Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Hilltop Park Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, vascular dementia, and prior stroke received quetiapine, including a dosage increase, without required written consent. Physician orders and the MAR showed the antipsychotic was initiated and then increased, but the EMR lacked HHSC Form 3713 and any signed consent from the resident or representative. A facility consent form for Seroquel had no signature, and a prior ADON documented only a verbal consent without evidence that side effects were explained or understood. In interviews, an LVN and the CCN confirmed that facility policy and state guidance require signed written consent, not verbal consent, before administering antipsychotic medications, and acknowledged that no valid consent or updated consent for the dosage change was on file.
A resident with Alzheimer’s disease, vascular dementia, and prior stroke was given Quetiapine (Seroquel) at bedtime, with the dose later increased, under an order written for “vascular dementia with agitation.” The MAR confirmed administration of the antipsychotic as ordered. The Interim DON and CCN acknowledged that this diagnosis was not appropriate to justify Quetiapine use and that it could cause oversedation in elderly residents. Facility policy limited antipsychotic use to specific psychiatric diagnoses such as schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, and psychosis, generally in the absence of dementia, and required use at the lowest effective dose for the shortest duration. The resident’s treatment did not conform to these policy criteria, resulting in a failure to ensure freedom from unnecessary chemical restraint.
A resident with Alzheimer’s disease, vascular dementia, acute cystitis, stroke history, severe cognitive impairment (BIMS 02), delusions, behavioral symptoms, incontinence, mobility limitations, and scheduled pain medication was admitted, but no baseline care plan was developed or implemented within 48 hours as required by facility policy. The EMR “Baseline Care Plan” form was not completed and was later found to have been deleted, with staff unable to explain who was responsible for completing or deleting it. The CCN and MDS nurse both acknowledged that this failure could put residents at risk for not receiving needed care.
Food service staff failed to keep kitchen and unit refrigerator items properly sealed, labeled, and within date. Surveyors found unsealed cheese, a bag of guacamole with unclear dating, expired milk, unlabeled drinks, and unlabeled leftovers in a nurses’ station refrigerator, along with visible soilage and rust/condensation inside the unit fridge. Staff and the DON stated that all staff were responsible for checking dates and discarding expired or unlabeled items, but the observed items remained out of compliance.
Medication room B and medication cart E were observed unsecured and unattended, with medications visible in the room and the medication refrigerator unlocked. An LVN stated she forgot to close and lock the room and cart, and the DON stated medication rooms and carts were expected to be kept locked when unattended. Facility policy required medications to be stored securely and locked when not in use.
A resident with a history of cerebral infarct and dysphagia experienced prolonged nausea, vomiting, and diarrhea without physician notification. The facility failed to inform the physician or family of the resident's deteriorating condition, leading to hospitalization for hypovolemic shock and sepsis. Staff interviews revealed a lack of awareness and action, resulting in an Immediate Jeopardy situation.
A resident with a history of cerebral infarct and dysphagia experienced nausea, vomiting, and diarrhea over eight days, but the facility failed to notify the physician or administer feedings as ordered. The resident was hospitalized for hypovolemic shock and sepsis. Staff were aware of the symptoms but did not communicate them, leading to a serious decline in health.
Two CNAs failed to follow proper hand hygiene protocols during incontinent care for two residents, leading to potential cross-contamination. One CNA did not wash or sanitize her hands before applying gloves and used the same gloves throughout the procedure. The other CNA did not change gloves or sanitize hands before handling a clean brief. Both CNAs had been trained and competency-checked, yet did not adhere to infection control policies, placing residents at risk for infection.
The facility failed to maintain food safety standards and equipment maintenance, with issues such as improperly stored utensils, soiled kitchen equipment, and inadequate dishwashing documentation. Additionally, the Memory Care Nourishment Room's refrigerator-freezer lacked a thermometer, and resident food was undated, posing risks to residents' health.
The facility failed to develop comprehensive care plans for two residents, one with complex mental health needs and another admitted to hospice care. The care plans lacked specific details on prescribed medications and hospice services, contrary to the facility's policy requiring measurable objectives and timetables to meet residents' needs.
