing staff. Both the MA and DON, who were responsible for posting, acknowledged the lapse and confirmed the importance of this regulatory requirement.
Surveyors found loose medication pills in two medication carts, with four loose pills in one cart and one in another. LVNs confirmed the findings, and interviews with the ADON and Administrator indicated that medication carts are supposed to be checked daily and that all drugs should be stored in their original packaging, as per facility policy.
A beauty shop was found unlocked and unattended, containing hazardous bleach wipes, hair color products with safety warnings, and plastic razors, all accessible to residents, staff, and the public. The Regional Nurse confirmed these items should not have been accessible, and facility policy requires storage areas to be maintained safely.
A resident with multiple medical conditions was admitted without an accurate assessment of her dental status. The MDS assessment failed to document missing teeth or dental issues, despite physical signs and staff knowledge of her partial edentulism. The MDS LVN reported confusion during coding, resulting in an incorrect assessment.
Surveyors found that a container of shredded cheese and a case of breakfast sausage in the kitchen's reach-in cooler were not properly sealed, leaving both items exposed to air. The Dietary Manager confirmed that staff are responsible for ensuring food is properly sealed, and facility policy requires all food to be covered to prevent contamination.
A resident with severe cognitive impairment and a history of wandering was able to exit the facility undetected and was found outside near a busy road. The facility failed to complete a care plan addressing wandering risk, did not ensure consistent monitoring of exit doors, and did not document or report the elopement incident as required by policy. Staff interviews revealed lapses in supervision and unclear responsibilities for monitoring the front entrance.
A resident with severe cognitive impairment and a history of wandering was found missing, and facility staff failed to notify the resident's physician and representative as required. Staff interviews revealed confusion about notification responsibilities, and documentation did not show that appropriate notifications were made. The family was informed by hospice, not the facility, and the physician was not notified at all.
A resident admitted for respite care with multiple medical and psychiatric diagnoses did not have a baseline care plan developed or implemented within 48 hours of admission. Key sections of the admission documentation were left blank, and staff interviews revealed confusion about responsibility and procedures for care plan completion, resulting in incomplete care planning and documentation.
A medication cart was found unlocked and unattended in a main pathway near several residents in wheelchairs. The cart, assigned to a medication aide, was supposed to be locked according to facility policy. Staff interviews confirmed that medication carts must remain locked when not in use to prevent unauthorized access.
The facility failed to maintain a safe and comfortable environment due to inadequate heating, leaving residents in cold conditions. The heating issues were known but not addressed, resulting in indoor temperatures as low as 51°F. Residents wore multiple layers and used several blankets to keep warm, with some refusing showers and therapy due to the cold. Family members expressed concern, and one family removed their relative from the facility. The situation led to an Immediate Jeopardy designation.
The facility failed to report a malfunctioning heating system to the State Survey Agency within the required timeframe, leaving residents in cold conditions during low temperatures. Despite known issues with the heating system, including clogged lines and broken valves, the facility did not consider it a reportable incident. Residents and staff experienced discomfort, with room temperatures dropping significantly, yet the Administrator did not report the issue, believing it did not constitute a total outage.
A resident was left unattended in a sling attached to a mechanical lift, despite requiring assistance from two staff members for transfers. The resident, who was cognitively intact and had multiple diagnoses, reported being left in the sling for about 10 minutes, causing feelings of helplessness. The CNA involved had not received training on mechanical lifts from the facility, and the DON confirmed that leaving a resident unattended in a lift is a safety hazard.
A resident with multiple health issues experienced a significant change in condition, including pain, vomiting, diarrhea, and low oxygenation, but the facility failed to immediately notify the physician. The resident's condition deteriorated, leading to CPR and eventual death. The nurse on duty was new and lacked contact information for other staff, contributing to the delay in medical intervention.
A resident with a Full Code status was found unresponsive, and the LVN on duty failed to provide continuous CPR, stopping once to obtain an AED. The resident, who had a complex medical history, was admitted with conditions like encephalopathy and acute kidney failure. Despite having physician orders for CPR, the LVN's actions led to a lapse in emergency protocol, contributing to the resident's death.
