Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Palms Rehabilitation And Retirement during CMS and state inspections, most recent first.
A resident with bronchiectasis, COPD, dyspnea, and acute respiratory failure did not receive prescribed Theophylline when he arrived at the facility because the medication was not immediately available from the pharmacy. Records and staff interviews showed conflicting handling of the resident’s home medication and delayed order entry, and the MAR reflected administration only after the delay.
Inaccurate MAR Documentation for Theophylline Administration: A resident with bronchiectasis, COPD, dyspnea, and respiratory failure had Theophylline orders entered in the EMR, but the MAR showed an incorrect administration entry for a 4-capsule dose while the RN stated she actually gave only 2 capsules from the resident’s home medication. The RN said she verified the MAR with the orders and documented medication administration, while the DON said an old order remained in the EMR and the RN should have accurately verified the orders against the MAR.
Exposed A-Bed Closet Clothing: The facility failed to ensure that 8 A-bed resident rooms had closet coverings or doors, leaving resident clothing exposed near the hallway. Staff reported the coverings had been removed during reconstruction, and interviews confirmed the closets had remained open for months without a covering. A resident said she did not want people looking at her things, and the facility could not provide a policy for a homelike environment.
The facility failed to notify the LTC Ombudsman of two resident discharges. One resident with UTI, weakness, cirrhosis, DM2, obesity, HTN, and sepsis was sent to the hospital, and another resident with CHF, PVD, and a pacemaker was discharged home; both had discharge plans and records showing no ombudsman notice. The SSD and ADM stated they were unaware the ombudsman had not been receiving discharge notifications, and the ombudsman reported no notices from the facility since 10/3/25.
A resident with CHF, acute respiratory failure, and COPD had stat verbal orders from an NP for a chest X-ray, EKG, and troponin communicated to the ADON. The ADON documented receipt of all three orders in a progress note but only entered the chest X-ray order, delegating entry of the EKG and troponin orders to the floor RN, contrary to facility practice that the person taking the verbal order must enter it. The DON and ADON acknowledged that this failure to immediately and completely enter the verbal orders into the medical record could delay necessary interventions and contribute to further deterioration in the resident’s condition.
A resident with peripheral vascular disease, bed confinement, and an existing heel pressure ulcer/DTI was sent to the ED for evaluation of a purple, non-open heel after an LPN obtained an order from a nurse practitioner and notified the charge LPN. The charge LPN reported calling the ED and arranging ambulance transfer but did not document the change in condition, the provider’s order, or the transfer in the medical record, stating she became busy and forgot. The other LPN did not document because she was not the assigned nurse. This resulted in an incomplete medical record that did not reflect the ED transfer or the associated order, contrary to facility policy and stated expectations for timely, accurate documentation.
The facility did not ensure that a registered nurse was present for at least 8 consecutive hours each day, as required. On multiple weekends, there was either no RN coverage or less than the required hours. Interviews revealed that only one RN regularly worked weekends, and RNs were not always present in the building. The DON and Administrator were unaware of the specific regulatory requirements, and the facility could not provide relevant staffing or scheduling policies.
Two residents with severe physical and cognitive impairments were assessed as dependent for ADLs and required a two-person assist for toileting, but their care plans and CNA electronic reports did not specify the required level of assistance. Staff interviews confirmed the omission, and facility policy mandates comprehensive care plans based on assessment findings.
A resident with multiple diagnoses and at risk for malnutrition did not receive prescribed liquid protein and Nepro supplements on numerous occasions because CMAs required clarification on the orders and did not obtain it, resulting in missed doses over several weeks. The lack of a clear process for resolving order clarifications contributed to the deficiency.
Two residents with end stage renal disease and documented dependence on dialysis were not accurately coded for dialysis in their MDS assessments, despite their medical records and care plans reflecting the need for this treatment. The omission was confirmed by the MDS nurse, and facility policy requires accurate documentation of such special treatments.
