Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillside Heights Rehabilitation Suites during CMS and state inspections, most recent first.
During one night shift, an LVN working alone without CNA support and with known physical limitations failed to provide necessary toileting, incontinence care, and safety checks to several dependent and cognitively impaired residents. The next morning, staff found multiple residents in beds soaked with urine, one resident lying in feces, a hospice resident asleep on a hallway‑visible couch wearing only a t‑shirt with a soaked brief on the floor and urine‑soaked upholstery, and a resident with a history of falls on the floor beside her bed after reporting she had fallen and had knee pain. Staff interviews and camera footage showed that the assigned LVN entered rooms late in the shift and only briefly, call lights from the hall went unanswered for extended periods, and no timely assessment was performed after the reported fall. Numerous staff described these conditions—unchanged briefs, soaked linens, lack of assessment after a fall, and a resident left partially undressed in public view—as neglect and dignity violations.
Improper Food Storage and Labeling in Kitchen: Surveyors observed multiple freezer items stored open to air or without labels/dates, along with a container of prepared frosting in the pantry labeled with an old date. The DM stated opened foods should be closed, labeled, and dated, and that foods not properly wrapped or labeled could cause contamination and sickness to residents.
A cognitively impaired, wheelchair‑using resident who required extensive assistance with toileting and transfers, and had orders for regular brief checks and incontinent care, was left overnight sleeping on a couch in the entryway of her suite, visible from the hallway, wearing only a t‑shirt and a soaked brief that was later found on the floor. An agency LVN working her first shift on the unit, without CNA support and reporting a back injury, provided minimal in‑room care during the night, as confirmed by camera footage, and did not ensure the resident was toileted, cleaned, appropriately dressed, or placed in bed or otherwise covered in a private area. Morning staff found the resident still on the couch, in only a t‑shirt, with urine soaking the couch, and multiple staff and leadership interviews, along with facility resident‑rights documents, confirmed that leaving a resident in wet briefs and exposed in public view was considered neglectful and a violation of the resident’s dignity, privacy, and right to safe, clean conditions.
A resident with multiple comorbidities, moderate cognitive impairment (BIMS 11), and dependence on staff for mobility alleged that a CNA slapped her hip during in-bed care while another CNA assisted. Staff interviews confirmed the allegation was reported to on-call nursing leadership but not communicated to the ADM until the following day, and the report to the state agency was made more than two hours after the facility became aware of the allegation. This delay violated facility abuse and resident rights policies requiring immediate, and no later than two-hour, reporting of alleged abuse to the ADM and state officials.
Incomplete OOH-DNR Forms for Two Residents: The facility failed to ensure two residents had properly completed advance directive documents. One resident’s OOH-DNR lacked a date by the physician signature, and another resident’s OOH-DNR was missing the attending physician signature in the required space. Staff reviewed both forms and stated they were incomplete or invalid DNRs.
Inaccurate MDS Coding for Bed Rail Use: The facility failed to accurately code a resident’s MDS for restraint use. A resident with heart failure, RA, pain, weakness, and muscle wasting had an MDS that coded daily bed rail use, even though observations showed no bedrails on the bed and the resident stated she had never had them. The MDS RN, DON, ADM, and RN F all stated bed rails were not restraints and should not have been coded that way.
Failure to assess a resident after a reported fall and inadequate on-call support. A resident with impaired cognition, weakness, and a hx of falls told an LPN she had fallen and had leg and knee pain, but no immediate fall assessment, neuro checks, or incident report were completed. Staff later found her on the floor with left hip and knee pain and guarding, and she was sent out for eval. The on-call response for the hall did not result in adequate follow-up or staffing support.
A resident with multiple chronic conditions and significant mobility dependence fell from a Hoyer lift during a transfer back to bed when a sling strap came off and she slid out of the sling. The resident and CNAs described the fall as unwitnessed by injury, but interviews showed confusion about Hoyer lift training and competency, with the DON stating no education had been completed and staff reporting they had not received lift-specific training. Records reviewed included transfer techniques and fall precautions in-services, but no lift-specific training documentation.
Failure to train CNA staff on Hoyer lift use led to a resident sliding out of a sling during a transfer. A resident with MS, severe mobility limitations, and dependence for many ADLs was being transferred with a Hoyer lift when a sling strap came off and she fell to the floor without injury. Interviews showed the CNAs were unsure how it happened, the DON initially believed PT handled lift training, and the facility had no documented Hoyer lift competencies or training in the records reviewed.
A resident with a PEG tube, severe cognitive impairment, and diagnoses including cerebral palsy and malnutrition was on EBP for PEG tube/ostomy care. An RN administered medications through the PEG tube, performed tube placement checks and flushing, but did not don the gown required for EBP even though a gown was brought into the room. The RN acknowledged the lapse, and the DON and ADON confirmed that gown and glove use was required for this type of direct care.
A resident with blindness and multiple comorbidities was left unattended and unsecured on a van lift during transport from dialysis, resulting in a fall from the elevated platform and multiple spinal fractures. The CNA responsible did not follow facility policy to secure the wheelchair or remain with the resident, and video evidence confirmed the resident was left alone on the lift, leading to hospitalization in the ICU.
