Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Harmony Care At Beaumont during CMS and state inspections, most recent first.
A facility failed to supervise residents while smoking and failed to keep smoking areas safe and an unoccupied room free of unsecured chemicals. A resident with aphasia and contractures, a resident with ESRD and heart disease, and a resident with stroke-related deficits were observed smoking without staff present or in an undesignated area near a water heater door, while a resident with bipolar disorder and seizures smoked on a secure-unit patio that lacked ash trays, fire safety equipment, and designated signage. An unlocked repair room also contained unsecured spray bottles, including bleach and diluted oven cleaner.
The facility failed to ensure RN coverage for 8 consecutive hours every day. Record review showed no RN coverage on multiple weekend days, and interviews with the HR, DON, and Administrator confirmed the facility had only 2 RNs during that period and they were not covering weekends.
Unsanitary kitchen conditions were observed when an uncovered piece of ham was left out and touching a dirty prep surface, the deep fryer contained brownish-black oil with thick grease and burnt food buildup, and a hallway trash can was overflowing with garbage and boxes piled about 3 feet above it and scattered on the floor. The DM acknowledged the ham should have remained refrigerated and covered, the fryer had persistent buildup, and the trash should have been removed before it overflowed.
Smoking Area Fire Cans Contained Trash: The facility failed to enforce its smoking policy in the main designated smoking area under the car port. An observation found two red fire cans containing cigarette butts, empty cigarette paper boxes, soda cans, chip bags, and other paper and plastic trash. The Maintenance Director said he was responsible for maintaining the smoking areas and emptying the fire cans, and the DON stated staff assisting residents with smoking should ensure there was no trash in the red fire can. The facility policy stated that ashtrays were to be emptied only into designated receptacles.
Call Light Not Left Within Reach After Care: A resident with metabolic encephalopathy, DM2, HTN, and immunodeficiency, and who was dependent for mobility and self-care with moderate cognitive impairment, had her call light left behind a roommate's dresser after brief care was completed. The CNA and LVN both stated they forgot to place the call light within reach, and the resident said she wanted it in her hand so she could call for help. The DON stated staff were expected to ensure residents had their call lights within reach.
MDS Assessment Incorrectly Coded Tobacco Use: A resident with ESRD, heart disease, depression, and anxiety was documented as a tobacco user on his smoking assessment and care plan, and he was observed smoking under supervision in the smoking area. However, his annual MDS was coded as not using tobacco. The MDS nurse said the assessment was miscoded, and the DON stated the MDS was expected to be accurate.
A resident with metabolic encephalopathy, dysphagia, immunodeficiency, and moderate cognitive impairment had a feeding tube noted on the MDS, but the baseline care plan did not include the g-tube. The MDS Nurse said she overlooked adding it, and the DON stated the baseline care plan should contain the information nurses need, including diet, treatments, goals, and interventions.
Failure to Provide Scheduled Shower and Bed Bath Care: A resident with moderate cognitive impairment, diabetes, HTN, and immunodeficiency did not receive scheduled shower/bed bath care and had no documented shower for several days. During observation, staff noted a foul odor, dry skin flakes, and greasy, uncombed hair; the resident said she was not offered an alternative bath day, while the CNA said it was her responsibility to ensure hygiene care was completed and reported if it could not be done.
Pest Control Program Not Effective: Surveyors observed live gnats, flies, and roaches in residents’ rooms. Two residents shared a room with gnats and flies, including a swarm coming from a garbage can, and two other residents shared a room where a large live cockroach and several additional roaches were seen near the beds, wall, dresser, and bathroom. Staff acknowledged the pest issues, noted the rooms needed to be logged or sprayed, and said pest control had been contacted, but live pests were still present during observation.
A cognitively impaired male resident with dementia and Alzheimer’s disease, assessed as severely impaired and rarely understood, was allegedly physically abused by a CNA during incontinence care after refusing care. Another CNA reported that the CNA forcibly pushed the resident onto the bed, manhandled him, hit his arms multiple times with a closed fist, pinned his hands, forcibly removed his shorts and brief, and then allowed him to walk out of the room with his lower body uncovered despite objections. The resident later showed no skin injury and could not recall the incident, while the alleged perpetrator denied the abuse and the reporting CNA and a family member confirmed and acted on the allegations.
Nursing and medication staff failed to consistently sign controlled drug count sheets at the start and end of their shifts, despite facility policy requiring shift-to-shift counting and documentation of controlled substances. Review of controlled drug records over several months showed multiple missing signatures by several LVNs and a medication aide on various halls and shifts, even though some staff reported they had performed the counts but forgot to sign. Leadership acknowledged that all nurses and MAs were responsible for signing the controlled drug sheets and that oversight of these records had been missed, and the report states this failure could place the facility at risk for drug diversion.
A CNA slapped a resident in the face while he was yelling and cursing in bed. The resident had dementia, a prior cerebral infarction, and severely impaired cognition. A LVN witnessed the slap and reported it to the DON, and the CNA then left the room after exchanging words with the resident.
RN Coverage Not Maintained Daily: Surveyors found the facility did not maintain RN coverage for 8 consecutive hours every day and had multiple days across several months with no RN coverage at all. Only the DON and one other RN were employed, and interviews confirmed the DON could not cover all required RN hours. The facility policy required RN supervision at all times and at least 8 consecutive hours of RN services every 24 hours, 7 days a week.
Failure to Submit PBJ Staffing Data: The facility failed to submit direct care staffing information to CMS for a quarterly reporting period. The CASPER PBJ report showed no data submitted for the quarter, and HR stated corporate HR was responsible for the quarterly submission. The Administrator also stated corporate handled the PBJ reports, and the facility did not have a PBJ reporting policy.
Homelike Environment Deficiencies in Secure Unit and Resident Rooms: The secure unit’s TV/dining area had only a plain table, bare walls, and no homelike furniture such as chairs, end tables, or couches. Two resident rooms had missing paint and scratched sheet rock, and one resident room’s shower had a missing drain grate, spider webs, and discolored grout. CNA staff, the maintenance supervisor, and the Administrator all acknowledged the unit and rooms needed repairs, paint, and more homelike features.
Failure to Screen Employees for Abuse History: The facility did not follow its abuse policy for 7 of 7 staff reviewed, including LVNs, CNAs, and a former SW. Employee files had no documentation that previous or current employers were contacted as part of the required screening for abuse, neglect, exploitation, misappropriation of property, or mistreatment. HR confirmed the files lacked this documentation, and the Administrator stated there was no way to show the checks were completed.
Dry pantry food items were found opened, undated, and unsealed, including muffin mix, vanilla wafers, and ribbon pasta. The DM said she did not know when or who opened the items and stated they should have been sealed and dated, while the Administrator said kitchen staff were expected to follow food storage policy and have everything dated.
The facility failed to employ or contract with a required SW. The DON's employee list showed no SW, and the VPO and HR stated the facility had no SW working on-site, by contract, or part-time after the previous SW was terminated. Record review confirmed the former SW had been hired and later terminated, leaving the facility without the required social services coverage.
Walk-in freezer had excessive ice accumulation and was not maintained in safe operating condition. Surveyors observed a freezer temperature of -19 with heavy ice build-up on the top shelf, around the freezer fan cord, along the doorway wall, and on the ceiling, including multiple icicles. The DM said the door was not properly closing and that she had talked to maintenance, but there was no evidence of a repair requisition; the MS said he was not aware of the extent of repairs needed and the maintenance log had no entry for service.
Kitchen Floor Missing Tiles and Grime: The kitchen floor under the back of the stove was observed with 8-10 missing tiles and a buildup of dirt and brown grime around the edges. The DM said the condition had been present for several months and there was no evidence of a repair requisition, while the MS said he was not aware the floor needed repair. The maintenance log had no entry for replacing the tiles, despite the facility policy requiring kitchen areas to be kept clean, safe, and in proper working condition.
Incomplete DNR Documentation: A resident with major depressive disorder, schizoaffective disorder bipolar type, legal blindness, and severely impaired cognition was listed as DNR-NO CPR, and he stated he did not want CPR. However, the OOH-DNR form was incomplete because the physicians’ license numbers and the dates they signed were missing. The ADON, DON, and Administrator acknowledged the form was not valid as completed, and the facility policy required a properly signed DNR order form.
A resident with paranoid schizophrenia, schizoaffective disorder, and psychosis was ordered Abilify for depression and Lexapro for major depressive disorder, but the hospital discharge summary and MDS did not show a diagnosis of depression. The record also lacked behavior monitoring for the Lexapro, and the LVN and DON acknowledged the missing monitoring and diagnosis mismatch during interview.
Inaccurate MDS Tobacco Status: A resident with diagnoses including HTN, major depressive disorder, cerebral infarction, and MI was coded on the admission MDS as not using tobacco, even though the smoker list, safe smoking evaluation, smoking assessment, and resident interview all showed he was a smoker who smoked 2-5 times a day and required supervision while smoking. The MDS Nurse said she missed the smoking documentation, while the AD, DON, and Administrator described their expectations for chart completion and accuracy.