A resident with multiple complex medical conditions experienced a change of condition, including nausea, which was observed and reported by a speech-language pathologist to an LVN. The LVN acknowledged being informed and stated she notified the physician, but failed to document the change of condition or any follow-up actions in the medical record, resulting in incomplete documentation as required by facility policy.
A resident with multiple chronic conditions did not have a care plan that addressed her ongoing noncompliance with medical recommendations, such as not wearing heel protectors, refusing dialysis, and not following fluid and dietary restrictions. Staff and family were aware of these behaviors, but the care plan was not updated to include interventions or measurable objectives related to them, contrary to facility policy.
A resident with moderately impaired cognition eloped from a facility due to an unsecured exit door with a silenced alarm. The resident, who required assistance for mobility, was found by hospital security guards at a neighboring hospital. The facility failed to assess the resident's elopement risk and ensure the door alarm was functioning, leading to the resident's unsupervised departure.
A resident with a history of respiratory issues was observed receiving oxygen at 1L/min instead of the prescribed 3L/min. The nurse on duty was unaware of the correct setting and had not checked the concentrator during her shift. The facility's policy required reassessment of the oxygen flowmeter, which was not followed.
The facility failed to maintain proper temperature controls for medications in the black fridge, with temperatures recorded at 45 and 50 degrees Fahrenheit, outside the facility's policy range. Insulins and eye drops stored in the fridge require specific temperature conditions. Staff interviews revealed inconsistent monitoring and reporting of refrigerator temperatures, with night nurses responsible for checks but lacking follow-up verification by ADON and DON.
A resident with a stage four pressure ulcer did not receive proper wound care labeling, as an LVN failed to label the dressing with the date, time, and initials after treatment. This occurred twice during the same session, even after contamination. Interviews with the LVN and DON highlighted the importance of labeling for continuity of care, as per facility policy.
A resident with multiple health conditions did not receive a scheduled dose of the antibiotic Ceftriaxone due to its unavailability at the facility. The medication order was not processed in time, and there was a lack of clear responsibility and documentation among staff to ensure the medication was obtained. The facility lacked a formal policy for verifying medication availability, contributing to the deficiency.
A resident with no cognitive impairment was found with rubbing alcohol in his room, leading to alcohol poisoning and hospitalization. Despite initial removal of the substance by staff, the resident accessed it again, highlighting a failure in monitoring and enforcing non-permitted item policies.
A resident with a history of multiple health issues was found with altered mental status and a partially empty bottle of rubbing alcohol, which he admitted to drinking. The facility failed to report this incident within the required two-hour timeframe, leading to a delay in notifying the appropriate authorities. Interviews revealed confusion among staff regarding reporting responsibilities, contributing to the delay.
Missed Theophylline Dose Due to Delayed Medication Availability
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring and receiving of all drugs and biologicals for one resident. The resident was admitted with diagnoses including bronchiectasis with acute exacerbation, dyspnea, acute respiratory failure, hypercapnia, and COPD with lower respiratory infection. The resident’s assessment reflected shortness of breath when lying flat and the use of oxygen therapy and respiratory therapy. The care plan identified a risk for altered respiratory status and directed that medications be administered as ordered. The resident had a medication reconciliation order from the hospital to continue Theophylline 100 mg/24 hours oral capsule extended release 400 mg daily, with the last hospital dose documented on 4/24/26. The resident and family reported that the last dose was given at the hospital before transfer and that the resident arrived at the facility later that evening. The resident stated that the facility did not have the prescribed Theophylline available on arrival and that he recalled not taking it the next day. The resident also stated that his family brought Theophylline from home and that he began taking it, but the facility told him it could not be used until approval and orders were obtained from the MD. Facility documentation showed conflicting and delayed handling of the medication. A progress note documented that RN C received Theophylline from the family member on 4/27/26, and the EMR later reflected a Theophylline order entered on 4/26/26 with a start date of 4/27/26. The MAR showed Theophylline administered beginning 4/27/26, while the record review and interviews indicated the resident did not receive Theophylline on 4/25/26. Staff interviews confirmed the medication was not immediately available from the pharmacy, that the pharmacy delivery was delayed, and that the resident may have missed a dose before the medication was obtained and entered for administration.
