Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Greenhill Villas during CMS and state inspections, most recent first.
A resident with multiple chronic conditions had a valid advance directive on file specifying limitations on life-sustaining treatments, but facility documentation was inconsistent and inaccurately communicated during a hospital transfer. Although the resident’s physician orders and care plan listed him as Full Code, the transfer form incorrectly indicated DNR status, and no copy of the advance directive was sent with EMS or to the hospital. The LVN who completed the transfer form admitted the error and acknowledged that the directive should have been provided, while the responsible party reported having asked staff to send the document. This conflicted documentation and failure to transmit the advance directive occurred despite a facility policy requiring accurate notation and respect for residents’ end-of-life wishes.
Two residents with sleep apnea and multiple comorbidities were receiving ordered nightly BiPAP therapy, documented in their care plans and TARs and confirmed by observation of BiPAP machines at bedside and resident reports of nightly use, but their Annual MDS assessments failed to code non-invasive mechanical ventilation in Section O. MDS staff acknowledged the assessments were incorrect despite long-standing BiPAP use, and leadership stated that MDS data are expected to accurately reflect resident needs and that improper coding could lead to inaccurate treatment plans and billing.
A medication aide failed to remain with a resident and directly observe the administration of prescribed medications, leaving the medication at the bedside and exiting the room before confirming ingestion. The resident, who was cognitively intact and had multiple chronic conditions, did not take the medication in the aide's presence, contrary to facility policy requiring observation during medication administration.
A resident with severe cognitive loss and multiple comorbidities did not receive required incontinent care, turning, or repositioning over two consecutive nights, as confirmed by video footage and staff interviews. This lack of care led to the development and worsening of pressure injuries, including a sacral wound with eschar and heel wounds, which were not promptly identified or treated due to missed assessments and documentation lapses.
Staff failed to use required PPE and implement Enhanced Barrier Precautions for multiple residents with wounds or indwelling devices. Care was provided without gowns or proper signage, and staff were unaware of EBP requirements, despite facility policy mandating these precautions for high-contact care activities.
A resident with dementia and other mental health conditions eloped from a facility and was found 38.1 miles away due to inadequate supervision and failure to monitor exit alarms. The resident bypassed a door requiring a code by holding it for 15 seconds, as instructed by a sign. Staff failed to conduct a thorough search when the alarm sounded, and the facility's elopement prevention policies were not effectively implemented.
A facility failed to provide a resident's medical records to her legal representative after a request was made. The resident, who had multiple health conditions, had her records requested by her family member and the ombudsman during a care plan meeting. The facility required a PHI form and fee before releasing records, which were not completed, leading to the deficiency.
A resident with Alzheimer's disease was incorrectly administered Aricept and Meloxicam during a respite care stay at an LTC facility. The resident was supposed to receive Meloxicam once daily, but it was given three times a day, and Aricept was administered despite being discontinued. The error was due to incorrect entry of medication orders by a nurse, leading to the administration of incorrect medications. The resident's family raised concerns after noticing the resident's lethargy and injuries upon discharge.
A resident with a laceration on the right lower leg did not receive prescribed wound care due to the treatment nurse's failure to transcribe and document the physician's orders in the EMR. This oversight led to the resident's hospitalization with cellulitis. The facility did not assess, document, or monitor the wound properly, and the weekend RN supervisor was unaware of the necessary wound care due to the lack of communication.
A resident's medical confidentiality was breached when a treatment nurse used a personal cell phone to send a picture of the resident's wound to a wound care NP, including the resident's name. This action violated HIPAA regulations as it involved unsecured transmission of sensitive information. The facility lacked a system to monitor such violations, compromising the resident's privacy.
A resident with severely impaired cognition was found with a laceration on her right lower leg, and the incident was unwitnessed. The facility failed to report the injury of unknown origin to the abuse coordinator or HHSC within the required timeframe. The RN attempted to contact the DON, ADON, and Administrator but was unsuccessful. The Administrator learned of the incident the following morning, and no thorough investigation was conducted.
A resident with severe cognitive impairment was found with a laceration and significant blood loss, but the LTC facility failed to report the injury of unknown origin to HHSC within the required two-hour timeframe. The incident was discovered by a CNA, assessed by an RN, and later reported to the DON and Administrator, but not in a timely manner as per facility policy.