A resident with a gastrostomy tube experienced a significant change in condition, including pain, decreased oxygenation, and multiple episodes of emesis, which were not appropriately recognized or responded to by the facility staff. The order for enteral feeding was incomplete, lacking details such as formula type, total volume, time of administration, or contraindications. Communication and procedural gaps, such as the LVN not knowing the phone numbers to other stations and using a personal phone to call the DON and 911, contributed to the deficiency.
The facility failed to comply with food safety standards, including not using beard restraints, improperly labeling refrigerated foods, and inadequate temperature monitoring. A staff member did not wear a beard guard, and refrigerated items lacked prepared and discard dates. Additionally, food temperatures were not consistently recorded, with one staff member failing to take temperatures for certain protein consistencies and another relying on refrigerator readings for cold items.
The facility failed to update care plans for four residents, leading to discrepancies in fall interventions and transfer methods. A resident's care plan lacked new fall interventions after major falls, while another's did not document transfer needs. Two residents' care plans inaccurately required a two-person Hoyer lift, despite staff using one-person transfers. These deficiencies could risk resident safety.
A resident with severe cognitive impairment and anxiety disorder was prescribed Citalopram Hydrobromide for depression without a documented diagnosis of depression. The facility's policy requires medication orders to include the clinical condition, but the resident's clinical record lacked this documentation. The DON noted the diagnosis was only in the doctor's notes, and the prescribing physician was on vacation.
A medication cart in a common area was found unlocked and unattended, containing prescription drugs and sharps. LVN A, responsible for the cart, was in a nearby room and unable to monitor it. The DON confirmed that carts should be locked when not in use, as per facility policy.
A resident with severe cognitive impairment and dietary needs did not receive a vegetable side during a lunch meal, contrary to the facility's menu. The RD and CDM were unable to identify the meal contents initially and later confirmed the resident received pureed cornbread instead of the vegetable option. The facility's policy requires nutritional equivalence in menu changes, which was not followed.
The facility failed to provide food in the correct minced and moist texture for a resident's lunch meal, as the food particles were too large to fit between the prongs of a standard fork. The RD confirmed the need for finer chopping to prevent choking, and the CDM acknowledged the lack of tools to ensure proper texture. Facility records and manuals outlined the required food texture, which was not followed.
The facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents of improper hand hygiene by staff. A CNA did not wash or sanitize her hands between glove changes during incontinent care for a resident with epilepsy and dementia. An RN failed to perform hand hygiene before donning gloves during medication administration for a resident with Parkinson's disease and dementia, only doing so after intervention by the VP RN. Both staff members were aware of the facility's hand hygiene policy, which was reinforced during training.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, lacking specific fall prevention interventions despite identifying them as fall risks. Interviews and record reviews revealed that care plans did not include individualized measures, only general fall protocols.
Failure to Obtain Consent Prior to Administration of Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's responsible party was informed in advance of the risks and benefits of a proposed anti-anxiety medication, Alprazolam, and did not obtain proper consent prior to administration. The resident, an elderly female with severe cognitive impairment, dementia, depression, and anxiety, was admitted for hospice respite care. Her medical records indicated that she required partial to moderate assistance with activities of daily living and had a physician's order for Alprazolam to be given as needed for anxiety, with a specific instruction that the responsible party must be notified before administration. Despite these orders, Alprazolam was administered to the resident before consent was obtained from the responsible party. The medication consent form, which included information about potential side effects, was signed by the responsible party after the medication had already been given. Interviews with facility staff revealed that nurses were aware that consent should be obtained prior to administering anti-anxiety medications, and the facility's policy required written or verbal consent before starting such medications. However, the nurse who administered the medication was not aware of the requirement to notify the responsible party prior to administration and did not confirm that consent had been obtained. The responsible party reported not being educated on the risks or side effects of Alprazolam by the facility and explicitly stated that she did not give consent for its administration. She also noted that she had observed the hospice orders, which required notification before administration, and that both hospice and facility staff were aware of this requirement. The failure to obtain consent and notify the responsible party prior to administering the medication was confirmed through interviews and record review.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's current status. Specifically, a male resident with diagnoses including Schizophrenia, Cerebral Palsy, and Dementia was not properly coded on his quarterly MDS assessment. The assessment omitted the diagnosis of Schizophrenia in the active diagnoses section, did not indicate the use of a lidocaine patch for pain management, and failed to record the administration of an antibiotic, Cipro, which the resident received during the look-back period. These omissions were identified through interviews and a review of the resident's medical records, including the Medication Administration Record (MAR) and the electronic medical record (EMR). The MDS Nurse, who was responsible for completing the assessment, acknowledged during an interview that the resident's Schizophrenia diagnosis, use of a lidocaine patch, and antibiotic administration should have been coded on the MDS. The nurse confirmed that information for the MDS is obtained through record review and that the look-back periods for diagnoses and medications were not properly followed in this case. The facility's policy requires all personnel completing any portion of the MDS to certify its accuracy, but this was not adhered to for this resident's assessment.