Inaccurate MAR Documentation for Theophylline Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one resident when the Medication Administration Record (MAR) did not correctly reflect administration of Theophylline on 4/27/26. Resident #1 was admitted on 4/24/26 with diagnoses including bronchiectasis with acute exacerbation, dyspnea, acute respiratory failure, hypercapnia, and COPD with acute lower respiratory infection. The resident’s assessment reflected a BIMS score of 14, shortness of breath when lying flat, and use of oxygen therapy and respiratory therapy. Physician orders in the EMR showed Theophylline ER 100 mg, 4 capsules by mouth once daily for shortness of breath, ordered on 4/26/26 with a start date of 4/27/26, and another order on 4/27/26 for Theophylline ER 200 mg, 2 capsules by mouth twice daily for shortness of breath. The MAR for April 2026 showed the 100 mg, 4-capsule once-daily order as administered on 4/27/26, and also showed the 200 mg, 2-capsule twice-daily order as administered from 4/27/26 through 4/30/26. During interview, RN C stated she verified the MAR with the orders, prepared and administered medications, and remembered waiting for the pharmacy to send the Theophylline. She said she gave the resident his own home medication after receiving the MD order and recalled giving only 2 capsules in the morning, with another dose planned for the evening. RN C stated she never administered 4 capsules and said inaccurate documentation could cause residents to receive inaccurate medication dosing. The DON reviewed the MAR and orders and stated the old Theophylline order appeared to have been discontinued in the EMR but remained visible, and that RN C should have accurately verified the orders against the MAR. Facility policy required oral medications to be accurately prepared, administered, and documented on the MAR.
Exposed A-Bed Closet Clothing
Penalty
Summary
The facility failed to ensure that resident rooms 1201-A, 1202-A, 1205-A, 1207-A, 1209-A, 1211-A, 1213-A, and 1215-A had a covering or door on the closets for 8 of 19 resident A-Beds reviewed for environment. Observations from 04/13/26 through 04/15/26 showed that these A-bed closets, located adjacent to the hallway door, had no covering or door, leaving resident clothing exposed in the rooms. The report states that anyone entering the rooms could easily rub against the exposed clothing, and anyone passing by in the hallway could easily touch or remove it. During interview, Resident #19 said she did not like her closet open because she did not want people looking at her things. The OM said the open closet doors had been that way for a while and estimated the A-bed closets had been without doors for 2-3 months, adding that contractors were ordering doors and that temporary curtains would be placed until solid doors were installed. The DON said the A-bed closets had never been covered since she started in February 2025 and stated the clothing could be contaminated or removed by someone passing by in the main hallway. The ADM said the A-bed closet coverings had been removed in preparation for reconstruction, while staff also reported the curtains had been removed when reconstruction started and that no one questioned the exposed clothing. The facility was unable to provide a policy for a homelike environment.
