Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highland Pines Nursing Home during CMS and state inspections, most recent first.
A facility failed to accurately complete MDS assessments for two residents. One resident's admission MDS did not code a recent fall that was documented in a nurse note and incident report, while another resident's annual MDS incorrectly marked PASRR negative despite a prior Level II PASRR showing mental illness and the care plan identifying the resident as PASRR positive. Staff interviews confirmed the coding errors and stated the MDSs should have accurately reflected each resident's status.
PASRR Level II Evaluation Not Completed Before Re-admission: A resident with bipolar disorder and psychotic features re-admitted from an in-patient psychiatric hospital without a PASRR Level II evaluation completed beforehand. Records showed only the PASRR Level I screening was available at the time of re-admission, and the Level II assessment was completed afterward and found the resident PASRR positive. The MDS Coordinator and Interim Administrator both acknowledged the evaluation should have been completed before admission/re-admission.
Baseline care plans were not completed or provided to two newly admitted residents. One resident had a Stage III sacral pressure ulcer, AFib, and pneumonia and reported not knowing why he was in isolation, why therapy was being done in his room, or what his wound was. Another resident with DM, UTI, and dysphagia said he was anxious because he did not understand his discharge goals or which meds he was supposed to be taking. The MDS Coordinator said the baseline care plan was completed by the IDT, and the DON said it should be discussed with the resident and representative, but no baseline care plans were found in either record.
A resident sustained a left leg laceration in the facility that required ER treatment and sutures, but the care plan did not include the wound or related interventions. Another resident with a history of trauma had a care plan that only noted trauma in general terms and did not identify the specific trauma or triggers, leaving staff unable to tell what should prompt a trauma-informed response.
Expired Gabapentin for a resident with Alzheimer’s disease, chronic pain, and Parkinson’s disease was found in a medication overflow area in a storage room. Staff interviews showed nurses were responsible for checking and removing expired meds, but the DON stated expired meds were kept in the storage room until monthly destruction. The facility policy stated unused and non-returnable meds should be removed from storage and secured until destroyed.
Unlocked Medication Cart Left Unattended: Medication Cart #1 was found unlocked and unattended near a resident room, elevator, and common area while a resident was nearby. CMA J said she forgot to lock the cart after stepping away to check on a resident. Interviews with the CMA, LVN, ADON, DON, and ADM confirmed that medication carts are expected to remain locked when not in use, and the facility policy required carts and medication supplies to be locked when not attended.
Food Storage and Labeling Deficiencies in Kitchen: The facility failed to store, prepare, distribute, and serve food according to professional standards when a large sack of flour was observed on the floor of dry storage and raisin bread, sliced cheese, and tortillas were found without labels or dates. The DM, DON, and Administrator all stated food should be stored off the floor and labeled/dated to prevent use of expired food and contamination.
A resident with an indwelling urinary catheter and hemodialysis needs was observed receiving high-contact care when an LVN and CNA pulled him up in bed while wearing gloves but no isolation gown. The resident’s care plan and orders required EBP with gown and gloves for high-contact activities, and the CNA later acknowledged the gown was missed even though she knew it was required.
A resident with severe cognitive impairment was allegedly slapped by an LVN during feeding, as witnessed by a CNA. The LVN denied hitting the resident, claiming she only moved his hands to prevent interference with his feeding tube. The incident was reported, and the resident showed no signs of distress or trauma. The LVN was terminated following an investigation.
A facility failed to provide adequate pressure ulcer care for three residents, leading to deficiencies in treatment. One resident's mattress was set incorrectly at 360 lbs, despite her actual weight being 240.3 lbs. Another resident, weighing 78 lbs, was found on a mattress set at 210 lbs. A third resident with multiple stage 4 pressure ulcers did not receive documented wound care on several occasions, and his mattress was set at 490 lbs, much higher than his actual weight of 134.6 lbs. Staff interviews revealed confusion about responsibility for mattress settings and wound care.
The facility failed to ensure proper catheter care for three residents, as catheter securement devices were not used, and a catheter bag was improperly placed on a bed during wound care. These actions could lead to urinary tract infections due to improper catheter management and infection control practices.
The facility failed to provide adequate respiratory care for three residents, leading to deficiencies in their care. A resident with chronic respiratory issues did not have a physician's order for oxygen therapy until surveyor intervention, and their oxygen concentrator filter was dirty. Another resident's CPAP mask was improperly stored, and their oxygen concentrator lacked a filter. A third resident's oxygen concentrator filter was not cleaned as required. Staff interviews revealed a lack of clarity on responsibilities for maintaining respiratory equipment, contributing to the deficiencies.
The facility failed to ensure safe and sanitary storage of food in residents' personal refrigerators, with one resident's fridge containing moldy meat and others lacking consistent temperature checks. Staff interviews revealed confusion over responsibilities, leading to potential health risks.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies in infection control practices. Staff did not change gloves or perform hand hygiene during incontinent care for a resident, and enhanced barrier precautions were not implemented for residents with medical devices. Observations showed staff not wearing PPE during care, despite signs indicating the need for enhanced precautions. These lapses placed residents at risk of infection.
A facility failed to protect residents from abuse, resulting in deficiencies in care. A resident with moderate cognitive impairment reported feeling abused during bed baths by a CNA, who was described as rough and unwilling to assist. Another resident was slapped by a fellow resident with a history of aggression, and a third resident experienced unwanted touching by a roommate with a history of inappropriate behavior. The facility did not adequately address these incidents, leading to deficiencies in abuse prevention measures.
The facility failed to provide two residents with a SNF ABN upon discharge from Medicare Part A services, as required by regulation. Both residents, who had intact cognition, were not informed of potential out-of-pocket costs after their covered days ended. Interviews revealed a lack of awareness about the requirement to issue the SNF ABN, which is crucial for informing residents about their financial liability.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect coding of medications and diagnoses. One resident was misclassified as being on an antipsychotic and having bipolar disorder, while another's PASRR positive status was omitted. These errors were due to data entry mistakes and a lack of available coding options, highlighting the need for accurate assessments to ensure proper care.
