Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Heritage Park Rehabilitation And Skilled Nursing C during CMS and state inspections, most recent first.
Failure to Provide and Document Fingernail Care: Two residents who needed extensive ADL assistance did not receive timely fingernail trimming, and the care was not documented in the ADL checklist or nursing notes. One resident said staff repeatedly promised nail care but did not provide it, and observations showed long, jagged fingernails. The other resident also reported repeated requests for nail clipping, and observation confirmed long fingernails. Staff interviews indicated fingernail care was expected during showers and that refusals should be documented, but documentation was missing.
An insulin pen for two residents with diabetes was found on a med cart without an open date, and a med cart was observed unattended and unlocked in a hallway. Staff stated insulin pens should be dated when opened and med carts should be locked whenever staff are away from them. The DON and ADM confirmed these were facility expectations, and the facility policy stated opened insulin pens should be clearly labeled and discarded after 28 days.
Failure to Provide Privacy During Incontinent Care: A cognitively intact male resident who required assistance with toileting was observed being changed after fecal incontinence with the privacy curtain pulled but the bedroom door left open. The resident said this had happened before and upset him, while CNA B stated staff were trained to close both the curtain and door during care. The DON and ADM confirmed that staff were responsible for providing privacy and that the door should have been closed.
Controlled medication records were not accurately reconciled for two residents when an LPN administered a pain medication to each resident but did not sign the narcotic log. Observation of the med cart showed the counts did not match the log for both controlled drugs. The LPN said she forgot to document the doses because she was busy, while the DON and ADM stated staff were responsible for accurate counts and immediate documentation of controlled meds.
Failure to perform hand hygiene during puree food preparation. A cook prepared puree meat, beans, corn, and bread while wearing gloves but did not wash her hands or change gloves as she moved between tasks, tasted food, handled equipment, and accessed kitchen storage areas. The DM, cook, and ADM all stated that hand hygiene was required when entering the kitchen, switching tasks, or touching food, and the facility policy stated that gloves do not replace hand hygiene.
Failure to Follow EBP During Peri Care: Staff provided peri care to a resident with EBP orders without wearing gowns, despite signage and care plan instructions indicating gown and glove use for high-contact care. The resident had CKD stage 5, DM II, legal blindness, HTN, and a dialysis fistula. CNAs said they believed the roommate, not the resident receiving care, was on EBP, while the DON and ADM stated staff were expected to follow EBP precautions and use PPE for close contact care.
A resident with dementia, schizophrenia, and impaired mobility was transported to a canceled off-site medical appointment without her required walker and left unsupervised by a facility van driver. The resident was found alone outside the hospital by security, after the facility failed to update the appointment schedule and communicate the cancellation. Facility protocols requiring supervision for such residents were not followed, resulting in a deficiency.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
The facility failed to maintain an effective pest control program, resulting in cockroach infestations in multiple rooms, including those of residents with severe cognitive impairments and chronic health conditions. Despite frequent spraying by a pest control company, the issue persisted, indicating ineffective treatments. Staff and residents reported sightings, but communication and awareness were lacking, compromising the residents' right to a safe and clean environment.
Surveyors found that the facility failed to maintain proper food storage, labeling, and sanitation practices, including using a cracked ice scoop receptacle, not cleaning the ice machine and stovetop range adequately, and not labeling or dating multiple food items. Some opened products were not refrigerated as required, and food items in storage were not consistently covered, secured, or properly identified.
The facility did not maintain an effective pest control program, resulting in the presence of flies, gnats, and roaches in resident rooms, dining areas, and common spaces. Staff interviews revealed no specific pest control policy, and resident council minutes documented ongoing complaints about infestations. Pest control service records showed treatments were performed, but pests continued to be observed throughout the facility.
Surveyors found that two residents with urinary catheters did not have privacy covers on their catheter bags, causing distress and embarrassment, despite staff training and facility policy requiring covers. Additionally, several residents seated at the same dining tables were not served their meal trays at the same time, leading to discomfort and signs of hunger. Staff interviews confirmed awareness of the policies, but the deficiencies persisted, affecting residents' dignity.
Staff conducted searches of residents' wheelchairs, belongings, and rooms for contraband without obtaining consent, affecting multiple cognitively intact residents. Residents reported feeling embarrassed, harassed, and singled out, with some stating that personal items were taken and given to others. Staff interviews revealed inconsistent practices and a lack of adherence to facility policy, which requires resident consent for searches.
Several residents were found living in unclean and cluttered rooms, with issues such as dirty linens, persistent flies, clutter, and lack of timely cleaning assistance despite repeated requests. Staff interviews confirmed that cleaning requests were not addressed promptly, and residents expressed distress over the unsanitary conditions. Facility policy required daily cleaning and timely response to resident needs, but these standards were not met.
Three residents did not have comprehensive care plans addressing their specific needs, including oxygen therapy, food allergies, dental care, and PTSD-related accommodations. One resident's care plan omitted oxygen use despite physician orders and observed use; another's plan lacked documentation of a food allergy and dental needs, resulting in continued exposure to allergens and missed dental care; and a third resident's PTSD diagnosis and related care preferences were not assessed or included in her plan, with staff unsure of their responsibilities.
Several residents with significant medical and cognitive needs did not receive regular showers as required, despite being scheduled and care planned for assistance with bathing. Documentation inconsistencies and staff interviews revealed that showers were frequently missed or marked as 'not applicable' without clear justification, and residents reported not refusing care. This resulted in poor hygiene and resident dissatisfaction, with some residents filing grievances and reporting the issue to facility leadership.
Three residents with cognitive and physical impairments did not receive individualized or in-room activities as outlined in their care plans, with repeated observations showing them without stimulation or engagement. Despite care plans and facility policy requiring regular 1:1 activities and staff encouragement, these interventions were not consistently provided or documented, as confirmed by staff interviews.
Staff did not consistently follow infection control protocols, including hand hygiene during meal tray distribution and peri care, and failed to provide proper catheter care for a resident. These lapses were observed despite staff being trained and aware of facility policies, and involved residents with significant medical needs.
Five shared rooms were found to have beds with less than the required 80 square feet per resident, with digital measurements confirming that several middle beds in these rooms did not meet regulatory standards. The ADM and DON were unaware of the deficiency and no waivers or variances were in place.
A resident with multiple neurological and psychiatric diagnoses was provided incontinent care without full privacy, as the privacy curtain was only partially closed and the door remained open while a roommate was present. The resident expressed discomfort, and the CNA acknowledged the failure to fully close the curtain, despite facility policy and prior staff training requiring privacy measures during personal care.
A resident was found with triangular wedges on her bed that restricted her movement, despite no medical need, pressure ulcer, or physician order documented. Staff interviews confirmed that wedges should only be used for positioning with a doctor's order, and the facility's policy prohibits restraints for staff convenience. The resident's care plan and medical chart did not include the use of wedges, and staff could not explain their presence.
A resident with a documented diagnosis of PTSD was admitted, but the facility did not include any instructions or interventions for PTSD in the baseline care plan within 48 hours. The resident was not asked about her triggers or preferences, and staff interviews revealed uncertainty about responsibility for updating care plans to address mental health needs.
A resident with cognitive impairment and swallowing difficulties was given a sip of shower gel from an unlabeled cup left in their room, after a family member mistook it for a thickened liquid. The resident immediately spit out the liquid and was assessed by an LVN, with no adverse effects noted. Staff and the DON were unable to determine how the soap ended up in the cup or who placed it there, and the facility's policy requiring a hazard-free environment was not followed.
A resident with PTSD did not have her diagnosis, triggers, or care preferences documented or addressed in her care plan, despite her clear communication of needs such as a preference for female and English-speaking staff. Facility staff were unclear about their responsibilities for trauma-informed care planning, and the facility's policy requiring individualized, trauma-informed, and culturally competent care was not followed.
The facility exceeded the acceptable medication error rate when two residents received medications contrary to physician orders: one was given a whole gel capsule instead of a crushed form, and another received Metoprolol ER despite vital signs outside the prescribed parameters. Both medication aides failed to follow established medication administration protocols.
A staff member administered a blood pressure medication to a resident with severe cognitive impairment, despite the resident's heart rate being below the physician-ordered threshold for administration. The staff member acknowledged the error and facility policy requires holding medications when vital signs are outside prescribed parameters.
Surveyors found that two medication carts were left unlocked and unattended, with one instance involving a medication aide leaving medications out of sight while seeking clarification from a nurse. Staff interviews confirmed knowledge of the policy requiring carts to be locked, but the written policy did not address medication storage.