Failure to Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to send copies of resident discharge notices to the representative of the Office of State Long-Term Care Ombudsman for 2 of 2 residents reviewed for discharge. One resident was discharged to the hospital after admission for urinary tract infection, muscle weakness, cirrhosis of the liver, type II diabetes mellitus with hyperglycemia, morbid obesity, hypertension, and sepsis. The resident’s MDS showed a BIMS score of 14, indicating intact cognition, and Section Q indicated a discharge goal to return to the community with active discharge planning already occurring. The care plan also reflected the resident’s wish to return home. Record review showed the resident was discharged to the hospital, but the electronic medical record contained no evidence that the LTC Ombudsman was notified of the discharge. During interviews, the SSD stated she had not been aware she needed to notify the ombudsman whenever a resident was discharged and said she later sent an email with names of residents discharged home since she started working at the facility. The SSD also stated she was not aware of the resident’s hospital discharge because it occurred before she began working at the facility, and the ADM stated she was not aware the ombudsman had not received discharge notifications since October 2025. The state managing local LTC Ombudsman stated she had not received any discharge notices from the facility since 10/3/25. A second resident, admitted with chronic systolic CHF, PVD, and a cardiac pacemaker, had an MDS discharge record showing independent cognitive skills and Section Q indicating the discharge plan was activated and already occurred for return to the community. The discharge summary showed the resident was discharged home, and the care plan documented the resident wished to return home with discharge goals to return home. The record contained no evidence that the LTC Ombudsman was notified of this discharge. The SSD and Administrator stated they were not aware the local ombudsman had not been notified of resident discharges, and the facility policy required the facility to notify the State LTC Ombudsman of discharges and, when a resident transferred with an expectation of returning could not return, that this constituted a discharge and the policy applied.
Failure to Properly Enter Verbal Stat Orders Into Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. A 74-year-old male resident with diagnoses including congestive heart failure, acute respiratory failure, and COPD had a quarterly MDS showing moderate cognitive impairment with a BIMS score of 8. On a specified date, the ADON documented in a progress note that she received new stat verbal orders from a nurse practitioner for a chest X-ray, EKG, and troponin. However, review of the physician’s orders for that date showed that the troponin and EKG orders were entered by RN A, while only the chest X-ray order was entered by the ADON. Interviews confirmed that the ADON was the person who took the verbal orders from the nurse practitioner and that facility practice was that the staff member who receives a verbal order is responsible for entering it into the resident’s record. The ADON stated she was acting as an extra set of hands and was not the resident’s nurse, and that she delegated entry of the troponin and EKG orders to RN A instead of entering them herself. The DON similarly stated that the ADON should have entered all three stat orders since she received them, and that orders should include the physician’s name, instructions, date, and time the order was given. Both the ADON and DON stated that not entering the order at the time of receipt could cause delays in treatment and may delay necessary interventions and potentially lead to further deterioration in the resident’s condition.
Failure to Document Hospital Transfer and Provider Order for Wound Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident who was at risk for pressure ulcers and had an existing unstageable heel pressure ulcer/deep tissue injury. The resident, an older female with peripheral vascular disease and bed confinement status, had a care plan identifying a pressure ulcer to the heel and interventions including immediate nurse notification of any new skin breakdown. On the referenced date, an LVN (LVN B) performed wound care, assessed the resident’s heel, and noted that it was purple but not open. LVN B contacted the nurse practitioner, who gave a new order to send the resident to the emergency room for further evaluation of the right heel wound, and LVN B then informed the charge nurse (LVN A) of this new order. According to interviews, LVN A stated that she called the emergency room to give report and that the resident was transferred via ambulance for evaluation of the right heel wound. However, LVN A acknowledged that she did not document in the resident’s medical record that the resident was transferred to the emergency room, stating she became busy with other residents and forgot to document the transfer and the physician’s order before the end of her shift, despite knowing documentation should have been completed. LVN B stated she did not document the change in condition because she was not the resident’s nurse and had informed LVN A, the charge nurse. The DON stated that the facility’s expectation is that documentation of changes in condition be timely, accurate, and completed in real time or before the end of the shift. Review of the facility’s documentation policy confirmed that cares provided are to be recorded in the electronic record each shift, but the resident’s record lacked documentation of the hospital transfer and the associated order for evaluation of the right heel wound.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, over a 90-day review period. Specifically, there was no RN coverage on several weekends, and on other weekends, RN coverage was less than 8 hours. Timesheet records confirmed these gaps in RN presence. Interviews with the Director of Nursing (DON) revealed that only one RN regularly worked weekends, and RNs assigned on weekends were not always present in the building unless called. The DON admitted to being unaware of the regulatory requirement for 8 consecutive hours of RN coverage daily and acknowledged it was her responsibility to ensure compliance. The Administrator also stated that ensuring RN coverage was ultimately her responsibility, despite having enough RNs on staff. Further, the facility was unable to provide requested policies regarding staffing, RN coverage, or scheduling, and only a job description for the DON was available. Both the DON and an RN interviewed recognized that certain tasks requiring an RN, such as signing off on baseline care plans, removing midline/PICC catheters, and pronouncing death, could not be performed without proper RN coverage. The lack of documented policies and inconsistent RN scheduling contributed to the deficiency.