A resident with schizophrenia was inaccurately marked as not having a mental illness in their PASRR Level I screening, despite having an active diagnosis and requiring psychotropic medication. The error was attributed to the hospital's incorrect marking, and facility staff displayed a lack of clarity regarding PASRR responsibilities. The facility's policy mandates screening for mental illness or intellectual disability before admission, which was not followed in this case.
A facility failed to notify the State Mental Health Authority of a significant change in a resident's mental condition after a PTSD diagnosis, neglecting to conduct a new PASRR Level 1 screening. Staff interviews revealed a lack of awareness that PTSD could necessitate a PASRR evaluation, contrary to facility policy requiring screenings for significant condition changes.
A facility failed to develop a comprehensive care plan for a resident requiring oxygen therapy, despite the resident's chronic respiratory conditions. The care plan did not address oxygen use, and a physician's order was missing until a state surveyor pointed it out. Staff interviews confirmed the oversight, highlighting the risk of unfamiliar staff being unaware of the resident's oxygen needs.
Two residents in a facility did not receive necessary care for personal hygiene and mobility. One resident experienced delayed incontinent care, leading to leakage, while another had inadequate oral hygiene and was not offered the chance to get out of bed. Staffing challenges were cited as a reason for these deficiencies.
A resident was found with Lidocaine patches in their personal refrigerator, which were not prescribed and should have been stored on the nurse's cart. Observations and staff interviews revealed confusion about who was responsible for checking and cleaning residents' refrigerators, leading to a failure in adhering to the facility's medication storage policy.
A facility failed to ensure a resident's drug regimen was free from unnecessary medications due to missing documented diagnoses for several prescribed drugs. Interviews with staff revealed confusion over responsibility for documenting diagnoses, with the MDS Coordinator and nurse managers identified as responsible. The absence of documented diagnoses could lead to unnecessary medication use and inaccurate assessments.
A resident with moderate cognitive impairment and on hospice care had a PRN order for Lorazepam that exceeded the 14-day limit without physician re-evaluation. The facility staff, including the DON, were unaware of this oversight, which contradicts the facility's policy and regulatory requirements.
A long-term care facility reported a medication error rate of 14.81%, involving two residents who did not receive their prescribed medications. One resident missed their vitamin B-complex and received an incorrect dose of Vitamin D3, while another did not receive Oxybutynin and Protonix. The errors were due to miscommunication and unclear responsibilities between nursing staff and central supply regarding medication reordering.
A resident with severe cognitive impairment and chronic pain did not receive scheduled doses of Acetaminophen-Codeine due to a misunderstanding by a newly employed MA. The MA believed there was a discrepancy between the medication blister pack and the EMR order and did not notify a nurse for clarification. This resulted in the resident missing three doses, potentially increasing her anxiety and behaviors.
Two residents had medications improperly stored in their rooms, with Santyl, Mupirocin, and Triamcinolone ointments found unsecured on bedside tables. Staff interviews confirmed that medications should be stored on medication carts, not in resident rooms, as per facility policy. The deficiency highlights a failure to adhere to proper medication storage protocols.
The facility failed to report the results of an investigation into an alleged abuse incident between two residents to the state survey agency within the required 5 working days. The incident involved a resident alleging being hit by another resident, but both were confused and unable to recall details. The report was submitted one day late, and the facility lacked a specific policy for timely submission.
A facility failed to document foley catheter changes for a resident with obstructive and reflux uropathy, COPD, and benign prostatic hyperplasia. Despite having a care plan and physician's orders for monthly catheter changes, there was no documentation of changes from January to September 2024. Staff interviews revealed inconsistencies in documentation practices, with catheter changes only recorded if abnormalities were present. This lack of documentation could lead to staff being unaware of completed tasks, potentially risking urinary tract issues.
A resident with a history of traumatic brain injury and dementia, identified as high fall risk, was not adequately supervised, resulting in a fall. Despite interventions in her care plan, such as keeping the call light within reach, the resident was found on the floor, indicating these measures were not effectively implemented. Staff interviews revealed inconsistencies in fall prevention practices, contributing to the incident.
A resident with cognitive impairment and a history of wandering eloped from a facility and was found on a busy street in a wheelchair. The staff were unaware of the resident's absence and did not know how he left. The resident's care plan and elopement risk evaluations were not updated to reflect his increased risk, and the facility failed to implement adequate interventions to prevent his elopement.
A resident with severe cognitive impairment and a history of wandering was found in traffic after leaving the facility unnoticed. Despite increased confusion due to a UTI, the resident was not monitored closely, and the incident was not reported to the state agency as required. The facility believed the resident did not intend to elope, leading to a failure in reporting the incident.
Inaccurate MDS Coding for Falls and PASRR Status
Penalty
Summary
The facility failed to ensure an accurate MDS assessment was completed for two residents reviewed for MDS accuracy. For one resident, the admission MDS dated 11/28/2025 documented a BIMS score of 15 and no falls prior to admission or since admission, even though a nurse note dated 11/26/2025 documented that the resident was found sitting in front of the wheelchair after dozing off while leaning on a bedside table, with no injury noted. The incident/accident report completed by the DON also did not include added instruction or intervention after the fall. During interview, the MDS Coordinator stated the resident should have been coded for falls on the admission MDS because the fall occurred prior to the assessment and should have been care planned. The Regional MDS Nurse stated it was the responsibility of the MDS nurse to ensure accurate MDSs were produced and transmitted to CMS, and the Administrator stated accuracy was important for revenue and for reporting correct information to CMS on quality measures. The facility policy stated the MDS should accurately reflect the resident's status. For the second resident, the annual MDS dated 07/24/2025 coded Section A1500 as not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability, indicating PASRR negative, even though a PASRR Level II evaluation completed on 11/26/2024 showed the resident met the PASRR definition of mental illness and was PASRR positive. The comprehensive care plan initiated on 09/25/2025 identified the resident as PASRR positive for mental illness, and the resident stated she had a mental illness diagnosis and was receiving psychiatric services in the facility. The MDS Coordinator stated the annual MDS was marked incorrectly and that she must have overlooked the question, while the Interim Administrator stated the MDS assessments were expected to accurately reflect the resident's status.