A facility failed to coordinate a PASRR assessment for a resident with mental illness, including diagnoses of paranoid schizophrenia and bipolar disorder. The resident's PASRR Level One Screening Form did not reflect her mental illness, and necessary forms were not completed. Interviews revealed that MDS Coordinators were aware of the need for accurate documentation but failed to ensure completion. The Regional Clinical Reimbursement Specialist confirmed incorrect coding on the PL1 form, attributing the failure to previous MDS Nurses' lack of monitoring.
A facility failed to obtain informed consent for bed rail use for a resident with a history of falls and dementia. Despite the absence of consent and assessment, bed rails were installed, contrary to facility policy requiring assessments and informed consent. Interviews with staff confirmed the oversight, highlighting a lapse in following established procedures.
A resident with C-Diff was not properly protected due to a nurse's failure to wear PPE and use effective hand hygiene. The nurse admitted to forgetting to don the necessary gear and initially used hand sanitizer instead of soap and water, which is ineffective against C-Diff. Interviews with facility staff confirmed the expectation for proper PPE use and hand hygiene, highlighting a lapse in following infection control protocols.
The facility did not post the actual hours worked by RNs, LVNs, and CNAs responsible for resident care per shift. Observations on two days showed missing information on the daily nursing staffing postings. Interviews revealed that the DON was unaware of the requirement, and the ADON admitted to not including the actual hours worked. The Administrator acknowledged the oversight and mentioned plans to modify the form to comply with the policy.
A resident's Admission MDS assessment failed to accurately reflect her skin integrity issues, treatments, and lower extremity impairments. The inaccuracies were confirmed by the Wound Care Nurse and the DON, who acknowledged that the MDS nurse responsible was no longer employed and that corrections were being made.
A facility failed to develop and implement a baseline care plan within 48 hours for a resident admitted with sepsis, cellulitis, and an unstageable pressure wound. The DON acknowledged the oversight, which did not comply with the facility's policy, potentially putting the resident at risk for not receiving necessary care.
The facility failed to maintain accurate clinical records for a resident, including wound treatments, shower schedules, and bladder records. Interviews revealed that wound care was performed but not documented, and the shower schedule was inaccurately entered into the electronic system, leading to discrepancies.
The facility failed to ensure that daily nurse staffing information was posted at the beginning of each shift in a prominent place accessible to residents and visitors. The staffing information was outdated and kept in a binder book instead of being displayed as required by the facility's policy. Both the DON and ADON acknowledged the oversight, which could cause confusion regarding staffing and resident care issues.
Failure to Obtain Written Consent for Antipsychotic Medication and Dosage Increase
Penalty
Summary
The deficiency involves the facility’s failure to obtain proper written informed consent for the use and dosage increase of an antipsychotic medication for one resident. The resident was an elderly female with Alzheimer’s disease, vascular dementia, and a history of stroke, admitted with significant cognitive impairment as evidenced by a BIMS score of 00, indicating she was unable to complete the BIMS test. Her MDS reflected that she was receiving an antipsychotic medication. Physician orders showed quetiapine 50 mg at bedtime was initiated and later increased to two 50 mg tablets at bedtime, and the MAR confirmed that these doses were administered over several days. Record review of the resident’s electronic medical record revealed there was no HHSC Form 3713, Consent for Antipsychotic or Neuroleptic Medication Treatment, on file. A facility consent form for Seroquel lacked a resident or representative signature, and although a verbal consent was documented by a prior ADON for quetiapine 50 mg at bedtime, there was no evidence that side effects were discussed or that the representative acknowledged understanding them. There was also no documentation that the resident or her representative consented to or was aware of the increased dosage of quetiapine before it was administered. Interviews with staff confirmed that the facility’s process required obtaining signed consents, including HHSC Form 3713 and a psychotropic consent form, prior to administering antipsychotic medications. LVN A stated that medications could not be given until both consents were signed by the resident or representative. The CCN, interviewed with the Interim DON present, acknowledged that nurses were responsible for obtaining consents before administering psychoactive medications, that no consent for quetiapine or updated dosage could be found for this resident, and that the existing Seroquel consent form lacked a physical signature. The CCN also stated she was unaware that verbal consents were not appropriate for this medication and noted that changes in nursing administration and unfamiliarity with consent requirements may have contributed to the missing consent. Facility policy and an HHSC provider letter specified that written consent on Form 3713 must be obtained prior to the first dose, that verbal consent does not meet rule requirements, and that NF staff cannot sign on behalf of the resident.
