Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Homeplace Manor Healthcare Center during CMS and state inspections, most recent first.
Failure to Complete Required Background and Registry Checks Before Hire: The facility failed to follow its background screening policy for an RN and the DON. Record review showed both were hired before criminal history checks were completed, and the RN’s EMR and NAR checks were also completed after hire. Interviews with the BOM, RN, and DON confirmed the employees had already been working at the facility when the required screening was not yet done.
A resident with documented generalized anxiety disorder, panic disorder, PTSD, and depression was admitted with intact cognition and active mental health diagnoses noted in the physician progress notes and MDS. However, the PASRR Level I screening completed by the referring entity indicated no mental illness, resulting in a negative screen despite state guidance listing PTSD and severe anxiety disorder as qualifying MI diagnoses. The resident reported having these conditions and not receiving mental health services, while the MDS Coordinator and Administrator later acknowledged that the PASRR should have been positive and that the MDS Coordinator was responsible for ensuring PASRR accuracy in accordance with Texas PASRR policy.
A resident with intact cognition and diagnoses of PTSD, depression, anxiety, and panic disorder had a care plan and physician orders indicating the need for psychiatric evaluation and treatment, along with behavior and psychoactive medication monitoring. Despite this, the resident did not receive psychiatrist services; a counselor who had been visiting stopped coming and could not adjust medications, and the resident reported repeatedly requesting psychiatric care from the Social Worker and Administrator without action. The resident ultimately scheduled her own psychiatric appointment, and an LVN documented that the Administrator instructed staff to tell the resident she could not make her own appointments and must coordinate with nursing. The physician stated he had been recommending mental health services, while the Social Worker and Administrator acknowledged gaps in counseling and psychiatric services and could not provide documentation of any refusal of on-site psychiatric NP services, contrary to the facility’s behavioral health services policy.
RN coverage and DON staffing deficiency: The facility failed to provide RN coverage for 8 consecutive hours a day, 7 days a week, and failed to designate an RN as the DON on a full-time basis. Record review showed multiple days and weeks without required RN or DON coverage, and interviews confirmed leadership was aware of the staffing gaps and had been unable to fill the positions.
Food storage, labeling, and temperature monitoring failures were identified in the kitchen. An unopened package and several opened food items in the refrigerator and freezer were not labeled with item names, opened dates, or use-by dates, and appliance temperature logs had not been documented since the prior week. During meal prep, a Dietary Assistant checked food temps for items such as lima beans, gravy, carrots, and chicken, but the temps were not observed being documented. The DM and Admin stated staff were expected to monitor refrigerator and freezer temps twice daily and log food temps during prep and service.
Missing Pre-Employment Screening and Background Check Documentation: The facility failed to maintain evidence that required CHC, EMR, and NAR screenings were completed before hire for multiple employees, including the AIT, ADON, SW, AD, DM, Maint D, DOR, RN A, LVNs, and CNAs. Interviews showed confusion related to a change in ownership and management, with the BO manager stating she had limited training and could not show proof that background checks had been reviewed, while the RDO said staff should have been screened before hire and before access to residents.
Failure to Transmit Completed MDS Assessments: Multiple residents had completed admission, quarterly, entry, discharge return anticipated, and significant change MDSs that remained in export ready status and were not transmitted to CMS. Staff stated the delay was related to a change of ownership and waiting for a new provider or contract number before the system could recognize the transmittal. The DON/ADON were responsible for MDS completion and preparation for submission, and they could not state any adverse effect on residents from the missed transmissions.
Missing Annual CNA Competency Evaluations: The facility failed to keep annual performance reviews and competency evaluations on file for 2 CNAs. Record review showed the CNAs had no competency documentation in their employee files, and the BO manager confirmed no annual competencies were available. The RCN stated he was searching for the records and noted CNAs should have training and competency checkoffs per regulation, while the facility did not have a DON at the time.
Failure to Coordinate and Document Hospice Services: The facility did not collaborate with hospice reps or document communication for 5 residents receiving hospice care. Records showed hospice orders and MDS hospice status, but no documented communication with the hospice provider, and several residents lacked required hospice forms, including the Hospice Election Form. The Administrator stated communication was handled verbally with charge nurses and that no staff member was designated to communicate with hospice.
Infection control failed when two CNAs provided peri-care to a resident with severe cognitive impairment and total incontinence: they used a draw mat that contacted soiled skin, removed gloves and continued care without hand hygiene, and handled clean items before cleaning their hands. The facility also stored an ice scoop inside the ice chest, and the ADON/IP stated the scoop should not have been left there because it could cause cross contamination.
The facility failed to maintain an effective staff training program because multiple newly hired and existing staff members had no evidence of required orientation training on HIV, restraint reduction, or fall prevention. Personnel record reviews for the AIT, SW, AD, DM, DOR, RN A, LVN D, CNA E, and HK H showed no documentation of these trainings, and interviews indicated confusion related to ownership and management changes, with training records from prior ownership not found in the payroll database.
The facility failed to ensure effective communication training was completed for multiple staff members, including the AIT, SW, DM, DOR, RN A, LVN D, CNA E, and HK H. Personnel record review showed no evidence that these employees received the required training upon hire or while working at the facility. Interviews reflected confusion related to ownership and management changes, and the facility’s orientation policy required general orientation before resident contact and documentation in personnel files, but no specific policy for effective communication training was provided.