A resident with HTN, major depressive disorder, CVA, and MI was admitted as a smoker, but the admission MDS and baseline care plan incorrectly marked him as not using tobacco. Records showed he smoked 2-5 times daily, could light his own cigarette, and required supervision while smoking, while the resident and AD confirmed he was a smoker.
Incomplete Care Plan for Psychiatric Diagnoses and Psychotropic Medications: A resident admitted with paranoid schizophrenia, schizoaffective disorder, psychosis, and other medical conditions had a care plan that did not address his psychiatric diagnoses or psychotropic meds, despite physician orders for Abilify and Lexapro. The resident reported prior nonadherence, hearing people, and wanting to hurt himself before the hospital restarted his meds; the DON said the diagnoses and meds were missed.
Unlocked medication and treatment carts were left unattended at the nurse station with prescription meds, OTC meds, creams, and bleach wipes inside. An LVN said the carts should have been locked, and the Administrator and DON stated carts are expected to remain locked when not in use or out of the nurse's sight. The facility policy also stated medication carts are kept closed and locked when out of sight of the medication nurse or aide.
Dirty Medication Cart During Medication Pass: The facility failed to keep the Hall 200 med cart clean during med pass. An observation found a buildup of black substance in a drawer where meds were stored, liquid med bottles with spills on the bottles and labels, and a sticky substance on the drawer bottom. An LVN said the cart needed to be cleaned and spills could make labels unreadable. The DON stated med carts should be kept clean and spills cleaned up immediately.
Unsupervised Smoking and Access to Smoking Materials: A resident with severely impaired cognition, high BP, and a seizure disorder was observed walking to the smoking area with a lighter in hand and a cigarette in his mouth while no staff were outside to supervise him. His care plan and safe smoking assessment required supervised smoking and that cigarettes and lighters be kept at the nurses' station, and staff stated smoking materials were supposed to be locked up and residents only smoked at set times with supervision.
Multiple residents experienced abuse and neglect, including unwanted sexual contact, physical and verbal abuse by staff, and repeated resident-to-resident altercations. Incidents involved individuals with significant cognitive and behavioral impairments, and staff failed to intervene effectively to prevent or stop the abuse, despite known risks and documented behavioral histories.
The facility did not update or implement comprehensive care plans for several residents following incidents of aggression and inappropriate sexual behavior. After a male resident inappropriately touched a female resident, his care plan lacked new interventions to prevent further episodes. Similarly, care plans for residents involved in multiple altercations were not revised to address their evolving needs, and there was no effective system to ensure care plan updates were completed after such incidents.
Staff failed to immediately report multiple incidents of alleged abuse and resident-to-resident altercations to the abuse coordinator and state authorities as required. In one case, a staff member witnessed a CNA verbally and physically abuse a resident with cognitive impairments but delayed reporting the incident. In other cases, a nurse did not promptly report a physical altercation between two residents, and another incident involving a resident being scratched and injured was not reported to the administrator until the following day. These lapses resulted in delayed investigations and placed residents at risk.
Multiple rooms were found with dead cockroaches, missing baseboards, stained flooring, cracked and missing tiles, and a bathroom vanity with missing doors. Several residents reported that while their rooms were cleaned, bathrooms were not properly maintained and pest issues persisted. Facility staff, including the Administrator and Maintenance Director, were unaware of these issues, and no maintenance requests had been logged for the observed deficiencies. The Housekeeping Supervisor acknowledged inadequate cleaning practices and the absence of a cleaning checklist.
Two CNAs failed to follow hand hygiene protocols while providing incontinent care to a resident with diabetes, severe obesity, and moderate cognitive impairment. After cleaning the resident, the CNAs did not perform hand hygiene when changing gloves or moving from dirty to clean tasks, only sanitizing their hands after care was completed. Interviews indicated inconsistent understanding and training regarding hand hygiene requirements, despite facility policies and in-services outlining these procedures.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident with multiple complex diagnoses, including quadriplegia, diabetes, and depression, did not have several active conditions accurately documented in the MDS assessment. Staff interviews revealed confusion over responsibility for MDS accuracy, absence of a current MDS Coordinator, and lack of a specific MDS policy, resulting in incomplete assessment of the resident's health status.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Persistent foul odors were present in a hallway and several rooms due to some residents refusing hygiene care, despite repeated cleaning by housekeeping staff. Additionally, a resident's dresser remained in disrepair for months, with broken and missing handles and drawers that would not close, causing frustration for the resident. These issues resulted in an environment that was not consistently clean, comfortable, or homelike.
Surveyors observed live and dead cockroaches and spiders in multiple resident rooms, including pests on furniture and food trays. Several residents reported feeling distressed by the presence of pests. Staff and maintenance confirmed periodic pest sightings and documented ongoing issues in facility logs, despite regular pest control treatments and reporting procedures.
A resident with a history of mental health conditions expressed grievances about specific CNAs providing her care, citing improper care and feeling unsafe. Despite being cognitively intact and able to communicate her needs, the facility failed to adequately address her concerns, as the CNAs continued to be assigned to her. The facility's grievance policy was not followed, leading to unresolved issues and potential decreased quality of life for the resident.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, for 24 out of 45 days reviewed. Interviews and record reviews revealed staffing challenges, including difficulties in hiring RNs and ensuring consistent coverage. The facility's policy requires an RN to be onsite for 8 consecutive hours daily, which was not consistently met.
The facility failed to submit complete and accurate direct care staffing information to CMS for two quarters in 2024. This was due to oversight and confusion about responsibilities among staff, with the Regional Director of Clinical Operations and Corporate HR unaware of the need to ensure timely submission. The facility's policy on reporting staffing information was not followed, leading to the deficiency.
The facility failed to maintain essential equipment safely, including a gas stove with non-igniting burners, a walk-in freezer with a loose gasket, and a milk box with mildew. Additionally, an electric bed in a resident's room had a spliced electrical cord with exposed live wires. The issues were not reported by staff, and the facility's Maintenance Service policy was not followed.
The facility's kitchen had unsanitary conditions, with baking sheets and pans showing buildup, improperly labeled and expired food items, and inadequate sanitizing solution. These issues could risk foodborne illness among residents.
The facility failed to maintain a safe and sanitary environment, with issues in Hall 200, the dining room, and specific resident rooms. Observations showed discolored tiles, missing paint on door frames, and a buildup of debris. An unlocked closet labeled for oxygen storage was found with black fuzzy substance and spider webs. Interviews with staff confirmed awareness of these issues, but no documented plans for repairs were in place.
A facility failed to properly store medications, leaving a resident's nystatin powder unsecured on a bedside table. The resident, who was cognitively intact and had diabetes, was unaware of the powder's presence. Interviews with the ADON and Administrator confirmed that medications should not be left in resident rooms and should be stored in the medication cart when not in use.
Two residents with cognitive impairments were involved in a sexual abuse incident in the dining room, highlighting a failure in the facility's protective measures. Despite having care plans addressing inappropriate sexual behaviors, the incident occurred, indicating a lapse in intervention implementation.
The facility failed to report abuse allegations involving four residents to the State Agency within the required 2-hour timeframe. In one case, a resident with cognitive impairment assaulted another resident, and in another, a resident with mental health issues attacked a fellow resident. Both incidents were documented, but the reports were delayed, violating the facility's policy for immediate notification.
A facility failed to implement the PASRR comprehensive service plan for a resident with schizoaffective disorder, cerebral palsy, dysphagia, and aphasia. The resident was identified as PASRR positive for intellectual disability, and the plan recommended specialized therapies. However, these services were not provided within the required timeframe due to authorization issues, delaying the initiation of therapy services. The facility did not meet PASRR requirements for timely service initiation, as confirmed by the Regional Director of Reimbursement.
A resident with dementia and a history of inappropriate sexual behavior was involved in two incidents of touching female residents' breasts. Despite interventions, the facility failed to ensure adequate monitoring and documentation, leading to an Immediate Jeopardy situation. Staff interviews revealed inconsistencies in awareness and reporting, highlighting deficiencies in the facility's abuse prevention policy.
A resident with a history of inappropriate sexual behavior was not adequately monitored, leading to incidents of inappropriate touching of two other residents. The facility failed to implement its policies for preventing abuse, neglect, and exploitation, resulting in a deficiency. Staff did not maintain one-on-one monitoring or update care plans, despite the resident's known behaviors.
