Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Plaza Nursing Center during CMS and state inspections, most recent first.
A resident with a history of abnormal weight loss and a recent ankle fracture experienced significant weight loss, poor intake, and swallowing difficulties. Despite staff observations and recommendations from the wound care physician, the care plan was not updated, and no dietician consult or therapeutic diet was provided in a timely manner. Staff attempted informal interventions, but there was no formal change in diet or coordinated response to the resident's nutritional decline.
Surveyors found that food items in the kitchen, including powdered sugar, mixed vegetables, and various meats, were not properly stored, labeled, or dated as required by facility policy. Staff interviews confirmed that these practices were not followed, and items with unknown storage times or improper sealing were present in both the refrigerator and freezer.
Three residents had broken dressers or wardrobes with missing or damaged drawer fronts and exposed personal items, while the dining room activity cabinet had removed doors left propped nearby. Staff and maintenance were either unaware or had not reported these issues, and no work orders were submitted for repairs. The facility's maintenance policy required all areas and equipment to be kept in good repair, but this was not followed.
Multiple infection control failures were observed, including staff not using required PPE or signage for a resident on droplet precautions, improper glove use and hand hygiene during catheter care for a resident with severe cognitive impairment, and failure to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during wound and incontinent care for a resident with wounds. Staff interviews confirmed knowledge of protocols but inconsistent adherence during care.
A resident with severe cognitive impairment and a Foley catheter was repeatedly observed without a privacy bag covering the catheter drainage bag, making it visible in both the resident's room and public areas. Staff interviews confirmed awareness of the requirement for privacy bags to maintain dignity, but the absence was not reported or corrected, and the facility's policy did not address dignity.
Two residents with cognitive impairment and documented needs for socialization did not receive consistent, scheduled activities as outlined in their care plans and physician orders. Activity participation records were not updated, and residents reported limited engagement, with activities often canceled or not started on time. Staff interviews confirmed that the Activity Director's additional duties interfered with the delivery of the activity program, resulting in a lack of variety and frequency of activities.
The facility did not employ a certified Activity Director to oversee its activities program. The individual in the role lacked the required certification and had limited experience, having previously worked as a CNA and in transportation. The Activity Director was enrolled in a certification course but had not yet started it, and continued to perform other duties in the facility. Facility policies did not specify the necessary qualifications for the position.
A resident with dementia and impaired mobility was transferred using a mechanical lift by a CNA who did not open the lift's legs to the wide position before lifting and moving the resident, as required by facility policy and best practices. The legs were only spread after the resident was already suspended and being moved, following a prompt from another CNA. Interviews and policy review confirmed this was not in accordance with safe transfer procedures.
A resident with an indwelling Foley catheter did not receive proper catheter care, including failure by a CNA to change gloves and perform hand hygiene after cleaning the resident, lack of a catheter securement device, and the catheter drainage bag being left on the floor. Staff interviews confirmed awareness of proper procedures, but these were not followed during the observed care.
A resident with a documented history of PTSD did not receive a trauma screening or assessment upon admission, despite facility policy and clear documentation of trauma history. The care plan did not address PTSD or identify potential triggers, and staff interviews confirmed the required screenings and assessments were not completed or documented.
A resident with a history of diverticulitis and an ileostomy was found covered in feces due to a leaking colostomy bag, highlighting a failure in providing dignified care. Despite the resident's and family's complaints, staff did not respond promptly, leaving the resident in distress for hours. Interviews revealed confusion among staff about responsibilities for colostomy care, contributing to the incident.
The facility failed to ensure call lights were within reach for two residents, both with cognitive impairments and fall risks. One resident's call light was found hanging on a curtain, while another's was on the floor, making them inaccessible. Staff interviews confirmed the expectation for call lights to be within reach to prevent falls and ensure timely assistance.
A resident with severe cognitive impairment was verbally abused by a CNA during shower assistance. The CNA accused the resident of lying and made derogatory comments, which were overheard by the previous DON. The incident was documented, and the resident did not appear to be in distress or injured, but the comments were deemed abusive.
A resident with a colostomy experienced multiple incidents of leaking bags, resulting in her being covered in feces for several hours. The facility staff were not adequately trained or informed about their responsibilities in managing colostomy care, leading to delays in addressing the leaks. The resident's call light was not answered promptly, and staff were unclear about their roles, resulting in the resident remaining in a soiled state.
A resident with severe cognitive impairment and multiple medical conditions frequently refused care, including repositioning and medication intake. Despite these refusals being noted in assessments, the facility failed to update the care plan to reflect these issues, leaving staff without proper guidance. Interviews with staff revealed a lack of clarity and responsibility in updating the care plan, leading to the deficiency.
A facility failed to implement its abuse prevention policies when a resident was roughly handled by a CNA during ADL care. The CNA was not suspended immediately, and the abuse was not reported to the state agency within the required timeframe. The resident, who had chronic health conditions and required assistance, was upset by the mistreatment. Despite being informed, the ADON delayed reporting the incident, allowing the CNA to continue working for several shifts. The facility's noncompliance was identified as PNC.
The facility failed to provide adequate supervision and safe practices for two residents, leading to a fall and injury during incontinent care and unsafe mechanical lift transfers. A resident with severe cognitive impairment fell off the bed during care by a single CNA, despite requiring two-person assistance. Another resident was transferred alone using a mechanical lift, contrary to care plan requirements. Staff reported frequent understaffing, contributing to these unsafe practices.