A LVN was found to have taken controlled substances, including pain medications, from two residents, resulting in missed doses and unrelieved pain. The LVN exhibited erratic behavior and admitted to taking the medications, with subsequent checks confirming discrepancies in medication counts and administration. Both residents had significant medical needs and experienced increased pain due to the missed doses. The LVN had a history of medication-related disciplinary issues, and facility procedures for controlled substance security and reconciliation were not effectively followed.
A facility failed to develop a comprehensive care plan for a resident with Spastic Quadriplegic Cerebral Palsy, omitting the use of an arm immobilizer from the care plan and medical orders. The resident, who required significant assistance, was observed wearing the device without documentation or instructions for its use, potentially leading to adverse outcomes.
A resident with multiple health conditions did not receive TED hose as ordered by a physician, observed over three days without the prescribed medical stockings. Staff interviews revealed a lack of awareness and adherence to the order, with the DON acknowledging the absence of specific training and policies on TED hose application. The oversight was not identified in daily reviews, highlighting a systemic issue in following physician orders.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in their treatment. A resident with chronic heart failure was receiving oxygen therapy without a physician's order, and another resident with COPD had not had her nebulizer tubing changed for four months. Additionally, a resident with heart failure and anxiety disorder was also receiving oxygen therapy without a physician's order. Staff interviews confirmed that facility policies regarding respiratory care were not followed.
The facility failed to maintain food safety and hygiene standards in their kitchen operations. Observations revealed improperly stored and unlabeled food items in the freezer, violating facility policies. Additionally, the Dietary Manager did not follow proper hand hygiene and glove use protocols during food preparation, risking cross-contamination. These actions contravened the facility's established procedures for safe food handling and preparation.
A resident with severely impaired cognition was administered Seroquel, a psychotropic medication, without obtaining a signed informed consent as required by the facility's policy. Interviews with the DON and ADON confirmed the oversight, noting that the medication was ordered by Hospice and that consent should have been obtained prior to administration.
A resident's DNR form was improperly completed, with witnesses signing before the Medical Power of Attorney, rendering it invalid. The resident, who had multiple health conditions and was cognitively intact, had her care plan indicating her wishes for a DNR. Facility staff recognized the error, acknowledging that the invalid DNR could lead to the resident being treated as a full code, contrary to her wishes.
A resident with congestive heart failure and anxiety disorder was admitted to a facility requiring oxygen therapy, but her baseline care plan failed to include this critical information. Despite the facility's policy requiring comprehensive care plans, the omission was noted during a review of her records and confirmed by staff interviews, highlighting a lapse in ensuring consistent and effective care.
The facility failed to develop comprehensive care plans for two residents, leading to potential inaccuracies in care. One resident receiving oxygen therapy did not have it included in his care plan, risking inconsistent care. Another resident, who was NPO and dependent on tube feeding, had conflicting care plan instructions about eating, risking aspiration. These deficiencies highlight a failure to adhere to care plan standards.
The facility failed to maintain accurate medical records for two residents, leading to potential care risks. One resident had no documented orders for catheter care, while another had inconsistent records regarding their NPO status and feeding instructions. Staff interviews revealed a lack of oversight in ensuring accurate records, and no policy was provided to address this issue.
The facility failed to maintain an effective infection prevention and control program. A CNA did not change gloves or wash hands during incontinent care for a resident, risking contamination. Another resident's catheter bag was repeatedly found on the floor, despite education on proper handling. The facility lacked a specific catheter care policy and proper documentation of resident education, contributing to these deficiencies.
Multiple Residents Left Soiled, Unassessed After Fall, and Exposed on Hallway Couch Overnight
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from neglect during a specific night shift, resulting in several residents being left in soiled or unsafe conditions. On the night in question, one LVN (LVN D), working her first shift at the facility, was assigned to provide total care for residents on one hall (hall 400) without CNA assistance, despite having a history of back surgeries and self-reported inability to perform transfers and extensive physical care alone. Camera footage later showed that she did not enter any resident room on that hall until after 10:00 PM and, when she did, she did not remain in any room for more than two minutes except for a brief three‑minute period around 4:30 AM when she and another LVN entered the suite shared by two residents. Staff interviews and observations the following morning documented that all residents on that hall required full bed changes due to soaked linens. Several residents with documented incontinence, mobility limitations, and cognitive impairment were found in neglected conditions. One male resident with muscle wasting, weakness, difficulty walking, and moderately impaired cognition, who required substantial/maximal assistance with toileting and transfers and had care plan interventions to keep him clean, dry, and with wrinkle‑free linens, was found lying in a bed covered in feces. Another male resident with diarrhea, lower extremity impairment, benign prostatic hyperplasia, and intact cognition, who required substantial/maximal assistance for toileting and transfers and was care planned for frequent diarrhea and incontinence with incontinent care after each episode, was found in a soaked brief with soaked bedding. A female hospice resident with severe cognitive impairment, wandering behavior, dependence for toileting, and orders for brief checks every three hours and toileting assistance every two hours, was observed by staff asleep on a couch in the entryway of her suite, visible from the hallway, wearing only a t‑shirt with a soaked brief on the floor and the couch itself soaked with urine; she was supposed to be monitored in bed with a fall mat and kept clean, dry, and comfortable. Additional residents on the same hall were also neglected. A female resident with dementia, overactive bladder, repeated falls, and moderately impaired cognition, who required substantial assistance