Failure to Specify Toileting Assistance in Care Plans for Dependent Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, specifically omitting clear documentation regarding the level of assistance required for toileting. Both residents had significant physical and cognitive impairments, including muscle weakness, lack of coordination, dementia, and were assessed as dependent for activities of daily living (ADLs), requiring the assistance of two staff members for toileting. However, their care plans did not specify whether a one or two-person assist was needed for this task, and the electronic reports used by CNAs to guide care either omitted the toileting task or failed to indicate the required level of assistance. Observations and interviews revealed that CNAs relied on these electronic reports to determine the care needs of residents, especially when unfamiliar with them. In these cases, the reports did not provide the necessary information, and staff had to rely on their own experience or consult with charge nurses. The MDS-RN and DON both confirmed that the care plans and electronic reports did not reflect the two-person assist requirement for toileting, despite both residents being bed bound and fully dependent for this activity. The facility's policy requires the interdisciplinary team to develop comprehensive, person-centered care plans that include measurable objectives and timeframes based on comprehensive assessments. In these instances, the care plans did not meet this standard, as they failed to include specific instructions for toileting assistance, which was a critical need identified in the residents' assessments.
Failure to Administer Physician-Ordered Therapeutic Supplements Due to Lack of Clarification
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including cerebral infarction, type 2 diabetes, protein-calorie malnutrition, hypertension, anemia, peripheral vascular disease, and end stage renal disease on dialysis, was not administered prescribed therapeutic dietary supplements. The resident had documented risk factors for malnutrition, as evidenced by a low BMI and nutritional assessments indicating risk, and was ordered a renal diet with liquid protein and Nepro supplements by the physician. These orders were clearly documented in the resident's care plan and medication administration records (MAR). Despite the physician's orders, the resident did not receive the liquid protein and Nepro supplements on multiple occasions. Medication administration notes repeatedly indicated that certified medication aides (CMAs) did not administer the supplements due to needing clarification on the type or quantity of supplement to give. The CMAs documented their need for clarification and reported notifying nurses, but there was no evidence that clarification was obtained or that the supplements were subsequently administered as ordered. The MAR reflected numerous missed doses over several weeks. Interviews with the CMAs confirmed that they withheld administration of the supplements pending clarification, and that they notified nurses but were unsure if clarification was ever received. The Director of Nursing (DON) acknowledged that the lack of follow-up or miscommunication led to the failure to administer the supplements as ordered. There was no specific policy in place for how CMAs should escalate clarification needs to nurses and physicians, contributing to the ongoing issue.
Failure to Accurately Code Dialysis in MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of two residents who were receiving dialysis. For both residents, medical records and care plans documented diagnoses of end stage renal disease and dependence on renal dialysis. However, review of their MDS assessments showed that dialysis was not coded in section O, which is designated for special treatments, procedures, and programs. Interviews with the MDS nurse confirmed that dialysis was omitted from the MDS coding for both residents. The residents involved had significant medical histories, including conditions such as cerebral infarction, muscle weakness, diabetes, malnutrition, hypertension, anemia, peripheral vascular disease, chronic kidney disease, and end stage renal disease. Despite these documented needs and the presence of care plans addressing dialysis, the MDS assessments did not reflect the dialysis treatment. Facility policy and CMS guidelines require that special treatments and procedures be accurately documented in the comprehensive assessment, including the MDS.