A resident with multiple medical conditions missed a scheduled MRI appointment because facility staff failed to arrange timely transportation, resulting in the appointment's cancellation. The resident was not informed about the rescheduling or future transportation plans, and staff interviews revealed confusion about transportation procedures and a lack of a formal policy.
A resident with multiple medical conditions missed a dental appointment for denture castings after the facility failed to arrange appropriate transportation. The facility van was unavailable, and the resident was given a public transportation pass that did not cover the dentist's location, resulting in the missed appointment. Staff interviews confirmed there was no transportation policy and that the responsibility for arranging transportation was not fulfilled.
A resident with a documented beet allergy and intact cognition was repeatedly served beets on meal trays despite clear documentation of the allergy on meal tickets and face sheets. The resident reported sending the trays back and expressed concern for others with cognitive impairment. Staff interviews confirmed awareness of the issue, and review of facility policies and audits showed that procedures and training were in place, but the allergy was not consistently honored.
A resident with cognitive impairment was admitted with an electronically signed Admission Agreement after consent was obtained by phone, but the process did not include two proper witnesses as required. Facility staff were unsure of the identity of the person who gave consent, and the second staff member signed the document without witnessing the conversation, resulting in incomplete and potentially inaccurate medical record documentation.
A resident with a history of cerebral infarction and other medical conditions eloped from a facility after breaking her window twice. Despite exhibiting anxiety and hallucinations, the facility failed to implement effective interventions to prevent her elopement. The resident was eventually found in a coffee shop and transported to the hospital. The facility's lack of adequate supervision and safety measures led to this deficiency.
A resident with multiple medical conditions eloped from the facility by breaking a window. Despite staff efforts to locate her, she was not found until an hour later at a nearby coffee shop. The facility did not report the incident to the State Agency within the required 24-hour timeframe, as the Administrator believed it did not meet the criteria for reporting.
A long-term care facility failed to maintain an effective pest control program, leading to the presence of cockroaches and other insects in resident rooms, the kitchen, and common areas. Observations and interviews with residents and staff confirmed frequent sightings of pests, particularly in the kitchen. Despite regular treatments, the issue persisted, with the pest control company noting resistance from management to authorize comprehensive treatment. The facility lacked a formal pest control policy, relying instead on a contract with a pest control company.
The facility failed to properly label and date food items in the kitchen, as observed during an inspection. A torn bag with exposed food was found in the freezer without a label or date, and another bag was dated but not labeled. Interviews revealed that all kitchen staff were responsible for labeling and dating food, as per facility policy, but this was not consistently followed.
A facility failed to ensure a resident's dignity and privacy during incontinent care when a CNA left the door open and did not draw the privacy curtain, leaving the resident exposed. The resident, with multiple health conditions and dependent on staff for toileting, was visible from the hallway. Interviews with staff confirmed that the expected procedure to ensure privacy was not followed, resulting in a deficiency related to the resident's right to dignity and respect.
A medication cart on the 300 hall was found unlocked and unsupervised, with three compartments accessible. RN A, responsible for the cart, admitted to leaving it unattended while attending to a resident's needs elsewhere, failing to lock it properly. The unlocked drawers contained routine medications, respiratory treatments, and cleaning items, although narcotics were secured. Interviews confirmed that the facility's policy requires medication carts to be locked when not in use.
A facility failed to identify a resident as an elopement risk and complete a wandering/elopement assessment within 24 hours of admission, leading to the resident eloping and being found 1-2 miles away. The resident had a history of elopement and severe cognitive impairment, which was not adequately addressed. Interviews revealed communication gaps and procedural failures among staff.
The facility failed to ensure resident dignity and a clean environment. One resident was found with her pants down, exposing her private parts, while another had a full urinal causing a strong urine odor in his room. Additionally, a resident exhibited disruptive behaviors, including urinating in common areas and damaging property, which were not effectively managed by the staff.
The facility failed to ensure a safe, clean, comfortable, and homelike environment for four residents, leading to rooms with a persistent urine odor. The memory care unit also had a pervasive urine odor and sticky floors, indicating inadequate cleaning practices. Staff interviews revealed inconsistencies in cleaning routines and responsibilities, and the facility lacked a specific policy on creating a homelike environment and managing urinals.
The facility failed to maintain an effective pest control program, leading to frequent sightings of insects such as crickets, cockroaches, and flies in various areas, including residents' rooms. Multiple residents and staff reported the presence of pests, and the facility's pest control measures were insufficient to address the ongoing issue effectively.
The facility failed to provide a communication aide for a resident diagnosed with hearing loss, compromising her right to a dignified existence and quality of life. Despite recommendations for follow-up with an ENT doctor, the resident lacked necessary communication tools, making it difficult to convey her needs. Interviews revealed a lack of awareness and concern from the DON and Administrator, and the facility lacked a specific policy to address communication needs.
The facility failed to protect a resident from verbal abuse by another resident during a supervised smoking session. Staff present did not intervene immediately, and interviews revealed a lack of awareness and consistent intervention. The affected resident, with a history of dementia and schizoaffective disorder, did not acknowledge the abuse and appeared unable to communicate effectively.
The facility failed to ensure residents who were unable to carry out activities of daily living received necessary grooming and personal hygiene services. An elderly female did not receive nail care, and another elderly female did not receive shaving care, despite their care plans indicating they required assistance. Staff inconsistencies and lack of documentation contributed to these deficiencies.
A facility failed to provide routine dental services for a resident with multiple medical conditions, including vascular dementia and dysphagia. The resident required dental extractions and dentures, but the facility did not obtain the necessary financial consent, leaving the resident without needed dental care. Lack of communication and follow-up among staff contributed to the deficiency.
Failure to Provide and Document Fingernail Care
Penalty
Summary
The facility failed to ensure that two residents who were dependent on staff for ADL care received timely fingernail care to maintain grooming and personal hygiene. Resident #128 was a male with diagnoses including dementia, cognitive communication deficit, muscle wasting, edema, chronic combined systolic heart failure, and major depression. His MDS reflected a BIMS score of 10, and his care plan stated he required assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. Resident #135 was a female with diagnoses including respiratory failure with hypoxia, major depression, morbid obesity, contractures to both hands, muscle wasting, need for assistance with personal care, and cognitive communication deficit. Her MDS reflected a BIMS score of 11, and her care plan stated she required dependent assistance with bed mobility, bathing, hygiene, toileting, dressing, grooming, eating, and all assisted daily living care needs. Record review showed both residents had nail care and facial hair removal scheduled for Tuesday, Thursday, and Saturday from 6:00 a.m. to 2:00 p.m., but there was no ADL documentation for fingernail trimming for the past month in the ADL task checklist for either resident. Nursing progress notes also did not document fingernail trimming for Resident #128 for the past three months or for Resident #135 for the past month. During interviews, Resident #128 stated he did not like his fingernails long, said staff had told him multiple times they would trim them but did not come, and said he had not had his fingernails trimmed or even offered nail care in a couple of months. He also stated he scratched himself because of his long fingernails. Observation of Resident #128 showed long, untrimmed fingernails with jagged edges, and later observation showed fingernails approximately one inch long on both hands. Resident #135 stated staff did not assist her with clipping her fingernails and that she had asked nursing staff on multiple occasions without receiving the care. She stated her fingernails were too long and uncomfortable for using her hands during ADL activities. Observation of Resident #135 showed long fingernails on several fingers of her left hand. Staff interviews reflected that fingernail care was expected during showers and that refusals should be documented, but the RN stated she had offered to clip Resident #135's fingernails earlier in the week, that the resident refused, and that she did not document the refusal. Other staff stated residents' fingernails should be trimmed routinely, that staff were responsible for documenting care or refusals, and that the DON and ADM were ultimately responsible for ensuring fingernail care was provided and documented.