Failure to Accurately Transcribe Hospice Medication Orders and Notification Instructions
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident who was admitted for hospice respite care. The resident, an elderly female with diagnoses including dementia, depression, and anxiety, had a hospice order upon admission specifying that her responsible party must be notified prior to the administration of Alprazolam .5mg as needed for anxiety. This instruction was documented in the hospice orders and discussed between the hospice RN and the admitting LVN, but it was not transcribed into the resident's physician orders or Medication Administration Record (MAR). As a result, the MAR only reflected an order for Alprazolam .5mg every 4 hours as needed for anxiety, without the requirement to notify the responsible party before administration. The medication was subsequently administered to the resident without prior notification to the responsible party, as confirmed by interviews with nursing staff and the responsible party. The responsible party became aware of the administration after observing the resident's drowsiness and inquiring with staff, at which point it was confirmed that the medication had been given without her knowledge or consent. Interviews with facility staff, including the LVN who completed the admission and the DON, revealed that the omission occurred because the responsible party notification instruction was not entered into the electronic medical record system or the MAR. The staff acknowledged the importance of accurately transcribing all hospice orders, including special instructions, to ensure that all care directives are followed as intended.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information on two consecutive days. Observations on the morning of the second day revealed that the staffing poster displayed in the front lobby was outdated, showing information from the previous day. Record reviews confirmed that the facility had scheduled various nursing staff, including CNAs, MAs, DON, ADON, MDS Nurse, Treatment Nurse, and LVN/RNs for both days in question, but the current staffing information was not posted as required. Interviews with staff clarified that the responsibility for posting the daily staffing numbers alternated between a medication aide (MA) and the DON, depending on their schedules. Both the MA and the DON acknowledged their roles in posting the information and confirmed that the posting had not occurred on the specified days. The DON admitted to not posting the staffing numbers when required, and both staff members recognized the importance of this task as a regulatory requirement.
Loose Medication Pills Found in Medication Carts
Penalty
Summary
Surveyors observed that two out of three medication carts contained loose medication pills that were not stored in their original packaging or containers. Specifically, the medication aide cart for station 2 had four loose pills in one of its drawers, and the medication aide cart for station 1 had one loose pill in a drawer. These findings were confirmed by interviews with the respective LVNs responsible for each cart, who acknowledged the presence of the loose pills. Further interviews with the ADON and the Administrator revealed that medication carts are expected to be checked daily by medication aides and nurses, with additional weekly checks by pharmacy staff. Facility policy requires that drugs and biologicals be stored in the packaging or containers in which they are received, and that nursing staff are responsible for maintaining proper medication storage. The presence of loose pills in the medication carts was not in accordance with these requirements.
Unlocked Beauty Shop with Hazardous Items Accessible
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the beauty shop area. On observation, the beauty shop was found unlocked and unattended, with no staff present. Inside the room, there were several potentially unsafe items accessible, including a container of bleach wipes labeled as hazardous, four tubes of hair color with warnings to avoid contact with eyes and skin and to keep out of reach of children, and a package of plastic razors. The Regional Nurse confirmed that these items were potentially unsafe and that the room should have been locked to prevent access by residents, staff, or the public. Review of facility policy indicated that maintenance storage areas are required to be kept in a clean and safe manner.
Inaccurate Dental Status Assessment on Admission
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected her dental status. Record review showed that the resident, an elderly female with diagnoses including hypertensive heart disease, dementia, major depressive disorder, and legal blindness, was admitted on a specialized diet but had no care plan focus area addressing her dental status. The admission MDS assessment did not indicate that the resident was edentulous or had obvious dental issues, despite observations of sunken lips suggesting missing teeth. The quarterly MDS assessment also did not document dental concerns. During interviews, the Administrator confirmed the resident had some upper teeth but no lower teeth and sometimes did not use her dentures. The MDS LVN admitted to being confused when completing the MDS, as there was no problem with the resident's denture itself, and acknowledged that the assessment was coded incorrectly. The facility used the RAI manual as their policy for coding resident assessments.