Two residents in a LTC facility were not treated with dignity and respect. One resident was denied assistance by a CNA when he requested to be repositioned in bed, while another resident was subjected to an inappropriate comment by the previous Administrator, comparing his appearance to that of a child molester. Both incidents were reported by staff and family, highlighting a breach of the residents' rights.
Two residents in a LTC facility experienced abuse by CNAs, one physically and the other verbally. The first resident, with mild cognitive deficit and multiple health issues, was roughly handled during bed transfer, while the second resident, with dementia and limited mobility, was subjected to inappropriate language during a verbal altercation. Both incidents violated the residents' rights and the facility's abuse policy.
A resident with chronic health issues and mild cognitive deficit experienced rough and verbally harsh treatment by a CNA, which was captured on video by the resident's family. The ADON was informed of the incident but delayed reporting it to the abuse coordinator and authorities, unaware of the 2-hour reporting requirement. The facility's policy mandates immediate reporting of abuse allegations, but the incident was reported to HHS eight days later.
The facility failed to provide a private space for Resident Council meetings, leading to continuous interruptions by staff. Despite the facility's policy that meetings should be private, staff entered the dining room during meetings, compromising residents' ability to voice their concerns without interference. The Administrator acknowledged the issue and the availability of alternative routes for staff to avoid disrupting the meetings.
A resident with multiple fractures and chronic pain did not receive the ordered Lidocaine 5% topical patch for several days after admission. The medication aide forgot to administer the patch, leading to ongoing pain for the resident. The Director of Nursing and Administrator confirmed the oversight, acknowledging it was against the facility's pain management policy.
The facility failed to lock medication carts and remove expired medications, posing risks of drug diversion and adverse reactions. Unlocked carts with various medications were observed, and expired eye drops were found in one cart. Staff acknowledged the policies but did not consistently follow them.
The facility failed to promote resident self-determination for two residents. One resident was not assisted out of bed as often as she preferred, and another was not provided with showers or shaves as requested. Both residents expressed dissatisfaction with their care, and staff confirmed issues with adhering to personal care schedules due to understaffing.
A facility failed to maintain a safe and comfortable environment for a resident with severe cognitive impairment and depression. The wall behind the resident's bed had multiple areas of damage, which had been reported but not repaired for months. Staff acknowledged the delay and the need to move the resident for the repair, but the family had been non-compliant in moving the resident's camera.
The facility failed to provide scheduled bathing and grooming services to two residents, leading to poor personal hygiene and unmet care needs. One resident did not receive scheduled showers, and another was not shaved as per his preference, despite both requiring assistance with activities of daily living.
The facility failed to provide a resident with consistent, scheduled activities and an activity calendar, despite the resident being cognitively intact and expressing interest in participating. The resident reported feeling ignored and was often found in bed, missing group activities. Staff interviews and observations confirmed the lack of engagement and documentation of activity refusals.
A facility failed to provide a catheter securement device for a resident with an indwelling urinary catheter, leading to increased risks of urethral trauma, dislodgement, infection, and skin breakdown. The oversight was confirmed through observations and staff interviews, revealing that the securement device had been missing for several hours.
A facility failed to ensure safe and sanitary storage of a resident's food items, leading to expired and decomposing meat products being found in the resident's personal refrigerator. Despite being informed, the housekeeping staff did not remove the expired food, and the Director of Nursing and Administrator acknowledged the oversight, highlighting a risk of foodborne illness.
Failure to Provide Therapeutic Diet and Timely Interventions for Resident with Nutritional Decline
Penalty
Summary
A deficiency occurred when the facility failed to ensure a therapeutic diet was offered and appropriate interventions were implemented for a resident experiencing nutritional problems, including poor intake related to swallowing difficulties and physical decline. The resident, an older female with a history of abnormal weight loss, was admitted with a left ankle fracture and subsequently developed a wound after cast removal. Despite documented weight loss, low prealbumin levels, and decreased oral intake, the care plan was not updated in a timely manner to reflect these changes, and no dietician consult was initiated as recommended by the wound care physician. Staff interviews and record reviews revealed that the resident's care plan had not been revised to address her weight loss, swallowing issues, or wound care needs since several months prior. The resident's diet remained unchanged, and although staff observed her difficulty swallowing and poor appetite, no formal order was placed to modify her diet consistency. The dietary manager and aides noted the resident's decreased intake and attempts to provide softer foods, but these actions were not supported by updated physician orders or care plan interventions. The speech therapist was only informally consulted and did not complete a formal assessment until much later. Multiple staff members, including nurses, aides, and dietary staff, reported the resident's declining intake and difficulty swallowing over a period of weeks. Despite these observations and the resident's significant weight loss, there was a lack of communication and follow-through to ensure appropriate dietary and therapeutic interventions were implemented. The facility's own policies required notification of the physician and dietitian for significant weight changes, but these steps were not taken in a timely manner, resulting in the resident not receiving the necessary nutritional support.