Unlabeled insulin pens and unsecured medication cart
Penalty
Summary
Drugs and biologicals used in the facility were not consistently labeled in accordance with accepted professional principles, and medication carts were not always secured. During observation, medication cart #1 was found unattended and unlocked outside a resident’s bedroom on the 2400 hall, and then observed again further down the hallway still unlocked with the red mark showing the lock was open. The hall was free from residents wandering at the time of the observation. The facility also failed to ensure that insulin pens for two residents were labeled with an open date. On the 2200/2500-hall nursing medication cart, an insulin pen for one resident and an insulin pen for another resident were observed without open date information. One resident was a 65-year-old male with type 2 diabetes mellitus and hyperglycemia who had an active order for Lantus 15 units subcutaneously at bedtime. The other resident was a 51-year-old female with type 2 diabetes mellitus who had an active order for Lantus 60 units subcutaneously twice a day and a care plan addressing altered endocrine status related to diabetes. Staff interviews confirmed that insulin pens were expected to be dated when opened and discarded after 28 days, and that medication carts were expected to be locked whenever staff were away from them. The LVN stated she forgot to check the open date labeling on the insulin pens. The DON stated nursing staff were responsible for labeling insulin pens before opening and for keeping medication carts locked, and the ADM stated the carts were to be secured at all times, especially when away from them. Record review of the facility’s insulin pen policy stated that once opened, clearly labeled insulin pens may be stored at room temperature and should be disposed of after 28 days or according to manufacturer recommendations.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to treat Resident #20 with respect and dignity and to provide care in an environment that maintained privacy during incontinent care. Resident #20 was a male resident admitted to the facility with diagnoses including depression, insomnia, muscle wasting, hypertension, gait and mobility abnormalities, hyperlipidemia, schizophrenia, and COPD. His quarterly MDS showed a BIMS score of 15, indicating intact cognitive response, and he required substantial/maximal assistance with toileting. His care plan identified an ADL self-care performance deficit related to schizophrenia and directed that he required supervision to limited assist by one staff member for toileting. During observation, staff took Resident #20 to his room after finding feces on the back of his pants and shirt, pulled the privacy curtains, and changed him without closing the bedroom door. Resident #20 stated staff had changed him with the door open before, that most of the time staff only closed the curtain, and that he wanted the door closed every time because it upset him when it was not. CNA B stated staff were trained on resident rights and that the policy required drawing the curtain and closing the bedroom door during care, but he did not plan to be stopped because Resident #20 had feces on him while in the hallway. The DON and ADM both stated that staff were responsible for providing privacy during care and that the door and curtain should be closed, and the DON said CNA B did not close the door because he could not remember whether he had done so after taking Resident #20 into the room.
Controlled Medication Documentation and Count Discrepancies
Penalty
Summary
The facility failed to establish a system of accurate reconciliation for controlled medications and failed to ensure that drug records were in order for one medication cart, affecting two residents. During observation of the 2200/2500-hall medication cart, the controlled medication log showed discrepancies for Resident #156’s Hydrocodone APAP 5-325 mg and Resident #71’s Hydromorphone HCl 2 mg, with one tablet of each medication removed from stock but not signed out in the narcotic log. The count on the log did not match the actual medication remaining in the cart for either resident. Resident #156 was a 66-year-old male with diagnoses including chronic pain, hypertension, and cervical disc disorder with myelopathy. His MDS showed severely impaired cognition with a BIMS score of 6, and his care plan identified ADL self-care deficits related to chronic pain syndrome and low back pain. He had an active order for Hydrocodone-Acetaminophen 5-325 mg, 1 tablet by mouth three times daily for pain. Resident #71 was a 72-year-old female with diagnoses including fibromyalgia, bipolar disorder, and muscle spasm of the back. Her MDS showed intact cognition with a BIMS score of 15, her care plan addressed acute/chronic pain related to fibromyalgia and chronic pain, and she had an active order for Hydromorphone HCl 2 mg, 1 tablet by mouth every 8 hours as needed for pain. During interview, LVN G stated she administered Resident #156’s Hydrocodone APAP and Resident #71’s Hydromorphone HCl that morning but forgot to sign for both controlled medications because she was busy with another resident leaving the facility. She acknowledged that failing to document controlled medication administration could cause a discrepancy in the count or a medication error because another nurse would not know the resident had already received the medication. The DON stated that charge nurses were responsible for monitoring accurate controlled medication counts and signing controlled medications as soon as they were administered, and that weekly audits were performed. The ADM stated that DON, ADONs, charge nurses, and medication aides were responsible for counting controlled medications at shift change and monitoring discrepancies to prevent drug diversion. Facility policy required medications to be documented as they were passed and controlled substances to be signed in the narcotic book, but the in-service records reviewed did not show completed nursing staff training on medication administration and signing controlled medications after administration.
Failure to Perform Hand Hygiene During Puree Food Preparation
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in the kitchen. During observation of puree food preparation, the cook wore gloves while placing meat and potatoes into the puree machine, transferring the food to a pan, tasting the puree, and placing it on the steam table. She then handled beans, corn, and bread items, including opening cabinets and refrigerator/freezer areas, checking temperatures, wiping the thermometer with an alcohol wipe, adding thickener, transferring food back into pans, and tasting the food, without washing her hands or changing gloves during the process. During interviews, the DM, the cook, and the ADM all stated that hand hygiene was required when entering the kitchen, touching food, switching tasks, or touching clothing, and that gloves do not replace hand hygiene. The DM said she monitored staff hand hygiene through observation and by asking staff if they washed their hands. The cook stated she had received infection control training and acknowledged that staff should wash hands when touching raw food, cooked food, or switching tasks. The ADM stated the cook did not sanitize her hands while fixing the puree foods and said he did not know why she did not do so. Record review of the Hand Hygiene Policy dated 10/24/2022 stated that all staff will perform proper hand hygiene procedures and that the use of gloves does not replace hand hygiene.
Failure to Follow EBP During Peri Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when staff did not follow Enhanced Barrier Precautions (EBP) during peri care for a resident who had an order for EBP. Resident #164 was a male with diagnoses including stage 5 chronic kidney disease, type II diabetes mellitus, legal blindness, hypertension, and a dialysis fistula to the left arm. His physician’s orders included EBP with gown and gloves for high-contact resident care activities, and his care plan identified EBP due to dialysis status, with interventions directing gown and glove use for activities including perineal/incontinent care. During observation, CNA D and CNA E provided peri care to Resident #164 using aseptic technique, changed gloves, and cleansed their hands at appropriate intervals, but they did not wear gowns while providing the care. Signage outside the room indicated that the resident in bed A was on EBP, and PPE was stored on the resident’s door. In interview, the CNAs stated they did not wear gowns because they believed the resident in bed B, not the resident in bed A, was on EBP, and they could not explain why the sign identified bed A. They later stated that after discussing the matter with the DON, they understood Resident #164 was on EBP and that the roommate was no longer on EBP. Additional interviews showed staff awareness that EBP required gown and glove use for close contact care such as peri care and bathing, and the DON and ADM stated they expected staff to follow EBP precautions when ordered. The DON stated the facility did not have a specific EBP policy and followed its infection control policy that included isolation types. The facility policy stated that all staff are responsible for following infection prevention and control policies and procedures and using PPE according to established facility policy.
Resident Left Unattended at Off-Site Appointment Due to Scheduling and Supervision Failures
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including dementia, schizophrenia, osteoporosis, impaired balance, and a moderate level of cognitive impairment, was left unattended at an off-site medical appointment. The resident was transported by a facility van driver to a hospital for a scheduled appointment that had actually been canceled. The driver, after confirming details with an overnight nurse but receiving no special instructions, dropped the resident off at the hospital and left, without ensuring appropriate supervision or arrangements for the resident's return. The resident was found unsupervised outside in a hospital courtyard by a security guard, who then notified hospital staff and the facility. The resident's care plan indicated a need for supervision during ambulation with a walker due to physical mobility needs, but the resident was sent to the appointment without her required assistive device. The facility's appointment scheduling process failed when the scheduler did not update the appointment book or notify the van driver of the cancellation, despite being informed by the MDS coordinator and the resident's guardian that the appointment was no longer needed. As a result, the resident was left alone in an unfamiliar environment, with diminished cognition and altered physical ability, and without the necessary mobility support. Interviews with facility staff, including the DON and Administrator, confirmed that the facility's protocol required staff to accompany residents to off-site appointments when supervision was indicated, and that this protocol was not followed in this instance. The incident was documented in the facility's incident report, and the failure to provide adequate supervision and assistance devices as required by the resident's care plan led to the identification of an Immediate Jeopardy situation.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established plan or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of cockroaches in multiple rooms, including those of residents with severe cognitive impairments and chronic health conditions. Observations revealed live roaches in Resident #1's room, with 20 live roaches noted under the bed and on the floor. Resident #7 also reported issues with roaches in her room, and Resident #6 mentioned seeing bugs recently. Despite frequent spraying by a pest control company, the problem persisted, indicating the treatments were ineffective. Interviews with staff and residents highlighted a lack of awareness and communication regarding the pest issue. The Maintenance Director was unaware of the roach problem on hall 2200 until the day of the survey, and staff were supposed to document pest sightings in a log for the pest control technician to review. However, the log entries showed multiple sightings, suggesting a disconnect between reporting and action. CNA A and CNA B confirmed seeing roaches and believed pest control measures were in place, but the effectiveness was questioned. The facility's Director of Nursing acknowledged the ongoing pest issue, attributing it to the building's age and stating that efforts to eliminate pests had been made. The facility's sighting logs documented several pest sightings, and the pest control company had visited multiple times. Despite these efforts, the presence of pests continued, compromising the residents' right to a safe and clean environment as outlined in the facility's resident rights documentation.