A resident with severe cognitive impairment sustained a laceration on her right lower leg, but the LTC facility failed to conduct a thorough investigation. Despite the presence of blood and the resident's inability to recall the incident, the facility did not document how the injury occurred. The RN attempted to report the incident but was unable to reach the necessary personnel, and the Administrator learned of the incident the following day. The facility's policy required comprehensive investigations for such incidents, but this was not followed.
The facility failed to maintain food safety standards by not properly dating, labeling, and sealing food items in refrigerators and freezers, risking food spoilage and contamination. Additionally, a staff member was observed not wearing a required facial hair covering, violating infection control policies.
A CNA failed to adhere to infection control protocols while caring for a resident with MDROs, including not changing gloves, handling dirty linen improperly, and neglecting hand hygiene. The resident had a history of dementia, UTIs, a stage 4 pressure ulcer, and was under enhanced barrier precautions. These lapses were observed despite clear facility policies requiring PPE and hand hygiene to prevent infection spread.
The facility failed to update care plans for two residents after significant changes. One resident returned from the hospital with a urinary catheter, but the care plan lacked interventions for its care, and the resident refused its removal. Another resident was placed on hospice, but this was not reflected in the care plan. Staff interviews revealed a lack of adherence to the facility's policy for revising care plans, potentially impacting residents' well-being.
A resident in an LTC facility was transferred using a mechanical lift without following safety protocols, as the lift's legs were not spread to the wide position and the wheels were not locked. Despite the presence of multiple staff members, the transfer was conducted unsafely, posing a risk to the resident, who was dependent on staff for mobility due to multiple health conditions.
Two residents with urinary catheters in an LTC facility did not receive appropriate care, leading to potential risks of infection. One resident lacked a securement device for her catheter, while another returned from the hospital without specific orders for catheter care. Staff interviews revealed a failure to adhere to physician orders and update care plans, increasing the risk of complications.
A resident with a history of malnutrition and dehydration did not receive the recommended tube feeding, resulting in insufficient caloric intake. The facility also failed to adhere to its weight monitoring policy, missing weekly weigh-ins after the resident's hospital readmission. Staff interviews revealed communication lapses and a lack of follow-through on dietary recommendations, contributing to the resident's continued malnutrition and potential wound deterioration.
A resident with multiple medical conditions, including spastic hemiplegia and paraplegia, experienced verbal abuse by a CNA who told him to 'hush' during an interaction. The resident, who was cognitively intact and dependent on staff for daily activities, felt scared and potentially neglected. The facility's investigation confirmed the incident as verbal abuse, aligning with their policy on abuse and neglect.
A resident with severe cognitive impairment and a history of wandering eloped from a memory care unit due to a malfunctioning door lock system. The facility failed to provide adequate supervision and did not conduct in-service training on elopement response. The resident was found outside by a staff member and returned to the unit. The door system malfunctioned during a power outage, and staff were not positioned to monitor exits, contributing to the incident.
Failure to Accurately Communicate and Transmit Advance Directive During Hospital Transfer
Penalty
Summary
The facility failed to ensure accurate communication of a resident's advance directive information during a transfer to the hospital. An older male resident with Alzheimer's disease, COPD, BPH, hypertension, and hyperlipidemia had a valid Directive to Physicians and Family or Surrogates on file that elected all treatments other than those needed to keep him comfortable be withheld, and specified no ventilator and no feeding tube. Despite this, his physician orders and care plan documented him as Full Code, with interventions including initiation of BLS/CPR if without a heartbeat. On the transfer form completed for his hospital transfer, the section on advance directives incorrectly indicated that the resident had a DNR, which directly contradicted both the Full Code status in his orders and care plan and the content of his directive. A copy of the advance directive was not provided to EMS or hospital staff at the time of transfer. The LVN who completed the transfer form acknowledged that she made an error by marking DNR and confirmed that the resident was Full Code at that time. She also stated she should have provided EMS with a copy of the advance directive to send with the resident. The resident’s responsible party reported having reminded the discharge nurse to send the advance directive with the resident. The physician stated he expected nursing staff to relay appropriate advance directive information and provide hard copies of documents on all transfers. Subsequent observation found the resident in bed with a bandage at the tracheal site indicating intubation tubing had been removed, and he was non-responsive to verbal or tactile stimuli. The facility’s policy on Self Determination End of Life Measures stated that the facility would respect residents’ wishes as outlined in advance directives and that the primary nurse would note resuscitation status on all applicable clinical records and document whether an advance directive had been executed, which was not accurately carried out in this case.