Failure to Properly Store, Label, and Date Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, and dating of food items. An opened box of powdered sugar was found in the dry goods pantry with the inner plastic bag cut open and not securely closed, nor was it placed in a sealed, labeled, and dated container. In the refrigerator, a clear plastic container with a red sauce and another with mixed vegetables (green beans, corn, and potatoes) were found without any labels or dates. Staff interviews confirmed that the red sauce was recently placed in the refrigerator, but the mixed vegetables' storage duration was unknown. Both items were discarded after discovery due to improper labeling and dating. Further inspection of the freezer revealed two plastic bags containing meat—one with an unknown type of meat and another with what appeared to be chicken—both covered in ice particles and lacking labels and dates. Staff interviews indicated that food items should be labeled and dated before being placed in storage, and that the presence of ice on meat could indicate freezer burn and improper storage duration. Staff acknowledged their responsibility for proper food storage, with the dietary manager (DM) ultimately accountable for ensuring compliance. The facility's policy requires all opened food packages to be stored in airtight containers or bags, accurately labeled with the item and date opened, and all foods in the refrigerator and freezer to be covered, labeled, and dated. The observed deficiencies in food storage, labeling, and dating were confirmed by staff and management interviews, as well as a review of facility policy, but no specific residents or patient conditions were mentioned in relation to the deficiency.
Failure to Maintain Resident and Common Area Furniture in Good Repair
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for three residents and the dining room, as evidenced by multiple pieces of furniture in disrepair. Observations revealed that one resident's dresser was missing the front of a bottom drawer, exposing personal clothing items, with worn and exposed wood. Another resident's dresser was missing the front of a drawer, also exposing personal items, and a third resident's wardrobe had a top drawer front hanging down and a door handle with a missing screw. In each case, the residents reported that the furniture had been broken for a long time and had not been reported to staff. Staff interviews indicated a lack of awareness and reporting regarding the broken furniture. A CNA stated she had not noticed any broken furniture but acknowledged that any staff entering a room should report such issues. An LVN admitted to noticing missing drawer fronts but never reported them. The Maintenance Supervisor was unaware of the specific furniture issues in the residents' rooms and stated that repairs were made only when work orders were submitted or when he noticed issues himself. The Maintenance Work Order book contained no entries for the broken furniture in question. Additionally, the activity cabinet in the dining room was observed to have its right-side doors removed and propped against another cabinet. The Maintenance Supervisor was aware of the broken cabinet but had not received approval to replace it and had no extra furniture available. The facility's maintenance policy required the building and equipment to be maintained in good repair and free from hazards, but these requirements were not met in the cases observed.
Infection Control Lapses in Isolation, Catheter, and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices for several residents. For one resident with a post-COVID-19 condition and COPD, staff did not place appropriate signage or a PPE supply cart outside the resident's room to indicate the need for transmission-based droplet precautions. Staff members, including CNAs, entered the resident's room without wearing required PPE, and some were unaware of the resident's isolation status. Interviews revealed that staff did not consistently know or follow the facility's infection control policies regarding isolation precautions. Another resident with severe cognitive impairment and an indwelling urinary catheter received catheter care from a CNA who failed to change gloves and perform hand hygiene after cleaning the resident's buttocks. The CNA continued to handle clean linens and reposition the resident without changing gloves or sanitizing hands. Both the CNA and other staff interviewed acknowledged the importance of glove changes and hand hygiene but did not consistently apply these practices during care. Additionally, a resident with wounds and requiring Enhanced Barrier Precautions (EBP) did not receive care in accordance with EBP protocols. During wound care and incontinent care, staff did not wear gowns as required, despite the presence of indicators (blue name tags) signaling the need for EBP. Staff interviews confirmed knowledge of the EBP requirements but revealed lapses in adherence, with staff admitting to not wearing gowns during high-contact care activities. These failures were observed during direct care and confirmed through staff interviews and record reviews.
Failure to Maintain Resident Dignity by Not Using Catheter Privacy Bag
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, chronic kidney disease, and an indwelling Foley catheter was repeatedly observed without a privacy bag covering the catheter drainage bag. Observations on multiple occasions showed the drainage bag was visible from the doorway and in public areas, with no privacy bag in place, despite care plan interventions and physician orders specifying the use of a privacy bag to maintain dignity. The resident was non-interviewable due to cognitive impairment. Interviews with CNAs, an LVN, the DON, and the Administrator confirmed that staff were aware of the expectation to use privacy bags for catheter drainage bags to promote resident dignity. Staff acknowledged the absence of the privacy bag and indicated that it should have been reported and replaced. Review of the facility's Resident Rights policy revealed it did not address dignity, and the failure to ensure the privacy bag was in place was not identified or corrected by staff prior to the survey.
Failure to Provide Consistent, Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being of two residents. Both residents had documented needs for socialization and activity participation, with care plans and physician orders specifying activities as tolerated. However, records showed a lack of consistent, scheduled activities, and daily participation forms had not been updated for either resident since February, despite their previous engagement in most activities except aromatherapy and manicures. Observations and interviews revealed that both residents expressed dissatisfaction with the lack of variety and frequency of activities, noting a decline in available options since the previous Activity Director left. One resident reported that the only activity offered was bingo, and both described feeling bored and lacking stimulation. Scheduled activities on the facility's calendar were not consistently carried out, with documented instances where activities were canceled or not started on time, and residents were left without engagement during scheduled activity periods. Staff interviews confirmed the inconsistency in the activity program. The Activity Director, who also held restorative aide and van driver duties, acknowledged that her additional responsibilities interfered with her ability to provide scheduled activities. Other staff members, including a CNA and LVN, noted the limited activities and recognized the potential impact on residents' mental and physical well-being. The DON and Administrator were aware of the dual roles held by the Activity Director and the resulting challenges in maintaining the activity schedule.