Failure to Document Change of Condition in Resident Medical Record
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to document a resident's change of condition, specifically an episode of nausea, as required by facility policy and accepted professional standards. The resident, an elderly female with multiple complex diagnoses including stroke, diabetes, malnutrition, hypertension, anemia, peripheral vascular disease, and end stage renal disease on dialysis, was observed by a speech-language pathologist (SLP) to be different than usual, eating less, and reporting nausea. The SLP completed a 'stop and watch' form and reported the change to the LVN, who acknowledged being informed and stated she notified the physician, but did not recall if any new orders were given or if she documented the event. Review of the resident's medical record confirmed that there was no documentation by the LVN regarding the change of condition or any follow-up actions taken. Interviews with the SLP, the LVN, another nurse, and the Director of Nursing (DON) corroborated that the required documentation was missing. Facility policy mandates that all changes in a resident's medical or mental condition be documented, including details such as assessment data, notifications, and conversations with physicians. The failure to document this change of condition resulted in an incomplete medical record for the resident.
Failure to Develop Comprehensive Care Plan Addressing Resident Noncompliance
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including end stage renal disease, diabetes, heart failure, peripheral vascular disease, and arterial wounds. Although the resident's care plan addressed some medical needs such as renal failure, dialysis, and nutritional risks, it did not include interventions or measurable objectives related to the resident's specific behaviors that impacted her care. These behaviors included not offloading pressure from her feet, not wearing heel protectors, bearing weight against recommendations, refusing dialysis, consuming excess fluids and soda, and not following dietary restrictions. Staff interviews revealed that the resident frequently removed her heel protectors, sat up in her chair, requested ice despite fluid restrictions, and sometimes refused dialysis appointments. Staff and family education was provided regarding the importance of adhering to medical recommendations, but the care plan was not updated to reflect these ongoing behaviors or the interventions used to address them. The resident's family also brought in outside food that was not consistent with her prescribed renal diet, and staff documented these occurrences but did not incorporate them into the care plan. The facility's own policy required that the care plan identify any care or service declined by the resident, the associated risks, and the efforts made by the interdisciplinary team to educate the resident and her representative. However, the care plan did not document the resident's noncompliance or the facility's interventions to address these behaviors, resulting in a lack of guidance for staff and potential gaps in care coordination.
Resident Elopement Due to Unsecured Exit Door
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, leading to the elopement of a resident. The resident, who had moderately impaired cognition and required partial to moderate assistance for mobility, was able to exit the facility through an unsecured door. The door alarm was found to be silenced, which allowed the resident to leave unnoticed. The resident was later found by hospital security guards at a neighboring hospital. The incident occurred shortly after the resident was admitted to the facility, indicating that the facility did not adequately assess and address the resident's risk of elopement. The resident had no previous history of elopement, and staff were not aware of any wandering behavior. The failure to secure the exit door and ensure the alarm was functioning contributed to the resident's ability to leave the facility unsupervised. Interviews with staff revealed that the alarm system for the exit door had been silenced, possibly by an IT person servicing the system days before the incident. Staff were not aware of the resident's elopement until a medication aide noticed the resident was missing during a routine check. The facility's lack of immediate response and failure to maintain a secure environment placed the resident at risk of harm.
Removal Plan
- Head to Toe Assessment completed
- Notification of MD
- Notification of RP
- Clinicians initiated and completed 100% re-evaluations for elopement risk and no other new residents were identified as medium to high risk. All new admissions to be reviewed by DON/designee and LN staff educated/inserviced to notify DON/designee of any new admissions flagging medium to high risk on UDA.
- In-service on Abuse and Neglect and Elopement initiated and completed
- 100% of resident head count was conducted by licensed nurses at time of incident and all active residents accounted for and Facility initiated 100% of head count qshift. 100% Head count will continue 3xW 2nd shift
- East exit door sound activated on door resident used to elope through.