with toileting and had care plan interventions for incontinence care after each episode, was found with a soaked bed and a brown ring on her bottom. Another female resident with moderately impaired cognition, muscle weakness, difficulty walking, and dependence for transfers, who had a history of falls and was to be placed in bed or a recliner rather than left in a wheelchair and observed frequently, reported to staff that she had fallen and that her knee hurt; she was later found on the floor beside her bed with her head at the foot of the bed and feet toward the head of the bed, with a blanket and pillow under her, and was complaining of pain. A male resident with reduced mobility, benign prostatic hyperplasia, frequent incontinence, and moderately impaired cognition, who required assistance with toileting and transfers and was care planned to be kept clean and dry with frequent toileting and incontinent care, was found soaking wet from his ankles or knees up to his neck, begging to get up and stating he was wet and cold. Multiple staff, including nurses and CNAs, stated in interviews that leaving residents in wet or soiled briefs, not checking on them regularly, not assessing a resident after a reported fall, and leaving a resident overnight on a couch in a soaked brief and t‑shirt in view of the hallway were examples of neglect and dignity violations. The sequence of events on the night shift further contributed to the deficiency. Around 4:30 AM, another LVN (LVN C) from a different hall responded to a request for help from LVN D and observed the hospice resident asleep on the couch in a soaked brief and t‑shirt in view of the hall, and the resident with a history of falls lying in bed upside down, reporting knee pain and stating she had fallen. LVN C expressed concern to LVN D and then called the on‑call ADON at approximately 4:35 AM to report worries about the residents on hall 400, including the couch situation and the resident who said she had fallen and had knee pain. The ADON texted two other LVNs asking them to send CNAs to assist on hall 400 but did not follow up to confirm that assistance was provided or to further check on the residents. One LVN later stated her CNAs did not go because they were busy finishing rounds, and she herself noticed call lights from hall 400 going off for long periods of time. The next morning, incoming nurses found multiple residents on hall 400 in soaked beds or briefs, one resident on the floor after a fall with pain, and one resident on the couch in a soaked state, confirming that residents’ toileting, incontinence, and safety needs had not been met during the night. Staff interviews consistently characterized the conditions found that morning as unacceptable and neglectful. Nurses and CNAs stated that not changing wet briefs, not answering call lights in a timely manner, not assessing a resident who reported a fall, and leaving a resident in public view in only a t‑shirt and brief were forms of neglect that violated residents’ dignity and care expectations. The administrator acknowledged that day shift nurses were upset because residents were wet and that all beds on hall 400 were soaked, prompting skin sweeps of the residents. Although no new skin breakdown was identified at that time, staff repeatedly described the overnight care on hall 400 as severely deficient, with one RN stating she had serious concerns about the care or lack of care provided overnight and another LVN stating she was in complete shock at the residents’ conditions when she arrived for her shift.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during review of the kitchen sanitation practices. In the walk-in freezer, surveyors observed a bag of rolls with no label or date and not in its original box, a box of frozen beef patties open to air, a box of frozen burritos open to air, and a box of frozen yeast rolls open to air. In the walk-in pantry, surveyors observed a plastic storage container of prepared frosting labeled "Frosting" and dated 02-12. The same freezer and pantry conditions were observed again on the following day, with the same items still present in the freezer and the frosting container still on the pantry shelf. During interview, the DM stated the facility policy required opened or expired foods to be thrown away after 3 days, but she was unsure whether the frosting should have been discarded. She stated the frosting had been transferred to the plastic container after the lid broke and that the date of 02-12 was the date the food was received. The DM also stated she expected staff to close food items after use and to label and date all food, and she acknowledged that improperly wrapped or labeled foods could cause contamination and sickness to residents.
Resident Left Overnight on Hallway-Visible Couch in Soaked Brief, Violating Dignity and Privacy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s dignity, privacy, and basic care needs were maintained during an overnight shift. The resident was an elderly female with severe cognitive impairment (BIMS score of 5), dementia with behavioral disturbance, cognitive communication deficit, muscle weakness, difficulty walking, insomnia, unsteadiness, and urinary frequency. Her care plan and MDS documented that she used a wheelchair, was dependent for toileting and transfers, required substantial/maximal assistance, and was to receive toileting assistance every two hours and as needed, with incontinent care after each episode. She was also on hospice with interventions to keep her clean and comfortable, and to maintain her dignity by being kept clean and dry. Active orders included brief checks every three hours and assistance of one to two staff for bed mobility and transfers. On the night in question, an LVN assigned to another hall (LVN C) was called to assist an agency LVN (LVN D) working her first shift in the facility on the 400 hall. When LVN C entered the suite shared by the resident and another resident, she observed the resident asleep on a couch in the entryway, visible from the hallway, wearing only a t‑shirt and a soaked brief. LVN C told LVN D that the situation was not acceptable, but LVN D responded that the resident would sleep wherever she wanted and stated she did not have time to “baby talk” residents. LVN C then returned to her own hall and called the on‑call ADON to report concerns about the residents on the 400 hall, including this resident lying on the couch in a soaked brief and t‑shirt. Camera footage later reviewed by the administrator showed that LVN D did not enter any resident room on that hall until after 10:00 PM and, throughout the night, did not remain in any room for more than two minutes, except for a three‑minute period around 4:30 AM when she and LVN C entered the suite of this resident and another resident. When day shift staff arrived the following morning, RN F and LVN H, after being alerted by LVN C, found the resident still asleep on the couch in the entryway to her suite, in view of the hallway, wearing only a t‑shirt, with a soaked brief on the floor next to the couch and urine soaking the couch around her. LVN H noted the resident’s wheelchair was next to her and