Improper Sealing and Storage of Food Items in Kitchen Cooler
Penalty
Summary
Surveyors observed that the facility failed to properly store food items in the kitchen's reach-in cooler. Specifically, a container of shredded cheese was found with its plastic lid not fully sealed, leaving one corner open and exposing the cheese to the ambient air. Additionally, a cardboard case of breakfast sausage was discovered open, with the bag inside also unsealed, resulting in the sausage being exposed to the cooler's air. These observations were made during a routine inspection of the kitchen. During an interview, the Dietary Manager confirmed that both the cheese and sausage should have been sealed to prevent exposure, acknowledging that all staff responsible for storing food in the cooler are expected to ensure proper sealing. Review of the facility's Food Safety and Sanitation policy, as well as the 2022 FDA Food Code, confirmed that food must be stored in covered containers or wrappings to prevent contamination. The facility's failure to adhere to these standards was documented as a deficiency.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and assistance devices to prevent accidents, specifically failing to prevent an elopement by a resident with severe cognitive impairment. The resident, a male with unspecified dementia and no behavioral disturbances noted on his MDS, was admitted for respite care and was independent with mobility. Documentation revealed gaps in the resident's baseline care plan, with several sections left blank, including those related to mood, behavior, and care planning. There was no physician order for monitoring the resident, and the admission documentation did not indicate any assessment or plan for wandering risk. On the day of the incident, the resident was observed to have increased wandering behavior. Staff interviews and record reviews confirmed that the resident was able to leave the facility undetected and was found outside near an access road by the expressway. The front door was observed to be unlocked and unattended at the time, and although staff stated that door alarms were in place, the monitoring of the front entrance was inconsistent. Multiple staff members recalled the event, noting that the receptionist was sometimes away from the desk, and that the resident was able to exit quickly. There was no incident report completed regarding the resident's wandering or elopement, and the family was notified of the attempt to leave by the hospice company, not the facility. Facility policies required identification and supervision of residents at risk for unsafe wandering, as well as completion of incident reports and notification of appropriate parties in the event of an elopement. However, these procedures were not followed in this case. The lack of a completed care plan, insufficient monitoring of exit doors, and failure to document and report the incident contributed to the deficiency. Staff interviews revealed inconsistent understanding and implementation of monitoring responsibilities, and the facility did not have effective measures in place to prevent the resident's elopement.
Failure to Notify Physician and Representative After Resident Went Missing
Penalty
Summary
The facility failed to notify a resident's physician and representative when there was a significant change in the resident's status, specifically when the resident was found missing. The resident, a male with severe cognitive impairment due to unspecified dementia and other psychiatric diagnoses, was admitted for a respite stay and was noted to have increased wandering behavior. On the day of the incident, staff discovered the resident was missing, initiated a search, and found him after a short period. Documentation revealed no evidence that the resident's representative or physician was notified about the wandering or the missing event. Interviews with facility staff indicated confusion and lack of clarity regarding notification responsibilities. The ADON reported being informed by a nurse that the resident was missing and subsequently notified the Administrator, who was already present in the building. The Administrator stated she notified the hospice company but did not notify the physician and believed the hospice company would inform the family. Nursing staff believed that the Administrator and ADON would handle notifications, and the family representative confirmed that notification came from the hospice company, not the facility. Facility policy required documentation of changes in a resident's condition and notification of family, physician, or other staff. However, the records lacked documentation of such notifications for this incident. Staff interviews further confirmed that the physician and family representative were not directly notified by the facility, and the Administrator acknowledged that the physician should have been notified but was not.