PASRR Level II Evaluation Not Completed Before Re-admission
Penalty
Summary
The facility failed to ensure that a resident with mental illness had a PASRR Level II evaluation completed prior to re-admission from an in-patient psychiatric facility. Resident #60 was a female with a diagnosis of bipolar disorder, severe with psychotic features, and the record showed she had a PASRR Level I screening indicating evidence of mental illness while at a psychiatric hospital. The PASRR Level II evaluation was completed after she had already re-admitted to the nursing facility, and it showed she met the PASRR definition of mental illness and was PASRR positive. The resident’s comprehensive care plan later reflected that she was PASRR positive for mental illness. During interview, the resident stated she had a diagnosis of mental illness and was receiving psychiatric services in the facility. The MDS Coordinator stated the resident re-admitted from an in-patient psychiatric hospital in another state and that the facility had difficulty obtaining PASRR records at times. She also stated there had been times when residents were admitted with only the PASRR Level I screening completed and acknowledged that the PASRR Level II evaluation should have been completed prior to admission or re-admission from a psychiatric facility. The Interim Administrator stated the PASRR Level I screening should have been completed prior to admission and that the Level II evaluation should have been completed prior to re-admitting the resident.
Baseline care plans not completed or provided for two new admissions
Penalty
Summary
The facility failed to ensure the baseline care plan, including instructions for resident care needed to provide effective and person-centered care, was completed and provided to the resident and/or representative for 2 of 5 newly admitted residents reviewed. Resident #103 was admitted with diagnoses including a Stage III sacral pressure ulcer, atrial fibrillation, and mycoplasma pneumonia. Record review showed no completed MDS assessments, no comprehensive care plan, and no baseline care plans created for this resident. During interview, the resident stated he did not remember a baseline care plan meeting and did not have a copy of the baseline care plan. He also stated he had questions about why he was in isolation, why therapy was being done in his room, and what kind of sore he had on his bottom. Resident #105 was admitted with diagnoses including diabetes mellitus, urinary tract infection, and dysphagia. Record review showed no completed MDS assessments, no comprehensive care plan, and no baseline care plans created for this resident. During interview, the resident stated he had concerns about discharge and wanted to discuss his discharge goals with the discharge planner. He stated he was unsure what medications he had been discharged from the hospital on versus what medications he was receiving at the facility, and that no one had explained it to him. The MDS Coordinator stated the baseline care plan was completed by the floor nurse, social worker, department head nurses, and therapy, and that the social worker conducted the baseline care plan meeting. The DON stated baseline care plans were used in place of a comprehensive care plan until one could be developed, that the baseline care plan needed to be completed with each department and discussed with the resident and representative, and that she was unsure why the baseline care plans were not completed for these residents.
Incomplete Care Planning for Wound Care and Trauma Triggers
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #17 after she sustained a left lower extremity laceration in the facility that required emergency evaluation and 9 sutures. Record review showed the resident was admitted with diagnoses including fracture of the left acetabulum, pulmonary edema, and atrial fibrillation, and her admission MDS indicated a BIMS of 13, substantial assistance with ADLs, and existing pressure ulcers. Nursing notes documented that a CNA alerted staff to the laceration, pressure dressing was applied, the DON and MD were notified, and the resident was sent out for treatment and later returned with orders for suture removal in 10 days. The care plan listed pressure ulcers to the heels, coccyx, and left trochanter, but did not include the laceration or related interventions. Interviews confirmed the laceration was not care planned. The MDS Coordinator stated the laceration treatment was on the admission MDS assessment and should have been care planned with interventions, and the Treatment Nurse stated the laceration should have been care planned with interventions for prevention and healing because it occurred while the resident was in the facility. The DON stated the care plan was an individualized guide to resident care and that Resident #17's laceration needed to be care planned so everyone was aware of the treatment. The facility also failed to ensure Resident #31's comprehensive care plan included specific triggers for a trauma-related problem. Resident #31 had diagnoses including anxiety disorder, bipolar disorder, and polyneuropathy, and a trauma assessment documented a history of trauma related to the death of a roommate. The comprehensive care plan identified a history of trauma and stated to create an emotionally and physically safe environment and respond with empathy and respect, but it did not describe what the trauma was from or identify triggers. Staff interviews showed they could not identify the resident's trauma triggers from the care plan, and the DON and Administrator stated the trauma should be fully described so staff would know the triggers.
Expired Gabapentin Left in Medication Storage Room
Penalty
Summary
The facility failed to ensure drugs and biologicals in Storage room [ROOM NUMBER] were labeled and maintained in accordance with accepted professional principles because expired Gabapentin remained in the medication overflow area. During observation, four blister packets of Gabapentin 100 mg for Resident #95 were found in the storage room, with expiration dates of 12/18/2025 and 11/14/2025. The medication was identified as being stored with overflow medications rather than being removed from the storage area. Resident #95 was a male admitted with diagnoses including Alzheimer's disease, chronic pulmonary edema, chronic pain syndrome, and Parkinson's disease with dyskinesia. The resident's quarterly MDS indicated severe cognitive deficits with a BIMS score of 5, and that he had a feeding tube and was on a mechanically altered diet. His MAR showed Gabapentin 100 mg via G-Tube three times daily for pain. During interviews, ADON L, CMA J, LVN H, and ADON C stated that nurses were responsible for checking medication storage for expired medications and removing them from overflow or storage. The DON stated she was not concerned with medications in the storage room being expired and said expired medications were stored there until nurses pulled them once a month for destruction. The facility policy titled Medication Destruction for Non-controlled medications stated unused and non-returnable medications should be removed from their storage area and secured until destroyed.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to store medications and biologicals in locked compartments for 1 of 4 medication carts reviewed. During an observation on 1/13/2026 at 7:25 a.m., Medication Cart #1 for the 200 short hall was found unlocked and unattended with no staff within eyesight. The cart was located near a resident's room, an elevator, and the main sitting area where staff and visitors congregated, and one resident was seen navigating the hallway in a wheelchair near the cart. CMA J later locked the cart when she returned and stated she had gone to check on a resident and forgot to lock it after hearing a noise. During interviews, CMA J stated she was responsible for keeping the cart locked and acknowledged that someone could access the cart, causing counts to be off, damaging the cart, or leading to an overdose. LVN H, ADON C, the DON, and the ADM all stated medication carts should be locked when not in use and that staff were responsible for ensuring they remained locked. Review of the facility policy titled Storage of Medications showed that medications and biologicals are to be stored safely and securely, and that medication rooms, carts, and supplies are locked when not attended by authorized persons.