Unsafe Smoking Supervision and Unsecured Chemicals
Penalty
Summary
The facility failed to ensure adequate supervision for residents who smoked and failed to keep smoking areas and an unoccupied room free of hazards. Resident #14, a cognitively intact female with aphasia, dysarthria, dysphagia, muscle wasting and atrophy, and right shoulder and hand contracture, was observed smoking in a motorized wheelchair in an undesignated area outside, within about 10 feet of the door enclosing the water heater. She was unsupervised, had her cigarette close to her pants, and flicked the unextinguished cigarette onto the grass. She stated she knew the area was not a designated smoking spot and said she sometimes smoked there when staff was not outside with her. Her cigarettes were not in the box maintained by staff, and CNA A stated staff was responsible for supervising residents during smoke breaks until the last person was done. Resident #6, who had ESRD, heart disease, depression, and anxiety, was also observed smoking unsupervised in the same undesignated area near the water heater door. He was in a wheelchair, kept his cigarettes with him, and said he did not know who lit his cigarette. He stated he knew the area was not a designated smoking spot and said he had smoked there more than once without staff moving him. Resident #9, who had cerebral infarction, hemiplegia, and hemiparesis and a BIMS of 13, was observed smoking in the designated smoking area under the carport with no staff present. He said it was his choice to keep his cigarettes in his own possession and declined to say who lit his cigarette. Resident #33, who had bipolar disorder and seizures and a BIMS of 00, was observed smoking on the secure unit patio. The patio had cigarette butts on the ground near dry leaves, and there were no ash trays, fire cans, designated smoking signs, fire extinguisher, or fire blanket at the time of the observation. Staff interviews indicated residents on the secure unit smoked there, but the area was not designated for smoking. In addition, an unoccupied room with a closed-for-repairs sign but an unlocked door contained a maintenance cart with two spray bottles hanging on it, including one marked 10% bleach and one unmarked bottle later identified as diluted oven cleaner. Staff stated the chemicals should be secured, and the Maintenance Director immediately marked the bottle and locked the chemicals in the cart.
RN Coverage Not Maintained Every Day
Penalty
Summary
The facility failed to ensure an RN was on duty for 8 consecutive hours 7 days a week for 1 of 3 months reviewed for RN coverage. Record review of the RN time sheets for December 2025 showed no RN coverage on 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, 12/27/2025, and 12/28/2025. During interviews, the HR said corporate submitted information to PBJ and that she would review sign-in sheets and time sheets for those weekend dates, then later stated there were only 2 RNs during that period and they were not covering weekends. The DON said she started in January 2026 and was unaware whether the facility had RN coverage 7 days a week in December 2025, and the Administrator said his expectation was for an RN on duty 8 hours a day every day.
Unsanitary food storage, fryer buildup, and overflowing trash in kitchen
Penalty
Summary
Food was not stored, prepared, and served under sanitary conditions in the kitchen. During observation, an uncovered piece of ham approximately 10 inches by 4 inches was found in the refrigerator area, with half of it touching a prep table that had food particles and pieces of paper that had covered the ham. The DM stated the ham should not have been left out of the refrigerator and uncovered to prevent food borne illness. The deep fryer contained cooking oil that was brownish black and had thick black buildup of burnt grease and food particles around the top of the fryer. The DM stated the oil was changed weekly and as needed, and that sometimes thick burnt-on food particles did not always come off. In the kitchen hallway by the dry storage room, a 64-gallon rolling trash can had bags of garbage and empty boxes piled approximately 3 feet above the can, with garbage and empty boxes also on the floor around it. The DM stated the garbage should have been taken out before running over in the hallway and that the kitchen should be kept clean and free of garbage to prevent food borne illnesses and pest issues.
Smoking Area Fire Cans Contained Trash
Penalty
Summary
The facility failed to ensure that its smoking policies were formulated, adopted, and enforced for the main designated smoking area under the car port. During an observation on 04/13/26 at 12:20 p.m., the two red fire cans in that smoking area were found to contain cigarette butts, empty cigarette paper boxes, empty soda cans, chip bags, and other plastic and paper trash. The Maintenance Director emptied the trash from both fire cans and stated that he was responsible for maintaining the smoking areas, including emptying the red fire cans, and that he had done so that morning. He said he would schedule rounding more frequently and stated that the red fire cans should only contain cigarette butts because other trash could be a fire hazard. During an interview on 04/13/2025 at 4:00 p.m., the DON stated that the designated smoking areas were to be maintained by the Maintenance Director, but all staff who assisted residents to smoke should be mindful of the ashtrays and fire cans and ensure there was no trash in the red fire can. She said she would see to it that staff were re-trained on the smoking policy and maintenance of the smoking areas. Record review of the facility's Smoking Policy-Resident dated 2001 stated that the facility had established and maintained safe resident smoking practices, that metal containers with self-closing cover devices were available in smoking areas, and that ashtrays were emptied only into designated receptacles.
Call Light Not Left Within Reach After Incontinent Care
Penalty
Summary
The facility failed to ensure the nurse call system was accessible for one resident who was reviewed for resident call system use. Resident #30 was a [AGE]-year-old female admitted on 03/20/2026 with diagnoses including metabolic encephalopathy, type 2 diabetes, essential primary hypertension, and immunodeficiency. Her admission MDS indicated a BIMS score of 10, showing moderate cognitive impairment, and Section GG showed she was dependent and required 2 or more staff members for mobility and self-care needs. Her baseline care plan stated she was dependent on staff members for mobility and self-care needs. During an observation and interview on 04/13/2026 at 9:45 a.m., CNA Z was changing Resident #30's brief with assistance from LVN C. After the care was completed, neither staff member placed the resident's call light within reach. The call light was observed behind her roommate's dresser, approximately 10 feet from the resident. During interviews, the resident stated she knew the purpose of the call light, had used it before, and wanted it in her hand so she could call for help. CNA Z and LVN C each stated they forgot to place the call light within reach before leaving the room, and the DON stated she expected all staff entering the room to ensure residents had their call lights within reach. The facility policy stated residents are to be provided with a means to call staff for assistance and that the call system will be in reach of each resident at the resident's preference.
MDS Assessment Incorrectly Coded Tobacco Use
Penalty
Summary
The facility failed to ensure that Resident #6’s annual MDS assessment accurately reflected his tobacco use status. Resident #6 was admitted with diagnoses including end stage renal disease, heart disease, depression, and anxiety. His smoking assessment indicated that he used tobacco and required supervision, and his care plan identified him as a tobacco smoker at risk for injury with interventions related to designated smoking areas, smoking times, and smoking material control. The annual MDS assessment dated [DATE] was coded as indicating that Resident #6 did not use tobacco, even though the resident was observed in the smoking area being supervised while smoking on 04/14/2026 at 1:30 p.m. During interview, the MDS Nurse stated she must have miscoded the annual MDS assessment, and the DON stated the expectation was for the MDS assessment to be accurate. The CMS RAI Manual excerpt included in the record stated that if a resident used tobacco during the 7-day look-back period, the item should be coded yes.
Baseline Care Plan Missing G-Tube Information
Penalty
Summary
The facility failed to develop and implement a baseline care plan for one resident that included the instructions needed to provide effective and person-centered care. Resident #30 was admitted with diagnoses including metabolic encephalopathy, dysphagia, and immunodeficiency, and her admission MDS indicated a BIMS score of 10, showing moderate cognitive impairment. Section K of the MDS also indicated that she had a feeding tube. However, the baseline care plan dated 03/20/2026 did not include the resident's g-tube. Record review of the care plan history showed the next review date for the care plan was 03/27/2026, and it was 18 days overdue on 03/31/2026. During interview, the MDS Nurse stated she overlooked adding the g-tube to the care plan and that it should have been listed, and she acknowledged that the interdisciplinary team provided input but she was responsible for completing the baseline care plan after the assessment was completed. The DON stated the baseline care plan should contain the information a nurse needs to care for a resident, including ADLs, medications, diet, treatments, goals, and interventions, and agreed the care plan was insufficient because the g-tube was not included.
Failure to Provide Scheduled Shower and Bed Bath Care
Penalty
Summary
The facility failed to ensure Resident #30 received appropriate ADL care to maintain good personal hygiene when she did not receive a shower on 04/08/2026, 04/10/2026, and 04/13/2026. Resident #30 was a [AGE]-year-old female admitted on 03/20/2026 with diagnoses including metabolic encephalopathy, type 2 diabetes, essential primary hypertension, and immunodeficiency. Her admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and she was dependent on 2 or more staff members for showering/bathing. The shower/ADL log showed her last bed bath was on 04/06/2026, and there was no documentation of a shower between 04/08/2026 and 04/13/2026. During observation on 04/13/2026, CNA Z and LVN C were changing Resident #30’s brief, and a foul odor was noted in the room after the brief was removed. Resident #30 had white skin flakes around her mouth, cheeks, and forehead, and her hair appeared greasy and uncombed. Resident #30 stated staff did not take her to the shower room and that she had received bed baths by choice, but she also said she went without a bed bath for multiple days and was not offered an alternative day. CNA Z stated she smelled odor from the resident’s body, that hygiene wipes did not remove it, and that soap and water were needed; she also said she was not aware when the resident last had a bed bath and that it was her responsibility to ensure the resident received a shower or bed bath and report if it was not possible. The DON stated it was her expectation that the resident be offered and given a shower or bed bath on assigned days and as needed, and the Administrator stated CNAs were expected to provide showers/bed baths and ADL care on assigned days.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program for residents’ rooms that were observed to have live pests. Resident #6, who had end stage renal disease, heart disease, depression, and anxiety and had an intact BIMS score, and Resident #34, who had epilepsy and bipolar disorder and had moderate cognitive impairment, were observed in a room with gnats and flies. During the observation, there were flies landing on Resident #34’s bed and a swarm of approximately 40 to 50 gnats coming out of the garbage can. Both residents stated they wanted the bugs gone. Staff acknowledged the pest problem in the room. An LVN stated the room had gnats and flies and said it needed to be sprayed, and she would place the room on the pest control list. The maintenance director stated staff should have placed the room number on the pest control log, but they did not. The administrator stated the facility had found the source was a refrigerator and had started a cleaning process. The pest log reviewed for the prior months showed only two reports of flies and gnats in other rooms. The facility also failed to keep another room free of roaches for Resident #23 and Resident #45, both cognitively intact and diagnosed with essential hypertension and hyperlipidemia. During observation, a large live cockroach was seen moving across the room, along with three other live roaches on the floor and wall between the beds and near the dresser and bathroom. Both residents said the roaches kept coming back, and one resident said maintenance was aware of the problem. Staff stated the room had been sprayed about 2 to 3 weeks earlier, that the room was logged for pest control, and that the maintenance director had spot sprayed the room and called pest control back out for service. The maintenance book showed the previous roach log entry was dated 03/08/26.