Inappropriate Antipsychotic Use Without Proper Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from chemical restraints not required to treat medical symptoms, specifically through the use of the antipsychotic medication Quetiapine (Seroquel) without an appropriate diagnosis. A female resident with Alzheimer’s disease, vascular dementia, and a history of stroke was admitted with these conditions documented on her face sheet. Physician orders showed Quetiapine 50 mg at bedtime for “vascular dementia with agitation,” later increased to two 50 mg tablets at bedtime for the same indication. The MAR confirmed that the resident received Quetiapine 50 mg nightly over multiple days, including after the dose increase. During interviews, the Interim DON and the CCN both stated that “vascular dementia with agitation” was not an appropriate diagnosis to justify the use of Quetiapine and acknowledged that the medication could cause oversedation in elderly residents. The CCN reported that the Hospice nurse had obtained the order for Quetiapine. Review of the facility’s Antipsychotic Medication Use policy, revised March 2025, showed that antipsychotics were to be used only when necessary to treat specific indicated conditions, generally limited to diagnoses such as schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, psychosis, and in the absence of dementia, and that they should be prescribed at the lowest possible dose for the shortest period of time. The resident’s use of Quetiapine for vascular dementia with agitation did not align with these stated indications, resulting in the cited deficiency.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed that the resident, an older female with Alzheimer’s disease, vascular dementia, acute cystitis, and a history of stroke, was admitted on an identified date, but no baseline care plan was completed within 48 hours following admission. Her admission MDS documented a BIMS score of 02 indicating severe cognitive impairment, the presence of delusions and physical behavioral symptoms directed toward others, use of a walker with need for touch assistance and supervision to ambulate, partial to moderate assistance with transfers, bowel and bladder incontinence, and receipt of scheduled pain medication. Despite these identified needs, the baseline care plan form in the EMR was not completed as required. During interviews, the Clinical Care Nurse (CCN) stated that the EMR form titled “Baseline care plan” for this resident was not completed and that the prior DON had been responsible for delegating the task, but she was unsure who had been assigned to complete it. The MDS nurse reported that the “Baseline Care Plan” form in the EMR had been deleted and was not completed, and although her name appeared on the deleted form, she did not know who deleted it or why it was not completed. Both staff members acknowledged that this failure could put residents at risk for not getting needed care. Review of the facility’s policy titled “Care Plans – Baseline” dated November 14, 2023, confirmed that a baseline plan of care to meet the resident’s immediate needs must be developed within 48 hours of admission, and that the interdisciplinary team is to review practitioner orders and implement a baseline care plan including initial goals, physician and dietary orders, therapy and social services, and provide a copy to the resident or representative.
Food Items Stored Unsealed, Unlabeled, and Expired
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen and in a nourishment refrigerator on the 200/300 hall. During an initial kitchen tour, surveyors observed a large walk-in fridge/freezer containing a large clear plastic zipper bag of cheese that was unsealed and marked only with a date of 7/25, and a sealed clear plastic zipper bag containing two smaller bags with a date of 8/5 and guacamole written on the bag with permanent marker. During rounds of the nourishment refrigerators, surveyors observed in the small refrigerator at the nurses’ station for the 200/300 hall an opened carton of milk that had expired on 08/29/2025, a plastic bottle that appeared to contain soda with no wrapper or label and the number 302 written on the lid, a glass container with leftover spaghetti with meat sauce and broccoli that was not labeled or dated, and an opened water bottle that was not labeled or dated. The refrigerator also had a crusty brown substance and a brown sticky substance on a door shelf, and condensation running down the back panel along with an orange rust substance from a screw. In interviews, the DM stated foods received were dated with green marker and opened items were marked with red marker, but he said he did not like this method and was in the process of changing back to printed labels. He stated the cheese dated 7/25 should have already been discarded and that opened items were good for 7 days, while leftovers such as mixed vegetables were good for 2 days. Other staff stated it was the responsibility of all staff to check dates every shift, that leftovers were only kept for 2 days and shredded cheese for 7 days after opening, and that expired or unlabeled items were to be discarded. The DON stated the night shift nurses were expected to update the temperature log and clean out expired or unlabeled foods and drinks, and that consumed expired items could cause someone to become sick.