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted for a respite stay and had multiple complex medical diagnoses, including unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. The resident was noted to be severely cognitively impaired for daily decision-making but was independent with mobility and transfers. Upon review, the baseline care plan for this resident was found to be blank and undated, and several sections of the clinical admission documentation, including care planning and special care, were also incomplete or left blank. Interviews with facility staff revealed confusion and lack of clarity regarding the process and responsibility for completing baseline care plans. Licensed vocational nurses involved in the admission assessment believed that the MDS Coordinator was responsible for generating the care plan, while the MDS Coordinator stated that the baseline care plan should be started on admission and completed within 72 hours, but acknowledged that the resident's care plan was incomplete. Other nursing staff were unaware of the requirements or their roles in the development of the baseline care plan, and the ADON was unsure of the required timeframe for completion. The facility's documentation policy required that all services provided, progress toward care plan goals, and changes in the resident's condition be documented in the medical record to facilitate communication among the interdisciplinary team. However, the lack of a completed baseline care plan and incomplete documentation in the resident's record indicated that these requirements were not met for this admission, resulting in a deficiency related to the timely development and implementation of a person-centered care plan.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on Unit 1 was observed left unlocked and unattended in front of the nurse's station, facing a main pathway where six residents were present in wheelchairs. The cart was assigned to a medication aide, who stated she believed she had locked the cart, but the lock must have popped open. The aide acknowledged that the cart should not be left unlocked and unattended, as only facility staff should have access to it, and she was the only one with the key. The LVN present confirmed the cart was assigned to the medication aide, and the administrator also identified the cart as belonging to her. Interviews with the ADON and the RN Corporate Nurse confirmed that facility policy requires medication carts to be locked when unattended to prevent unauthorized access. Both staff members stated that leaving the cart unlocked could allow residents or others to access medications. A review of the facility's policy document titled 'Security of Medication Cart' indicated that medication carts must be securely locked at all times when out of the nurse's view and when not in use, they must be locked and parked at the nurse's station or inside the medication room.
Inadequate Heating System Leads to Cold Conditions for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the inadequate heating system that left residents in cold conditions. The heating issues were known to the facility, with the heater motor on the 300-hallway being out since January 22, 2025, and the 200-hallway heaters not functioning adequately. Additionally, the motor on the 100-hallway heater had not been operational for an unknown period. This resulted in indoor temperatures dropping as low as 51 degrees Fahrenheit during a period when outdoor temperatures were as low as 21 degrees Fahrenheit, affecting all three hallways, the common living room area, and all rooms on the 300-hallway. Multiple residents reported being cold, with some wearing multiple layers of clothing and using several blankets to keep warm. For instance, one resident on the 300-hallway stated that he wore a winter hat, sweatpants, socks, shoes, and a vest, yet his feet remained cold even with socks. Another resident reported hearing others crying out due to the cold, and one resident was found on the floor having removed her clothes because she was cold. Family members of residents also expressed concern, with one family removing their relative from the facility due to the cold conditions. The facility's failure to address the heating issues in a timely manner led to residents refusing showers and therapy due to the cold. Some residents were observed visibly shivering, and others had moved their beds closer to walls in an attempt to stay warm. The facility's inaction in repairing the heating system and ensuring adequate temperatures for residents resulted in an Immediate Jeopardy situation, highlighting the severity of the deficiency.
Failure to Report Heating System Malfunction
Penalty
Summary
The facility failed to report an incident involving the malfunction of its heating system to the State Survey Agency within the required 24-hour timeframe. The heating system on the 300-hallway was not operational since January 22, 2025, and when a resident complained about the lack of heat on the 200-hallway, the repair could not be completed immediately. This left the facility without adequate heating during a period when local temperatures dropped to 21 degrees Fahrenheit. Observations and interviews revealed that room temperatures in various parts of the facility were significantly below comfortable levels, with some rooms as low as 55 degrees Fahrenheit. The Maintenance Director acknowledged the issue and stated that the heater repairman had been called to address the problem. However, the repairman indicated that the facility's heating system had multiple issues, including clogged water lines and broken valves, which required manual intervention. Despite these known issues, the facility did not report the heating failure to the State Survey Agency, as the Administrator believed it did not constitute a total outage. Interviews with staff and residents indicated widespread awareness of the cold conditions within the facility. Residents, including one with moderate cognitive impairment, expressed discomfort due to the cold, and staff members reported wearing layered clothing to cope with the low temperatures. The facility's policy required immediate reporting of any allegations of neglect, but the Administrator did not consider the heating issue as meeting the criteria for reporting, despite the significant impact on residents' comfort and well-being.