Inaccurate MDS Coding for Non-Invasive Ventilation Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected the use of non-invasive mechanical ventilation (BiPAP/CPAP) for two residents. For the first resident, an older male with obstructive sleep apnea, diabetes mellitus type II, dementia, hypertension, and hyperlipidemia, the Annual MDS documented severe cognitive impairment, mobility limitations, and extensive ADL assistance needs. However, the MDS did not indicate that the resident utilized a non-invasive mechanical ventilator, despite existing documentation elsewhere in the record. Record review for this resident showed a care plan focus area initiated and revised over time that identified the need for BiPAP use related to sleep apnea, and a Treatment Administration Record (TAR) order for BiPAP at bedtime for obstructive sleep apnea. During observation, the resident’s BiPAP machine was seen on the nightstand, and the resident stated he used the BiPAP every night. Interviews with MDS staff confirmed that the Annual MDS was incorrect because the resident had been receiving non-invasive ventilation therapy for an extended period according to the care plan. For the second resident, an older male with sleep apnea, diabetes mellitus type II, end stage renal disease, atrial fibrillation, hypertension, congestive heart failure, and hyperlipidemia, the Annual MDS documented intact cognition, lower extremity range of motion impairment, wheelchair use, and extensive assistance needs with ADLs. As with the first resident, the MDS did not indicate use of a non-invasive mechanical ventilator. The care plan documented a focus area for BiPAP use related to sleep apnea, and the TAR contained an order for BiPAP every night shift. Observation showed the BiPAP on the nightstand, and the resident reported staff applied it every night. MDS staff and the Regional Reimbursement Nurse acknowledged that the non-invasive ventilator item on the MDS had not been correctly coded, despite the residents’ ongoing BiPAP therapy, and the DON and Administrator stated that the MDS is expected to accurately reflect resident needs and that inaccurate coding could result in improper treatment plans and billing.
Failure to Ensure Direct Observation of Medication Administration
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to ensure a resident took her prescribed medications during a medication pass. The aide entered the resident's room, handed her a medication cup, and was told by the resident that she would take the medication later. Despite this, the aide instructed the resident to take the medication immediately but then left the room before confirming that the medication was actually taken. Video evidence confirmed that the aide left the medication at the bedside and exited the room prior to the resident ingesting the medication. The resident involved was a cognitively intact female with multiple diagnoses, including COPD, diabetes, hypertension, peripheral vascular disease, and congestive heart failure. Facility records indicated that the resident had impaired visual function and required assistance with activities of daily living. The facility's medication administration policy required staff to observe residents taking their medications and to monitor for adverse effects, contraindications, and effectiveness, which was not followed in this instance.
Failure to Provide Timely Incontinent Care and Repositioning Leads to Worsening Pressure Injuries
Penalty
Summary
A resident with a history of atherosclerotic heart disease, anxiety, depression, and hypertension, and who was assessed as having severe cognitive loss, was admitted to the facility and identified as being at risk for pressure ulcers. The resident's care plan included interventions for bladder incontinence and required that incontinent care be provided at least every two hours. Despite these interventions, the resident did not have any unhealed pressure ulcers at admission, and initial assessments indicated only redness to the buttocks with barrier cream applied. On two consecutive nights, certified nursing assistants (CNAs) failed to provide required incontinent care, turning, and repositioning for the resident, as confirmed by video footage showing no such care was given during overnight shifts. Staff interviews revealed that the CNAs were either short-staffed or too busy to provide care, and neither the charge nurse nor other staff were notified of the missed care. As a result, the resident's skin condition deteriorated, with a hospice nurse later identifying a stage II sacral wound, which progressed to include a right heel abrasion, a left heel blister, and a sacral wound with eschar within days. Documentation and progress notes were also missing for the period when the wounds developed. The facility failed to identify the new wounds prior to the hospice nurse's visit and did not initiate wound care orders promptly after the wounds were discovered. There was no system in place to ensure that CNAs were consistently turning and repositioning residents, and the charge nurses did not adequately monitor or document these interventions. The facility's own policy required regular skin assessments, timely notification of changes, and documentation, but these procedures were not followed, resulting in the resident's wounds worsening.
Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Observations revealed that a treatment nurse did not use the required personal protective equipment (PPE) beyond gloves while providing wound care to a resident with a sacral wound. Additionally, certified nursing assistants (CNAs) provided incontinent care to the same resident without using gowns or other PPE, and both staff members were unaware of the EBP requirements. There was also no EBP signage or PPE cart visible outside the resident's room during these care activities. Further review showed that two other residents, both with conditions requiring EBP (such as open wounds or indwelling catheters), also did not have EBP signage or PPE available outside their rooms. Staff members providing care to these residents were not informed about the need for EBP, and one CNA reported not receiving a report from the previous shift regarding necessary precautions. The facility's policy required the use of gowns and gloves for high-contact care activities for residents with wounds or indwelling devices, but this was not consistently communicated or implemented. Interviews with the Director of Nursing (DON) and the Administrator confirmed that it was their expectation and responsibility to ensure proper signage, PPE availability, and staff awareness for residents requiring EBP. However, these measures were not in place for the residents reviewed, resulting in a failure to follow the facility's own infection control policy and potentially increasing the risk of communicable disease transmission among residents and staff.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure a resident environment free from accident hazards and did not provide adequate supervision to prevent accidents, specifically for a resident who was at high risk for elopement. This deficiency resulted in the resident leaving the facility unsupervised and being found at a gas station 38.1 miles away. The resident, who had a history of dementia with behaviors, delusional disorder, hallucinations, psychosis, depression, and anxiety, was able to leave the facility through a door that required a code to exit, which she managed to bypass by holding the door for 15 seconds as instructed by a sign. The resident's elopement risk assessments indicated an increasing risk score, yet the facility did not implement sufficient measures to prevent her from leaving. On the day of the incident, the resident was last seen walking around the dining room before disappearing. Staff failed to conduct a thorough search of the surrounding area when a door alarm sounded, and it was later discovered that the resident had left through the laundry room door. The facility's response was inadequate as they did not immediately realize the resident was missing, and the door alarm was not properly investigated. Interviews with staff revealed a lack of awareness and training regarding the resident's elopement risk and the proper response to door alarms. The facility's policies on elopement prevention and response were not effectively implemented, as evidenced by the staff's failure to monitor the resident adequately and the lack of immediate action when the door alarm was triggered. The resident was eventually found in another town, having been transported by an unknown individual, highlighting the serious oversight in supervision and security measures at the facility.
Failure to Provide Resident's Medical Records
Penalty
Summary
The facility failed to provide a resident's legal representative with access to the resident's medical records upon request, as required by regulations. The deficiency involved Resident #2, an elderly female with multiple diagnoses including type 2 diabetes, Alzheimer's disease, heart failure, and anxiety. The resident's family member and the ombudsman requested access to the medical records during a care plan meeting, but the facility did not fulfill this request. The facility's process required the completion of a PHI form and payment of a fee before releasing medical records. Despite the ombudsman providing a copy of the state regulation indicating her access rights, the facility insisted on the completion of their form. The family member did not return the signed form, relying on the ombudsman to handle the request. Consequently, the records were not released, and the facility maintained that the family had the right to the records if they followed the policy. Interviews with facility staff, including the MDS Coordinator, DON, and Medical Records personnel, confirmed that the request for records was acknowledged but not processed due to the lack of a completed PHI form. The facility's policy required verification of the requestor's identity and legal authority, completion of the authorization form, and payment of a fee before records could be released. This process was not completed, resulting in the failure to provide the requested records.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident during their stay for respite care. The resident, who had severe cognitive impairment due to Alzheimer's disease, was incorrectly administered Aricept and Meloxicam after these medications were discontinued. The resident was supposed to receive Meloxicam once daily, but it was administered three times a day, and Aricept was given despite being discontinued. This error was discovered after the resident's family raised concerns following the resident's return home. The medication errors were attributed to incorrect entry of medication orders into the system by a nurse who was in a hurry and did not verify the orders properly. The charge nurse was responsible for entering the orders into the system, but the process was not followed correctly, leading to the administration of incorrect medications. Interviews with staff revealed that the medication aide and nurses were aware of the five rights of medication administration, but the error still occurred due to the initial incorrect entry of orders. The resident's family reported that the resident had a fall during their stay, resulting in a bruise and a black eye, and upon discharge, the resident was lethargic and unable to open her eyes or transfer into a vehicle. The facility's Director of Nursing acknowledged the importance of correct order entry to ensure residents receive the care they require. The error was discovered through an audit, and the facility took steps to address the issue, including terminating the nurse responsible for the error.
Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The treatment nurse did not transcribe the physician's orders for wound care for a resident's right lower shin, nor did they provide the necessary wound care from August 23 to August 31, resulting in the resident's hospitalization with a diagnosis of cellulitis. The resident had a history of type 2 diabetes mellitus and a laceration on the right lower leg, which required specific wound care that was not administered as ordered. The facility also failed to assess, document, and monitor the resident's wound properly. The treatment nurse did not document the wound care in the electronic medical records (EMR) and failed to notify the charge nurses, ADON, and DON of the wound care orders. This lack of documentation and communication led to the wound care not being performed over the weekend, as the weekend RN supervisor was unaware of the orders. The wound care NP had provided specific treatment orders via text, which were not entered into the system, leading to a lack of proper wound management. Interviews with facility staff revealed that the treatment nurse admitted to forgetting to input the orders into the EMR and acknowledged the risk of infection due to this oversight. The DON was unaware of the orders not being placed in the system and stated that the treatment nurse was responsible for ensuring the implementation of wound care orders. The facility's policy required wound assessments and treatment plans to be documented promptly, which was not adhered to in this case.
Removal Plan
- Resident #1 has returned to the facility and all wound treatment orders initiated. Treatment nurse completed wound care per physicians' orders.
- All residents in the facility received a skin assessment by the ADON/Tx Nurse/Regional compliance nurse/MDS nurse. No new skin issues identified.
- Wound treatment records audited to verify that all residents with skin conditions orders are in place and match current wound care physician orders. Completed by ADON and Treatment nurse.
- A 1:1 in-service was completed by the Regional Compliance Nurse with the DON/ADON/Tx Nurse on entering orders for treatments in EMR, completing all ordered treatments and documenting in EMR, and Assessing and reporting new or worsened wounds to the physician and family and documenting notification in EMR.
- The Medical Director was notified of the immediate jeopardy situation.
- An ADHOC QAPI meeting was conducted to include the IDT Team to discuss the immediate jeopardy and subsequent plan of removal.
- DON or designee will monitor clinical alerts daily for any new skin issues and follow up to assure all skin conditions proper orders, assessments, and notifications in place in EMR.
- Skin integrity Management policy reviewed and no changes made to current policy.
- All charge nurses were in-serviced on entering new physicians' orders in EMR without delay, completing all orders treatments and documenting treatments in EMR, and new or worsened wound should be assessed, and the physician and family notified and documented in EMR. All staff not present for in-servicing will not be allowed to resume their scheduled assignment until in-serviced. All new hired staff will be in-serviced during facility orientation. All agency staff will be in-serviced prior to start of their shift. Verification of comprehension will be made through a post test for topics in-serviced on.
HIPAA Violation Due to Use of Personal Device for Medical Communication
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records, specifically for a resident with type 2 diabetes mellitus and a laceration on the right lower leg. The treatment nurse used a personal cell phone to send a picture of the resident's wound, along with the resident's name, to the wound care nurse practitioner (NP) to request treatment orders. This action was identified as a violation of HIPAA regulations, as it involved the use of an unsecured telephonic device to transmit sensitive medical information. The incident was discovered during a state surveyor's intervention, and the facility administrator acknowledged the lack of a system to oversee and monitor HIPAA violations. The facility's policy on resident rights emphasizes the importance of treating residents with respect and maintaining the confidentiality of their personal and medical records. However, the absence of a secure method for transmitting medical images led to the breach of the resident's privacy and confidentiality.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse and neglect policy and procedure regarding the reporting of an injury of unknown origin for a resident. The policy required facility employees to report any allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injury of unknown source to the facility administrator, who would then report to the Health and Human Services Commission (HHSC) if the incident met certain criteria. However, in the case of a resident with a laceration on the right lower leg, the facility did not follow these procedures. The resident, who had a severely impaired cognition and required assistance with daily activities, was found with a laceration on her right lower leg while sitting in her wheelchair. The incident was unwitnessed, and the resident was unable to recall how the injury occurred. Despite the severity of the situation, the incident was not reported to the abuse coordinator or HHSC within the required two-hour timeframe. The RN who assessed the resident attempted to contact the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator but was unsuccessful. The Administrator, who was the facility's Abuse Coordinator, only learned of the incident the following morning during a meeting. Although the ADON and Administrator later obtained statements from the resident and her family, no thorough investigation was conducted. The failure to report the incident in a timely manner and conduct a proper investigation could potentially place the resident at risk for infection, abuse, or neglect.