Unsecured medication room and cart observed
Penalty
Summary
Medication storage was found unsecured in the facility when surveyors observed medication room B on hall 300 unlocked with the door open and no nurse or staff at the nurses' station for approximately 10 minutes. After entering the room, medications were seen on the counter in plain sight, and the medication storage refrigerator inside the room was also unlocked with medications inside. Surveyors also observed medication cart E on hall 300 unlocked and unattended in the hall while the nurse removed items from the cart and walked across the hall into a resident room without locking it. During interview, LVN D stated she forgot to close the medication room and did not realize she had not shut and locked the medication cart. She stated the room and cart were supposed to be locked, that she was the only one with a key to the room, and that other residents could go in and take medications that could harm them. The DON stated nurses were expected to keep medication rooms and carts locked and clean when unattended. Record review showed the facility policy required drugs and biologicals to be stored securely, with compartments locked when not in use and unlocked medication carts not left unattended.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately inform a resident's physician and family member of a significant change in the resident's condition, which included nausea, vomiting, and diarrhea lasting over eight days. The resident, who had a history of cerebral infarct, dysphagia, and was dependent on a feeding tube, experienced these symptoms from December 22 to December 30 without improvement. Despite having orders for Zofran to manage nausea and vomiting, the facility did not notify the physician until December 30, when the resident's condition had severely deteriorated. During the period of illness, the resident's feeding tube was intermittently turned off, and the resident's condition was not properly assessed or communicated to the physician. The nursing staff, including several LVNs, failed to recognize the need for medical intervention and did not follow the facility's policy for notifying the physician of a significant change in condition. The resident was eventually transferred to the hospital, where she was diagnosed with hypovolemic shock, sepsis, and required emergency surgical intervention. Interviews with staff revealed a lack of awareness and action regarding the resident's deteriorating condition. The Director of Nursing and the Administrator were unaware of the situation until it was brought to their attention by surveyors. The facility's policy required prompt notification of the physician and family in the event of a significant change in a resident's condition, which was not adhered to in this case, leading to an Immediate Jeopardy situation.
Removal Plan
- Verbal policy review of Policy of Change of Condition or Status/SBAR change of condition was provided by the Corporate Quality Improvement Nurse to DON/ADON.
- In-services were initiated by the Director of Nursing/Quality Improvement Nurse to educate on notifying physicians immediately following detailed assessment with any resident change of condition to include the use of the SBAR/eInteract.
- Education/In-service was initiated to the DON, ADONs by the Corporate Quality Improvement Nurse on the morning clinical start-up process to ensure that any changes of condition would be addressed.
- The Stop and Watch early warning communication tool was initiated, training and education started to the certified nurses' aides utilizing the alert system.
- The SBAR/eInteract is being monitored in the clinical morning startup daily by DON/ADON/Designee.
- Oversight will be provided by the Administrator/DON/Designee.
- Notification protocol and SBAR understanding will be tested by giving a test to LVNs and RNs that cover SBAR education and notification of physician regarding change of condition.
- Change of condition will be reported from shift to shift up to nurse management by utilizing the SBAR/eInteract process and 24-hour report tool and reviewed daily in clinical start-up with oversight provided by DON/ADON/Designee.
- DON/ADON/Designee will be responsible for reviewing SBAR/24-hour report/nurse to nurse huddle and hand-off, daily at morning clinical start up.
- Discrepancies will be addressed immediately with root-cause analysis and brought to QAPI with the oversight with the Medical Director monthly for six months.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident who was reviewed for notification of change in condition. The resident, who had a history of cerebral infarct, dysphagia, and was dependent on a feeding tube, experienced nausea, vomiting, and diarrhea over a period of eight days. Despite these symptoms, the facility did not notify the resident's attending physician of the condition change, nor did they ensure the resident's feedings were administered as ordered by the physician. During the period from December 22 to December 30, the resident's condition deteriorated, leading to hospitalization for hypovolemic shock, sepsis, and a urinary tract infection. The facility's nursing staff failed to document or communicate the resident's ongoing symptoms and the holding of feedings to the physician. Interviews with staff revealed that multiple nurses were aware of the resident's symptoms but did not notify the physician, believing that the standing order for Zofran was sufficient. The facility's Director of Nursing and Administrator were unaware of the resident's condition change until it was brought to their attention by a surveyor. The facility's policy required prompt notification of the physician for any significant change in a resident's condition, which was not followed in this case. The lack of communication and failure to adhere to the care plan resulted in a serious decline in the resident's health, necessitating emergency medical intervention.