Failure to Protect Cognitively Impaired Resident From Physical Abuse During Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA. The resident was an elderly male with dementia, anxiety disorder, and Alzheimer’s disease, admitted in February and assessed as severely cognitively impaired with a BIMS score of 3.0 and rarely/never understood. His care plan identified impaired cognition and risk for further decline and injury. Despite these vulnerabilities, the resident was subjected to alleged physical abuse during care provision by a CNA. According to a written statement from another CNA who was present, the incident occurred when the two CNAs attempted to provide incontinence care and the resident refused. After the resident refused care multiple times, the reporting CNA began to leave the room, at which point the other CNA allegedly tried to force the resident onto the bed. The resident became somewhat aggressive, and the CNA allegedly responded by manhandling him, forcing him into the bed, and, when the resident tried to push him away, hitting the resident on the arms approximately three to four times with a closed fist. The CNA then allegedly pinned both of the resident’s hands down, forcibly pulled down his shorts, and ripped off his brief, leaving him lying on the bed with his bottom uncovered. The reporting CNA stated she repeatedly told the other CNA to leave the resident alone and to report the situation, but he refused. When the CNA realized the resident would not allow him to complete the change, he allowed the resident to get up and walk out of the room with no clothing on his lower body. The reporting CNA attempted to stop the resident from leaving the room without pants, but the resident did not allow her to do so. The resident was later assessed multiple times with no skin injuries noted, and he was unable to recall any issues with staff during interview attempts. The alleged perpetrating CNA denied being rough or abusive, while the reporting CNA confirmed her written account during a subsequent phone interview. The resident’s family member later stated she filed charges against the CNA and described being extremely upset and traumatized by the incident.
Incomplete Controlled Drug Count Documentation by Nursing and Medication Staff
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate controlled drug count records and to ensure that all staff responsible for controlled medications signed the controlled drug count sheets as required. Review of controlled drug count sheets for multiple halls and shifts in January and February showed missing signatures from several LVNs and a medication aide on dates and shifts when they had responsibility for the medication carts. The controlled drug count forms stated that signing acknowledges the staff member has counted the controlled drugs on hand and verified that the quantity matches the Controlled Drug Administration Record, but these signatures were absent on numerous shifts across different halls. Interviews with involved nursing staff confirmed that they understood they were responsible for signing the controlled drug sheets at the beginning and end of their shifts to document that they had counted and assumed responsibility for the controlled medications. One LVN stated she had counted the controlled medications on the identified dates but could not recall why she did not sign the sheets, acknowledging that she had been trained to sign when coming on and leaving her shift. Another LVN reported that she had counted the drugs on the listed dates and attributed the missing signatures to forgetting after working double shifts, while stating that her narcotic counts had always been accurate. A third LVN similarly stated she always counted the controlled medications before taking responsibility for them but could not recall why she did not sign on the specified dates. Additional attempts to interview a medication aide and another LVN involved were unsuccessful. The DON stated that nurses and MAs were expected to sign in and out on the controlled drug sheets to ensure controlled drugs were being counted accurately and acknowledged that she and the ADON were responsible for reviewing the sheets twice weekly, but that the sheets had been overlooked while she was adjusting to her role. The Administrator also stated that all nurses and MAs were responsible for signing in and out on the controlled drug count sheets. The facility’s written policy on controlled substances required nursing staff to count controlled medications at the end of each shift, with the oncoming and offgoing nurses counting together and documenting the count, and using these records to reconcile inventory and identify loss or potential diversion. The report notes that this failure could place the facility at risk for drug diversion.
Physical Abuse of a Resident by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse when a CNA slapped him in the face while he was in bed yelling and cursing. The resident was a male with dementia and a prior cerebral infarction, and his quarterly MDS indicated severely impaired cognition with a BIMS score of 03 out of 15, though he had adequate hearing, clear speech, and was usually understood by others and usually made himself understood. An incident report stated that the CNA extended her right hand and smacked the left side of the resident’s face with an open hand while he was sitting in bed. A LVN witnessed the event and reported that the resident and CNA exchanged words afterward, and the CNA then picked up the meal tray and left the room. During interview, the LVN confirmed she saw the CNA slap the resident and then notified the DON. The DON and Administrator later described the incident as an abuse allegation involving the resident and the CNA.
RN Coverage Not Maintained Daily
Penalty
Summary
The facility failed to ensure an RN was on duty for 8 consecutive hours every day and failed to maintain RN coverage 7 days a week for multiple months reviewed. Surveyors reviewed RN time sheets and found days in April, May, June, July, August, September, October, and November 2025 with no RN coverage at all, and other days when RN R worked only partial shifts that did not provide 8 consecutive hours of RN coverage. The report states the facility had only two RNs employed: the DON and RN R. During interviews, the Administrator explained that the Exel form listed raw hours as potential hours and work hours as actual hours worked, and that if no hours appeared under work hours then the nurse did not work. The DON said she tried to cover as much of the RN hours as possible but could not do it all. The Administrator later acknowledged there was an issue with RN coverage and stated there should be an RN on duty 8 hours a day every day. The facility policy reviewed stated that nursing services shall be under the direct supervision of an RN or LPN/VN at all times and that an RN provides services at least eight consecutive hours every 24 hours, seven days a week.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to submit direct care staffing information to CMS for the 3rd quarter of fiscal year 2025 based on payroll and other verifiable and auditable data in the required uniform format. Record review of the CMS PBJ Staffing Data Report (CASPER Report 1705D FY Quarter 3 2025, April 1-June 30) showed "Failed to Submit Data for the Quarter" and "No Data Submitted for the Quarter." During interviews, HR stated that the corporate HR department was responsible for submitting staffing data to CMS every quarter, and the Administrator stated he understood corporate handled the PBJ reports. A policy regarding PBJ reporting was requested, but the facility did not have a PBJ reporting policy. The facility's Civil Rights form dated 12/03/25 listed staffing numbers including 2 RNs, 9 LVNs, 20 direct care staff, 9 dietary, 8 housekeeping and laundry, and 6 all others.
Homelike Environment Deficiencies in Secure Unit and Resident Rooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in the secure unit and in two resident rooms reviewed for homelike environment. During observation, the TV room and dining area in the secure unit had a plain table with no placemats, tablecloth, decorations, chairs, end tables, or couches, and the walls were bare and not homelike. The report also noted that two resident rooms had areas of missing paint by the beds and scratches on the sheet rock. In one resident room, the shower had a missing grate over the drain, leaving a 3-inch hole, spider webs were present in both corners of the shower area, and the grout was discolored and thick along the base of the shower walls. During interview, CNA staff stated the secure unit needed homelike furniture and that the resident rooms needed to be painted, while the maintenance supervisor stated the walls needed repairs and paint and that the grout would have to be removed. The Administrator stated the secure unit needed to be updated with paint and furniture, and the facility’s Homelike Environment policy required a safe, clean, comfortable, and homelike environment with inviting colors and decor.
Failure to Screen Employees for Abuse History
Penalty
Summary
The facility failed to implement its written abuse policy that prohibits mistreatment, neglect, abuse, misappropriation of property, exploitation, and neglect for 7 of 7 staff reviewed for abuse: LVN A, LVN F, Former SW, CNA B, CNA G, CNA M, and CNA Q. The policy stated that the facility must screen potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreating residents, including attempting to obtain information from previous employers and/or current employers and checking with the appropriate licensing boards and registries. Record review showed that the employee files for LVN A, LVN F, Former SW, CNA B, CNA G, CNA M, and CNA Q contained no documentation of information from previous employers and/or current employers. The listed employees had hire dates of 06/26/25, 09/18/25, 07/10/25, 06/11/25, 11/12/25, 09/11/25, and 10/16/25, respectively. During interview, HR stated there was no documentation in the employee files showing the previous or current employers were contacted, and the Administrator stated that if there was no documentation in the files, there was no way to show the checks were done.