Unqualified Activity Director Leading Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required. Review of the personnel file for the Activity Director revealed that the individual did not possess an Activity Director Certification and had only two years of experience in a social or recreational program. The Activity Director had been hired in January and previously worked as a CNA and in transportation, with no prior experience as an activity director. She reported having completed only one training class and was not yet certified, although she was enrolled in a certification course scheduled to begin in several months. During this period, she also performed duties as a restorative aide and occasionally drove the facility van. Interviews with the Activity Director and the Administrator confirmed that the Activity Director was not certified and had limited experience in the role. The Administrator acknowledged that the Activity Director was receiving support and oversight from another individual but confirmed that the required certification had not been obtained. Review of the facility's policies and procedures for wellness and life enrichment activities did not specify the required qualifications for the Activity Director position.
Failure to Perform Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to perform a safe mechanical lift transfer for a resident with dementia, heart failure, hypertension, and anxiety. The resident, who weighed 250.2 pounds and was at risk for falls with impaired physical mobility, required assistance with transfers. During an observed transfer from bed to a high back wheelchair, the CNA did not open the legs of the mechanical lift to the wide position before lifting and moving the resident, contrary to facility policy and manufacturer guidelines. The transfer was conducted with the lift pad already under the resident, and both CNAs attached the straps to the mechanical lift. The primary CNA lifted the resident without spreading the lift legs, then moved the resident suspended in the lift pad out from over the bed and toward the wheelchair. The legs of the lift were only spread to the wide position after the resident was already being moved, following a prompt from the assisting CNA. The resident was then lowered into the wheelchair and positioned for comfort. Interviews with the assisting CNA, the primary CNA, the DON, and the administrator confirmed that the mechanical lift legs should be opened wide prior to lifting for stability and to prevent tipping. The facility's policy and FDA best practices both require the lift base to be at its maximum open position during transfers. The DON was unable to locate the mechanical lift competency check-off form for the CNA who performed the transfer.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
A resident with severe cognitive impairment, chronic kidney disease, and an indwelling Foley catheter did not receive appropriate catheter care as required by facility policy and physician orders. During an observed catheter care procedure, a CNA failed to change gloves and perform hand hygiene after cleaning the resident’s buttocks and before handling clean linens and clothing. The same gloves were used throughout the process, and the CNA was uncertain about the correct protocol for glove changes and hand hygiene. Another CNA present did not intervene or clarify the procedure, despite recognizing the lapse. Additionally, the resident’s Foley catheter was not secured with a catheter securement device as required by the care plan and treatment orders. Both CNAs and the LVN confirmed that the securement device was missing and acknowledged its importance in preventing injury from catheter pulling. The absence of the securement device was not reported to the nurse, and the LVN was unaware of its omission until the surveyor’s observation. The resident’s Foley catheter drainage bag was also observed touching the floor after the bed was lowered by a CNA. Both CNAs and the LVN recognized that the drainage bag should not be on the floor, as per facility policy, but the issue was not corrected during care. Interviews with staff, including the DON and Administrator, confirmed expectations for proper catheter care, use of securement devices, and keeping drainage bags off the floor, but these standards were not met during the observed care for this resident.
Failure to Complete Trauma Screening and Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a known history of trauma and a diagnosis of PTSD received trauma-informed, culturally competent care in accordance with professional standards. Upon admission, the resident's records, including the admission referral packet, MDS assessment, and admission assessment, all documented a diagnosis of PTSD and a history of trauma. Despite this, there was no evidence that a trauma screening or trauma assessment was completed upon admission or at any point since admission. The resident's comprehensive care plan did not address PTSD or identify potential triggers for re-traumatization, and social services notes also lacked any trauma screening or identification of triggers. Interviews with facility staff, including the Social Services Director, DON, and Administrator, confirmed that trauma screenings were expected to be completed upon admission and that a positive screening should trigger a more comprehensive assessment. However, staff were unable to locate any trauma screening or assessment for the resident in the medical record, and there was uncertainty regarding whether a diagnosis of PTSD would automatically trigger further assessment. The facility's own policy required trauma screening upon admission, annually, and as needed, with identified triggers to be incorporated into the care plan, but this was not followed for the resident in question.