Deficient Food Storage, Labeling, and Sanitation Practices Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, preparation, and sanitation practices. Observations revealed that the ice scoop storage receptacle was cracked and had pieces missing from the bottom, and the inside of the ice machine had visible brown and white substances on the upper inside of the door. The stovetop range's drip pans contained orange and brown dried food particles and substances, and the foil liners were soiled. Additionally, the facility was not using an ice scoop receptacle that was intact and clean, as required by professional standards. Further observations in the kitchen and dry storage area showed that several food items were not properly labeled or dated. For example, a bus tub of individually wrapped wheat bread slices lacked a preparation date, time, product name, or discard date. Multiple bags and packages of food, such as coconut flakes, cake mixes, noodles, pinto beans, and cornmeal, were either undated, unlabeled, or had unclear dating information. Some opened products, including Italian dressing, teriyaki marinade, and soy sauce, were not refrigerated as required by the manufacturer’s label. In the walk-in refrigerator, a steam table pan of meatballs was labeled incorrectly as salsa and did not have a discard date. Interviews with the Dietary Director and Administrator confirmed that their expectations were for all food items to be labeled and dated upon receipt and preparation, and for staff to be trained on these procedures. However, review of the daily kitchen cleaning schedule showed that the ice machine was not included, and in-service training records indicated that staff had received training on labeling, dating, storage, and sanitation. The facility’s food storage policy and the FDA Food Code require proper labeling, dating, and storage of food items, as well as regular cleaning and sanitation of equipment, which were not consistently followed in this case.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective and ongoing pest control program, resulting in the presence of flies, gnats, and roaches in multiple areas throughout the building. Observations documented pests in resident rooms, the dining room, conference room, and near food service areas. Specific incidents included flies and gnats on and around a resident's bedside table, on bedsheets, and landing on the resident's skin, as well as roaches crawling on conference room walls and tables. Gnats were also observed near a resident's refrigerator that did not close properly, and flies were seen in the conference room and around food and beverage areas. Interviews with staff revealed a lack of a specific pest control policy, and staff acknowledged that the presence of pests could be related to cleanliness issues and was uncomfortable for residents. The administrator expressed surprise at the pest activity and was unable to comment on how residents felt about pests landing on them or their belongings. Resident council meeting minutes documented ongoing complaints about roach infestations over several months, with residents describing the situation as 'horrible.' Review of pest control invoices showed that while treatments were performed for cockroaches and flying insects, there were gaps in service documentation and continued evidence of pest activity. Emergency pest control services were provided in response to complaints, with recommendations for cleaning and removal of food sources, but pests remained present in the facility during the survey period.
Failure to Maintain Resident Dignity During Catheter Care and Meal Service
Penalty
Summary
Surveyors identified that the facility failed to maintain resident dignity in two key areas: the use of privacy covers for urinary catheter bags and the simultaneous serving of meal trays to residents seated at the same table. Two residents with indwelling urinary catheters were observed without privacy covers on their catheter bags, both in their rooms and while ambulating in the hallway. Interviews with these residents revealed that the absence of privacy covers was distressing, with one resident expressing embarrassment and a desire for privacy. Staff interviews confirmed that facility policy and training required catheter bags to be covered at all times, yet the deficiency persisted, and there was no facility policy document specifically addressing catheter privacy covers. Additionally, surveyors observed that residents seated at the same dining table did not receive their meal trays at the same time. On multiple occasions, some residents were served and began eating while their tablemates waited for their trays, sometimes for several minutes. Observations included residents displaying signs of hunger and discomfort while waiting. Staff interviews confirmed that the facility's meal service policy required all residents at a table to be served before moving to the next table, and staff acknowledged that failing to do so could impact residents' sense of dignity and comfort. The report included detailed medical histories and care needs for the affected residents, many of whom had cognitive impairments, communication difficulties, or required assistance with eating. Despite these needs and established policies, the facility did not consistently implement practices to protect resident dignity during catheter care and meal service. Staff and administration interviews indicated awareness of the policies and the importance of these practices, but could not explain why the deficiencies occurred.
Failure to Obtain Resident Consent for Searches of Personal Belongings and Living Spaces
Penalty
Summary
Facility staff failed to honor residents' rights to be treated with respect and dignity, specifically by conducting searches of residents' wheelchairs, belongings, and rooms without obtaining resident consent. Multiple residents, all cognitively intact, reported that a social worker (SS) and other unidentified staff searched their personal possessions and living spaces for contraband, such as cigarettes and lighters, without permission. These actions were corroborated by resident interviews, staff interviews, and witness statements, as well as documentation in resident records. Residents described feeling embarrassed, harassed, angry, and singled out as a result of these searches, and some reported emotional distress and a decline in self-esteem. Specific incidents included a resident with a history of COPD, dementia, and muscle wasting, who was searched by the SS without consent while exiting and entering the facility. The SS took cigarettes from the resident's wheelchair without permission, leading to a confrontation and emotional upset. Another resident, with a history of stroke and muscle atrophy, reported that the SS searched her wheelchair for marijuana without asking for consent, and took her cigarette case. A third resident, with diagnoses including dementia and bipolar disorder, also reported being searched by the SS without consent. These residents stated that the searches made them feel unwanted and disrespected, and some altered their behavior out of fear of further searches. During a resident council meeting, nine additional residents confirmed that their rooms and belongings had been searched by staff without their consent, and some reported that personal items were taken and given to other residents. Staff interviews revealed inconsistent understanding and application of facility policy regarding searches, with some staff stating they always asked for consent, while others admitted to searching when contraband was suspected. The facility's written policy explicitly prohibits searching a resident's body or possessions without consent, yet the administrator and other staff acknowledged that searches were conducted without consent, particularly when illegal substances were suspected.
Failure to Maintain Clean, Safe, and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four residents whose rooms were observed to be unclean, cluttered, and unsanitary. Observations revealed that one resident's room had a persistent fly problem, while another resident's room was cluttered with dirty clothes, food containers, and trash, despite repeated requests for assistance with cleaning and organizing. Staff interviews confirmed that requests for cleaning help were not addressed in a timely manner, and the resident expressed distress over the situation, stating it made her feel claustrophobic and wanting to leave the facility. Another resident was found in a room with dirty and stained bed linens, lacking a blanket and pillowcase, and the room had a noticeable odor of cigarette smoke. The resident expressed a desire for clean bedding but did not receive it. Additionally, a fourth resident reported that housekeeping did not clean her room unless specifically asked, and that linens provided were often stained and had holes. The resident also noted a loose baseboard in the bathroom, which she stated allowed roaches to enter, and expressed fear of walking on the dirty floor due to a recent toe amputation and surgical wound. Facility policy required daily cleaning of resident rooms and timely response to requests for assistance, but interviews with staff, including the DON and ADM, revealed that these expectations were not met. Staff acknowledged that cluttered and unclean rooms were not homelike and that residents should receive cleaning assistance promptly, yet the observed conditions and resident reports indicated that these standards were not upheld.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to the management of their medical, dental, and psychosocial needs. For one resident with multiple complex diagnoses, including cerebrovascular disease, schizoaffective disorder, and vascular dementia, the care plan did not address her physician-ordered oxygen therapy. Despite clinical orders for oxygen use and observations confirming the resident's use of oxygen, there was no documentation in the care plan regarding oxygen administration or care, nor instructions for changing or cleaning oxygen equipment. Another resident with diagnoses such as bladder cancer, diabetes, and muscle wasting had a documented food allergy to beets and had requested a dental exam upon admission. The care plan did not include information about his food allergy or dental needs, and there was no record of a dental exam being completed. The resident reported receiving meals containing beets despite his allergy and missing a dental appointment for dentures, which he had scheduled himself and communicated to staff. A third resident with a diagnosis of PTSD did not have her mental health needs addressed in her care plan. The resident reported that no staff had inquired about her PTSD, triggers, or necessary interventions, despite her preference for female staff and English-speaking caregivers due to past trauma. Interviews with staff revealed uncertainty about responsibility for updating care plans to address PTSD and related accommodations, and the care plan lacked any documentation of her diagnosis or required interventions.