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident's laceration to the right lower leg to the Health and Human Services Commission (HHSC) within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment, as indicated by a BIMS score of 5, who was found with a laceration and a significant amount of blood in her room. Despite the resident's inability to recall how the injury occurred, the facility did not report the incident immediately as required by their policy. The incident was first discovered by a CNA who heard the resident calling for help and found her with a bleeding leg. The CNA alerted an RN, who assessed the situation and called EMS for further evaluation. The RN attempted to contact the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator but was unsuccessful. The DON was notified via text but did not see the message until the following morning. The Administrator, who is the facility's Abuse Coordinator, was informed of the incident during a morning meeting the next day. The facility's policy requires that any allegations of abuse, neglect, or injuries of unknown origin be reported to the administrator and then to HHSC within two hours if they involve abuse or result in serious bodily injury. However, this protocol was not followed, as the incident was not reported within the required timeframe. The failure to report timely was acknowledged by the DON and the Administrator, who both emphasized the importance of timely reporting to ensure resident safety and to verify if anyone was connected to the abuse.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident involving a resident who sustained a laceration on her right lower leg. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was found with a significant amount of blood around her after calling for help. Despite the presence of blood and the resident's inability to recall the incident, the facility did not document how the injury occurred or conduct a comprehensive investigation. The incident was initially reported by a CNA who found the resident and called for an RN to assess the situation. The RN attempted to contact the DON, ADON, and Administrator but was unsuccessful. The RN recognized the importance of timely reporting to ensure resident safety but was unable to reach the necessary personnel. The DON was informed of the incident via text the following morning, acknowledging that the incident should have been reported to the state within two hours due to its unwitnessed nature and the resident's inability to explain what happened. The Administrator, who also served as the Abuse Coordinator, learned of the incident during a morning meeting the day after it occurred. She admitted that a thorough investigation was not completed and emphasized the importance of timely reporting to prevent potential risks such as infection, abuse, or neglect. The facility's policy required comprehensive investigations for all allegations of abuse, neglect, and injuries of unknown origin, but this protocol was not followed in this case.
Food Safety and Infection Control Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was noted that several food items in Refrigerator #1, Refrigerator #2, and Freezer #2 were not properly dated or labeled. Specifically, various food items such as a thick yellow food item, round purple food items, and red food items were found without any date or label. Additionally, a large plastic bag containing an unknown meat in Freezer #2 and a round dark brown patty in Refrigerator #1 were also not labeled. This lack of proper labeling and dating could lead to food spoilage and potential health risks for residents. Further observations revealed that food items in Freezer #1 were not properly sealed, with an open bag of onion rings exposed to air and an onion ring found outside the bag. This improper sealing could result in food contamination and freezer burn, compromising the quality and safety of the food served to residents. The facility's policy mandates that open packages of food should be stored in closed containers or sealed bags and dated, which was not followed in these instances. Additionally, the facility did not ensure that all kitchen staff adhered to infection control policies. Dishwasher E was observed handling silverware near the steam table without wearing a facial hair covering, despite having a beard and mustache. This was acknowledged by the Dietary Manager, who stated that all male staff were required to wear facial hair coverings to prevent hair from contaminating food or dishes. The lack of compliance with these infection control measures poses a risk of food contamination, potentially affecting the health of the residents.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in protocol by a certified nursing assistant (CNA) while providing care to a resident. The resident, who had a history of dementia, urinary tract infections, a stage 4 pressure ulcer, diabetes, and urine retention, was under enhanced barrier precautions due to the presence of multidrug-resistant organisms (MDROs). Despite these precautions, the CNA did not adhere to the required infection control measures, such as changing gloves after providing incontinent care and before touching clean items, handling dirty linen appropriately, and performing hand hygiene before handling the resident's personal items. During an observation, the CNA was seen entering the resident's room without donning a gown, which was required under the enhanced barrier precautions. The CNA proceeded to provide incontinent care without changing gloves between tasks, allowing her clothing to come into contact with the resident, and handling soiled items without proper hand hygiene. These actions were contrary to the facility's infection control policies, which required the use of personal protective equipment (PPE) and hand hygiene to prevent the spread of infections. Interviews with the CNA and facility staff revealed a lack of awareness and adherence to the enhanced barrier precautions. The CNA admitted to not following the required protocols, which could lead to cross-contamination and increased risk of infection for the resident and others. The facility's policies clearly outlined the need for PPE and hand hygiene, yet these were not followed, indicating a significant deficiency in the infection control program.