- Maintenance director tested all doors with alarms to ensure alarm sounds at in working order. Maintenance director/designee will test alarm sounds 3xW for working order.
- Alert system placed to residents left wrist
- Elopement drills initiated and continued. Elopement drills will be conducted 2xW for both 1st and 2nd shift for a period of 2 weeks
Failure to Administer Correct Oxygen Setting
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care received oxygen therapy at the correct setting as ordered by the physician. The resident, who was cognitively intact and had a history of acute and chronic respiratory failure with hypoxia, bronchiectasis, and idiopathic pulmonary fibrosis, was observed receiving oxygen at 1 liter per minute instead of the prescribed 3 liters per minute. This discrepancy was noted during an observation, and the resident did not exhibit signs of respiratory distress at that time. The nurse responsible for the resident's care was unaware of the correct oxygen setting and had not checked the oxygen concentrator during her shift. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that it was the responsibility of the floor nurse to verify the oxygen settings, and that training on oxygen administration was provided upon hire and annually. The facility's policy required reassessment of the oxygen flowmeter for correct liter flow, which was not adhered to in this instance.
Improper Medication Storage Temperature Control
Penalty
Summary
The facility failed to maintain proper temperature controls for medications stored in one of its medication storage refrigerators, specifically the black fridge. During an observation, the temperature inside the black fridge was recorded at 45 degrees Fahrenheit and later at 50 degrees Fahrenheit, which was outside the facility's policy range. This fridge contained insulins and eye drops, which require specific temperature conditions to remain effective. The temperature log indicated that the temperature should be between a specified range, and any deviation should be reported immediately to a supervisor. Interviews with staff revealed a lack of consistent monitoring and reporting of refrigerator temperatures. LVN D stated that night nurses were responsible for checking the temperatures, and if the temperature was outside the recommended range, the medications could expire. LVN E admitted to not checking the black fridge on a particular day because it was already marked as checked by another nurse. The ADON and DON also confirmed that night nurses were responsible for temperature checks, but there was a lack of follow-up verification. The ADON was unsure of the protocol for handling out-of-range temperatures due to being in training. The facility's policy required medications to be stored according to manufacturer recommendations, and any expired or deteriorated medications should be removed immediately.
Failure to Label Wound Dressings in Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with pressure ulcers, leading to a deficiency in quality of care. Specifically, a resident with a stage four pressure ulcer on the sacral area did not receive proper wound care labeling during treatment. The resident, who had severe cognitive impairment and multiple medical conditions including cerebral infarction and osteoarthritis, was observed receiving wound care from an LVN who did not label the dressing with the date, time, and initials after completing the treatment. This omission occurred twice during the same treatment session, even after the dressing was contaminated and replaced. Interviews with the LVN and the Director of Nursing (DON) revealed that labeling the dressing is a critical step in the wound care process to ensure continuity of care and prevent the worsening of the wound. The facility's policy and skills checklist also emphasized the importance of labeling wound dressings. The failure to label the dressing could lead to inadequate treatment and potential worsening of the resident's condition, as it is the only way for staff and physicians to know when the dressing was last changed.
Failure to Ensure Timely Availability of Antibiotic for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically by not ensuring the availability of a physician-ordered antibiotic, Ceftriaxone sodium, for a resident on the scheduled date. The resident, a male with a history of acute respiratory failure, diabetes, hypertension, acute kidney failure, and a urinary tract infection, was admitted to the facility and had an order for Ceftriaxone to be administered at 4:00 PM on a specific date. However, the medication was not available at the facility at the scheduled time, and the nurse documented that the medication was not in the facility and faxed the information to the pharmacy. Interviews with various staff members, including nurses and pharmacy personnel, revealed a lack of clarity and responsibility regarding the process for ensuring that newly admitted residents have their medications available as ordered. The admitting nurse and subsequent shifts were responsible for ensuring the availability of the medication, but there was no clear documentation or evidence that the necessary steps were taken to obtain the medication in a timely manner. The pharmacy received the order the following day and sent the medication STAT, but it was not delivered until after the scheduled administration time. The Director of Nursing (DON) and Clinical Resource personnel acknowledged the importance of ensuring residents receive their medications as scheduled to avoid adverse health impacts. However, there was no documented policy or procedure in place for verifying the availability of residents' medications, and it was noted that the process was more of an informal procedure provided during staff orientation. The lack of a formal policy and clear documentation contributed to the failure to provide the necessary pharmaceutical services for the resident.