Failure to Provide Regular Showers and Maintain Resident Hygiene
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received necessary services to maintain good grooming and personal hygiene. Four residents were identified as not receiving regular showers as scheduled, despite their care plans and shower schedules indicating the need for assistance with bathing. Documentation in shower logs frequently marked residents as 'not available,' 'refused,' or 'not applicable,' but interviews with residents revealed discrepancies, with some residents stating they did not refuse showers and were available on their scheduled days. Residents affected included individuals with significant medical and cognitive conditions, such as schizophrenia, anemia, hemiplegia, diabetes, and morbid obesity. These residents required varying levels of assistance with personal hygiene, as documented in their Minimum Data Set (MDS) assessments and care plans. Observations noted poor hygiene, such as oily and dirty hair, and residents expressed dissatisfaction with the lack of regular showers, with some reporting feelings of uncleanliness and discomfort. In some cases, residents proactively reported the issue to facility leadership, and grievances were filed regarding missed showers. Interviews with staff, including CNAs, RNs, the DON, and the ADON, revealed inconsistent understanding and documentation practices regarding shower provision and refusal. Staff provided varying explanations for the use of 'not applicable' in shower logs, including residents being out of the facility, room changes, or staff running out of time. There was also a lack of clarity on follow-up procedures when showers were missed or refused. Facility policy required that residents unable to perform ADLs receive necessary care to maintain hygiene, but this was not consistently implemented, resulting in missed showers for multiple residents.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the comprehensive assessments, care plans, and preferences of three residents, resulting in a lack of both group and individual activities designed to meet their physical, mental, and psychosocial needs. Observations revealed that these residents, who had varying degrees of cognitive impairment, physical limitations, and health conditions such as intellectual disabilities, dementia, and terminal illness, were frequently left without any form of stimulation or engagement in their rooms. Despite care plans specifying the need for sensory stimulation, 1:1 in-room activities, and honoring resident preferences, these interventions were not consistently implemented. For one resident with severe cognitive impairment and a history of enjoying music and sports, multiple observations showed him awake in his room without any stimulation, contrary to his care plan which called for regular sensory and 1:1 activities. Another resident, who preferred to stay in his room and had mild cognitive impairment, was also observed repeatedly without any activities or stimulation, despite a care plan that required staff to encourage participation and provide individual activities several times a week. A third resident, on hospice care and with significant memory issues, was similarly found asleep or awake in his room with no evidence of activities being offered, despite interventions calling for 1:1 in-room engagement. Interviews with facility staff, including the newly appointed activity director, DON, and administrator, confirmed that there was a lack of consistent activity provision and documentation for these residents. The activity director acknowledged being new to the role and still familiarizing himself with residents' needs, while the DON and administrator expressed expectations that bedbound residents should receive in-room activities as per policy. However, documentation and direct observations indicated that these expectations were not being met, and the facility's own policy requiring regular in-room visits for such residents was not followed.
Failure to Maintain Infection Control and Hand Hygiene Practices
Penalty
Summary
Staff failed to follow proper hand hygiene protocols during meal tray distribution and personal care activities for multiple residents. One CNA did not wash or sanitize hands between handling meal trays for three different residents, despite being trained on infection control procedures. Both the CNA and a nurse confirmed that the policy required hand sanitizing between each tray, and the CNA admitted to forgetting to perform hand hygiene. The nurse and administrator also acknowledged the expectation for hand hygiene and monitoring by nursing staff, but could not explain the lapse. During peri care for a resident with multiple diagnoses including diabetes, dementia, and chronic obstructive pulmonary disease, a CNA did not perform hand hygiene before or after care, nor when changing gloves. The CNA also reused disposable wipes by folding them, contrary to policy. The CNA and ADON both stated that hand hygiene should be performed before and after resident contact and when changing gloves, and that wipes should not be reused. The resident's care plan required cleansing the peri-area with each incontinent episode to prevent infection and skin breakdown. Another resident with an indwelling urinary catheter reported that no one had cleaned his catheter since admission, and that the cleaning performed was painful. The DON stated there was no specific policy for catheter care, while the administrator expected daily cleaning. The resident's care plan included monitoring for signs of infection and trauma related to the catheter. Facility policies reviewed required hand hygiene and proper glove use during peri care, and the hand washing policy emphasized infection prevention for all staff.
Failure to Provide Required Square Footage in Shared Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in five shared resident rooms, specifically rooms 201, 404, 504, 2405, and 2505. Observations revealed that each of these rooms contained three beds, with the beds arranged in a row, and the middle bed (Bed B) in each room having significantly less living space than the others. Digital measurements confirmed that several beds, particularly the middle beds in these rooms, had less than the required 80 square feet of space, with some as low as 48.84 square feet. The facility's Bed Classification form certified these rooms for three residents each, but actual measurements did not meet regulatory requirements for all beds. Interviews with the Administrator (ADM) and Director of Nursing (DON) indicated a lack of awareness regarding the specific square footage requirements and the absence of any waivers or variances for these rooms. The ADM stated that he relied on the Bed Classification form and was unaware that some beds did not meet the minimum space requirement. The DON also confirmed she was not aware of the requirements until informed by surveyors and acknowledged that insufficient space could impact residents' ability to move and receive care. No residents were reported to have complained about the space at the time of the survey.
Failure to Ensure Privacy During Incontinent Care
Penalty
Summary
A deficiency was identified when a staff member failed to provide full personal privacy for a male resident during incontinent care. The resident, who had a history of dementia, psychotic and mood disturbances, hemiplegia, traumatic brain injury, schizophrenia, major depressive disorder, and aphasia, was observed receiving pericare with the privacy curtain only partially closed between beds and the front curtain left open. The resident's roommate was present in the room, watching television at a high volume. During the care, the resident attempted to close the curtain further himself to increase his privacy. Interviews confirmed that the resident felt uncomfortable and lacked privacy during the care, and the CNA involved acknowledged that the curtain should have been fully closed. The DON also stated that staff are expected to close both the door and privacy curtains during such care. Review of facility in-service records and policy indicated that staff had been instructed to ensure privacy by closing curtains and doors during personal care, but this procedure was not followed during the observed incident.
Unauthorized Use of Physical Restraints Without Medical Need or Physician Order
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless required for medical treatment. Specifically, a cognitively intact female resident with a history of dementia, bipolar disorder, major depressive disorder, cognitive communication deficit, and muscle wasting was found with two triangular wedges on her bed that prevented her from getting off the bed. The resident's care plan and medical orders did not include the use of wedges, and there was no documentation of a medical need or physician order for their use. Observations confirmed that the resident did not have a pressure ulcer, which is the stated reason for wedge use according to facility staff. Interviews with staff, including an LVN, CNA, DON, and the administrator, revealed that the facility identifies itself as a no-restraint facility and that wedges are only to be used for positioning residents with pressure ulcers and require a physician's order. Staff were unable to provide a reason for the use of wedges in this case, and there was no communication or documentation supporting their use for this resident. The facility's restraint policy requires a specific medical symptom and physician order before restraints are used, which was not followed in this instance.
Failure to Address PTSD in Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that addressed a resident's diagnosis of PTSD. The resident, an adult female with a history of PTSD related to past abuse by males, was admitted with this diagnosis clearly documented in her records. Despite this, the baseline care plan did not include any instructions or interventions to address her PTSD. Interviews revealed that the resident was not asked about her PTSD, triggers, or preferred interventions, and she expressed a preference for female care staff and for being spoken to in English, as these factors affected her comfort and mental health. Staff interviews indicated uncertainty regarding responsibility for updating care plans to address PTSD and its accommodations. The social worker was unsure if PTSD should be included in the care plan and had not inquired about the resident's needs related to this diagnosis. Other staff members, including the social services staff and DON, acknowledged that care plans should be updated to reflect mental health diagnoses and related interventions, but this was not done for the resident in question. The facility's policy on baseline care plans was requested but not provided before the survey exit.