Dry pantry food items were left unlabeled, undated, and unsealed
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During an observation of dry storage on 12/01/2025 at 8:10 AM, surveyors found 2 large plastic gallon zipper top bags each containing an opened and used original container bag of cornbread and muffin mix with no use-by date or open date, 1 11-ounce box of vanilla wafers with the bag ripped open in the original box and not sealed with no use-by date or open date, and 1 opened and used 12-ounce bag of Best Choice ribbon pasta that was not sealed and had no use-by date or open date. During an interview on 12/01/2025 at 8:20 AM, the DM said she did not know when or who opened the muffin mix, wafers, or pasta and stated she would discard them. She said all products should have a received date or used-by date and should be sealed, and that it was the responsibility of dietary staff to ensure products were labeled and stored correctly. She also stated she was responsible for monitoring kitchen staff and ensuring products were labeled, sealed, and dated, but had not checked that day because of the survey. The Administrator later stated his expectation was for kitchen staff to follow food storage policies and that everything be dated, and that the DM was responsible for monitoring compliance.
Missing Required Social Worker
Penalty
Summary
The facility's governing body failed to operate and provide services in compliance with applicable Federal, State, and local laws, regulations, and codes because it did not employ or contract with a Social Worker as required by Texas regulations. Record review of the employee list provided by the DON on 12/01/25 showed no SW listed. During interviews on 12/01/25, the VPO stated the facility did not have a SW working either on contract or part-time and had not had one for a couple of weeks, and HR stated the previous SW had been terminated a couple of weeks earlier. Record review of the former SW's employee file showed she was hired on 07/10/25, and an Employee Change of Status form dated 11/18/25 showed she was terminated on 11/18/25. Texas Administrative Code 554.703(a)(2) requires a facility of 120 beds or less to employ or contract with a qualified social worker to provide social services sufficient to meet resident needs.
Walk-in freezer had excessive ice accumulation and was not maintained in safe operating condition
Penalty
Summary
The facility failed to maintain the walk-in freezer in safe operating condition. During observation on 12/01/25 at 9:00 a.m., the freezer temperature was -19, but there was excessive ice build-up on the top shelf and around the electrical cord of the freezer fan, with the cord drooping under a large block of ice. Ice was also accumulated on the left side of the doorway wall entering the freezer, with 30 icicles about 1-inch thick and 6 inches long covering the upper left area of the wall, and multiple frozen water drops were observed on the ceiling. During interview, the DM said the freezer door was not properly closing and causing icicles to form on the wall and ceiling, and that a couple of weeks earlier the freezer door would not seal and the MS had replaced the rubber seal along the bottom. The DM said she had talked to maintenance about the freezer but had no evidence that a repair requisition had been made, and the dietary department did not have its own log. The MS said he was not aware of the extent of repairs needed, said the DM had not made him aware of the freezer condition, and stated the freezer needed to be replaced because it was old and he could not find or buy the needed part. The maintenance log had no entry to service the walk-in freezer.
Kitchen Floor Missing Tiles and Grime
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for staff in the kitchen because the floor under the back of the stove was missing 8-10 tiles. During an observation on 12/01/25 at 9:15 a.m., the kitchen floor was seen with missing tiles under the back of the stove, and there was a build up of dirt and brown grime around the edges. During interviews, the DM stated she had been in the facility for 6 months and confirmed the missing tiles, adding that the kitchen floor had been in that condition for several months and that she had no evidence a repair requisition had been made. She also stated the dietary department did not have its own log. The MS stated he had been at the facility for 6 months, was not aware of the extent of kitchen repairs needed, and was not aware the floor under the stove needed repairing. Record review of the maintenance log showed no entry to replace the floor tiles under the stove, and the facility policy stated kitchen equipment and storage areas must be kept clean, safe, and in proper working condition.
Incomplete DNR Documentation
Penalty
Summary
The facility failed to ensure that one resident had a complete advance directive record for a DNR order. Resident #9, who had diagnoses including major depressive disorder, schizoaffective disorder bipolar type, and legal blindness, was listed on the face sheet as DNR-NO CPR. The quarterly MDS showed severely impaired cognition with a BIMS score of 6 out of 15, though the resident could make himself understood and understand others. The care plan and physician order both reflected DNR-NO CPR status, and the resident stated during interview that he did not want CPR and wanted to pass peacefully. Review of the resident’s OOH-DNR form showed that the section for directive by two physicians was incomplete because each physician’s license number was missing and there was no date showing when each physician completed the form. During interviews, the ADON, DON, and Administrator all acknowledged that the form was not completed and that a DNR without the required information would not be valid. The DON and Administrator also stated that if the form was not completed correctly, CPR could be initiated against the resident’s wishes. The facility policy stated that a DNR order form must be completed and signed by the attending physician and resident or legal surrogate and placed in the front of the medical record.
Unnecessary Psychotropic Medication Use Without Supporting Diagnosis or Monitoring
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary medications. Resident #4, a male admitted with diagnoses including paranoid schizophrenia, schizoaffective disorder, psychosis, hypertension, type 2 diabetes mellitus, and cirrhosis of the liver, was ordered Abilify 5 mg daily for depression and Lexapro 10 mg daily for major depressive disorder. However, the psychiatric hospital discharge summary did not indicate a diagnosis of depression or major depressive disorder, and the admission MDS also did not check depression as a diagnosis. The record review showed no indication that the resident had a documented diagnosis supporting the Abilify order as written. The record also showed there was no behavior monitoring order for the Lexapro. During interview, an LVN stated there was no behavior monitoring for the Lexapro and that psychotropic medications should be monitored for behaviors to determine whether the medication was working properly or whether a dosage change was needed. The DON acknowledged she did not realize behavior monitoring was not ordered and stated she thought the resident had a diagnosis of depression, while the psychiatric discharge summary showed no such diagnosis. The Administrator stated staff were expected to review hospital records for diagnoses.
Inaccurate MDS Tobacco Status
Penalty
Summary
The facility failed to ensure an accurate assessment for Resident #16 by marking current tobacco use as no on the admission MDS, even though other records showed he was a smoker. Record review showed the resident was a [AGE] year-old male admitted with diagnoses including hypertension, major depressive disorder, cerebral infarction, and myocardial infarction. The face sheet, smoker list, safe smoking evaluation, and smoking assessment all indicated that he used tobacco, smoked 2-5 times a day, smoked in the afternoon, could light his own cigarette, and required supervision while smoking. During observation, Resident #16 was in his room sitting up in his wheelchair and stated that he had smoked for many years and had been told the smoking times and where he could go to smoke. The AD said she would do some of the smoking assessments and confirmed the resident was a smoker. The MDS Nurse said she reviewed the chart and spoke with staff but must have missed the smoking assessment and safe smoking evaluation showing the resident was a smoker. The DON said she only checked the MDS for completion and expected staff responsible for it to ensure the information was correct, and the Administrator said he expected staff to be professional and complete information for the clinical record accurately. Surveyors requested an MDS policy, but an MDS Assessment Coordinator job description was provided instead.
Baseline Care Plan Did Not Reflect Smoking Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #16 that accurately addressed his smoking needs. Record review showed the resident was admitted with diagnoses including hypertension, major depressive disorder, cerebral infarction, and myocardial infarction. He was listed on the facility smoker list, a safe smoking evaluation indicated he used tobacco, and a smoking assessment documented that he smoked 2-5 times a day, smoked in the afternoon, could light his own cigarette, and required supervision while smoking. The admission MDS marked current tobacco use as no, and the baseline care plan dated 11/19/25 also marked the resident as not a smoker. During interview, the resident stated he had smoked for many years and had been told the smoking times and where he could go smoke. The AD said Resident #16 was a smoker and that she would do some of the smoking assessments. The LVN who completed the baseline care plan said she did not realize she had marked no for smoking. The DON stated she was responsible for all care plans and that the admission nurse usually completed the baseline care plan when residents were admitted.
Incomplete Care Plan for Psychiatric Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #4 that included measurable objectives and timeframes to meet his medical, nursing, mental, and psychosocial needs. Record review showed the resident was admitted with diagnoses including paranoid schizophrenia, schizoaffective disorder, psychosis, hypertension, type 2 diabetes mellitus, and cirrhosis of the liver. A psychiatric hospital discharge summary also listed paranoid schizophrenia, schizoaffective disorder, and psychosis, and physician orders for December 2025 included Abilify 5 mg daily and Lexapro 10 mg daily. The admission MDS indicated diagnoses of psychotic disorder and schizophrenia and noted that he received antipsychotic and antidepressant medications. The care plan dated 11/17/25 had no indication that the resident's psychiatric diagnoses or psychotropic medications were addressed. During observation and interview, the resident was awake and alert and stated he had not been taking medications for years for paranoid schizophrenia or psychosis, had been hearing people and wanting to hurt himself, and was doing better after the hospital restarted his medication. The DON stated she was responsible for all care plans and that the resident's diagnoses and medications were missed, and the Administrator stated he expected staff to be professional and complete information for the clinical record to accurately reflect residents' needs.