Failure to Update Care Plans for Residents with Significant Changes
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for two residents. Resident #25's care plan was not updated after returning from the hospital with a urinary catheter. Despite having a urinary catheter, the care plan did not include any interventions for its care. Additionally, there were no orders for the urinary catheter, and the resident refused to have it removed, which was not documented in the care plan. Interviews with staff revealed that the responsibility for updating care plans lay with the nursing staff, ADON, or DON, but this was not done, leading to an increased risk of infection or neglect. Resident #34's care plan was not updated to reflect that the resident was placed on hospice. Although the resident was receiving hospice services, this was not documented in the care plan. The MDS nurse acknowledged missing this update, and the ADON confirmed that care plans should communicate the care and needs of each resident, including hospice services. The lack of documentation in the care plan could lead to a failure in providing individualized care. The facility's policy indicated that care plans should be reviewed and revised after each assessment, including significant changes. However, this was not adhered to, resulting in deficiencies in the care plans for both residents. The failure to update care plans with necessary interventions and services could potentially impact the residents' ability to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Unsafe Mechanical Lift Transfer in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision during a mechanical lift transfer for a resident. The resident, who was cognitively intact and dependent on staff for transfers, was transferred using a mechanical lift by CNA A, assisted by CNA B and CNA H. During the transfer, the mechanical lift's legs were kept in a narrow position, and the wheels were not locked, which could have led to instability and potential injury. The resident involved was an elderly individual with multiple diagnoses, including osteoarthritis, chronic pain, depression, hemiplegia, and high blood pressure. The resident was dependent on staff for transfers and used a wheelchair for mobility. Despite the resident's cognitive awareness and the presence of multiple staff members during the transfer, the procedure was not conducted according to safety protocols, as the mechanical lift's legs were not spread to the wide position, and the wheels were not locked. Interviews with the staff involved, including CNA A and CNA B, revealed a lack of adherence to the facility's mechanical lift policy. Both CNAs acknowledged the importance of locking the wheels and spreading the lift's legs to the wide position for stability. The Assistant Director of Nursing and the Regional Compliance Nurse confirmed that the staff did not follow the expected procedures, which could have resulted in the mechanical lift tipping over, posing a risk to the resident's safety.
Failure to Provide Proper Catheter Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents with urinary catheters, leading to potential risks of urinary tract infections and other complications. Resident #17, who had a history of urinary tract infections and other medical conditions, was observed without a securement device for her indwelling urinary catheter. Despite having an order for a catheter strap, the staff member providing care was unaware of its necessity and did not report its absence. This oversight left the catheter unsecured, increasing the risk of dislodgement and infection. Resident #25, who was admitted to hospice care, returned from the hospital with a new urinary catheter but lacked specific orders for its care. The resident's care plan did not include interventions for the catheter, and there was no documentation of catheter care in the treatment administration record. Despite the resident's refusal to have the catheter removed, the facility did not update the care plan or obtain necessary orders from hospice, leaving the resident at risk of inadequate care and potential infection. Interviews with facility staff, including a Licensed Vocational Nurse and the Assistant Director of Nursing, revealed a lack of adherence to physician orders and care plan updates. The staff acknowledged the importance of securement devices and proper catheter care to prevent complications but failed to implement these measures. The facility's policy and CDC guidelines emphasize the need for securement devices and documented care to prevent catheter-associated urinary tract infections, which were not followed in these cases.