Resident's Dignity Compromised Due to Inadequate Colostomy Care
Penalty
Summary
The facility failed to ensure a dignified existence for Resident #4, who was found covered in feces due to a leaking colostomy bag. The incident occurred on 2/27/25, when Resident #4's family discovered her in this state, leading to significant distress and embarrassment for the resident. The resident had been admitted to the facility with a history of diverticulitis, hypertension, and depression, and had an ileostomy due to a perforated diverticulitis. Despite these conditions, the facility did not provide timely care to prevent the colostomy bag from leaking, resulting in feces covering the resident and her wound. Interviews and observations revealed that the staff did not respond promptly to Resident #4's needs. The resident reported that her colostomy bag frequently leaked during her first three days at the facility, and on 2/27/25, she lay in her own feces for approximately four hours. Family members confirmed the resident's account, noting that calls to the facility went unanswered and that staff were unresponsive to the resident's call light. The resident's family expressed their frustration and concern, highlighting the lack of timely intervention by the facility staff. Staff interviews indicated a lack of clarity regarding responsibilities for managing the resident's colostomy care. CNA B was unaware that she could empty the colostomy bag, and LVN C claimed to have emptied and changed the bag multiple times, yet was unaware of any ongoing issues. The Director of Nursing acknowledged the challenges in sealing the colostomy bag due to the resident's wound but admitted responsibility for ensuring staff were knowledgeable and provided timely care. The facility's failure to address these issues resulted in a significant breach of the resident's dignity and quality of life.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating resident needs and preferences. Resident #1, who had dementia, an amputation, and impulse disorder, was observed with his call light hanging on the privacy curtain at the foot of his bed, out of reach. He reported that this was a frequent issue, requiring him to holler for help. His care plan indicated he was a fall risk, and the intervention was to keep the call light within reach, which was not adhered to. Similarly, Resident #2, who had an overactive bladder, a femur fracture, and major depressive disorder, was found with his call light under the head of his bed on the floor, making it inaccessible. He was unaware of its location and stated he would have to yell for assistance. His care plan also noted a fall risk with an intervention to keep the call light within reach. Interviews with staff, including an LVN, CNA, and the DON, confirmed the expectation that call lights should be within reach, acknowledging the potential for falls or missed changes in condition if residents could not access their call lights.
Verbal Abuse Incident Involving Resident and CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA), identified as CNA D. The incident occurred when the resident, who has severe cognitive impairment due to dementia and other medical conditions, was being assisted in the shower. During this time, CNA D accused the resident of lying and made derogatory comments, stating that the resident was a liar and that people did not want to deal with him. This interaction was overheard by the previous Director of Nursing (DON), who intervened and later reported the incident. The resident involved in the incident is an elderly individual with a history of dementia, Parkinson's disease, and insomnia, requiring moderate to maximal assistance with activities of daily living. The resident's cognitive impairment was evident, with a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Despite the resident's condition, the facility did not ensure that the resident was free from verbal abuse, as evidenced by the derogatory remarks made by CNA D during the shower assistance. The incident was documented in a Provider Investigation Report, which included statements from the resident, the previous DON, and CNA D. The report indicated that the resident did not appear to be in distress following the incident, and no physical injuries were observed. However, the verbal abuse was acknowledged by the previous DON, who deemed the comments made by CNA D as abusive. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents from verbal abuse, which was not upheld in this case.
Inadequate Colostomy Care Leads to Resident Being Covered in Feces
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident, resulting in the resident being covered in feces due to a leaking colostomy bag. The resident, who had been admitted to the facility with a history of diverticulitis with perforation and abscess, hypertension, and depression, experienced multiple incidents of her colostomy bag leaking during her initial days at the facility. On one particular day, the resident's family found her covered in feces, which had leaked from her colostomy bag and had not been addressed by the staff for several hours. Interviews with staff and family members revealed that the resident's colostomy bag had been leaking frequently, and the staff had not been adequately trained or informed about their responsibilities in managing the colostomy care. The resident reported that her call light was not answered in a timely manner, leading to the colostomy bag becoming too full and leaking. The staff, including CNAs and LVNs, were unclear about their roles in emptying and changing the colostomy bag, resulting in the resident remaining in a soiled state for an extended period. The facility's Director of Nursing (DON) acknowledged that there was a lack of in-service training for staff regarding colostomy care upon the resident's admission. The DON admitted that the staff should have been knowledgeable about colostomy care from their training, but no specific in-service was conducted to ensure competency. The deficiency in care was further compounded by the physical challenges of sealing the colostomy bag due to the resident's surgical wound, which contributed to the frequent leaks.
Failure to Update Care Plan for Resident's Refusal of Care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who had multiple medical conditions, including acute respiratory failure, cardiomyopathy, and severe cognitive impairment. The resident was noted to have a self-care deficit and was at risk for skin breakdown, but the care plan did not address his frequent refusals of care, including repositioning, medication intake, and other necessary interventions. Despite being marked as rejecting care in the MDS assessment, these refusals were not documented in the care plan, leaving staff without guidance on how to manage the resident's non-compliance effectively. Interviews with various staff members, including LVNs, the ADON, RN, CNA, and the MDS Coordinator, revealed a lack of clarity and responsibility regarding updating the care plan. Staff members acknowledged the resident's severe pain and refusal of care but did not ensure these issues were reflected in the care plan. The MDS Coordinator admitted that any refusals of care should have been documented if there was supporting evidence, but this was not done for the resident in question. The facility's policy required the interdisciplinary team to coordinate and update care plans based on assessments and changes in the resident's condition. However, the failure to revise the care plan for the resident's refusals of care placed him at risk of not receiving the necessary care and services. The DON and ADM confirmed that the care plan should have been updated to reflect the resident's needs and refusals, but this was not executed, leading to the deficiency noted in the report.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, exploitation, or mistreatment of residents, specifically in the case of a resident who was roughly handled by a CNA during ADL care. The incident involved a CNA who did not suspend the alleged perpetrator immediately after the rough handling was reported. The CNA continued to work for seven more shifts before being suspended, and the facility did not report the abuse to the state agency within the required 24-hour timeframe. The resident involved was an elderly male with chronic respiratory failure, major depression, anemia, and congestive heart failure, who required moderate assistance for ADLs. The resident's family member provided video evidence showing the CNA handling the resident roughly, which upset the resident. Despite the family member reporting the incident to the ADON, the abuse was not reported to the abuse coordinator immediately, and the CNA continued to work with the resident and potentially other residents. Interviews revealed that the ADON was aware of the incident but delayed reporting it to the DON and Administrator, who were on vacation at the time. The DON was informed about the incident a week later and took action to suspend the CNA. The facility's failure to report the abuse immediately allowed the CNA to continue working, potentially putting other residents at risk. The facility's noncompliance was identified as PNC, with the Immediate Jeopardy beginning and ending within a specified timeframe.