that the resident’s bed was unmade. The resident later did not recall sleeping on the sofa. Multiple staff members, including LVNs, CNAs, the social worker, dietary staff, ADONs, the DON, and the administrator, stated in interviews that leaving a resident in a wet or soiled brief, or sleeping overnight on a couch in view of the hallway in only a t‑shirt and brief or just a t‑shirt, was not acceptable, was considered neglect, and negatively affected dignity, privacy, and basic care expectations. Facility documents, including the admission packet and the Patient/Resident Rights policy, stated that residents have the right to a dignified existence, privacy, and to be treated with respect and dignity, and that the facility must protect and promote these rights and provide care in a manner that maintains or enhances quality of life. The resident’s care plan and orders required regular toileting assistance, incontinent care after each episode, monitoring of appearance, and measures to keep her clean, dry, and comfortable, including checks of her brief every three hours. Despite these documented needs and interventions, the resident was left overnight on a couch in a public‑view area, inadequately clothed and in a soaked brief that was ultimately removed and left on the floor, with urine saturating the couch. The agency LVN assigned to her hall reported being alone without CNA support and unable to perform transfers due to a back injury, and stated that the resident had refused care and insisted the couch was her bed. However, the video evidence and staff interviews showed that the LVN provided minimal in‑room care throughout the night and did not ensure the resident was toileted, cleaned, appropriately dressed, or placed in bed or otherwise covered in a private setting. This sequence of inactions and observations led to the determination that the facility failed to treat the resident with respect and dignity and to provide care in an environment that maintained or enhanced her quality of life, as required by resident rights and facility policy. Staff interviews consistently characterized leaving a resident in unchanged, wet briefs and exposed in a public‑view area as neglectful and as a violation of dignity and privacy. The DON, ADONs, and other staff stated that any staff member who observed such a situation was responsible for intervening, including waking the resident, returning her to bed, dressing and covering her, or at minimum providing a blanket and pillow and ensuring she was not visible from the hallway. The facility’s own resident rights documents emphasized the right to safe, decent, and clean conditions, courtesy, consideration, respect, and privacy in personal care and accommodations. The events of that night, as documented by staff accounts, video footage, and the resident’s condition when found by day shift, demonstrated that these standards were not upheld for this resident.
Failure to Timely Report Alleged Staff-to-Resident Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of staff-to-resident abuse was reported immediately, but not later than two hours after the allegation was made, to the administrator and appropriate state authorities, as required by facility policy and federal regulations. An intake investigation report for a specific resident documented an incident date and time of 04/18/26 at 12:35 PM, with the facility first learning of the incident on 04/20/26 at 11:00 AM. TULIP intake information showed the state received the report on 04/20/26 at 12:42 PM, indicating that the allegation was not reported within the required two-hour timeframe after the facility became aware of it. The resident involved was an older female with multiple diagnoses, including bipolar disorder, history of opioid abuse, altered mental status, unspecified psychosis, depression, heart failure, rheumatoid arthritis, pain, muscle weakness, and muscle wasting and atrophy. Her most recent MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and she required substantial to maximal assistance with bed mobility, toileting, and transfers, with an active order for use of a mechanical lift for all transfers. Her care plan included a problem for making false accusations regarding staff treatment, with an approach to redirect her when such accusations were made, and a problem related to behavioral symptoms associated with a history of opioid abuse. According to interviews and record review, the resident alleged that a CNA slapped her hip during in-bed care while another CNA was assisting with turning. One CNA reported that the resident became irritated and aggressive during a brief change and later claimed that the CNA had hit her, which the CNA denied witnessing. The ADON, who was on call the night of the incident, stated she did not remember hearing about it at that time and acknowledged that the incident occurred on 04/19/26 and was not reported to the state until 04/20/26, which she stated was not timely. The DON confirmed that the administrator was responsible for reporting abuse allegations, that the incident occurred while the ADON was on call, and that the report was delayed until the following day. The administrator stated that the incident was reported to the on-call nurse on 04/19/26 but not to her until 04/20/26, identifying a breakdown in communication that resulted in delayed reporting, contrary to the facility’s abuse and resident rights policies requiring immediate reporting, and in no case later than two hours, for allegations involving abuse.
Incomplete OOH-DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had properly completed out-of-hospital do-not-resuscitate (OOH-DNR) orders as part of their advance directives. For one resident, the OOH-DNR contained the physician signature under the physician statement section, but no date was documented by that signature. For the other resident, the OOH-DNR form dated [DATE] did not include a physician signature in the required attending physician signature space under the section stating that all persons who signed above must sign below. Resident #15 was an [AGE]-year-old female admitted with diagnoses including unspecified dementia with behavioral disturbance, intermittent explosive disorder, psychotic disorder with delusions due to a known physiological condition, and major depressive disorder, recurrent severe without psychotic features. Her quarterly MDS showed a BIMS of 05, and her care plan addressed advance care planning with code status DNR and placement of advance directives in the medical record. Her OOH-DNR order had the physician signature present, but the date was missing. Resident #103 was an [AGE]-year-old male admitted with diagnoses including metabolic encephalopathy, emphysema, COPD, acute respiratory failure with hypoxia, chronic viral hepatitis C, and unspecified dementia. His care plan also addressed advance care planning with code status DNR. During interviews, multiple staff members reviewed both OOH-DNR forms and stated that Resident #15’s form was incorrect because the physician signature was not dated and Resident #103’s form was missing the physician signature; staff described the forms as incomplete or invalid DNRs.