Failure to Maintain Nutritional Parameters and Weight Monitoring
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, identified as Resident #66, who was reviewed for nutrition. The resident, who had a history of dehydration, protein-calorie malnutrition, diabetes, and required a gastrostomy tube for feeding, did not receive the recommended tube feeding as per the dietician's orders. The dietician had recommended Glucerna 1.2 at 474 ml four times a day to meet the resident's caloric needs of 2275 calories per day. However, the facility administered only 355 ml four times a day, providing only 1704 calories, which was insufficient for the resident's needs. Additionally, the facility did not adhere to its weight policy for Resident #66, who experienced a significant weight loss of 15 pounds from admission to readmission. The resident was not weighed weekly for four weeks after readmission from the hospital, as required by the facility's policy. Furthermore, no weight was obtained within 24 hours after the resident's readmission from the hospital, which was another deviation from the facility's policy. This lack of monitoring and follow-up on the resident's weight could have contributed to the resident's continued malnutrition and potential deterioration of pressure ulcers. Interviews with facility staff, including the dietician, LVN, ADON, and Regional Compliance Nurse, revealed a lack of communication and follow-through on dietary recommendations and weight monitoring. The dietician's recommendations were not implemented, and there was confusion about who was responsible for updating resident orders and ensuring weights were completed. The facility's policy required weights to be obtained and documented at admission, readmissions, and monthly, with more frequent monitoring for residents with significant weight changes or unresolved pressure ulcers. The failure to follow these protocols placed the resident at risk for further weight loss, dehydration, and wound deterioration.
Verbal Abuse Incident by CNA in LTC Facility
Penalty
Summary
The facility failed to ensure the right of a resident to be free from abuse and/or neglect, specifically verbal abuse, by a Certified Nursing Assistant (CNA). The incident involved a male resident with multiple medical conditions, including spastic hemiplegia, neuromuscular dysfunction of the bladder, depressive disorder, anxiety disorder, paraplegia, and multiple sclerosis. The resident was cognitively intact, as indicated by a BIMS score of 15, and was totally dependent on staff for activities of daily living. The deficiency occurred when CNA A told the resident to 'hush' in a non-threatening manner during an interaction where the resident was upset and had requested assistance. This interaction was perceived by the resident as verbal abuse, leading to feelings of fear and potential neglect of care. The investigation revealed that CNA A had a history of multiple infractions and was aware of the facility's policies and procedures, as indicated by her signature on the Employee Handbook Acknowledgement form. During interviews, other staff members confirmed hearing CNA A tell the resident to 'hush,' and the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator in Training all agreed that such behavior could be considered verbal abuse. The facility's policy on abuse and neglect defines verbal abuse as any use of language that includes disparaging and derogatory terms to residents, which aligns with the actions of CNA A in this incident.
Resident Elopement Due to Door Lock Malfunction
Penalty
Summary
The facility failed to ensure adequate supervision and safety for a resident in the memory care unit, leading to an elopement incident. The resident, a female with severe cognitive impairment and a history of wandering, was able to exit the memory care unit due to a malfunction with the door locking system. The resident was found outside the facility by a laundry aide, who then returned her to the unit. At the time of the incident, the doors were not locking properly, and staff were not adequately monitoring the exits. The resident's care plan identified her as at risk for wandering, with interventions such as disguising exits and distracting her with pleasant diversions. However, these measures were not effectively implemented, as evidenced by the resident's ability to leave the secure unit. The facility's failure to monitor and supervise the resident, particularly during the door system malfunction, contributed to the elopement. Interviews with staff revealed that there was a lack of awareness and response to the door system's failure, and no staff member was positioned to monitor the exits during the incident. Additionally, the facility did not conduct an in-service training on elopement response prior to the incident, which may have contributed to the inadequate supervision. The maintenance supervisor acknowledged that the door system could go offline during power outages or fire alarms, but there was no immediate inspection or resolution to prevent future occurrences. The lack of a timely and effective response to the door malfunction and the absence of a comprehensive elopement response plan highlight the facility's deficiencies in ensuring resident safety.
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 55 citations issued within 25 miles in the last 12 months — including the 2 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 Mount Pleasant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Mount Pleasant | 1.4 mi | ★★★★★ | 10 | 0 |
| Pleasant Springs Healthcare Center | 1.6 mi | ★★★★★ | 13 | 1 |
| Avir At Pittsburg | 13.9 mi | ★★★★★ | 13 | 0 |
| Cypress Springs Wellness & Rehabilitation | 14.7 mi | ★★★★★ | 4 | 0 |
| Capstone Healthcare Of Daingerfield | 18.8 mi | ★★★★★ | 1 | 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.