Unlocked Medication and Treatment Carts Left Unsecured
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the medication and treatment carts. During an observation and interview on 12/01/25, the treatment cart at the main nurse station was found unsecured and unsupervised, and it contained AmLactin cream, ketoconazole shampoo 2%, nystatin cream, and a container of bleach wipes. An LVN stated the cart was the treatment cart and the treatment nurse was not on duty, and said all nurses should have ensured it remained locked. The Administrator later stated the expectation was for medication carts and the treatment cart to be locked when not in use or within eyesight of the nurse responsible for the cart. During a separate observation on 12/02/25, an unlocked medication cart was found near the nurse's station with cards of prescription medications for high blood pressure, seizures, and heart medications, along with bottles of over-the-counter medications, vitamins, stool softeners, and natural tears. The LVN who said the cart belonged to her stated it should have been locked to prevent residents and visitors from taking medications that did not belong to them. The DON stated licensed nursing staff performed treatments for residents they oversaw when the treatment nurse was not at the facility, and said medication and treatment carts should be kept locked and secured when not in use. The facility policy reviewed stated that during medication administration, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.
Dirty Medication Cart During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program during medication pass for 1 of 4 medication carts reviewed, specifically the Hall 200 medication cart. During an observation and interview on 12/02/25 at 10:20 a.m., the inside of the second drawer of the Hall 200 medication cart had a buildup of black substance where medications were kept. The lower drawer contained bottles of liquid medications with spills on the bottles and labels, and the bottom of the drawer had a sticky substance. LVN C stated the cart needed to be cleaned and that spills could make labels unreadable. During an interview on 12/03/25 at 1:10 p.m., the DON stated medication carts should be kept clean and that if medication was spilled, nurses were to clean up spills immediately. Record review of the Pharmacy Services for Nursing Facilities indicated medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity.
Unsupervised Smoking and Access to Smoking Materials
Penalty
Summary
The facility failed to follow its smoking policy for Resident #30, a male resident with diagnoses including high blood pressure and seizure disorder. His BIMS score was 05, indicating severely impaired cognition. His care plan dated 05/09/25 identified him as a tobacco smoker at risk for injury and directed staff to keep his smoking materials at the nurses' station and observe him as needed when smoking to assure his safety. His safe smoking assessment also indicated he was to smoke with supervision and that the facility would keep his cigarettes and lighters so he would be safe. On 12/03/25 at 12:30 p.m., Resident #30 was observed walking toward the smoking area with a lighter in his right hand and a cigarette in his lips, and he said he was going to smoke as he walked by the surveyor. No staff were outside to supervise him. CNA D stated residents only smoked at certain times with supervision and that cigarettes and lighters were kept locked up, but she was unaware he was outside smoking until she was told and then went to supervise him. The DON stated smoking materials were to be kept at the nurses' stations and residents should not keep cigarettes and lighters when not supervised. The facility's Smoking Policy-Residents stated residents' smoking status is evaluated upon admission and their ability to smoke safely with or without supervision is determined through a Safe Smoking Evaluation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse and neglect, as evidenced by several incidents involving both staff-to-resident and resident-to-resident abuse. In one instance, a female resident with a history of cerebral infarction, schizophrenia, and hemiplegia was subjected to unwanted sexual contact by another resident, who entered her room and rubbed her leg under the covers without consent. The incident was witnessed by a hospice RN, and the resident expressed that she was upset by the event. The perpetrator had a documented history of inappropriate sexual behaviors and was cognitively intact at the time of the incident. There were also multiple cases of physical and verbal abuse perpetrated by staff members against a male resident with traumatic brain injury, dementia, and severe cognitive impairment. One CNA was observed by another staff member to have called the resident derogatory names, physically restrained him during care, and used excessive force, including pinning him against a wall and stomping on his feet. Another CNA was reported to have verbally abused the same resident and forcefully pushed him into a chair. Both incidents were substantiated by witness statements and resulted in the termination of the staff involved. Additionally, the facility failed to prevent and appropriately manage numerous resident-to-resident altercations, resulting in physical harm such as scratches, hitting, and other aggressive behaviors. These incidents involved residents with significant cognitive and behavioral impairments, including dementia, bipolar disorder, and psychotic disorders. The care plans for these residents indicated known risks for aggression and behavioral issues, yet the facility did not effectively intervene to prevent repeated episodes of abuse among residents.
Failure to Update and Implement Comprehensive Care Plans After Resident-to-Resident Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents following incidents of resident-to-resident aggression and inappropriate sexual behavior. In several cases, care plans were not updated to reflect new or recurring behavioral incidents, nor were interventions added to prevent further occurrences. For example, after an incident where a male resident inappropriately touched a female resident, the care plan for the perpetrator did not include specific interventions to prevent further sexual abuse episodes, despite documentation of the event and its investigation. Additionally, care plans for residents who were either aggressors or victims in multiple resident-to-resident altercations were not revised to address their changing needs. One resident with a history of physical aggression was involved in several incidents with other residents, resulting in scratches, skin tears, and emotional distress. Despite these events, the care plans for both the aggressor and the victims were not promptly or adequately updated to include new interventions or strategies to mitigate future risks or address the impact of the incidents. The deficiency was further compounded by a lack of verification and follow-through in the care plan update process. The administrator acknowledged that while requests to update care plans were communicated via email to the MDS contractor, there was no system in place to ensure these updates were completed. This breakdown in communication and oversight resulted in care plans that did not accurately reflect the residents' current needs or the interventions required to ensure their safety and well-being, as evidenced by repeated incidents and confirmed findings in the facility's own investigations.
Removal Plan
- Resident #1's care plan was updated; psych NP discontinued Buspirone 5 mg with new order for Buspirone 20 mg every evening.
- Resident #2, #3 and #5 care plans updated regarding receiving abuse
Failure to Timely Report Alleged Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator and within the required two-hour timeframe to the administrator and state authorities. In one instance, a staff member witnessed a certified nursing assistant verbally and physically abuse a male resident with traumatic brain injury, dementia, and other cognitive impairments. The staff member did not report the incident immediately, only disclosing it during an unrelated investigation approximately 1.5 weeks later. The abuse coordinator became aware of the incident during staff interviews, and the administrator did not report the new allegation to the state as a separate event. In another case, a licensed vocational nurse failed to report an allegation of abuse involving two residents engaged in a physical altercation. The nurse documented the incident but did not notify the administrator or director of nursing as required. The director of nursing only became aware of the incident upon reviewing progress notes the following day. The nurse involved stated she was not present during the incident and did not recall being trained to report abuse immediately to the administrator. A third incident involved a delay in reporting a resident-to-resident altercation where one resident scratched and pulled another resident's hair, resulting in a visible injury. The administrator was not informed of the incident until the following day, after the resident reported it and showed the injury. The administrator acknowledged that the allegation was reported late and that all abuse allegations are required to be reported to state agencies within two hours of the incident. These failures were identified through observations, interviews, and record reviews, and were found to place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
Failure to Maintain Clean, Safe, and Functional Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, functional, and comfortable environment for residents in several rooms, as evidenced by the presence of dead bug carcasses and dead cockroaches in resident bathrooms and vanities. Observations revealed missing baseboards, stained caulk and flooring, cracked and missing tiles, and a bathroom vanity with missing doors. Multiple residents confirmed that while housekeeping staff cleaned their rooms, the bathrooms were not cleaned properly, and dead cockroaches were not removed. Residents also reported that the bathroom tiles had been falling off for some time. Interviews with facility staff, including the Administrator, Maintenance Director, and Housekeeping Supervisor, revealed a lack of awareness regarding the physical plant issues and the presence of pests. The Maintenance Director and Administrator both acknowledged the observed deficiencies during walkthroughs but stated they had not received any maintenance requests for the repairs. The Housekeeping Supervisor admitted that bathrooms and vanities were not cleaned as thoroughly as required and that there was no cleaning checklist or follow-up to ensure proper cleaning. Staff indicated that maintenance requests were supposed to be logged at the nurse station, but no such requests had been made for the observed issues. A review of facility policies indicated that the maintenance department is responsible for keeping the building in good repair and free from hazards, and that staff are expected to provide a clean, sanitary, and homelike environment. Despite these policies, the observed conditions in the resident rooms and bathrooms did not meet these standards, as evidenced by the lack of cleanliness, unrepaired damage, and unaddressed pest issues.