Food Storage and Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During an observation and interview on 1/12/26 at 8:05 a.m., a large sack of flour was observed lying on the floor of the dry food storage area. The Dietary Manager stated the bag was recently delivered and said she needed help lifting it because it was too heavy. In the same observation, raisin bread stored in dry food storage, sliced cheese on a preparation table, and tortillas stored in dry food storage were observed without labels or dates. The cheese was in a gallon-size bag on top of a preparation table that had recently been used. During interviews on 1/14/26, the Dietary Manager stated food should not be left on the floor because regulations require storage at least six inches off the floor and said this could expose food to contamination by rodents or pests. The DON stated food should be labeled and dated so old or expired food would not be used to feed residents, and said feeding expired or old food could place residents at risk of foodborne illness. The Administrator stated flour or any food should not be left on the floor because it could contaminate the food and encourage rodents, and said food should be labeled and dated to prevent residents from eating expired food. Review of the facility's Food Labeling and Dating policy dated 01/01/22 stated dietary employees will be trained regarding proper food storage procedures, labeling, and dating, and that items stored should be dated upon receipt unless they contain a manufacturer's use-by date or delivery date.
Failure to Use Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents reviewed for infection control practices. The deficiency involved Resident #106, a male who was re-admitted with diagnoses including sepsis due to E. coli, chronic kidney disease, and obstructive and reflux uropathy. His MDS reflected a BIMS score of 12, clear speech, ability to understand and be understood, and an indwelling urinary catheter. He also received hemodialysis three times a week while a resident. Resident #106’s care plan and order summary reflected that he required Enhanced Barrier Precautions related to his indwelling urinary catheter, with staff to wear a clean gown and gloves during high-contact resident care activities. During observation on 01/12/2026 at 11:16 a.m., LVN A and CNA B entered the resident’s room and applied clean gloves. While the resident was lying sideways in bed, they pulled him up in bed by lifting and repositioning him underneath the legs, near the indwelling urinary catheter, and they did not wear an isolation gown. During interview, CNA B stated residents with an indwelling urinary catheter or who received dialysis required Enhanced Barrier Precautions during high-contact resident care activities, including pulling someone up in bed, and that the precautions included gown and gloves. She stated she realized she had not worn a gown after leaving the room. The DON stated nursing staff were expected to ensure Enhanced Barrier Precautions were being used, and the ADON, who served as the infection control preventionist, stated she monitored infection control practices and taught staff as needed. The Interim Administrator stated staff were expected to use all available PPE as required or indicated, and that nursing staff were responsible for monitoring use of Enhanced Barrier Precautions during high-contact care activities.
Resident Abuse Incident Involving LVN
Penalty
Summary
The facility failed to ensure that a resident was free from abuse, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) and a resident. On the morning of the incident, a Certified Nursing Assistant (CNA) heard the LVN being loud in the resident's room and subsequently witnessed the LVN slap the top of the resident's hands. The CNA reported that the slap was not a light tap but a hard hit, which was confirmed by another CNA who heard the skin-on-skin contact. The LVN claimed that she only moved the resident's hands to prevent him from interfering with his feeding tube, denying any hitting or slapping. The resident involved was an elderly male with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. He had a history of interfering with his feeding tube and was being fed by the LVN at the time of the incident. Despite the alleged abuse, the resident did not show signs of distress or recall the incident when questioned later. The facility's records indicated that the resident was assessed for physical injury and trauma following the incident, with no impairments or trauma found. The incident was reported to the Texas Health and Human Services Commission, and an investigation was conducted. Interviews with staff revealed that they were aware of the facility's abuse and neglect policies, including the requirement to report any suspected abuse and ensure the resident's safety. The LVN involved was terminated following the investigation, and the facility conducted in-service training on abuse and neglect for its staff.
Inadequate Pressure Ulcer Care and Mattress Setting Management
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their treatment. Resident #21, a 69-year-old female with multiple health issues including diabetes and chronic kidney disease, was observed lying on a pressure-relieving mattress set incorrectly at 360 lbs, despite her actual weight being 240.3 lbs. This discrepancy was noted during multiple observations, indicating a failure to adjust the mattress settings according to the resident's weight, as per the physician's orders. Resident #51, a 60-year-old female with severe cognitive impairment and weighing 78 lbs, was also found lying on a low air loss mattress set at 210 lbs. This incorrect setting was observed over several days, suggesting a lack of adherence to the physician's directive to check mattress settings every shift. The resident's care plan highlighted her risk for pressure ulcers due to fragile skin, yet the facility did not ensure the mattress settings were within the therapeutic range. Resident #79, a 55-year-old male with paraplegia and multiple stage 4 pressure ulcers, did not receive documented wound care on several occasions. His mattress was set at 490 lbs, significantly higher than his actual weight of 134.6 lbs. Interviews with staff revealed confusion and lack of responsibility regarding who should ensure correct mattress settings and perform wound care. The failure to perform wound care as ordered and document it properly could lead to delayed healing and increased risk of infection, as noted by the staff during interviews.