Inadequate Supervision and Unsafe Practices in Resident Care
Penalty
Summary
The facility failed to ensure a safe environment for Resident #3 during incontinent care, resulting in a fall and injury. Resident #3, who had severe cognitive impairment and was a high fall risk, required extensive assistance from two staff members for bed mobility and personal hygiene. However, CNA D attempted to perform incontinent care alone, which led to Resident #3 rolling off the bed while reaching for something on her bedside table. This incident resulted in Resident #3 sustaining a laceration to her lip, requiring stitches, and being sent to the emergency room. In another incident, the facility failed to provide adequate supervision during mechanical lift transfers for Resident #5, who also had severe cognitive impairment and required two-person assistance for transfers. Despite this requirement, video evidence showed that CNA F transferred Resident #5 alone on multiple occasions. This practice was confirmed by interviews with staff, who reported that they often had to perform transfers alone due to staffing constraints, despite understanding the safety risks involved. The facility's policies and staff training were insufficient to prevent these incidents. Interviews with staff revealed a lack of adherence to care plans and inadequate staffing levels, which contributed to the unsafe practices. The DON and ADM were unaware of these issues, indicating a gap in oversight and communication within the facility. The absence of specific policies on repositioning during incontinent care and mechanical lift transfers further exacerbated the risk of accidents and injuries.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, leading to deficiencies in their care. The first incident involved a resident who was denied assistance by a CNA when he requested to be repositioned in bed. The resident, who had a mild cognitive deficit and required moderate assistance for activities of daily living, was left in an uncomfortable position after the CNA refused to help due to her own physical limitations. The CNA admitted to not seeking help from other staff members and acknowledged that her actions were disrespectful. The second incident involved another resident who was subjected to an inappropriate comment by the previous Administrator. After the resident had been shaved, the Administrator made a remark comparing his appearance to that of a child molester, which embarrassed the resident. Although the resident initially laughed off the comment, he later expressed feeling embarrassed and did not want to discuss the incident further. The Administrator claimed the comment was made in jest, but the resident and other staff members reported the incident, leading to the Administrator's termination. Both incidents highlight a failure to uphold the residents' rights to dignity and respect, as outlined in the facility's policy. The actions of the CNA and the Administrator were reported by other staff members and family, indicating a breach of the residents' rights and a lack of adherence to the facility's standards for resident care.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in deficiencies in care. The first incident involved a resident who required moderate assistance with activities of daily living (ADLs) due to conditions such as chronic respiratory failure, major depression, anemia, and congestive heart failure. The resident, who had a mild cognitive deficit, was roughly handled by a CNA when being assisted into bed. Video evidence showed the CNA forcibly moving the resident's legs onto the bed, despite the resident's protests and expressions of pain. The CNA justified her actions by citing her own physical limitations and the resident's size, but her behavior was deemed inappropriate and led to her termination. The second incident involved another resident with dementia, heart failure, and limited mobility, who was verbally abused by a different CNA. The resident, who had moderate cognitive impairment, reported that the CNA used inappropriate language and engaged in a verbal altercation when the resident expressed dissatisfaction with being put to bed late. The CNA admitted to using a curse word and acknowledged that she should have handled the situation differently. The resident's care plan indicated a preference for not being cussed at, and the CNA's actions were inconsistent with the facility's policy on abuse and neglect. Both incidents highlight failures in the facility's ability to ensure a safe and respectful environment for its residents. The interactions between the CNAs and the residents were not only inappropriate but also violated the residents' rights to be free from abuse. The facility's policy mandates immediate reporting of abuse allegations, but the delay in addressing these incidents suggests a lapse in adherence to these procedures.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident within the required 2-hour timeframe. The incident involved a resident who was an elderly male with a history of chronic respiratory failure, major depression, anemia, and congestive heart failure. The resident required moderate assistance with activities of daily living (ADLs) and had a mild cognitive deficit. The incident was captured on video by the resident's family member, showing a certified nursing assistant (CNA) being rough and verbally harsh with the resident during care. The Assistant Director of Nursing (ADON) was informed of the incident by the resident's family member on the same day it occurred. However, the ADON did not report the incident to the facility's abuse coordinator or other authorities until eight days later. The delay was attributed to the ADON's uncertainty about whether the behavior constituted abuse and the absence of the Director of Nursing (DON) and Administrator, who were on vacation at the time. The facility's policy required immediate reporting of abuse allegations, but the ADON was unaware of the 2-hour reporting requirement. The DON was informed of the incident by the ADON after returning from vacation, and the abuse was reported to the Health and Human Services Commission (HHS) within one hour of notification. The facility's policy mandates that all allegations of abuse be reported immediately to the Administrator or their designee. The failure to report the abuse allegation in a timely manner could delay the investigation by the state agency, as noted by the Administrator. The facility's policy emphasizes a zero-tolerance approach to any form of abuse or mistreatment of residents.