Failure to Maintain Proper Hand Hygiene During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to adhere to proper hand hygiene protocols while providing incontinent care to a resident with multiple comorbidities, including diabetes mellitus type 2, severe obesity, and moderate cognitive impairment. During the observed care, both CNAs wore gowns and gloves, but after cleaning the resident, one CNA did not perform hand hygiene after changing gloves or when transitioning from dirty to clean supplies. The other CNA, after removing a soiled brief and cleaning the resident, touched clean linens and adjusted a clean brief without changing gloves or performing hand hygiene. Both CNAs only completed hand hygiene after the care was finished and gloves were removed. Interviews revealed that one CNA acknowledged the need for hand hygiene after glove changes and when moving from dirty to clean, as trained by the facility, but apologized for not having hand sanitizer available during care. The other CNA was unclear about the specific requirements for hand hygiene after glove changes or when moving from dirty to clean, stating she was not trained in those aspects. The Director of Nursing confirmed that infection control in-services were conducted regularly and that staff were expected to follow the hand hygiene policy, which requires hand hygiene before and after resident contact, between glove changes, and after soiled hands. Facility policy and recent in-service documentation supported these requirements.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Accurately Complete MDS Assessment for Resident with Multiple Diagnoses
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment reflective of their current status, specifically regarding the completion of the Minimum Data Set (MDS) assessment. Record review showed that the resident, a male with multiple complex diagnoses including quadriplegia, diabetes, chronic kidney disease, neurogenic bladder, and major depressive disorder, had an MDS assessment that did not include several of his active diagnoses such as coronary artery disease, neurogenic bladder, quadriplegia, or depression. The resident was cognitively intact, used a wheelchair, and was dependent for most activities of daily living (ADLs). Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for the accuracy and completion of the MDS. The DON stated that although her signature appeared on the MDS, she could not verify it and was not informed she should review the MDS for accuracy. The Administrator and VPO both indicated that the facility did not have a current MDS Coordinator at the time, and that oversight was expected from either the DON or a Regional MDS Coordinator, who had also recently been terminated. The facility did not have a specific MDS policy and relied on the RAI manual. This lack of accurate assessment and clear responsibility could result in residents not receiving appropriate care and services.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Sanitary Environment and Functional Resident Furnishings
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents in rooms 217 through 224, as evidenced by persistent foul odors in the hallway and in front of specific rooms. Observations revealed a strong smell of urine, feces, and body odor throughout the hallway, with the odor being most pronounced in front of one room. The odor was present at multiple times during the day, despite the presence of housekeeping staff and repeated cleaning efforts. Interviews with staff and residents confirmed that some residents refused hygiene care and bathing, contributing to the ongoing odor issue. Housekeeping staff reported cleaning certain rooms multiple times daily and using specific chemicals to address the odor, but the problem persisted, particularly in rooms where residents refused showers. Additionally, a dresser in one resident's room was found to be in disrepair, with multiple broken or missing handles and drawers that would not close properly. The resident reported that the dresser had been broken for several months and expressed frustration about the situation. The Maintenance Director stated that maintenance issues were addressed as reported, but there was no record of the broken dresser being reported. The administrator confirmed that a replacement dresser had been ordered but had not yet arrived, resulting in the continued use of the damaged furniture. These deficiencies were observed to negatively impact the quality of life and comfort of the residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in multiple resident rooms being infested with cockroaches and spiders. Observations by surveyors revealed live and dead cockroaches in several rooms, including instances where cockroaches were seen running across furniture, breakfast trays, and restroom sinks. Spiders, both live and dead, were also found in resident rooms. Residents expressed distress about the presence of pests, with one resident stating that the cockroaches made her feel terrible and another reporting roaches on her breakfast tray. Staff interviews confirmed that pests were seen occasionally, with sightings of flies and cockroaches occurring a couple of times a month. The facility maintained a pest control log and had a contract with a pest control company to spray monthly and as needed, with additional treatments in certain months. Staff were instructed to report pest sightings in a binder at the nurses' station, and plastic containers were provided to residents who kept food in their rooms to help limit pest issues. Despite these measures, maintenance records and pest control logs documented ongoing reports of roaches in specific rooms over the preceding months. The facility's policy required maintaining an effective pest control program to keep the building free of insects and rodents, but observations and records indicated that this standard was not met for several residents.
Failure to Resolve Resident Grievances Regarding CNA Assignments
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident who expressed dissatisfaction with certain CNAs providing her care. The resident, who was cognitively intact and able to communicate her needs, had a history of mental health conditions including dementia, anxiety, schizophrenia, and bipolar disorder. She repeatedly voiced grievances about not wanting specific CNAs, identified as CNA A and CNA B, to enter her room or provide care, citing reasons such as improper care and feeling unsafe. Despite the resident's grievances being documented, the facility did not take adequate action to address her concerns. The grievances were not thoroughly investigated, and there was a lack of communication among staff regarding the resident's preferences. The facility's staffing sheets indicated that CNA A and CNA B continued to be assigned to the resident on multiple occasions, contrary to her expressed wishes. Interviews with staff revealed a lack of awareness and communication about the resident's grievances, with some staff members unaware of the resident's requests or the grievances filed. The facility's grievance policy required immediate action to resolve complaints, but this was not adhered to in the case of the resident. The failure to address the resident's grievances could lead to unresolved issues and a decreased quality of life for the resident. The facility's leadership, including the DON and the grievance official, were not fully informed or proactive in resolving the resident's concerns, resulting in continued dissatisfaction and anxiety for the resident.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 24 out of 45 days reviewed. This deficiency was identified through interviews and record reviews, which revealed that there were no RN hours recorded on several specific dates, and on some days, the RN hours were less than the required 8 hours. The facility's records indicated that there were 4 RNs employed, but the facility struggled with staffing issues, including hiring a Director of Nursing (DON) and ensuring consistent RN coverage. Interviews with the Human Resources representative, the DON, and the Administrator highlighted the staffing challenges faced by the facility. The HR representative acknowledged the missing RN hours and the difficulty in hiring RNs. The DON, who started in November, confirmed the lack of sufficient staff to provide the required RN coverage before her tenure and emphasized the importance of adhering to the policy. The Administrator also acknowledged the staffing issues and the potential impact on resident care due to inadequate RN coverage. The facility's policy mandates that an RN must be onsite for 8 consecutive hours daily, which was not consistently met during the review period.
Failure to Submit Staffing Information to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for two of the three quarters reviewed, specifically for Quarter 2 and Quarter 3 of 2024. This deficiency was identified through interviews and record reviews, which revealed that the facility did not submit the required Payroll-Based Journal (PBJ) reports for these periods. The failure to submit these reports was attributed to a lack of oversight and responsibility confusion among the staff. The Regional Director of Clinical Operations was identified as the person responsible for submitting the PBJ reports, but it was discovered that a third-party company previously tasked with this responsibility had not been submitting the reports, leading to the termination of their contract. Interviews with various staff members, including the HR, the Regional Director of Clinical Operations, the Director of Nursing (DON), the Administrator, and the Corporate HR, highlighted a lack of awareness and education regarding the submission process. The HR mentioned that the staff clock in and out, and the system logs the times, but the PBJ reports were not submitted due to oversight. The Regional Director of Clinical Operations and the Corporate HR both acknowledged that they were not aware of the need to check if the reports were submitted. The facility's policy on reporting direct-care staffing information was not followed, resulting in the failure to submit the PBJ reports timely, which could affect the facility's ability to take credit for the staff present and potentially impact the quality of care provided.