Failure to Ensure Proper Catheter Care and Securement
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, which could lead to urinary tract infections. Specifically, three residents with catheters did not have catheter securement devices to anchor the catheters to their legs over several days. This lack of securement was observed during multiple instances, where the catheter tubing was not anchored to the residents' thighs, increasing the risk of catheter movement and potential injury. Additionally, during a wound care session, a treatment nurse placed a resident's catheter bag on the bed, which is against infection control practices. The catheter bag should have been kept below the level of the bladder to prevent urine backflow, which can cause infections. The nurse acknowledged the mistake and the potential risks associated with improper catheter bag placement. Interviews with various staff members, including nurses and the interim administrator, revealed a lack of consistent practice in ensuring catheter securement devices were used. Staff members recognized the importance of these devices in preventing catheter-related injuries and infections but admitted to lapses in their application. The facility's catheter care policy emphasizes the need for securement devices and proper catheter bag placement, yet these guidelines were not consistently followed.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to deficiencies in their care. Resident #25, a male with chronic respiratory failure, heart failure, chronic obstructive pulmonary disease, and chronic pulmonary edema, did not have a physician's order for oxygen therapy until it was pointed out by a surveyor. Observations revealed that his oxygen concentrator filter was dirty, covered with gray and black debris, which was not addressed by the staff until after surveyor intervention. The Assistant Director of Nursing (ADON) admitted to not being aware of the dirty filter and acknowledged the risk of potential infection due to this oversight. Resident #15, a 96-year-old female with respiratory disorders, shortness of breath, chronic obstructive pulmonary disease, and obstructive sleep apnea, was found to have her CPAP mask improperly stored on the machine instead of in a bag, and her oxygen concentrator lacked a filter. These issues persisted over multiple observations, indicating a lack of adherence to proper storage and maintenance protocols for respiratory equipment. Interviews with staff revealed a lack of clarity on responsibilities for storing and maintaining the equipment, further contributing to the deficiency. Resident #16, a 71-year-old female with shortness of breath and congestive heart failure, had an oxygen concentrator filter with gray, fuzzy material on it, indicating it had not been cleaned as required. Despite having orders to change and clean respiratory equipment weekly, observations and interviews with staff showed that these tasks were not consistently performed. The staff acknowledged the importance of cleaning and storing equipment properly for infection control but admitted to lapses in following these protocols, which could affect the residents' oxygenation and increase the risk of infection.
Deficiency in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to maintain safe and sanitary storage of residents' food items in personal refrigerators, affecting five residents. Specifically, Resident #72's refrigerator was found to be cluttered, unclean, and contained meat with green mold. Observations revealed ice build-up in the refrigerator, and interviews with staff indicated a lack of clarity regarding responsibility for checking and cleaning the refrigerators. Staff members acknowledged the potential health risks associated with the presence of moldy food, including the possibility of the resident becoming ill. Additionally, the facility did not consistently check and log the temperatures of personal refrigerators for Residents #42, #49, #51, and #81. Temperature logs were incomplete or missing for these residents, and interviews with staff revealed confusion about who was responsible for maintaining these logs. Housekeeping staff admitted to not always recording temperatures on the log sheets, and there was a lack of oversight to ensure that temperature checks were performed daily. The facility's policies required daily temperature checks and weekly cleanliness checks of personal refrigerators, but these procedures were not followed. Interviews with various staff members, including housekeeping, nursing, and administrative personnel, highlighted a lack of adherence to these policies, resulting in the potential for food spoilage and health risks to residents. The failure to maintain proper food storage practices could lead to foodborne illnesses among residents.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple deficiencies related to infection control practices. Specifically, the facility did not ensure that staff members changed gloves and performed hand hygiene appropriately during incontinent care for a resident with cognitive impairments and incontinence issues. Observations revealed that a CNA did not change gloves after cleaning the resident's front area before touching other items, which posed a risk of cross-contamination and infection. Interviews with staff confirmed that the CNA was aware of the proper procedure but failed to follow it due to nervousness. Additionally, the facility did not implement enhanced barrier precautions for several residents with medical devices such as feeding tubes, Foley catheters, and IV therapy. For instance, a resident with a feeding tube did not have an enhanced barrier precautions sign posted on the door, and staff were observed not wearing the required PPE during care. Another resident with a Foley catheter and a history of infections did not have proper PPE storage outside the room, and staff were not consistently using PPE during care. These lapses in infection control practices were acknowledged by staff, who cited a lack of awareness or understanding of the enhanced barrier precautions requirements. The facility's infection control program was further compromised by the absence of PPE usage during catheter care for a resident on enhanced barrier precautions. Staff members were observed performing catheter care without donning the necessary PPE, despite the presence of a sign indicating the need for enhanced precautions. Interviews with staff revealed a lack of adherence to the facility's infection control policies, with some staff members forgetting to wear PPE or being unaware of the updated protocols. The facility's failure to ensure consistent implementation of infection control measures placed residents at risk of exposure to communicable diseases and infections.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect three residents from abuse, resulting in deficiencies in care. Resident #21, a 69-year-old female with moderate cognitive impairment, reported feeling abused during bed baths by a CNA. She described the CNA as rough and unwilling to assist her, causing her pain and emotional distress. Despite informing a nurse about the situation, no action was taken, and the CNA continued to provide care in a manner that Resident #21 perceived as abusive. Resident #50, a 68-year-old male with moderate cognitive impairment, was involved in an altercation with another resident, Resident #70. Resident #70, who also had moderate cognitive impairment, slapped Resident #50 in the face after perceiving him as being mean to the staff. The incident occurred in the dining room and was witnessed by a nurse. Despite Resident #70's history of aggressive behavior, the facility failed to prevent the altercation, resulting in physical abuse of Resident #50. Resident #74, a female with intact cognition, experienced unwanted touching by her roommate, Resident #77, who was moderately cognitively impaired. Resident #77, who had a history of sexually inappropriate behavior, approached Resident #74 while naked and attempted to touch her. Although the incident was reported, the facility did not adequately address the situation, allowing Resident #77 to remain in the same room as Resident #74. This failure to separate the residents and prevent further incidents constituted a deficiency in the facility's abuse prevention measures.