Inaccurate MDS Coding for Bed Rail Use
Penalty
Summary
The facility failed to ensure that Resident #9’s assessment accurately reflected her status for the use of a restraint on the MDS. Resident #9 was a [AGE]-year-old female admitted with diagnoses including heart failure, rheumatoid arthritis, pain, muscle weakness, and muscle wasting and atrophy. Her most recent quarterly MDS completed 02/23/26 showed a BIMS score of 11 and indicated substantial to maximal assistance with bed mobility. On that assessment, Section P0100 - Physical Restraints indicated that she used bed rails daily. Record review showed a care plan problem started 10/16/25 stating the resident was in need of a side/rail assist bar related to increased weakness, with the approach to utilize the side rail/assist bar. The clinical record also included an active order stating the resident required the use of a side/rail assist bar as an enabler for transfers and/or repositioning, with the same start date. During observation on 04/28/2026 and again on 04/29/26, the resident’s bed had no bedrails, and the resident stated she had never had bedrails on her bed. The MDS RN, RN F, the DON, and the ADM all stated bed rails were not used as restraints and should not have been coded as such on the MDS; the MDS RN stated the assessment would be corrected. The facility policy stated the MDS must be a comprehensive, accurate, standardized, reproducible assessment completed for each resident using the RAI process.
Failure to Assess Resident After Reported Fall and Inadequate On-Call Support
Penalty
Summary
The facility failed to follow its fall management policy and assess a resident after she reported that she had fallen. The resident had diagnoses including unspecified lack of coordination, altered mental status, muscle weakness, difficulty walking, and muscle wasting and atrophy. Her quarterly MDS showed a BIMS of 9, indicating moderately impaired cognition, and her care plan identified a history of falling with interventions to keep her in bed or a recliner while in her room, not leave her in her wheelchair, observe her frequently, and place her in a supervised area when out of bed. On the night in question, an LVN later stated that another nurse asked for help in the resident’s room and that she heard the resident say, “Help.” The resident was found in bed positioned with her head at the footboard and her feet at the headboard, and she told the nurse she did not want to talk to the other nurse. The resident stated her leg and knee hurt and that they did not start hurting until she fell. The LVN said the other nurse denied that the resident had fallen, and the resident then shut down and would not talk for a bit. The LVN placed a pillow between the resident’s legs, covered her with a blanket, and left the room without completing an assessment. The resident was not assessed at that time for injury, pain, or neurological status, and no incident report was completed then. The next morning, staff found the resident on the floor beside her bed with her head toward the footboard and her feet toward the headboard. She complained of pain in her left hip and knee and displayed guarding of her left leg, so she was sent to the hospital. Facility staff and leadership stated that a resident who reports a fall is to be treated as having an unwitnessed fall and assessed, including neurological checks and required paperwork, but that did not occur when the resident first reported the fall. The facility also failed to follow its on-call policy when staff called for support during the night and the response did not result in adequate follow-up on the residents on the hall.
Failure to Ensure Safe Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure the resident environment remained free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents for one resident. Resident #83 was admitted with multiple diagnoses including multiple sclerosis, type 2 diabetes mellitus, hypertension, neuromuscular bladder dysfunction, dysphagia, cognitive communication deficit, reduced mobility, muscle weakness, lack of coordination, and immobility syndrome. Her MDS showed a BIMS score of 14, impairment in both upper and lower extremities, wheelchair use, and dependence for multiple activities of daily living, including toileting hygiene, bathing, dressing, footwear, and personal hygiene. The resident’s record documented a witnessed fall during a transfer with a Hoyer lift. The resident stated that while staff were lifting her back to bed, a strap on the sling came off the lift and she slid out of the sling onto the ground. She stated she did not sustain injuries, but afterward she double checked the sling straps before staff lifted her. The DON and CNA Q both described the incident as the resident sliding out of the sling and falling to the floor during the transfer, with no injuries noted. Interviews showed confusion and inconsistency regarding Hoyer lift training and competency. The DON initially stated PT oversaw Hoyer lift training, then stated PT did not do the training and that no education had been completed. CNA R stated she had not received training on Hoyer lift use before or after the incident, and CNA Q was unsure about the training process. The record contained in-services on transfer techniques and fall precautions, but no documentation specific to mechanical lifts or Hoyer lift use, and the staff education/orientation policy reviewed did not mention Hoyer lift transfers.