Facility Fails to Maintain Safe Operating Condition of Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as observed during a survey. The gas stove in the kitchen had three burners that would not ignite, and there was a black buildup on the griddle next to the burners. The walk-in freezer had a loose and hanging door gasket, with icy frost and frozen liquid on the floor. Additionally, the milk box had a loose gasket with mildew. These issues were acknowledged by the Dietary Manager (DM) and Maintenance Director (MD), who were unaware of the severity of the problems. In a resident's room, an electric bed was found with a spliced electrical cord, exposing live wires without proper insulation or a connection box. The Administrator expressed that the electric beds should be in good working condition and noted that staff had not reported the unsafe wiring. The facility's Maintenance Service policy indicates that the Maintenance Department is responsible for ensuring all equipment is safe and operable, which was not adhered to in these instances.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. Baking sheets, pans, and skillets were found with dark-colored buildup on both the inside and outside surfaces, indicating they were not properly cleaned. Additionally, food items in the walk-in cooler were not managed according to professional standards. A container of pureed food was found with an unreadable label and was past its use-by date, while another container of fruit lacked any labeling. These lapses in food storage and labeling could potentially lead to foodborne illnesses among residents. Furthermore, the facility did not ensure that the sanitizing solution used for cleaning kitchen surfaces was at the correct concentration. A red bucket of sanitizing solution was found to have less than 50 ppm of chlorine, indicating it was ineffective. The chlorine solution container was not connected to the dispenser, which is used to fill the sanitizing bucket. These deficiencies were in violation of the facility's own policies and the 2022 Food Code, which require proper labeling, cleaning, and sanitizing practices to prevent contamination and ensure food safety.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in several areas, including Hall 200, the dining room, and specific resident rooms. Observations revealed that door frames in Hall 200 were not intact, with missing paint and wood pieces, and the floor tiles were discolored with a buildup of glue, paint, and debris. The exit corridor to the smoking area had six missing floor tiles, exposing discolored concrete. In the main dining room, there was a buildup of old paint and dried glue along the back wall, and a missing tile near the door created a floor level difference. An unlocked closet labeled for oxygen storage was found empty, with walls covered in a black fuzzy substance, a white substance on the door, and spider webs with sacs, emitting a smell of wet dirt. Additionally, specific resident rooms were not properly maintained. One room had a 6-inch base trim detached from the wall and lying on the floor for approximately 5 feet. Another room had a beige substance splattered on the ceiling and curtains with rips along the bottom. Interviews with the maintenance director and the administrator revealed acknowledgment of these issues, with the maintenance director admitting to never opening the problematic closet and the administrator confirming the need for repairs but lacking documented plans for such actions. The facility's maintenance service policy indicated that the maintenance department is responsible for keeping the building safe and operable at all times.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and allowed unauthorized access to medication, specifically affecting one resident. During an observation, a 30-cc medicine cup containing approximately 20 cc of white powder was found on the nightside table next to the resident's bed. The resident, who was cognitively intact and had diabetes, stated that the powder was not her medication and was unaware of how it got there. The powder was identified as nystatin powder, which was prescribed to be applied to the resident's abdominal folds for yeast treatment. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that the medication should not have been left in the resident's room and should have been stored in the medication cart when not in use. The ADON confirmed that nurses were responsible for ensuring medications and treatment items were not left in resident rooms. The Administrator stated that her expectation was for nurses to keep medications within their eyesight and not leave them at the bedside, indicating a lapse in following proper medication storage protocols.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure the safety and protection of two residents from sexual abuse. On June 15, 2024, an incident occurred in the dining room where one resident, who has moderate intellectual disabilities and is non-verbal, was observed performing oral sex on another resident. The first resident has a history of inappropriate sexual behaviors and is severely cognitively impaired, as indicated by a BIMS score of 03. The second resident, who has a BIMS score of 10 indicating moderate cognitive impairment, did not exhibit any behaviors over the previous seven days. Both residents were known to have inappropriate sexual behaviors and were at risk for further episodes. The incident was witnessed by another resident, who reported it to the staff. The staff responded by separating the involved residents and notifying the appropriate authorities, including the police. The second resident, who was on parole, was noted to have been in a motorized wheelchair and did not attempt to remove himself from the situation. The police were involved, and statements were taken from the residents involved. The facility's records indicate that the second resident was aware of the incident and expressed a desire to have it documented by the police. The facility's failure to prevent this incident highlights a deficiency in protecting residents from abuse, as both residents involved had documented histories of inappropriate sexual behavior. The facility's care plans for both residents included interventions to manage these behaviors, but the incident still occurred, indicating a lapse in the implementation of these interventions. The facility's policy on abuse and neglect emphasizes the importance of preventing such incidents, but the occurrence of this event suggests that the policy was not effectively enforced at the time.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency within the required 2-hour timeframe for four residents. In the first incident, Resident #4, who has a history of behavioral issues and cognitive impairment, verbally and physically assaulted Resident #5. Despite the incident being documented by an LVN, the facility did not notify the State Agency within the mandated period. Resident #4 was later transferred to a behavioral center for further management of his behavior. In the second incident, Resident #6, who suffers from severe cognitive impairment and mental health issues, physically assaulted Resident #7 after a minor altercation involving a wheelchair. The incident was documented, and both residents were assessed for injuries, but the report to the State Agency was delayed beyond the required 2-hour window. Resident #6 was subsequently transferred to a behavioral hospital for further evaluation and treatment. Interviews with facility staff, including the ADON and the Administrator, revealed that there was a lack of immediate reporting to the Abuse Coordinator, which contributed to the delay in notifying the State Agency. The facility's policy mandates immediate reporting of abuse allegations to the Administrator or their designee, but this protocol was not followed, resulting in the deficiency.
Failure to Implement PASRR Service Plan for Resident
Penalty
Summary
The facility failed to implement the PASRR comprehensive service plan for a resident who was reviewed for PASRR assessments. The resident, a male with diagnoses including schizoaffective disorder, cerebral palsy, dysphagia, and aphasia, was admitted to the facility and was identified as PASRR positive for intellectual disability. The PASRR Comprehensive Service Plan recommended specialized occupational therapy, physical therapy, and speech therapy, which were not provided within the required timeframe. The Director of Rehabilitation indicated that therapy evaluations were submitted but not authorized, resulting in a delay in the initiation of therapy services. The Regional Director of Reimbursement confirmed that the facility did not meet the PASRR requirements, which mandate that specialized services be requested and initiated within specific timeframes. The resident did not receive the agreed-upon therapy services through PASRR until several months after the initial PCSP and IDT meeting. The Administrator, who was not present during the initial meeting, acknowledged the potential negative outcomes of not meeting PASRR timeframes. The facility's policy indicated that they should coordinate services per state policy and develop a care plan addressing specific needs when special services are required.
Failure to Protect Residents from Abuse Due to Inadequate Monitoring and Reporting
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving inappropriate sexual behavior by a resident with dementia and other mental health conditions. The resident, who had a history of inappropriate sexual behaviors, was involved in two incidents where he touched the breasts of two different female residents. The first incident occurred in the dining room, where the resident grabbed another resident's breast and made lewd comments. Despite being redirected and sent for a psychiatric evaluation, the resident returned to the facility without increased monitoring. In the second incident, the same resident was observed touching another female resident's breast while reaching for a coloring book. The staff separated the residents and initiated behavioral monitoring, but there was no documentation of continued monitoring after a certain period. The facility's care plan for the resident did not reflect the incidents, and there was a lack of incident reporting and proper documentation. Interviews with staff revealed inconsistencies in awareness and reporting of the incidents. Some staff were unaware of the resident's behaviors and the need for close monitoring. The facility's policy on abuse and neglect was not effectively implemented, as evidenced by the lack of immediate separation of residents and inadequate monitoring of the aggressor. The facility's failure to protect residents from abuse and ensure proper documentation and reporting led to the identification of an Immediate Jeopardy situation.
Removal Plan
- R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors.
- R1 will remain on q 15-minute checks until IDT team meets and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors.
- Charge nurse/nurse managers assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found.
- Administrator/abuse coordinator reeducated all staff 100% completion on Abuse & Neglect policy for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test.
- Staff were reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur.
- Staff were reeducated to stay with the aggressor one-on-one until further instruction from the abuse coordinator and/or until the evaluation or further intervention.
- The Administrator reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation.
- Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached.
- MDS nurse reviewed and updated care plan to reflect sexually inappropriate behaviors.
- The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC).
- Administrator/and or designee will reeducate floor staff to review Kardex in PCC (EHC) for updated interventions for each resident.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified in the cases of two residents who were subjected to inappropriate sexual behavior by another resident. The incidents involved a resident with a history of inappropriate sexual behaviors, who was not adequately monitored or managed according to the facility's policies. In one incident, a resident with dementia and other cognitive impairments was observed grabbing the breast of another resident in the dining room. Despite the resident's known history of inappropriate sexual behavior, the facility did not implement sufficient monitoring or interventions to prevent further incidents. The staff failed to maintain one-on-one monitoring or update care plans to reflect the resident's behaviors, which were necessary steps outlined in the facility's abuse and neglect policy. Another incident involved the same resident inappropriately touching a different resident's breast. The staff's response was inadequate, as they did not initiate one-on-one monitoring or update the care plans to address the behavior. The facility's failure to follow its own policies and procedures for preventing and addressing abuse and neglect placed residents at risk of further harm.
Removal Plan
- R1 was immediately placed on q 15-minute checks for close monitoring for further behaviors.
- R1 will remain on q 15-minute checks until IDT team meets and reevaluate his behaviors for medical adjustment and determine if R1 will remain on q 15-minute checks or can be discontinued. If Res #1 has additional behaviors, he will be placed one-on-one until psychiatric services can reevaluate his behaviors.
- Charge nurse/nurse managers assessed R2 and the rest of the residents in the secure unit for possible mental, physical, or sexual abuse, no additional mental health needs were identified, nor any suspected physical abuse found.
- Administrator/abuse coordinator in-service all staff 100% completion on Abuse & Neglect policy for types of abuse (physical, sexual, mental, verbal, neglect, exploitation, and misappropriation) through verbal in-service and written test.
- Staff were reeducated for the identification, and intervention in a situation in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur. This education included protecting and/or removing the resident from the situation, as well as who the abuse coordinator is, when to report, and how to report abuse.
- Staff were reeducated to stay with the aggressor until further instruction from the abuse coordinator and/or until the evaluation or further intervention.
- The Administrator reeducated 100% of staff on behavioral management policy which included resident to resident abuse in regard to residents exhibiting sexual behaviors towards other and steps to do and approach the situation.
- Reeducation was provided for the staff with instructions for proper documentation for the behavior monitoring log through verbal in-service with monitoring log attached.
- MDS nurse reviewed and updated care plan to reflect sexually inappropriate behaviors.
- The MDS nurse will review all incident reports related to sexual behaviors to make sure interventions were in place, for the floor staff to be able to see in electronic health record (EHC).
- Administrator/and or designee will reeducate floor staff to review Kardex in PCC (EHC) for updated interventions for each resident.
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 156 citations issued within 25 miles in the last 12 months — including the 11 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 Beaumont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| College Street Health Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Beaumont Nursing And Rehabilitation | 2.6 mi | ★★★★★ | 1 | 1 |
| Spindletop Hill Nursing & Rehab Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Avir At Beaumont | 2.8 mi | ★★★★★ | 4 | 0 |
| Beaumont Health Care Center | 3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.