Removal Plan
- Verbal policy review of Policy of Change of Condition or Status/SBAR change of condition was provided by the Corporate Quality Improvement Nurse to DON/ADON.
- In-services were initiated by the Director of Nursing/Quality Improvement Nurse to educate on notifying physicians immediately following detailed assessment with any resident change of condition to include the use of the SBAR/eInteract.
- Education/In-service was initiated to the DON, ADONs by the Corporate Quality Improvement Nurse on the morning clinical start-up process to ensure that any changes of condition would be addressed.
- The Stop and Watch early warning communication tool was initiated, training and education started to the certified nurses' aides utilizing the alert system.
- The SBAR/eInteract is being monitored in the clinical morning startup by DON/ADON/Designee.
- Oversight will be provided by the Administrator/DON/Designee.
- Notification protocol and SBAR understanding will be tested by giving a test to LVNs and RNs that cover SBAR education and notification of physician regarding change of condition.
- Change of condition will be reported from shift to shift up to nurse management by utilizing the SBAR/eInteract process and 24-hour report tool and reviewed in clinical start-up with oversight provided by DON/ADON/Designee.
- DON/ADON/Designee will be responsible for reviewing SBAR/24-hour report/nurse to nurse huddle and hand-off at morning clinical start up.
- Discrepancies will be addressed with root-cause analysis and brought to QAPI with the oversight with the Medical Director.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during incontinent care for two residents. CNA J did not wash or sanitize her hands before applying gloves and improperly donned a gown, leaving parts of her body exposed. She used the same pair of gloves throughout the entire procedure, including when cleaning the resident's perineal area and applying a clean brief. After completing the care, she realized there was no hand sanitizer in the room and did not wash her hands before leaving. CNA D, while providing incontinent care to another resident, did not change her gloves or sanitize her hands before touching a clean brief after disposing of a soiled one. Although she washed her hands before leaving the room, she acknowledged her failure to sanitize and change gloves during the procedure, attributing it to nervousness. Both CNAs had been trained and competency-checked on infection control procedures, yet failed to adhere to the facility's policies during the observed care. The Director of Nursing (DON) confirmed that staff were expected to perform hand hygiene after touching a dirty area and before moving to a clean area during incontinent care. The facility's policies on perineal care and hand hygiene emphasize the importance of handwashing and glove use to prevent infection. Despite this, the observed deficiencies in hand hygiene practices placed residents at risk for cross-contamination and infection.
Food Safety and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen and resident nourishment rooms. Knives and serving utensils were improperly stored on a rack, exposing sanitized surfaces to potential contaminants from a nearby air duct vent. Additionally, various kitchen appliances and equipment were found soiled with grease and food residues, including a Cambro warmer cart and a manual can opener. The deep fryer unit contained dark cooking oil and food crumbs, and a cardboard box of diced potatoes was stored directly on the floor of the walk-in freezer. An ice scoop was improperly placed on top of the ice inside the ice machine. Further deficiencies were noted in the documentation and operation of the dishwashing process. Dishwasher A recorded water temperature and sanitizer levels for the low-temperature dish machine before actually running it, citing a concern about forgetting to document later. The dish machine log was not readily available in the dish machine room but was found in a separate cabinet. Additionally, the Memory Care Nourishment Room's refrigerator-freezer lacked an interior thermometer, and resident food was undated. The freezer compartment door gasket was loose, leading to icicles forming inside. Interviews with staff revealed a lack of adherence to policies and procedures for kitchen sanitation and equipment maintenance. The Dietary Manager acknowledged the need for inservice training for dietary staff and stated that the nourishment room refrigerator was the responsibility of the housekeeping department. The Registered Dietician Consultant and the ADON for the secure unit also recognized the need for training and policy review, indicating a systemic issue in maintaining food safety standards and equipment functionality.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #26, who had a complex medical history including unspecified dementia, anxiety disorder, major depressive disorder, bipolar disorder, and other mental health conditions, was prescribed antipsychotic medication Seroquel and mood stabilizing medication Nuedexta. However, these medications were not included in the resident's comprehensive care plan, nor were the indications for their use specified. The care plan also lacked details on mood state, mental health services, and the administration of Nuedexta for mood stabilization. Resident #61, diagnosed with Alzheimer's disease and other conditions, was admitted to hospice care services. Despite a significant change MDS assessment being completed due to this admission, the resident's comprehensive care plan did not address the hospice care services. The ADON acknowledged that hospice care should be included in the care plan and noted the absence of documentation regarding the hospice nurse's attendance during the care plan conference in the progress notes. The facility's policy and procedure for comprehensive person-centered care plans, revised in December 2016, requires that care plans include measurable objectives and timetables to meet residents' needs. The policy also mandates that care plan interventions be derived from a thorough analysis of comprehensive assessment information and that the interdisciplinary team includes appropriate staff or professionals as determined by the resident's needs. The deficiencies in the care plans for Residents #26 and #61 placed them at risk for not receiving necessary care and services to meet their individual needs.