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to ensure that residents were informed of their Medicare/Medicaid coverage and potential liability for services not covered. Specifically, two residents were not provided with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when they were discharged from skilled services before their covered days were exhausted. This notice is crucial as it informs residents that Medicare will no longer pay for skilled services, allowing them to understand potential out-of-pocket costs. The absence of this notice was confirmed through interviews and record reviews, indicating a lapse in the facility's adherence to regulatory requirements. Resident #274, a female with intact cognition, was admitted with conditions including embolism and thrombosis of arteries of the upper extremities and type 2 diabetes. She received Medicare Part A skilled services, but the facility did not provide her with a SNF ABN upon discharge. Similarly, Resident #275, also with intact cognition, was admitted with metabolic encephalopathy and chronic obstructive pulmonary disease. She too was not given a SNF ABN when her Medicare Part A services ended. Interviews with the social worker and interim administrator revealed a lack of awareness and understanding of the requirement to issue the SNF ABN, which is mandated by the facility's policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. For Resident #49, the MDS assessment inaccurately coded the resident as being on an antipsychotic medication and having a diagnosis of bipolar disorder. The resident was actually prescribed Depakote, an anticonvulsant, for a mood disorder, not an antipsychotic. The MDS Coordinator, who was new to the facility, misclassified the medication due to a lack of available coding options at the time and incorrectly coded the mood disorder as bipolar without supporting documentation. Resident #88's MDS assessment failed to reflect the resident's PASRR positive status for developmental disability, which was crucial for ensuring the resident received appropriate services. The MDS Coordinator responsible for this assessment admitted to a data entry error, acknowledging that the resident's PASRR status should have been included in the MDS to ensure the resident's needs were met. The oversight was identified during interviews with the MDS Coordinators and the Regional MDS Coordinator, who emphasized the importance of accurate MDS assessments. The report highlights the responsibility of the MDS Coordinators and the RN who signs off on the assessments to ensure accuracy. The facility's policy mandates adherence to RAI guidelines for MDS coding, but the errors in these cases suggest a lapse in following these procedures. The inaccuracies in the MDS assessments could potentially lead to residents not receiving the care they require, as the assessments are integral to planning and delivering appropriate care.
Inaccurate PASRR Level I Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessment for a resident diagnosed with schizophrenia. The resident's PASRR Level I screening inaccurately indicated that the resident did not have a mental illness, despite having an active diagnosis of schizophrenia and requiring psychotropic medication. This discrepancy was identified during a review of the resident's records, which included a face sheet, quarterly MDS, and care plan. The MDS Coordinator acknowledged that the hospital had incorrectly marked the mental illness section as 'no' and had since completed the necessary form to rectify the error. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASRR process. The social worker was unaware of which residents were receiving PASRR services, and the ADON expressed uncertainty about PASRR procedures. The MDS Coordinator and Regional Nurse indicated that the MDS nurse was responsible for ensuring PASRR forms were completed accurately. The facility's policy stated that all applicants should be screened for mental illness or intellectual disability before admission, but this was not adhered to in the case of the resident with schizophrenia.
Failure to Notify SMHA of Significant Change in Condition
Penalty
Summary
The facility failed to notify the State Mental Health Authority (SMHA) of a significant change in mental condition for a resident, specifically regarding the diagnosis of post-traumatic stress disorder (PTSD). This oversight was identified during a review of the resident's records, which showed that the resident was diagnosed with PTSD on a specific date, but the facility did not conduct a new Preadmissions Screening and Annual Resident Review (PASRR) Level 1 screening following this diagnosis. The resident's initial PASRR Level 1 screening, conducted upon admission, indicated no mental illness, intellectual disability, or developmental disability, and no subsequent screening was performed after the PTSD diagnosis. Interviews with facility staff revealed a lack of awareness that PTSD could necessitate a positive PASRR evaluation. The Regional MDS Coordinator and MDS Coordinator both indicated that they were unaware PTSD alone could trigger a PASRR requirement. The facility's policy requires a Level 1 screening for residents experiencing a significant change in condition, but this was not adhered to in this case. The failure to conduct a new PASRR evaluation could potentially affect the resident's access to necessary services, such as counseling, that could benefit their daily life.
Failure to Implement Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with chronic respiratory failure, heart failure, chronic obstructive pulmonary disease, and chronic pulmonary edema. Despite the resident's need for oxygen therapy, the care plan did not address his oxygen use. The resident was observed using oxygen via nasal cannula on multiple occasions, yet there was no physician's order for oxygen until it was pointed out by a state surveyor. The Assistant Director of Nursing (ADON) acknowledged the oversight and obtained the necessary order only after the surveyor's intervention. Interviews with facility staff, including the ADON, Director of Nursing (DON), Interim Administrator, and MDS Coordinator, revealed a consensus that the resident should have had a care plan for oxygen. The lack of a care plan posed a risk that unfamiliar staff might not be aware of the resident's need for oxygen, as it was not documented in the care plan. The facility's policy on care planning emphasized the importance of developing a comprehensive care plan based on individual assessed needs, which was not adhered to in this case.
Deficiencies in Personal Hygiene and Mobility Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for two residents, leading to deficiencies in care. Resident #81, a 75-year-old female with chronic respiratory failure and a need for assistance with personal care, did not receive timely incontinent care. On 10/15/24, she reported not being changed from 10 a.m. until 4 p.m., resulting in her brief leaking through her clothes and sheets. She mentioned that the CNA responsible for her care cited short staffing as the reason for the delay. Resident #88, a 59-year-old male with Asperger's syndrome and severe cognitive impairment, was observed with a yellow substance on his gum line and teeth on multiple occasions. Despite requiring substantial assistance for oral hygiene, the facility failed to ensure his oral care was adequately provided. Additionally, Resident #88 was not offered the opportunity to get out of bed throughout October 2024, despite expressing a desire to do so. The CNA responsible for his care admitted to not asking him if he wanted to get out of bed and cited staffing challenges as a barrier to providing the necessary assistance. Interviews with various staff members, including CNAs, LVNs, and the acting DON, revealed a lack of adherence to the facility's policies regarding incontinent care, oral hygiene, and encouraging residents to get out of bed. Staff acknowledged the importance of these care practices in preventing skin breakdown, maintaining oral health, and promoting socialization and physical activity. However, the facility's failure to implement these practices consistently resulted in deficiencies in the care provided to Residents #81 and #88.