Failure to Train Staff on Hoyer Lift Use
Penalty
Summary
The facility failed to ensure that nurse aides were competent to use Hoyer lifts for resident transfers. Resident #83, a female with multiple sclerosis, type 2 diabetes, hypertension, neuromuscular bladder dysfunction, dysphagia, cognitive communication deficit, reduced mobility, muscle weakness, difficulty walking, and immobility syndrome, had a care plan and physician order allowing use of a Hoyer lift for transfers. Her quarterly MDS showed a BIMS score of 14 and significant dependence for many activities of daily living, including toileting hygiene, bathing, dressing, footwear, and personal hygiene. On 01/10/2026, Resident #83 had a witnessed fall while being transferred with a Hoyer lift by staff. The resident stated that while staff were lifting her in the sling, a strap came off the lift, causing her to slide out of the sling and onto the ground. She stated she did not sustain injuries, but now double checks the straps before staff lift her. The DON confirmed the incident involved CNA Q and CNA R transferring the resident back to bed when the sling strap slipped off and the resident fell to the floor without injury. During interviews, CNA Q and CNA R stated they were unsure how the strap came off and both acknowledged that improper use of the Hoyer lift could seriously injure a resident. The DON initially stated PT oversaw Hoyer lift training, then stated that was incorrect and that no education had been completed. ADON B stated he thought quarterly competency training included Hoyer lift use, but later said he was incorrect and that the DON was supposed to complete it. Record review showed in-services on transfer techniques and fall precautions, but nothing on mechanical lifts or Hoyer lift use, and the facility could not produce employee competencies for Hoyer lift use during the investigation.
Failure to Use EBP During PEG Tube Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #68, who was admitted with cerebral palsy, malnutrition, muscle wasting, and a gastrostomy tube and was severely cognitively impaired with a BIMS score of 00. The resident’s record showed an order for Enhanced Barrier Precautions (EBP) for PEG tube and ostomy care, and the care plan identified the resident as being on EBP related to the PEG tube/ostomy. During observation, RN F administered seven medications through the resident’s PEG tube, checked tube placement by aspirating stomach contents, and flushed the tube before and after medication administration. RN F brought a gown into the room but placed it on the back of the resident’s wheelchair and did not put it on while providing PEG tube care. In interview, RN F stated she forgot to don the gown and acknowledged she could have brought something into the resident or carried something out to another resident. The DON and ADON A stated that staff should wear gloves and a gown when providing direct care to residents on EBP, including residents with feeding tubes, and the facility’s EBP training and infection prevention policy both identified PEG tube care as requiring gown use.
Failure to Secure and Supervise Wheelchair-Bound Resident During Transport
Penalty
Summary
The facility failed to ensure a resident received adequate supervision to prevent accidents during transport, resulting in a serious incident. A cognitively intact male resident, who was blind and dependent on a wheelchair for ambulation, was being transported back to the facility after dialysis. The CNA responsible for transport did not secure the resident's wheelchair with the van lift strap while the lift was in use. The CNA pushed the resident onto the lift, activated it, and rode with the resident to the top. The CNA then stepped inside the van, leaving the resident unattended on the elevated lift platform. The resident, still in his wheelchair, rolled off the back of the lift and fell approximately 3 to 3.5 feet onto the parking lot pavement below. Eyewitness accounts and video footage from the dialysis center confirmed that the resident was left unattended on the lift and was not properly secured. The incident occurred in cold, wet, and snowy conditions, and the resident was not dressed for the weather, landing in a puddle after the fall. The facility's own policy required that wheelchair brakes be set and the lift safety restraint fastened, but the CNA did not follow these procedures. The van's lift was found to be functioning properly, and the safety barrier was operational at the time of the incident. As a result of the fall, the resident sustained multiple fractures to his thoracic spine, specifically at T4 and T5, and was hospitalized in the intensive care unit. Medical records indicated the resident had significant comorbidities, including diabetes, chronic kidney disease requiring dialysis, muscle weakness, and visual impairment. The resident's condition was critical following the incident, with ongoing pain and loss of independence. Interviews with facility staff and the resident's responsible representative confirmed that the resident was not secured on the lift and was left without supervision at a critical moment, directly leading to the accident and subsequent injuries.
Misappropriation of Resident Medications by LVN
Penalty
Summary
A licensed vocational nurse (LVN) was found to have taken controlled substances, including pain medications and a syringe of an unknown substance, belonging to two residents at the end of his shift. The incident was observed by a registered nurse (RN), who noticed the LVN behaving erratically and discovered the medications in his possession as he was leaving the facility. The LVN admitted to taking the narcotics and other pills from the medication cart. Subsequent checks revealed that the controlled substance counts were not correct at the end of the shift, and specific doses of pain medication had not been administered to the affected residents. The two residents involved had significant medical histories, including chronic pain, dementia, and other comorbidities. One resident was found to have missed her morning dose of Lorazepam and reported a pain level of 9 out of 10, while the other missed her dose of Tramadol and reported a pain level of 6 out of 10. Medication administration records confirmed that the medications were not given as ordered, and pain assessment rounds corroborated the residents' reports of unrelieved pain. The facility's medication count records and interviews with staff further confirmed the discrepancies and the failure to administer the prescribed medications. The LVN had a documented history of disciplinary issues related to medication administration and charting, including previous write-ups for leaving the medication cart unlocked, medication errors, and incomplete charting. Despite these issues, the LVN continued to work in the facility due to a progressive discipline policy. The facility's policy required secure storage and reconciliation of controlled substances, but the procedures were not effectively followed, resulting in the misappropriation of resident medications and failure to protect residents from exploitation.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with Spastic Quadriplegic Cerebral Palsy. The resident, who was cognitively intact with a BIMS score of 13, required full assistance with dressing, a 1-2 person assist with transfers and toileting, and set-up with weighted silverware for eating. Despite these needs, the care plan did not address the use of an arm immobilizing device that the resident was observed wearing. The device was not included in the resident's medical orders or care plan, and there was no documentation of its necessity or instructions for its use. The Director of Nursing (DON) acknowledged the absence of an order and care plan for the immobilizer, which was reportedly placed by an unknown Physical Therapist. The lack of documentation and care planning could lead to new staff being unaware of the need to remove the immobilizer at night, potentially causing pressure injuries. Additionally, not wearing the immobilizer during the day could result in the resident's spastic arm hitting doorways. The facility's policy requires a person-centered care plan that includes measurable objectives and timeframes, which was not adhered to in this case.