Failure to Coordinate PASRR Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to coordinate the assessment for a resident with the Pre-Admission Screening and Resident Review (PASRR) program. The resident, a female with diagnoses of paranoid schizophrenia, bipolar disorder, and dementia, was not identified as having a mental illness on the PASRR Level One Screening Form. This oversight meant that the necessary PASRR 1012 form or a new PL1 form was not completed to initiate a PASRR evaluation by the local intellectual and developmental disability authorities. The resident's medical records indicated the use of psychotropic medications for her mental health conditions, yet the PASRR documentation did not reflect her mental illness diagnoses. Interviews with facility staff revealed that the MDS Coordinators were aware of the need for accurate PASRR documentation but failed to ensure the forms were completed correctly. The MDS Coordinator with forty years of experience acknowledged the error and stated that she was in the process of auditing diagnoses for all residents. The Regional Clinical Reimbursement Specialist confirmed that the PL1 form was not coded correctly for mental illness, attributing the failure to the previous MDS Nurses' lack of routine monitoring of diagnoses. The facility's policy on preadmission screening for mental illness was not adhered to, resulting in the deficiency.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for a resident prior to their installation. The resident, a female with a history of acute respiratory failure, lack of coordination, muscle wasting, muscle weakness, unspecified dementia, and a history of falling, was admitted to the facility without any documented orders or consent for bed rail use. Despite the absence of consent, observations revealed that bed rails were installed on both sides of the resident's bed. The resident's care plan and electronic health records did not reflect any assessment or informed consent for the use of bed rails. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that no side rail assessment was conducted for the resident. The DON acknowledged that assessments for side rails should be performed upon admission, readmission, quarterly, or with significant changes in the resident's condition. The facility's policy on the proper use of side rails emphasized the need for a side rail utilization assessment and obtaining informed consent from the resident or their legal representative. The lack of adherence to these procedures could potentially lead to negative outcomes such as entrapment.
Inadequate Infection Control Practices for C-Diff Isolation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) and inadequate hand hygiene practices. During an observation, a Licensed Vocational Nurse (LVN) was seen providing care to a resident on isolation precautions for Clostridium difficile (C-Diff) without wearing the required PPE, which includes a gown, gloves, and mask. The LVN admitted to forgetting to don the necessary protective gear and initially used hand sanitizer instead of washing hands with soap and water, which is ineffective against C-Diff. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the expectation for staff to use proper PPE and hand hygiene techniques, specifically soap and water, when dealing with C-Diff cases. The resident involved was a female with a history of enterocolitis due to C-Diff, Parkinson's Disease, and dehydration, and had been on isolation precautions since early August. The facility's policy on infection prevention and control, as well as CDC guidelines, emphasize the importance of contact precautions and proper hand hygiene to prevent the spread of infections. Despite these guidelines, the failure to adhere to established protocols placed residents at risk for cross-contamination and infection, as noted by the Director of Operations and other staff members during interviews.