Failure to Prevent Access to Hazardous Substances
Penalty
Summary
The facility failed to maintain a safe environment for Resident #1, who was found with rubbing alcohol in his room, leading to an incident of alcohol poisoning. On the morning of 06/19/24, Medical Records staff discovered two bottles of rubbing alcohol in Resident #1's room, which were accessible to him. Despite removing these bottles and informing a family member that such items were not allowed, later that day, the Assistant Director of Nursing (ADON) found Resident #1 with altered mental status and a partially empty bottle of rubbing alcohol. This incident resulted in Resident #1 being sent to the emergency room for evaluation and treatment. Resident #1, a male with a history of pulmonary hypertension, endocarditis, type 2 diabetes, end-stage renal disease, and nicotine dependence, was admitted to the facility with no cognitive impairment as indicated by a BIMS score of 14. Despite this, the facility did not adequately monitor or restrict access to hazardous substances, as evidenced by the presence of rubbing alcohol in his room. The resident admitted to drinking the rubbing alcohol with the intention of getting drunk, which led to his hospitalization for alcohol poisoning. Interviews with facility staff revealed a lack of consistent monitoring and enforcement of policies regarding non-permitted items. The Medical Records staff and ADON were aware of the regulations but failed to prevent the re-entry of rubbing alcohol into Resident #1's environment. The facility's procedures for checking and inventorying residents' belongings upon admission were not effectively implemented, as Resident #1's inventory sheet did not list rubbing alcohol, and staff were unaware of its presence until the incident occurred.
Failure to Timely Report Alleged Abuse Involving Rubbing Alcohol Ingestion
Penalty
Summary
The facility failed to report an alleged violation involving a resident who was found with altered mental status and a partially empty bottle of rubbing alcohol within the required two-hour timeframe. The incident occurred when the resident was discovered with a 1/4 empty bottle of rubbing alcohol and exhibiting signs of altered mental status. Despite the urgency of the situation, the facility did not report the incident to the appropriate authorities until more than two hours after the discovery. The resident involved was a male with a history of pulmonary hypertension, endocarditis, type 2 diabetes mellitus, peripheral vascular disease, end-stage renal disease, and nicotine dependence. He was initially admitted to the facility with no cognitive impairment, as indicated by a BIMS score of 14. The resident was found with rubbing alcohol, which he reportedly used for his dry legs, and later admitted to drinking it in an attempt to get drunk. This led to his hospitalization for alcohol poisoning. Interviews with facility staff revealed a lack of clarity and adherence to the reporting protocol. The ADON was informed of the situation by the dialysis center and assessed the resident, but the report to the state agency was delayed. The Interim Administrator/Clinical Resource, responsible for reporting, did not act within the two-hour window, citing hearsay information as a reason for the delay. This failure to report promptly could have placed residents at risk for undetected abuse, neglect, and a decline in their sense of safety and well-being.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 180 citations issued within 25 miles in the last 12 months — including the 6 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Harlingen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Treasure Hills Healthcare And Rehabilitation Cente | 0.3 mi | ★★★★★ | 10 | 0 |
| Sun Valley Rehabilitation And Healthcare Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Windsor Atrium | 0.7 mi | ★★★★★ | 17 | 1 |
| Windsor Nursing And Rehabilitation Center Of Harli | 1 mi | ★★★★★ | 4 | 0 |
| Harlingen Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 11 | 1 |
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.