Failure to Ensure Privacy During Resident Council Meetings
Penalty
Summary
The facility failed to allow for private Resident Council meetings and did not provide a private space for these meetings. During a confidential resident group interview, residents expressed their dissatisfaction with staff continuously interrupting their meetings held in the dining room. The interruptions were observed by the surveyor, who noted that staff entered the dining room through the back door, which led to the parking lot, despite being informed that a private meeting was in progress. The staff members claimed they were unaware of the meeting due to the absence of a sign indicating that a meeting was taking place. The Activity Director and the Ombudsman confirmed that staff interruptions were a recurring issue, and the Administrator acknowledged that the meetings should have been private and that staff behavior was inappropriate. The facility's policy on Resident Council meetings indicated that these meetings should be private and that staff could only attend if invited. However, the policy was not effectively implemented, as evidenced by the repeated interruptions by dietary staff. The lack of proper signage and the staff's disregard for the privacy of the meetings compromised the residents' ability to voice their concerns without interference. The Administrator admitted that alternative routes were available for staff to access the time clock and kitchen without disrupting the meetings, but these routes were not utilized.
Failure to Administer Ordered Pain Medication
Penalty
Summary
The facility failed to manage a resident's pain by not administering the ordered pain medication. Resident #144, who was admitted with multiple fractures and chronic pain, had an open-ended physician's order for a Lidocaine 5% topical patch to be applied daily. However, the medication was not administered from the date of admission until it was brought to the facility's attention by the resident and his family. Interviews with the resident, his family, and staff confirmed that the Lidocaine patch was not given, and the resident experienced ongoing pain as a result. The Director of Nursing acknowledged that the order for the Lidocaine patch was received from the hospital and should have been administered. The medication aide admitted to forgetting to give the patch due to being too busy. The Administrator also confirmed that it was the medication aide's responsibility to administer the patch and that the resident's pain could affect his mood and quality of life. The facility's policy on pain management indicated that staff should evaluate pain and provide medication as prescribed, which was not followed in this case.
Failure to Lock Medication Carts and Remove Expired Medications
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments for two of the four medication carts reviewed. During an observation, the 100-hall nurse medication cart was found unlocked with no staff present, containing various medications including Levetiracetam, Gabapentin, and Lisinopril. Similarly, the medication cart for the 300/400 hall was observed to be unlocked near the nurse's station, with medications such as Ondansetron and Eliquis accessible. Multiple staff members, including the ADM, RN, and LVN, acknowledged that medication carts should be locked when not in use, but the policy was not consistently followed, leading to potential risks of drug diversion and unauthorized access to medications by residents or others in the facility. Additionally, the facility failed to remove expired medications from the 100-hall nurse medication cart. Expired eye drops, Lumigan and Simbrinza, were found in the cart, and LVN E confirmed their expiration and removed them. Interviews with staff, including LVNs and MAs, revealed that they were responsible for checking and removing expired medications, but this was not consistently done. The DON and ADON also confirmed that expired medications should be removed and that administering expired medications could cause adverse side effects. The report highlights that the facility's staff, including nurses and MAs, were aware of the policies regarding locking medication carts and removing expired medications but failed to adhere to these policies consistently. This lack of compliance was observed during multiple instances, posing risks to resident safety and medication management within the facility.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote resident self-determination through support of resident choice for two residents. Resident #32, who was cognitively intact and had a history of depression, was not assisted out of bed as often as she preferred. Despite her requests to be gotten out of bed once or twice a week, staff did not consistently honor her wishes, leading her to feel ignored and annoyed. Multiple staff members confirmed that Resident #32 was rarely gotten out of bed, and her refusals were not always documented as required. Resident #35, who had moderate cognitive impairment and a history of depression, was not provided with showers as per his request. He reported receiving only six showers since his admission and was often given bed baths instead. Additionally, Resident #35 preferred to be clean-shaven but was not shaved regularly, leading to a full beard of facial hair. Staff interviews revealed that the facility was understaffed, making it difficult to adhere to the residents' bathing schedules and personal care requests. Both residents expressed dissatisfaction with the care they received, which could negatively impact their psychological well-being. The facility's failure to honor these residents' preferences for personal care and mobility was acknowledged by the Director of Nursing and the Administrator, who admitted that the residents' wishes should have been respected and documented properly.
Failure to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for a resident with severe cognitive impairment and a history of depression. The wall behind the resident's bed had multiple areas of peeled paint, damaged sheetrock, and an old wallpaper cutout, which had been in this condition for months. The damage was reportedly caused by a hospice aide, the resident's family, and the bed's movement. Despite being aware of the issue, the Maintenance Supervisor had not yet repaired the wall, citing other priorities and the need to move the resident to another room for the repair. The family had been non-compliant in moving the resident's camera, which was necessary for the repair to proceed. The Maintenance Supervisor acknowledged the delay was his fault, and the Director of Nursing and other staff expressed that the wall should have been fixed sooner. Interviews with staff revealed that the issue had been reported to the Maintenance Supervisor long ago, but no work order was logged. The Maintenance Supervisor relied on verbal reports and had mentioned the issue in a stand-up meeting two weeks prior. The Administrator confirmed the need to move the resident for the repair and stated that the family had been asked for months to move the cameras. The facility's Homelike Environment policy indicated that resident rooms should be kept in good repair, but this was not adhered to in this case, leading to an unsafe and uncomfortable environment for the resident.