Unlabeled Soap in Resident Room Leads to Accidental Ingestion
Penalty
Summary
A deficiency occurred when a resident's environment was not kept free from accident hazards, resulting in a resident being given a sip of shower gel that was left in an unlabeled cup in the resident's room. The incident involved an 80-year-old male with vascular dementia, dysphagia, and cognitive communication deficits, who was on a mechanical soft diet with nectar thick liquids. The resident's family member (FM) found a cup of red liquid next to the TV in the resident's room and, mistaking it for a consumable item, gave it to the resident. The resident immediately spit out the liquid and began coughing. Nursing progress notes and interviews confirmed that the cup containing the soap was not labeled and was left in an accessible area of the resident's room. The FM believed the liquid was Jello due to its consistency, which was similar to the thickened liquids prescribed for the resident. Staff, including an LVN and the DON, were unable to determine how the soap ended up in the cup or who placed it there. The LVN assessed the resident after the incident and found no immediate adverse effects, and the resident was monitored as per protocol. The facility's policy required that the environment be kept as free from accident hazards as possible and that all incidents be reported and investigated. However, the presence of an unlabeled cup containing soap in the resident's room constituted a failure to secure potentially hazardous substances, directly leading to the incident. The investigation did not reveal the source of the soap or how it was left in the resident's room, and staff interviews indicated a lack of awareness regarding the potential harm of ingesting soap.
Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD. The resident's comprehensive and baseline care plans did not document the PTSD diagnosis or include any interventions to address or mitigate the resident's trauma-related needs. Despite the resident's intact cognition and clear communication of her preferences and triggers, such as a preference for female care staff and English-speaking staff due to past abuse by males and discomfort with other languages, these needs were not assessed or incorporated into her care plan. Interviews with facility staff revealed a lack of clarity and responsibility regarding the assessment and care planning for residents with PTSD. The social worker (SW) admitted to not asking about PTSD-related accommodations and was unsure about the process for updating care plans for such diagnoses. The staff scheduler (SS) and DON both acknowledged that care plans should be individualized for residents with PTSD, including identification of triggers and appropriate interventions, but these steps were not taken for the resident in question. The facility's own policy requires that care plans be person-centered, trauma-informed, and culturally competent, incorporating residents' diagnoses, preferences, and triggers. However, the policy was not followed in this case, as the resident's PTSD and associated care needs were omitted from her care plan, and staff were not aware of or addressing her specific triggers. The absence of this information in the care plan meant that staff were not equipped to provide appropriate care for the resident's mental health needs.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a calculated rate of 7.69% based on 2 errors out of 26 observed opportunities. One incident involved a medication aide (MA R) administering a whole Fish Oil 1000 MG gel capsule to a resident who had physician orders for all medications to be crushed. MA R did not crush the gel capsule, stating that it could not be crushed and that the resident typically takes it whole. MA R was unaware of the facility's policy regarding gel capsules with crush orders and relied on personal experience rather than established protocols. Another incident involved a medication aide (MA T) administering Metoprolol Succinate ER to a resident despite the resident's blood pressure and heart rate being outside the parameters specified in the physician's order, which required the medication to be held under such conditions. Both medication aides demonstrated a lack of adherence to the facility's medication administration policy, which requires medications to be administered as ordered and in accordance with manufacturer specifications, including holding medications when vital signs are outside prescribed parameters and crushing medications as ordered.
Significant Medication Error Due to Failure to Follow Blood Pressure Parameters
Penalty
Summary
A medication administration error occurred when a staff member administered Metoprolol Succinate ER to a male resident diagnosed with essential hypertension, despite the resident's vital signs being outside the prescribed parameters. The physician's order specified that the medication should be held if the systolic blood pressure was less than 110 or the heart rate was less than 60. On the observed date, the resident's blood pressure was 145/67 and heart rate was 54, yet the medication was still given. The resident was noted to be severely cognitively impaired, with a BIMS score of 6, and required staff to follow medication administration protocols closely. The staff member acknowledged in an interview that the medication should not have been administered under these circumstances and that staff are regularly in-serviced on proper medication administration procedures. Facility policy also requires staff to obtain and record vital signs and to hold medications when vital signs fall outside of physician-ordered parameters.
Unsecured Medication Carts and Improper Medication Storage
Penalty
Summary
Surveyors observed that drugs and biologicals were not consistently stored in locked compartments as required by state and federal regulations. Specifically, two out of four medication carts reviewed were found unlocked: one on the 2400 hall and another by the front entrance on the lower level. During a medication pass, a medication aide (MA T) left the medication cart unlocked and unattended while seeking clarification from the charge nurse, leaving medications out of her sight and in the presence of the surveyor. Later that day, another medication cart was found unlocked and unattended near the front entrance, with no staff nearby and residents present in the area. Interviews with MA T revealed an awareness of the facility's policy requiring medication carts to be locked when unattended, but she admitted to leaving the cart unlocked because the surveyor was present, despite knowing the rules. The Director of Nursing (DON) confirmed that staff are expected to lock carts when not in use to prevent unauthorized access. Review of facility records showed that staff had been in-serviced on medication storage, but the written medication administration policy did not address medication storage or locking carts.
Failure to Provide Timely Transportation for Diagnostic Services
Penalty
Summary
A deficiency occurred when the facility failed to provide timely transportation for a resident to a scheduled MRI imaging appointment, resulting in the appointment being canceled due to late arrival. The resident, who has a history of schizophrenia, epilepsy, chronic right hip pain, and a pelvis fracture, expressed frustration over the missed appointment and ongoing pelvic pain. The resident was not informed about the rescheduling of the appointment or who would be responsible for future transportation, especially after being told that the facility van driver would no longer be working there. No communication was provided to the resident regarding future appointments. Interviews with staff revealed that the process for arranging transportation involved scheduling appointments in a central book, but a breakdown occurred when the facility van was unavailable and the driver was unaware that an alternative vehicle had been secured. This miscommunication led to the resident being transported late. The staff responsible for transportation coordination were unsure if the resident or the medical provider had been notified about the missed appointment. Additionally, the facility administrator confirmed that there was no transportation policy in place at the time of the incident.
Failure to Arrange Transportation for Dental Appointment
Penalty
Summary
The facility failed to assist a resident in arranging transportation to and from a dental services location, resulting in the resident missing a dental appointment for denture castings. The resident, who had diagnoses including bladder cancer, muscle wasting, malaise, and vitamin D deficiency, had requested a dental exam upon admission, but there was no record of a dental exam in his medical record. The resident made his own dental appointment and informed the facility's CST, who was responsible for scheduling transportation. However, the facility van was unavailable due to repairs, and the CST provided a public transportation pass without confirming that the public transit covered the dentist's location. As a result, the resident was unable to reach the appointment and missed it. Interviews with the CST and ADM confirmed that the facility did not have a transportation policy and that it was the responsibility of the interdisciplinary team to ensure residents were transported to appointments. The CST acknowledged not verifying the public transportation coverage area and stated it was their responsibility to secure transportation. The ADM also stated that residents should be transported as scheduled and that missing appointments could negatively affect residents. The resident expressed concern about missing necessary dental care and uncertainty about future transportation arrangements.
Failure to Accommodate Documented Food Allergy
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's documented allergy. The resident, a male with diagnoses including anemia, type 2 diabetes with a foot ulcer, and vitamin D deficiency, had a known allergy to beets, which was clearly listed on his face sheet and meal ticket. Despite this documentation, the resident was served beets on his meal tray, as confirmed by both his statements and review of meal tickets. The resident, who was cognitively intact, reported that he repeatedly received trays containing beets and had to send them back, expressing concern for other residents who might not be able to recognize or report such errors due to cognitive impairment. Observations of meal service showed that staff performed hand hygiene and checked trays, but no discrepancies were noted during the observed meal. However, interviews with dietary and nursing staff confirmed awareness of the resident's allergy and acknowledged that the resident had received beets on his tray at times. The facility's process involved multiple checkpoints by different staff members, including the cook, diet aide, nurse, and CNA, to verify tray accuracy, yet the error still occurred. Review of facility policies indicated that tray line audits and allergy awareness procedures were in place, and in-service trainings on food allergies had been conducted. Despite these measures, the resident's allergy was not consistently honored, as evidenced by the repeated serving of beets. The care plan for the resident did not document the food allergy, and tray line audits did not identify any concerns or trends related to this issue.