Failure to Apply TED Hose as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the application of TED hose as ordered by a physician. Over the course of three days, the resident was observed multiple times without the prescribed TED hose on his left leg, which were intended to be worn while awake to prevent blood clots. The resident, who has a history of dementia, diabetes with neuropathy, and heart failure, expressed that he was aware of the need for the TED hose but was unable to put them on himself and noted that staff had not assisted him in wearing them. Interviews with staff revealed a lack of awareness and adherence to the physician's orders. An LVN, who was familiar with the resident's needs, incorrectly assumed the resident was wearing the TED hose and acknowledged the potential risk of blood clots from not wearing them. A CNA, upon realizing the oversight, immediately put the TED hose on the resident, who then noted swelling in his foot. The Director of Nursing (DON) stated that the facility's system should have prompted staff to follow the physician's orders, but the oversight was not caught in their daily reviews. The DON admitted that there had been no specific training on TED hose application and that the facility lacked policies on TED hose, quality of care, or documentation of treatment administration. The administrator was unable to locate any relevant policies, indicating a systemic issue in ensuring compliance with physician orders and proper documentation, which contributed to the deficiency.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in their treatment. Resident #68, a male with a history of wheezing, cognitive communication deficit, and chronic combined congestive heart failure, was receiving oxygen therapy without a physician's order. His care plan did not include any mention of oxygen therapy, and there were no orders for oxygen administration in his records, despite observations of him receiving oxygen multiple times during his stay. Resident #78, a female with chronic obstructive pulmonary disease and muscle wasting, had not had her nebulizer tubing changed for four months. The tubing was dated 9/2/24, and the mask was discolored with particulates. Despite using the nebulizer regularly, there were no approaches listed in her care plan related to nebulizer care. The facility's policy required weekly changes of respiratory equipment, which was not adhered to, as confirmed by staff interviews. Resident #246, a female with combined congestive heart failure and anxiety disorder, was also receiving oxygen therapy without a physician's order. Her care plan and records did not mention oxygen administration, yet she was observed receiving oxygen multiple times. Staff interviews revealed that nurses were responsible for setting oxygen levels based on physician's orders, but no such orders were found for this resident. The facility's policy required verification of provider's orders for oxygen therapy, which was not followed in these cases.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During multiple observations of the walk-in freezer, various food items were found improperly stored in a large plastic bucket without labels or dates, and not in their original packaging. These items included a Ziplock bag of an unspecified item, bags of frozen okra, hash brown patty triangles, biscuits, unidentifiable brown food, and cookie dough. The absence of proper labeling and dating of these food items violates the facility's policy and procedure, which mandates that all foods removed from their original packaging must be stored in closed containers, labeled with the common name, and dated. Additionally, the facility failed to ensure proper hand hygiene and glove use during food preparation and service. An observation of the Dietary Manager (DM) revealed that she handled various surfaces and food items without changing gloves or using tongs, despite being aware of the correct procedures. The DM admitted to forgetting to change gloves and use tongs, acknowledging the risk of cross-contamination. The facility's policies require employees to wash hands before handling food, change gloves when switching tasks, and avoid bare hand contact with ready-to-eat foods, which were not followed in this instance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the administration of psychotropic medications. This deficiency was identified for one resident who was prescribed Seroquel, a psychotropic medication, without obtaining a signed informed consent. The resident, who had a severely impaired cognition with a BIMS score of 7 out of 15, was taking antidepressants, antipsychotics, and antianxiety medications. The facility's policy required a signed consent form for each psychotropic medication, but this was not obtained for the resident's Seroquel prescription. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that the facility did not have a signed consent form for the resident's Seroquel. The DON acknowledged that the medication was ordered by Hospice and that the facility required a signed consent form for all psychotropic medications. The ADON stated that the consent should have been obtained prior to administering the medication. The facility's policy on psychotropic drugs, dated April 2022, specified that a consent form must be completed for each psychotropic medication prescribed, which was not adhered to in this case.
Improper Completion of DNR Form for Resident
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advanced directive, specifically for one resident who had a Do Not Resuscitate (DNR) order in her record. The DNR document was improperly completed, with both witnesses signing the document five days before the Medical Power of Attorney (MPOA) signed it. This discrepancy was identified during a review of the resident's records, which showed that the DNR was not valid due to the incorrect order of signatures. The resident in question was a female with multiple health conditions, including multiple sclerosis, diabetes, and paraplegia, and was cognitively intact with a BIMS score of 15. Her care plan indicated that she was to be informed of her rights to complete advanced directives, and her stated desires were to be honored. However, the invalid DNR form meant that her wishes regarding resuscitation might not be respected, as the facility staff would have to treat her as a full code in the absence of a valid DNR. Interviews with facility staff, including the LVN, ADON, DON, and social worker, revealed that the error was recognized, and the staff acknowledged the importance of having a valid DNR. The social worker admitted that the facility did not complete the DNR form and that the witnesses were not affiliated with the facility. The facility's policy on advanced directives emphasized compliance with state law, but the oversight in checking the order of signatures led to the deficiency.