Failure to Provide Scheduled Bathing and Grooming Services
Penalty
Summary
The facility failed to ensure that two residents, who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene. Resident #21, a [AGE] year-old with severe cognitive impairment, did not receive scheduled baths/showers as per the facility's shower schedule. Despite being scheduled for showers on Monday, Wednesday, and Friday, the records indicated that Resident #21 only had six documented baths over a month. Interviews with staff revealed inconsistencies in the shower schedule and documentation, and the resident's representative expressed concerns about the resident's hygiene. Resident #35, a [AGE] year-old male with multiple diagnoses including traumatic amputation and severe kidney disease, also did not receive scheduled baths/showers and was not shaved as per his preference. The resident reported receiving only six showers since his admission and stated that he preferred to be clean-shaven. Observations confirmed that Resident #35 had a full beard, and staff interviews revealed that the resident's bathing and shaving needs were not consistently met due to staffing issues and time constraints. The facility's policies on comprehensive care planning, bathing, and hair care were not followed, leading to deficiencies in the care provided to these residents. Staff interviews indicated a lack of communication and documentation regarding residents' refusals and care needs. The DON and ADM acknowledged the issues and stated that residents should receive showers and shaves as per their schedules and requests, but these expectations were not met in practice.
Failure to Provide Scheduled Activities and Activity Calendar
Penalty
Summary
The facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being of Resident #32. The resident, who was cognitively intact with a BIMS score of 14, expressed that she was not aware of any activities being provided and had not received an activities calendar. Despite the care plan indicating that the resident should be encouraged to participate in activities and provided with a schedule of events, these interventions were not consistently implemented. The resident reported feeling ignored and annoyed by the lack of engagement from the staff, and there were no documented refusals of activities in her records during the review period. Observations and interviews revealed that Resident #32 was often found in bed and not participating in group activities, such as arts and crafts or music sessions, which she stated she would have liked to attend if she had been informed. The Activity Director claimed to visit the resident daily and provide calendars, but this was contradicted by the resident's statements and the lack of documentation. The CNA and LVN interviewed also noted that the resident rarely got out of bed and did not attend activities, which could negatively impact her well-being. The facility's policy on one-on-one wellness visits was not followed, as there was no evidence of such activities being offered to Resident #32. The DON and Administrator acknowledged that the resident should have been provided with an activity calendar and offered activities, with any refusals documented. The failure to engage the resident in activities and provide her with the necessary information and encouragement could lead to feelings of isolation and depression, as noted by the staff interviewed.
Failure to Provide Catheter Securement Device
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, the facility did not provide an indwelling urinary catheter securement device for a resident, which is necessary to prevent catheter dislodgement, urethral damage, pain, and UTIs. The resident, who had severe cognitive impairment and a stage 4 pressure ulcer, required maximal to total assistance with most activities of daily living (ADLs) and had an indwelling urinary catheter. The care plan and physician orders indicated the need for a catheter securement device, but it was not in place during multiple observations by surveyors and staff interviews confirmed the oversight. During an observation, the resident's indwelling urinary catheter tubing was found pressed between her upper legs, causing red lines, and there was no securement device attached. The RN acknowledged noticing the missing securement device earlier but had not yet replaced it. The Director of Nursing (DON) confirmed that the securement device should have been replaced immediately or as soon as possible to prevent risks such as urethral trauma, dislodgement, infection, and skin breakdown. The facility's policy and CDC guidelines also emphasized the importance of securing indwelling catheters to prevent movement and urethral traction. Interviews with the RN and DON revealed that the securement device was likely missing since the previous day, and the RN had not had time to replace it. The DON stated that the nurses were responsible for ensuring the securement devices were in place and monitored each shift. The facility's administrator, who was not a nurse, also expected physician orders to be followed. The failure to replace the securement device promptly led to the deficiency noted in the report.
Failure to Ensure Safe and Sanitary Storage of Resident's Food Items
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of a resident's food items, specifically in the personal refrigerator of a resident diagnosed with dementia, anxiety, and heart failure. During an observation, expired and decomposing meat products were found in the resident's refrigerator, including pickle and pimento loaf, salami, bologna, and smoked sausage. The expired foods were not removed even after the issue was brought to the attention of the housekeeping staff. The housekeeper admitted to not knowing who was responsible for cleaning out the personal refrigerators and stated that she would have thrown away the expired meat if instructed to do so. The Director of Nursing and the Administrator both acknowledged that anyone observing expired or decomposing food should have discarded it to prevent the risk of foodborne illness. The Administrator also mentioned that the resident's family should have helped in cleaning out the refrigerator, given the resident's cognitive impairments. Despite these acknowledgments, the expired food remained in the refrigerator, posing a potential health risk to the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 114 citations issued within 25 miles in the last 12 months — including the 7 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 Texarkana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Texarkana | 0.2 mi | ★★★★★ | 7 | 3 |
| The Villa At Texarkana | 0.3 mi | ★★★★★ | 9 | 0 |
| Reunion Plaza Senior Care And Rehabilitation Cente | 0.8 mi | ★★★★★ | 25 | 2 |
| The Cottages At Texarkana | 1 mi | ★★★★★ | 0 | 0 |
| Bailey Creek Health And Rehab | 1.3 mi | ★★★★★ | 4 | 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.