Failure to Properly Witness and Document Admission Agreement
Penalty
Summary
The facility failed to ensure that a resident's medical records, specifically the Admission Agreement, were accurately documented and properly witnessed according to policy. The Admission Agreement for an 80-year-old male resident with multiple diagnoses, including vascular dementia and impaired decision-making ability, was signed electronically after consent was received during a phone conversation. However, the process did not include two witnesses to the consent, as required. The staff member responsible for obtaining consent was unsure whether she spoke with the correct family member and entered the name based on information from the hospital face sheet, without confirming the power of attorney status at the time. Further review revealed that the electronic system required two facility representatives to sign the document, but the second signatory did not actually witness the phone conversation. Both the Admissions Coordinator and the Assistant Business Office Manager confirmed in interviews that the second signature was added after reviewing the form, not after witnessing the consent. The Assistant Business Office Manager stated he was unaware of who was spoken to and did not witness the conversation, despite signing as a witness. The facility's policy requires that documentation in the medical record be accurate, complete, and timely, reflecting the actual experiences of the resident. In this case, the Admission Agreement was not properly witnessed, and there was uncertainty about the identity of the person who provided consent. This resulted in incomplete and potentially inaccurate documentation in the resident's medical record.
Resident Elopement Due to Inadequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, leading to a resident's elopement. The resident, who had a history of cerebral infarction, hypertension, aphasia, and other medical conditions, broke her window and attempted to leave the facility. Despite this initial attempt, the facility did not implement effective interventions to prevent further incidents. On a subsequent occasion, the resident successfully eloped from the facility after breaking her window again. The staff's response included attempts to follow the resident and notify the police, but they were initially unable to locate her. The resident was eventually found in a coffee shop, where she was agitated and refused assistance, leading to her being transported to the hospital. The facility's records and interviews revealed that the resident had exhibited signs of anxiety, hallucinations, and restlessness prior to the incidents. Despite these behaviors, there were no documented reevaluations of her wandering risk, and the care plan did not adequately address her needs for supervision and safety. The facility's failure to address these issues resulted in a deficiency that placed the resident at risk for harm.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report an elopement incident involving a resident within the required 24-hour timeframe. The resident, who had a history of cerebral infarction, hypertension, aphasia, and other medical conditions, broke a window and left the facility. Despite staff efforts to locate her, she was not found until an hour later at a nearby coffee shop. The facility did not report this incident to the State Agency (SA) as required by regulations. The resident's care plan indicated she had behavior problems and required monitoring for adverse reactions to anti-anxiety medications. On the night of the incident, staff observed the resident breaking a window and leaving the facility. Although staff followed her and eventually found her, the facility's administration did not consider the incident reportable, as they believed the resident was within eyesight at all times and did not meet the definition of elopement. Interviews with staff revealed confusion about the reporting requirements and the definition of elopement. The Administrator believed the incident did not meet the criteria for reporting, while other staff members considered it an elopement. The facility's policies required reporting such incidents, but the Administrator did not report it, believing the staff's response was appropriate. This failure to report could place residents at risk of harm.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests, including cockroaches and other insects, in various areas such as resident rooms, the kitchen, dining room, and shower room. Observations on 08/06/2024 revealed multiple instances of insects, including crickets and small bugs, in these areas. Interviews with residents and staff confirmed frequent sightings of cockroaches, particularly in resident rooms and the kitchen, indicating an ongoing issue with pest control. Interviews with staff members, including the Dietary Aide (DA), Assistant Food Service Supervisor (AFSS), and cooks, revealed that cockroaches were a known problem throughout the facility. The Maintenance Director (MD) and Food Service Supervisor (FSS) acknowledged the issue, with the MD noting that a full treatment had not been conducted in over a year and a half. The pest control company confirmed the presence of a significant infestation in the kitchen and indicated that the facility's management had been resistant to authorizing a comprehensive treatment. The facility's pest control logs and service reports documented numerous sightings and treatments for cockroaches and other pests over several months. Despite regular monthly treatments and additional services as needed, the pest problem persisted, with sightings recorded in various locations, including resident rooms, the kitchen, and common areas. The facility's administration acknowledged the ongoing challenge and the need for a more extensive pest control approach, but no formal pest control policy was in place, only a contract with a pest control company.
Deficiency in Food Labeling and Storage
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed in the kitchen. During an inspection, a torn bag with exposed food was found in the freezer without any label or date. Another bag of food was observed with a date but no label indicating its contents. The Food Service Supervisor (FSS) instructed staff to re-bag and date the exposed food, indicating a lack of initial compliance with labeling protocols. Interviews with the FSS and other staff members revealed that all kitchen staff were responsible for labeling and dating food items, including the date of receipt or expiration. The facility's policy required all food to be labeled, dated, and covered, as confirmed by a review of the policy and the Dietary Manager Daily Checklist. Despite these guidelines, the deficiency in labeling and dating was evident, as acknowledged by the staff and administration during interviews.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure that a resident was treated with respect, dignity, and care in a manner that promoted the maintenance or enhancement of their quality of life. Specifically, a Certified Nursing Assistant (CNA) did not provide privacy to a resident during incontinent care by leaving the door open and not drawing the privacy curtain, which left the resident exposed and visible from the hallway. This incident involved a female resident with multiple diagnoses, including conversion disorder with seizures, cerebral palsy, peripheral vascular disease, muscle wasting, repeated falls, depression, and moderate intellectual disabilities. The resident was dependent on staff for toileting and was always incontinent of bowel and bladder. During the investigation, interviews with staff, including the CNA involved, revealed that the expected procedure for providing privacy during incontinent care was not followed. The CNA admitted to not closing the door or drawing the curtain, acknowledging that this could lead to the resident being seen by others, which is a dignity issue. Other staff members, including another CNA and the Director of Nursing (DON), confirmed that the standard practice was to ensure privacy by closing the door or curtain. The facility's policy on perineal care also emphasized the importance of providing privacy. The failure to adhere to these procedures resulted in a deficiency related to the resident's right to dignity and respect.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs were stored in locked compartments with access restricted to authorized personnel only. During an observation, a medication cart on the 300 hall was found unlocked and unsupervised, with three compartments accessible. RN A, who was responsible for the cart, admitted to leaving it unattended while attending to a resident's needs elsewhere. She acknowledged that she should have locked the cart and taken the keys with her but believed she might not have pressed the lock hard enough. The unlocked drawers contained routine medications, respiratory treatments, and cleaning items, although narcotics were secured in a separate locked drawer. Interviews with staff, including MA D and the DON, confirmed that the facility's policy requires medication carts to be locked when not in use. The DON and RCN both expressed that leaving carts unlocked could lead to unauthorized access to medications. The facility's policy, last revised in 2019, clearly states that medication carts must be locked at all times when not in use and should not be left unattended in resident care areas.
Failure to Identify and Manage Elopement Risk
Penalty
Summary
The facility failed to identify a resident as an elopement risk from his admission paperwork or complete a wandering/elopement assessment within 24 hours of admission. This resulted in the resident eloping from the facility for approximately three hours and being located 1-2 miles away at a busy intersection. The resident had a history of elopement and severe cognitive impairment, which was not adequately addressed upon his admission to the facility. The resident's care plan was only revised to include elopement risk interventions after the incident occurred. The Director of Nursing (DON) admitted that the wandering/elopement assessment had not been completed prior to the elopement and that it was the responsibility of the social worker, who was subsequently suspended and then voluntarily quit. The DON also acknowledged that the resident was known to be at risk of elopement but was placed on the second floor instead of the memory care unit, which was deemed too restrictive. The failure to complete the assessment in the required timeframe directly led to the resident's elopement. Interviews with various staff members revealed a lack of communication and proper procedures in place to prevent such incidents. The receptionist, social workers, and nurses all provided accounts of the events leading up to and following the elopement, highlighting gaps in the facility's processes. The facility's investigation confirmed that no specific individual was at fault, but the overall lack of diligence in assessing the resident's elopement risk and implementing appropriate interventions was evident.