Failure to Include Oxygen Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident that included necessary instructions for oxygen therapy, which is crucial for providing effective and person-centered care. The resident, a female with a history of congestive heart failure and anxiety disorder, was admitted to the facility and required oxygen therapy. However, her baseline care plan, last reviewed by the Assistant Director of Nursing (ADON), did not mention her oxygen therapy needs. This omission was identified during a review of the resident's records, which showed that her oxygen saturation was checked multiple times, and she was receiving oxygen during most of these checks. Interviews with facility staff, including the Minimum Data Set (MDS) Licensed Vocational Nurse (LVN), MDS Registered Nurse (RN), and the Director of Nursing (DON), revealed that the responsibility for completing baseline care plans lay with the DON and ADONs. Despite this, the care plan for the resident did not include details about her oxygen therapy, which staff acknowledged could lead to inconsistencies in care and potential negative outcomes such as hypoxia or changes in mental status. The facility's policy on care planning emphasized the importance of including all necessary healthcare information in baseline care plans, but this was not adhered to in the case of the resident in question.
Care Plan Deficiencies for Oxygen Therapy and NPO Status
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential inaccuracies in care. Resident #68, a male with a history of wheezing, cognitive communication deficit, and chronic combined congestive heart failure, was observed receiving oxygen therapy, which was not included in his care plan. Despite being monitored for respiratory distress, there was no mention of how to address these concerns, and no orders for oxygen administration were found in his records. This oversight could lead to inconsistent care among nursing staff. Resident #92, a male with pneumonitis and dysphagia, had conflicting information in his care plan regarding his eating status. Although he was NPO and dependent on tube feeding, his care plan included instructions for dining room attendance and food preferences, which were inappropriate given his condition. Interviews with staff revealed a lack of awareness about these discrepancies, which could result in contraindicated care, such as feeding by mouth, posing a risk of aspiration. The facility's policy on care plan processes emphasizes the need for comprehensive and person-centered care plans, including specific interventions and services. However, the deficiencies in the care plans for Residents #68 and #92 highlight a failure to adhere to these standards, potentially compromising the residents' well-being and leading to adverse outcomes.
Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to potential risks in their care. For one resident, there were no documented orders for the care of an indwelling catheter, despite the resident having a catheter in place. This oversight was confirmed during an interview with an LVN who could not find any catheter-related orders in the resident's electronic health record (EHR). The lack of documented orders could result in staff being unaware of the necessary catheter care, potentially leading to issues such as infection or discomfort. Another resident's records were inconsistent regarding their feeding status. The resident was documented as NPO (nothing by mouth) due to swallowing difficulties, yet the care plan included instructions for dining room attendance and assistance with meals. Additionally, CNA documentation inaccurately recorded the resident as eating independently or with assistance, despite the resident and their family confirming that no oral intake had occurred. This discrepancy in records could lead to inappropriate feeding, risking aspiration. Interviews with facility staff, including the DON and ADONs, revealed a lack of clarity and oversight in ensuring accurate medical records. The staff acknowledged the potential negative outcomes of inaccurate records, such as medication errors and inappropriate care. Despite requests, the facility did not provide a policy addressing the accuracy of medical records, highlighting a gap in their documentation practices.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA H and the condition of Resident #79's catheter bag. CNA H did not change her gloves or wash her hands while providing incontinent care to Resident #18, which could lead to contamination and infection. This was acknowledged by CNA H, who admitted to not following proper hand hygiene protocols during the care process. Resident #79's catheter bag was repeatedly observed lying on the floor in various locations, including the dining room and rehabilitation room. Despite being educated by the nursing staff about the importance of keeping the catheter bag off the floor, Resident #79 continued to place it there, citing advice from a family member. The facility's staff, including the DON and ADON, acknowledged the lack of documentation regarding the education provided to Resident #79, which could lead to inconsistencies in care. The facility lacked a specific policy for catheter care, relying instead on general guidelines from the Lippincott Nursing Procedures. The absence of a detailed policy and proper documentation of resident education contributed to the deficiencies observed. The facility's infection prevention and control policy was not effectively implemented, as evidenced by the failure to adhere to hand hygiene protocols and the improper handling of catheter bags.
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 78 citations issued within 25 miles in the last 12 months — including the 6 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 Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Five Points Nursing And Rehabilitation | 3.4 mi | ★★★★★ | 7 | 1 |
| Legacy Rehabilitation And Living | 3.4 mi | ★★★★★ | 5 | 1 |
| Kirkland Court Health And Rehabilitation Center | 3.7 mi | ★★★★★ | 8 | 3 |
| Amarillo Center For Skilled Care | 4 mi | ★★★★★ | 8 | 0 |
| Heritage Convalescent Center | 4.6 mi | ★★★★★ | 9 | 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.