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a safe environment for Resident #17 by not providing adequate supervision during a mechanical lift transfer. The resident, who was cognitively intact and required assistance from two staff members for transfers, was left alone in a sling attached to a mechanical lift. This occurred when a CNA left the resident unattended in the sling to assist another resident, despite knowing the importance of not leaving a resident suspended in a sling. Resident #17, a female with multiple diagnoses including heart failure and diabetes, was observed by a surveyor in a sling attached to a mechanical lift, with no staff present in the room. The resident reported that staff often left her in the sling while they went to get help, and she had been left in the sling for approximately 10 minutes on this occasion. The resident expressed feelings of helplessness and anxiety about missing her scheduled activities due to being left in the sling. Interviews with staff revealed that CNA A had not received training on mechanical lifts from the facility, although she had been trained at a previous job. The Director of Nursing confirmed that two staff members should always be present during mechanical lift transfers and that leaving a resident unattended in a lift is a safety hazard. The facility's policy on safe lifting and movement of residents requires staff to be trained in the use of lifting devices, but CNA A was not included in the last in-service training for mechanical lifts.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to immediately inform a resident's physician when there was a significant change in the resident's physical condition. This deficiency was identified for a resident who experienced a significant change in condition, including pain, vomiting, diarrhea, and low oxygenation, and subsequently died. The resident was a male with a primary diagnosis of encephalopathy, noninfective gastroenteritis and colitis, rhabdomyolysis, and acute kidney failure. The resident had been admitted from a short-term general hospital and had unclear speech, memory problems, and required partial assistance with eating. On the night of the incident, the resident was restless and experienced multiple episodes of vomiting and bowel movements. The resident's oxygen saturation dropped to 90%, prompting the nurse to administer supplemental oxygen, which increased the saturation to 97%. Despite these significant changes, the nurse did not immediately notify the physician. The nurse attempted to contact the physician after consulting with the DON, but the physician did not return the call. The resident's condition continued to deteriorate, and he was found unresponsive, leading to CPR being initiated and EMS being called. The resident was pronounced dead by EMS upon their arrival. Interviews with staff revealed that the nurse on duty was new to the facility and did not have contact information for other staff members. The nurse was working alone on a hallway with a low census and did not have CNA assistance. The DON stated that a resident requiring supplemental oxygen should have been reported as a change in condition, and the facility's policy required immediate notification of the physician and DON in such cases. The facility's failure to follow these protocols contributed to the delay in medical intervention for the resident.
Failure to Provide Continuous CPR to Resident with Full Code Status
Penalty
Summary
The deficiency involved a failure to provide basic life support, including CPR, to a resident who required emergency care. The resident, a male with a Full Code status, was found unresponsive with no pulse or respirations. Despite having physician orders for CPR, the LVN on duty did not provide continuous and uninterrupted CPR. The LVN stopped CPR once to obtain an AED, which was against professional standards of practice. This lapse in emergency protocol resulted in the resident's death. The resident had a complex medical history, including encephalopathy, noninfective gastroenteritis, colitis, rhabdomyolysis, and acute kidney failure. He was admitted to the facility from a short-term general hospital and had unclear speech, memory problems, and required modified independence for daily decision-making. The resident was on enteral feeding and had a Full Code order in place, indicating that CPR should be performed in the event of cardiac arrest. The LVN, who was on his first shift after completing new hire orientation, found the resident unresponsive and initiated CPR. However, he left the resident during CPR to retrieve the Crash Cart and AED, which interrupted the resuscitation efforts. The LVN also faced challenges in contacting other staff for assistance due to a lack of phone numbers and was the only nurse assigned to the hallway with no CNA support. The delay in continuous CPR and the miscommunication with emergency services contributed to the resident's death.