Failure to Ensure Resident Dignity and Clean Environment
Penalty
Summary
The facility failed to ensure that Resident #20 was treated with respect and dignity. During an observation, Resident #20 was found sitting on her walker with her pants down, exposing her private parts. The resident's call light was on the ground and away from her bed, making it difficult for her to call for assistance. Interviews with CNAs revealed that they were unaware of the incident and did not recognize the potential negative impact on other residents. The resident's care plan indicated she required extensive assistance with dressing due to her cognitive impairments and physical debility, but this assistance was not provided in a timely manner. Resident #395 experienced neglect in the form of inadequate toileting assistance. His urinal was found full and on the ground next to his bed, causing a strong urine odor in his room. Despite the facility's policy that urinals should be emptied and cleaned every two hours, staff interviews indicated that this was not consistently done. The resident reported that his urinal had been full for three hours and that he had requested a new urinal but did not receive one. Housekeeping staff confirmed that they had received complaints about the cleanliness of residents' rooms and the smell of urine. Resident #65 exhibited disruptive and unsanitary behaviors, including urinating in common areas and damaging facility property. Despite being care planned for these behaviors, the facility failed to manage them effectively. Interviews with staff and other residents revealed that Resident #65's actions created an uncomfortable and unsanitary environment. The resident's behaviors, such as urinating in the elevator and dining room, were well-known to the staff, including the Administrator and DON, but were not adequately addressed. This failure to manage the resident's behaviors compromised the safety and comfort of other residents in the facility.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for four residents, leading to rooms with a persistent urine odor. Resident #41's room smelled of urine, and her call light was found behind her bed, making it inaccessible. Resident #129's room also had a urine odor, and he was found sleeping with a bed sheet covering his body and face. Resident #395's room had a full urinal on the ground, which had been there for three hours, causing a strong urine odor that bothered him. Resident #141's room also smelled of urine, and she reported that staff did not clean her room as requested. The memory care unit had a pervasive urine odor and sticky floors, indicating inadequate cleaning practices. Staff interviews revealed inconsistencies in cleaning routines and responsibilities. CNA I stated that residents' rooms were cleaned every 20 minutes, while housekeeping staff were responsible for cleaning rooms three times a day. However, multiple staff members, including CNA E and HK Q, acknowledged that the urine odor was a persistent issue and that residents could be negatively affected by it. Despite these claims, there was no evidence of a consistent and effective cleaning protocol to address the urine odor. The facility's policies on housekeeping and resident rights emphasized the importance of maintaining a clean and safe environment. However, observations and interviews indicated that these policies were not effectively implemented. The facility lacked a specific policy on creating a homelike environment and managing urinals, contributing to the ongoing issue of urine odor in residents' rooms and the memory care unit. This deficiency placed residents at risk of discomfort and diminished quality of life, as evidenced by the persistent urine odor and residents' complaints about inadequate cleaning.
Inadequate Pest Control Program
Penalty
Summary
The facility failed to maintain an effective ongoing pest control program, which placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Observations and interviews revealed the presence of insects such as crickets, cockroaches, and flies in various areas of the facility, including residents' rooms, the nursing station, and the dining area. Multiple residents and staff members reported frequent sightings of insects, and some residents expressed concerns about the cleanliness of their rooms and the presence of pests. Despite these reports, the facility's pest control measures were insufficient to address the ongoing issue effectively. Resident #4, a male with severe cognitive impairment, was observed to have crickets in his room on multiple occasions. Resident #141, a female with severe cognitive impairment, reported that insects were always present in residents' rooms and expressed dissatisfaction with the cleaning efforts. Additionally, Resident #13, a male with moderate cognitive impairment, was observed with a fly on his shirt, and Resident #184, a female who was cognitively intact, reported seeing cockroaches in residents' restrooms. These observations and interviews indicate that the facility's pest control program was not adequately addressing the pest problem, leading to a compromised living environment for the residents. Interviews with staff members, including CNAs, housekeeping staff, and the Maintenance Director, revealed inconsistencies in the frequency and effectiveness of pest control treatments. While some staff members stated that pest control visited the facility once a month, others mentioned more frequent visits. However, the presence of pests persisted, and staff members acknowledged that residents could be negatively affected by insects in their rooms. The facility's pest control logs and service reports indicated that treatments were conducted, but the ongoing sightings of pests suggest that these measures were not sufficient to eliminate the problem. The lack of a policy and procedure on maintaining a homelike environment further contributed to the deficiency in pest control management.
Failure to Provide Communication Aide for Resident with Hearing Loss
Penalty
Summary
The facility failed to provide a communication aide for a resident diagnosed with hearing loss, which compromised the resident's right to a dignified existence, self-determination, and quality of life. The resident, who has a history of cerebral infarction, vascular dementia, and other mental health conditions, was found to have profound hearing loss and was recommended for follow-up with an ENT doctor. Despite this, the facility did not provide necessary communication tools such as a whiteboard or writing implements, making it difficult for the resident to communicate her needs effectively. During an observation, the surveyor noted the absence of any communication devices in the resident's room. The resident confirmed that she had been communicating with staff by writing everything down but faced difficulties when she did not have paper or a pencil. This lack of communication tools hindered her ability to convey her needs to the staff, affecting her overall quality of life. Interviews with the DON and the Administrator revealed a lack of awareness and concern regarding the resident's communication needs. The DON acknowledged the importance of communication aids, while the Administrator initially dismissed the issue as psychological rather than medical. The facility also lacked a specific policy to address resident communication needs, further contributing to the deficiency.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident. During a supervised smoking session, one resident verbally abused another by yelling and making demeaning comments. Two staff members were present but did not intervene immediately. The affected resident, who has a history of dementia and schizoaffective disorder, did not acknowledge the abuse and appeared unable to communicate effectively, using hand gestures instead of verbal requests. Interviews with staff revealed a lack of awareness and intervention regarding the verbal abuse. One staff member claimed not to recall the incident, while another admitted to being preoccupied with handing out cigarettes. The Activity Aide/Smoke Aide acknowledged that some residents were mean to the affected resident and tried to redirect them, but the abuse persisted. The resident's guardian also reported instances of bullying and verbal abuse during visits, which were communicated to the facility's social worker. The facility's policies on promoting resident dignity and preventing abuse were not effectively implemented. Staff interviews indicated a lack of consistent intervention and awareness of the resident's emotional state. The Director of Nursing and the Administrator both acknowledged the verbal abuse but did not initially recognize it as such. The facility's failure to protect the resident from verbal abuse and to ensure a safe and respectful environment was evident in the observations and interviews conducted during the survey.
Failure to Provide Necessary Grooming and Personal Hygiene Services
Penalty
Summary
The facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #102 did not receive nail care, and Resident #182 did not receive shaving care. These deficiencies were identified through observations, interviews, and record reviews conducted by surveyors. Resident #102, an elderly female with diagnoses including schizophrenia, unspecified dementia, and major depressive disorder, was observed with long fingernails. Despite her care plan indicating she required assistance with personal hygiene, there was no documented history of her refusing nail care. Interviews with staff revealed inconsistencies in the provision of nail care, with some staff unaware of the schedule or failing to offer nail trims due to shift changes or personal emergencies. Resident #182, an elderly female with severe cognitive impairment and a history of CVA, was observed with long whiskers on her chin. She expressed a preference for shaving, but staff had not offered this service. Interviews indicated that shaving was supposed to be offered on shower days and Sundays, but there was no consistent documentation or follow-up on refusals. Staff were also unsure about the last time she received a shave, and there was no in-service training on grooming, showers, nail care, or shaving care documented for the year.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide or obtain routine dental services for a resident with multiple medical conditions, including vascular dementia, iron deficiency anemia, and dysphagia. The resident, who had no natural teeth and was on a mechanically altered diet, required dental extractions and dentures as recommended by a dentist. However, the facility did not obtain the necessary financial consent or declination for the recommended dental services, leaving the resident without the needed dental care. The deficiency was identified through a series of interviews and record reviews. The social workers (SW A and SW B) were responsible for obtaining consents for treatment, but there was a lack of communication and follow-up between them. SW A was initially responsible for obtaining the consent but did not complete the process. SW B, who took over the responsibility after returning from maternity leave, also did not follow up adequately. The dental provider had sent multiple requests for a signed payment letter, but no action was taken by the facility staff. The Director of Nursing (DON) and the Administrator were not fully aware of the resident's dental needs and the financial requirements for the dental services. The resident expressed a desire for dentures despite the cost, but the facility did not take the necessary steps to facilitate the process. The lack of coordination and communication among the facility staff led to the resident not receiving the required dental care, which could impact her ability to chew and enjoy her food.
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 333 citations issued within 25 miles in the last 12 months — including the 17 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 Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Arbour At Westminster Manor | 3.5 mi | ★★★★★ | 4 | 0 |
| Riverside Nursing And Rehabilitation Center | 4.2 mi | ★★★★★ | 12 | 0 |
| Sedona Trace Health And Wellness Center | 4.3 mi | ★★★★★ | 3 | 0 |
| Coral Rehabilitation And Nursing Of Austin | 4.6 mi | ★★★★★ | 52 | 10 |
| Brookdale Westlake Hills | 4.7 mi | ★★★★★ | 9 | 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.