Failure to Post Actual Nursing Staff Hours
Penalty
Summary
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff, including RNs, LVNs, and CNAs, who are directly responsible for resident care per shift daily. Observations on two separate days revealed that the daily nursing staffing information was posted but did not include the total numbers of actual hours worked for each type of nursing staff. This omission was noted during observations conducted on the mornings of both days. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator revealed a lack of awareness and adherence to the facility's policy regarding the posting of actual hours worked. The DON was unaware of the requirement until it was brought to her attention, while the ADON, responsible for staffing and daily postings, admitted to never including the actual hours worked. The Administrator acknowledged that the policy was not followed and stated that the form would be modified to meet the requirements. The facility's policy, last reviewed in July 2016, mandates that within two hours of each shift's start, the number of licensed and unlicensed nursing personnel and their actual hours worked must be posted in a prominent location.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that Resident #1's assessments accurately reflected her medical condition and needs. Specifically, the Admission MDS assessment did not accurately document the resident's skin integrity issues, treatments, and impairment in lower extremities. The resident's face sheet indicated she was admitted with sepsis, cellulitis of the right lower limb, and a local infection of the skin and tissue. However, the MDS assessment inaccurately reported that the resident did not have an impairment in her lower extremities and did not require pressure-reducing devices for her chair. Additionally, the MDS assessment incorrectly documented the presence of an unstageable pressure wound and failed to note moisture-associated skin damage, despite the resident having a Stage 3 pressure wound on her sacrum, a lymphademic wound on her right lower extremity, and a candidiasis rash of the abdomen as per the initial skin assessment and treatment records. Interviews with the Wound Care Nurse and the Director of Nursing (DON) confirmed the inaccuracies in the MDS assessment. The Wound Care Nurse stated that the resident did not have an unstageable pressure ulcer and did have an impairment in her lower extremities, as well as a pressure-reducing device in her chair. The DON acknowledged that the MDS nurse responsible for the assessment was no longer employed at the facility and that the inaccuracies were being corrected. The DON also confirmed that the incorrect MDS assessment could potentially affect the resident's care plan, although the actual care provided to the resident was consistent with her needs as documented in other records and observations.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission. Specifically, a resident admitted with diagnoses of sepsis, cellulitis of the right lower limb, and an unstageable pressure wound did not have a baseline care plan created or reviewed by an RN following their admission. The resident's clinical record showed no evidence of a baseline care plan being completed within the required timeframe. During an interview, the DON acknowledged that the baseline care plan form in the resident's EMR was not completed and was unsure who was assigned to complete it. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission to ensure residents' immediate care needs are met. However, this policy was not followed, potentially putting the resident at risk for not receiving necessary care and services from the time of admission.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain accurate and current clinical records for a resident, specifically in the areas of wound treatments, shower records, and bladder records. The resident, a cognitively intact female with a history of sepsis, cellulitis, and local skin infection, had several wound care orders that were not documented as completed on a specific date. Additionally, the resident's shower schedule was not accurately reflected in the electronic records, leading to discrepancies between the scheduled and actual shower days. The resident's bladder records were also inaccurately documented, showing inconsistencies in the resident's incontinence status. Interviews with the Wound Care Nurse and the Director of Nursing (DON) revealed that the wound care was performed but not documented, and the shower schedule was not correctly entered into the electronic system. The DON acknowledged that the resident's daily skilled evaluation contained inaccuracies and that the nursing staff had been trained on proper documentation procedures. The facility's policy on charting and documentation emphasized the importance of accurate record-keeping to facilitate communication among the interdisciplinary team, but this was not adhered to in this case.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. On 05/22/2024, it was observed that the daily staffing pattern posted on the wall by the copier room and the DON's office was outdated, showing the date 05/16/2024. The DON confirmed that the staffing information had not been updated or posted since 05/16/2024 and that the last posting was kept in a binder book instead of being displayed prominently. The ADON also confirmed that the staffing sheets were placed in a binder book at the front desk, which was not readily accessible to residents and visitors as required by the facility's policy and procedure dated July 2016. The facility's policy mandates that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care must be posted in a prominent location accessible to residents and visitors. The failure to update and post the daily staffing information could cause confusion regarding staffing and resident care issues. Both the DON and ADON acknowledged the oversight and mentioned that the staffing sheets were supposed to be kept at the front desk but were not posted as required. This deficiency could affect residents, their families, and facility visitors by not providing them with access to current staffing data and facility census information.
What surveyors are citing around you — mapped
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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 314 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 Weatherford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holland Lake Rehabilitation And Wellness Center | 0.2 mi | ★★★★★ | 3 | 0 |
| Santa Fe Health & Rehabilitation Center | 0.3 mi | ★★★★★ | 3 | 0 |
| College Park Rehabilitation And Care Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Peach Tree Place | 1.4 mi | ★★★★★ | 8 | 5 |
| Avir At Keeneland | 2.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.