Failure to Provide Appropriate Enteral Feeding 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. The resident, a male with a primary diagnosis of encephalopathy, noninfective gastroenteritis and colitis, rhabdomyolysis, and acute kidney failure, was admitted to the facility with a gastrostomy tube. However, the order for enteral feeding was incomplete, lacking details such as formula type, total volume, time of administration, or contraindications. This oversight in the resident's care plan was a significant factor leading to the deficiency. The resident experienced a significant change in condition, including pain, decreased oxygenation, multiple episodes of emesis, and fecal incontinence, which were not appropriately recognized or responded to by the facility staff. Despite the resident's complaints of stomach discomfort and vomiting, the feeding was only turned off after the first emesis, and the DON was called. The LVN on duty did not receive a return call from the doctor and continued to manage the resident's symptoms without further medical intervention. The resident's condition deteriorated, leading to his death. Interviews with facility staff revealed communication and procedural gaps, such as the LVN not knowing the phone numbers to other stations and using a personal phone to call the DON and 911. The facility's policy required immediate notification of the MD and DON in case of a significant change in condition, which was not adhered to. The lack of adequate staffing and support on the 300-hallway, where the resident was located, further contributed to the deficiency, as the LVN was left to manage the situation without assistance.
Food Safety and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, distribution, and service, as observed during a survey. One staff member, identified as [NAME] Z, did not wear a beard restraint despite having facial hair, contrary to the facility's policy requiring personnel with facial hair to wear a beard guard. Additionally, the facility did not label refrigerated food items with prepared and discard dates, which is against their policy. The CDM admitted that the kitchen staff did not add discard dates to food products, relying instead on their knowledge to discard prepared foods after three days. Furthermore, the facility did not consistently monitor food temperatures. [NAME] AA failed to take temperatures for proteins with specific consistencies due to a lack of space on the temperature log. The CDM also did not check the temperatures of cold food products, such as milk, relying instead on the refrigerator's temperature reading. These practices were not in line with the facility's policy, which requires recording food temperatures at the start, end, and every 30 minutes during meal service. These deficiencies could potentially place residents at risk for foodborne illness.
Care Plan Deficiencies in Resident Transfers and Fall Interventions
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for four residents were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. For Resident #29, the care plan was not updated with new fall interventions after two major falls that resulted in hospitalization. Despite the resident being identified as a fall risk, the care plan lacked documentation of additional interventions that staff were implementing, such as following the resident to activities and frequent rounding. Resident #36's care plan did not document the resident's transfer needs, despite being totally dependent on staff for mobility. The MDS Coordinator acknowledged that the care plan should have included transfer documentation under ADLs or mobility for safety reasons. The absence of this information in the care plan could lead to unsafe transfer practices by staff. For Residents #35 and #50, the care plans inaccurately reflected the need for a two-person Hoyer lift transfer, while staff and the residents themselves indicated that one-person transfers were often sufficient. This discrepancy between the care plan and actual practice was confirmed by staff interviews, highlighting the need for care plan updates to ensure resident safety and appropriate care.
Unnecessary Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident, who had not been diagnosed with depression, was not given psychotropic medication unnecessarily. The resident, a female with severe cognitive impairment and a history of anxiety disorder, was prescribed Citalopram Hydrobromide, an antidepressant, for depression. However, there was no documented diagnosis of depression in her clinical record or comprehensive MDS assessment. The Director of Nursing (DON) acknowledged that the diagnosis was only mentioned in the doctor's notes and not formally documented in the resident's clinical record. The facility's policy requires that medication orders include the clinical condition or symptoms for which the medication is prescribed. Despite this, the resident was receiving the medication without a documented diagnosis of depression, which is a violation of the facility's policy and could lead to unnecessary medication administration. The prescribing physician was unavailable for clarification as they were on vacation at the time of the interview.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, the 300-hallway Nurses Medication Cart was found unlocked and unattended in a common area in front of the nurses' station. The cart contained prescription and over-the-counter medications, sharps for blood glucose monitoring, and other paraphernalia for administering drugs. At the time, there were staff, residents, and visitors in the area, posing a risk of medication misuse or drug diversion. LVN A, who was responsible for the medication cart, was observed discarding a cooler of ice in a nutrition room with his back turned to the common area, unable to see the cart. Despite LVN A's belief that he could monitor the cart while handling the cooler, the cart was left unattended and accessible. The Director of Nursing (DON) confirmed that the expectation was for medication carts to be locked when not in active use, and staff were trained on this principle during onboarding and annual refresher trainings. The facility's policy on the storage of medications also required that compartments containing drugs and biologicals be locked when not in use.