Improper Medication Storage and Monitoring
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of drugs for one resident. Specifically, Resident #72 was found to have Lidocaine patches 5% strength stored in his personal refrigerator, which were not prescribed by a physician. The presence of these patches in the resident's possession was against the facility's policy, which mandates that medications should be stored securely and only accessible to authorized personnel. Observations over several days revealed that the Lidocaine patches remained in the resident's refrigerator, indicating a lack of monitoring and adherence to medication storage policies. Interviews with various staff members, including licensed vocational nurses (LVNs), restorative aides, assistant directors of nursing (ADONs), and housekeeping staff, highlighted confusion and inconsistency regarding the responsibility for checking and cleaning residents' refrigerators. Staff members acknowledged that residents should not have medications in their possession and that the patches should have been stored on the nurse's cart. The facility's policy on medication storage, revised in August 2020, clearly states that medications should be stored safely and only accessible to licensed personnel. However, the lack of clarity among staff about their roles in monitoring and cleaning refrigerators contributed to the oversight. The administrator and ADONs admitted to the need for a change in the monitoring process to prevent such incidents from occurring in the future.
Failure to Document Diagnoses for Medications
Penalty
Summary
The facility failed to ensure that Resident #21's drug regimen was free from unnecessary medications, as there were no documented diagnoses for several medications prescribed to the resident. These medications included Atorvastatin for hyperlipidemia, Furosemide and Lasix for heart failure, Gabapentin for neuropathy, Melatonin for insomnia, and Allopurinol for gout. The absence of documented diagnoses in the resident's medical records could lead to the resident receiving unnecessary medications. Interviews with facility staff revealed a lack of clarity and responsibility regarding the documentation of diagnoses for medications. Licensed Vocational Nurse (LVN) K mentioned that the MDS Coordinator was responsible for adding diagnoses to the resident's medical record, but there was no clear process for ensuring that all medications had appropriate diagnoses. The Assistant Director of Nursing (ADON) and the MDS Coordinator both acknowledged the importance of having accurate diagnoses linked to medications to prevent unnecessary medication use. The facility's failure to document appropriate diagnoses for Resident #21's medications was further highlighted by the Regional RN and the Interim Administrator, who both stated that the MDS Coordinator and nurse managers were responsible for ensuring that medications had appropriate diagnoses. The lack of documented diagnoses could lead to inaccurate assessments and the potential for unnecessary medication use, as noted by the staff during interviews.
Failure to Limit PRN Psychotropic Medication Order to 14 Days
Penalty
Summary
The facility failed to ensure that a resident's PRN order for the psychotropic medication Lorazepam was limited to fourteen days, as required by regulations. The resident, a male with moderate cognitive impairment and on hospice care, had a PRN order for Lorazepam to manage anxiety and restlessness. This order, initiated on August 29, 2024, did not have an end date and was not re-evaluated by a physician to determine if it should continue as a PRN or become a scheduled medication. The medication was administered twice in September 2024, but there was no documentation of a physician's rationale for extending the PRN order beyond the 14-day limit. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed a lack of awareness regarding the resident's PRN order for Lorazepam exceeding the 14-day limit. The DON acknowledged that PRN orders for psychotropic drugs should not exceed 14 days without a physician's documented rationale. The facility's Psychotherapeutic Drug Management Policy also stipulates that PRN orders for psychotropic drugs are limited to 14 days unless extended with documented justification. This oversight could place residents at risk of receiving unnecessary medications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 14.81% due to four errors out of 27 opportunities. These errors involved two residents, one of whom did not receive their prescribed vitamin B-complex and was given an incorrect dose of Vitamin D3. The other resident did not receive their prescribed medications, Oxybutynin and Protonix, as ordered. These deficiencies were identified through observation, interviews, and record reviews. Resident #39, an elderly female with multiple diagnoses including cerebral infarction and type II diabetes, was not administered her prescribed vitamin B-complex and received an incorrect dose of Vitamin D3. The nurse responsible for her care noted that the vitamin was out of stock and had not been reordered. This oversight was attributed to a lack of clarity regarding who was responsible for restocking the vitamins, as well as a failure in communication between nursing staff and central supply. Resident #90, a male with a history of traumatic brain injury and intellectual disabilities, did not receive his prescribed medications for overactive bladder and GERD. Interviews with nursing staff and the administration revealed that there was confusion over the responsibility for reordering medications, with central supply handling over-the-counter and supplements, while nurses were expected to reorder prescription medications. This miscommunication and lack of timely ordering led to the medication errors observed.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Acetaminophen-Codeine Oral Tablet 300-60mg. The resident, a female with severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and chronic pain, was supposed to receive this medication three times a day for pain management. However, the medication was not administered as scheduled on three occasions due to a misunderstanding by a medication aide (MA) who thought there was a discrepancy between the medication blister pack and the electronic medical record (EMR) order. The MA, who had been employed at the facility for only a week, did not administer the medication on the specified dates because she believed the blister pack labeled Tylenol #4 did not match the EMR order for Tylenol #3. Despite being aware of the issue, the MA did not notify a nurse immediately to clarify the order, resulting in the resident missing three doses of her pain medication. This oversight was noted to have potentially increased the resident's anxiety and behaviors, as she exhibited signs of distress such as cussing and throwing water. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the acting Director of Nursing (DON), revealed that the MA did not report the missed doses to the appropriate personnel. The acting DON emphasized that the MA should have sought clarification from a licensed nurse and that the nursing staff is expected to administer medications as scheduled. The facility's medication administration policy requires resolving any discrepancies before administering medication, which was not adhered to in this case.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls, allowing only authorized personnel access to the keys. This deficiency was observed in the cases of two residents. For one resident, Santyl and Mupirocin ointment 2% were found on the bedside table, not properly stored or locked as per professional standards. The resident, who was moderately cognitively impaired, did not recall where the medications came from and had a history of bringing outdated ointments from home to self-apply, against medical advice. In the case of the second resident, Triamcinolone Acetonide Ointment 1% was found on the bedside table without a prescription. The resident was cognitively intact but was not present in the room at the time of observation. Staff interviews revealed that medications should not be in resident rooms and should be stored on medication carts. However, the ointment was left unsecured, posing a risk of misuse by other residents or visitors. Interviews with various staff members, including CNAs, LVNs, and the ADON, confirmed that medications should be stored securely and not left in resident rooms. The facility's policy mandates that medications be stored safely and securely, accessible only to authorized personnel. Despite these policies, the medications were found unsecured, indicating a lapse in adherence to the facility's procedures for medication storage and security.