Failure to Provide Balanced Diet to Resident
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of a resident. Specifically, the facility did not ensure that a resident received a vegetable side during a lunch meal. The resident, who had severe cognitive impairment, muscle wasting, anorexia, and dysphagia, did not receive the vegetable option as per the facility's menu. The resident's care plan and doctor's orders did not contain pertinent information related to this deficiency. During the meal observation, the registered dietitian (RD) and certified dietary manager (CDM) were unable to identify the contents of the resident's meal tray and later confirmed that the resident received pureed cornbread instead of the vegetable option. The CDM eventually provided green beans with the appropriate texture. The facility's policy requires that menu changes based on resident preferences should ensure nutritional equivalence, but this was not adhered to, as the resident was not given a vegetable due to her dislike of the option provided.
Failure to Provide Correct Food Texture for Minced and Moist Diet
Penalty
Summary
The facility failed to ensure that residents received food and drink prepared in a form designed to meet individual needs, specifically for a minced and moist textured diet during a lunch meal. Observations and interviews revealed that the food particles, such as browned potatoes and carrots, were not chopped finely enough to fit between the prongs of a standard-sized metal fork, which is the required size for a minced and moist diet. The Registered Dietitian (RD) confirmed that the food should have been more finely chopped to prevent choking. Further investigation showed that the Certified Dietary Manager (CDM) acknowledged the lack of tools, such as pictures or rulers, in the kitchen to ensure the correct food texture. The CDM admitted that the potatoes could have been chopped more finely and that he had to manually adjust the texture. The facility's records, including therapeutic spreadsheets and recipes, indicated specific instructions for preparing minced and moist foods, which were not followed. The facility's Diet Manual and Policy and Procedure handbook also outlined the requirements for food texture, which were not adhered to during the meal preparation.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving improper hand hygiene practices by staff members. In the first incident, a Certified Nursing Assistant (CNA) failed to wash or sanitize her hands between glove changes while providing incontinent care to a resident. The resident, a male with a history of epilepsy and dementia, required moderate assistance for toileting and was at risk for skin breakdown. The CNA acknowledged her failure to perform hand hygiene, attributing it to nervousness and the absence of pump-style hand sanitizer bottles on the unit. In the second incident, a Registered Nurse (RN) did not wash or sanitize her hands before donning gloves during medication administration for another resident. This resident, an elderly female with Parkinson's disease and dementia, was observed by the Vice President of Nursing (VP RN) who intervened to ensure proper hand hygiene was performed. The RN admitted to knowing the requirement for hand hygiene but stated that nervousness led to her oversight. She also mentioned that hand sanitizer was readily available in the care areas. Both staff members involved in these incidents were aware of the facility's hand hygiene policy, which mandates hand washing or sanitizing before applying gloves. The Director of Nursing (DON) confirmed that the facility's policy was communicated during new hire orientation, in-service trainings, and annual competency assessments. The failure to adhere to these protocols could lead to cross-contamination and increased risk of infection among residents.
Failure to Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental needs. The care plans for these residents did not include specific fall prevention interventions such as appropriate footwear, non-slip socks, and bed in low position, despite these residents being identified as fall risks. This deficiency was identified through interviews, observations, and record reviews conducted by the surveyors. Resident #1, a [AGE] year-old female with diagnoses including muscle wasting, difficulty walking, and muscle weakness, was found to have a care plan that lacked specific fall prevention interventions. Similarly, Resident #2, a [AGE] year-old female with dementia and muscle weakness, and Resident #3, a [AGE] year-old female with unspecified dementia and difficulty walking, also had care plans that did not list individual fall prevention measures. The care plans only mentioned following the facility's fall protocol without detailing specific interventions for each resident. Interviews with the Director of Nursing (DON), MDS Nurse, CNA, and LVN revealed that while the facility had a general fall prevention policy, the care plans did not reflect individualized interventions for each resident. The staff were aware of the fall risks and the general interventions, but these were not documented in the care plans. The facility's policy on falls indicated that interventions should be identified based on assessments, but this was not adequately reflected in the care plans of the residents reviewed.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 940 citations issued within 25 miles in the last 12 months — including the 20 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morningside Manor | 0.8 mi | ★★★★★ | 9 | 1 |
| The Lev At San Antonio | 1.8 mi | ★★★★★ | 30 | 0 |
| The Sarah Roberts French Home | 2.4 mi | ★★★★★ | 8 | 0 |
| Inspiration Hills Rehabilitation Center | 2.4 mi | ★★★★★ | 21 | 0 |
| Oak Park Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 25 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.