Failure to Timely Report Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of an investigation regarding an alleged abuse incident involving two residents to the state survey agency within the required 5 working days. The incident involved a resident who alleged that another resident hit her on the back after an argument. Both residents were confused and unable to recall the details or timing of the incident. A head-to-toe assessment revealed no injuries to the resident who made the allegation, and the investigation concluded that the allegation was inconclusive. The facility's administrator acknowledged that the provider investigation report was submitted to the state survey agency one day late, on the sixth day instead of within the required five days. The facility did not have a specific policy for submitting the provider investigation report within the required timeframe, other than the general abuse policy. The administrator, who was new to the position, confirmed that the report should have been submitted within the specified timeframe.
Failure to Document Foley Catheter Changes
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically by not documenting foley catheter changes. The resident, who was admitted with diagnoses including obstructive and reflux uropathy, COPD, and benign prostatic hyperplasia, used a foley catheter as indicated in their medical records. However, the care plan did not specify the frequency of catheter changes, and there was no documentation of catheter changes from January to September 2024. This lack of documentation was confirmed during interviews with facility staff, who acknowledged that catheter changes were not consistently recorded unless there were abnormalities. The facility's policy required documentation of catheter changes, including details such as the type and size of the catheter, urine characteristics, and any difficulties encountered. Despite this policy, the staff failed to document the catheter changes, which could lead to other staff being unaware of whether the task had been completed. Interviews with the Director of Nursing and the Administrator confirmed that it was the responsibility of the nursing staff to ensure catheter changes were documented, and the failure to do so could place residents at risk for urinary tract problems.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as high fall risk. The resident, a female with a history of traumatic subdural hemorrhage, dementia, depression, seizures, muscle wasting, and reduced mobility, was admitted to the facility with a severely impaired cognitive status. Her care plan indicated she was at high risk for falls due to confusion and required substantial assistance with self-care and mobility. Despite these assessments, the resident was not monitored closely enough, leading to a fall incident. The resident's care plan included interventions such as keeping the call light within reach, providing a safe environment, and educating the resident and family about safety. However, during an incident, the resident was found on the floor by LVN E, indicating that these interventions were not effectively implemented. The resident complained of head pain after the fall, suggesting a potential injury. Interviews with staff revealed that the resident did not have a fall mat next to her bed, and there was uncertainty about whether the call light was within reach at the time of the fall. The facility's policy on fall prevention emphasizes evaluating residents for fall risk upon admission and developing appropriate interventions. However, the staff interviews indicated inconsistencies in the implementation of these policies. The DON and other staff members expressed differing opinions on the use of fall mats and the placement of high-risk residents, which may have contributed to the inadequate supervision and subsequent fall of the resident.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for a resident identified as confused and a wanderer. This resident, who had a history of cognitive impairment and was at risk for elopement, was found on a high-traffic street in a wheelchair. The facility staff were unaware of the resident's elopement and did not know how he left the facility. The resident had a history of wandering into other residents' rooms and had been recently confused due to a urinary tract infection (UTI). The resident's care plan and elopement risk evaluations were not adequately updated to reflect his increased risk of elopement. Despite being identified as having an imminent risk for elopement, the facility did not implement sufficient interventions to prevent the resident from leaving the premises. The staff failed to monitor the resident closely, and there was a lack of communication and coordination among the staff regarding the resident's whereabouts and condition. Interviews with staff revealed that there was confusion about how the resident managed to leave the facility. It was suggested that the resident might have exited with a family that was moving another resident's belongings, but no alarms were heard, and no staff witnessed the resident leaving. The facility's investigation into the incident was incomplete, and the administrator did not initially report the incident to the state agency, believing the resident did not intend to elope.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an incident involving a resident who was found in traffic on a busy street, which was a violation of the requirement to report alleged violations involving abuse, neglect, exploitation, or mistreatment immediately. The resident, who was severely cognitively impaired and identified as a wanderer, was not monitored closely despite increased confusion. The facility did not report the incident to the Health and Human Services Commission (HHSC) when the resident was discovered in traffic, placing the resident at risk for harm. The resident, an elderly male with a history of cognitive communication deficit, muscle weakness, unsteadiness on feet, lack of coordination, and stroke, was admitted to the facility with a BIMS score indicating severe cognitive impairment. Despite being identified as a wanderer and having a wander guard in place, the resident was able to leave the facility unnoticed. The facility's records indicated that the resident had a history of wandering into other residents' rooms and using their bathrooms, but there was no indication of an increased risk for elopement until the incident occurred. On the day of the incident, the resident was seen self-propelling in his wheelchair around the facility, and staff noted his increased confusion due to a urinary tract infection. However, the facility failed to monitor him adequately, and he was able to leave the building, possibly unnoticed by staff due to a family moving another resident's belongings. The police found the resident in the street and returned him to the facility, but the facility did not report the incident to the state agency as required, as they did not believe the resident intended to elope.
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 237 citations issued within 25 miles in the last 12 months — including the 16 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 Longview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whispering Pines Lodge | 1.5 mi | ★★★★★ | 34 | 7 |
| Heritage At Longview Healthcare Center | 1.6 mi | ★★★★★ | 1 | 0 |
| The Oaks At Longview | 1.6 mi | ★★★★★ | 8 | 0 |
| Avir At Longview | 1.7 mi | ★★★★★ | 8 | 0 |
| Longview Hill Nursing And Rehabilitation Center | 2 mi | ★★★★★ | 13 | 0 |
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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.