Failure to Train Staff on Resident Rights: Staff records showed 9 of 15 employees, including the AIT, SW, AD, DM, DOR, RN A, LVN D, CNA E, and HK H, had no evidence of required resident rights training upon hire or while working at the facility. Interviews reflected confusion about orientation and training responsibilities after changes in ownership and management, and the facility’s orientation policy required general orientation before resident contact and documentation in the personnel file.
Failure to Train Staff on ANE and Dementia Care: The facility failed to document required orientation and in-service training on abuse, neglect, exploitation, reporting procedures, misappropriation of resident property, and dementia management for multiple staff, including the AIT, SW, AD, DM, DOR, RN A, LVN D, CNA E, and HK H. Personnel records showed no evidence of the required training, and interviews confirmed confusion about orientation requirements after changes in ownership and management.
Failure to Provide QAPI Orientation Training: The facility failed to ensure required QAPI orientation training was completed for 9 of 15 staff reviewed, including an AIT, SW, AD, DM, DOR, RN, LVN, CNA, and HK. Record review showed no evidence of QAPI training upon hire or while employed, and interviews reflected confusion related to ownership and management changes, with staff stating orientation training requirements were not understood or completed.
Failure to provide mandatory infection control training was identified for 8 of 15 staff reviewed, including the AIT, SW, DM, DOR, RN A, LVN D, CNA E, and HK H. Personnel records showed no evidence of infection control education upon hire or while working at the facility, and the facility did not have a policy specifically requiring staff to be trained on infection control. Interviews reflected confusion related to orientation requirements and changes in ownership and management.
The facility failed to provide compliance and ethics training as part of its orientation and annual training process for multiple staff, including an AIT, SW, DM, DOR, RN A, LVN D, CNA E, and HK H. Personnel records showed no evidence of training upon hire or while working at the facility, and staff interviews confirmed gaps in orientation and awareness of training requirements. The facility’s orientation policy required general and departmental orientation, but no specific policy for compliance and ethics training was provided.
Failure to Provide Behavioral Health Training Upon Hire: The facility failed to ensure the AIT, SW, DM, DOR, RN A, LVN D, CNA E, and HK H had behavioral health training upon hire or while working at the facility. Record review showed no evidence of this training in their personnel files, and interviews described gaps related to orientation, change in ownership, and missing training records in the payroll database. The facility policy required general orientation before resident contact and documentation in the personnel file, but no policy specifically required behavioral health training.
Incomplete Care Plans for Hospice and Diabetes Needs: Two residents had care plans that did not reflect key assessed needs. One resident with severe cognitive impairment was on hospice, but the care plan did not include hospice services or code status. Another resident with dementia and diabetes received daily insulin, but the care plan did not include diabetes or insulin despite MDS findings and physician orders. The RCN stated these items should have been on the care plan and that he was responsible for keeping care plans current and accurate.
Activities Program Not Directed by Qualified Professional: The facility’s AD was hired without evidence of certification or training as a qualified therapeutic recreation specialist or activities professional meeting state licensing requirements. Interviews showed the RDO expected proper education and certification, the AD had previously worked as a CNA and was hired as an activities assistant, and the AIT confirmed the AD was not certified and was working on it. The unsigned job description required the activities program to be directed by a qualified professional.
The facility failed to follow the posted menu for a lunch meal, serving different items without notifying residents or obtaining dietician approval. A resident with dietary restrictions expressed dissatisfaction with the food quality and lack of menu communication. The dietary manager admitted the menu change was due to a delay in grocery delivery, and the administrator confirmed the dietician was not consulted.
The facility failed to maintain food safety and hygiene standards in its kitchen. Observations revealed improper storage and labeling of food items, and temperature logs for the freezer and refrigerators were not up-to-date. Additionally, a dietary staff member was not wearing a hair net due to a shortage, posing a risk of food contamination.
The facility failed to ensure that 7 out of 19 employees received mandatory effective communication training, risking resident miscommunication and social isolation. Staff interviews revealed confusion over training documentation responsibilities, exacerbated by a transition to electronic records and leadership changes.
The facility failed to provide timely training on resident rights to five staff members, including a DM, an LVN, and housekeeping staff. Record reviews showed no documentation of such training in their files, despite their employment dates ranging from August 2022 to September 2023. Interviews revealed issues with tracking and documentation due to a transition to electronic records and leadership changes.
The facility failed to provide adequate training on abuse, neglect, exploitation, and dementia care to two employees, DM and HSKP F, as revealed by missing documentation. Interviews indicated confusion over training responsibilities and a transition to electronic records, potentially placing residents at risk.
The facility failed to document infection control training for three staff members, potentially risking resident safety. Interviews revealed confusion over training responsibilities and record-keeping, with transitions to electronic records and leadership changes cited as contributing factors.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with moderate cognitive impairment. The resident did not receive a summary of the care plan, and staff interviews confirmed the absence of required documentation and discussions. This oversight could disrupt continuity of care, contrary to the facility's policy.
The facility failed to conduct annual competency evaluations for CNAs, specifically for one CNA, which could affect residents' care. The DON was responsible for these evaluations but was unavailable, and the transition to electronic records and leadership changes were cited as reasons for missing documentation.
The facility failed to properly post survey results and plans of correction in an accessible location, and included resident identifiers in the binder, potentially violating privacy rights. The administrator, responsible for maintaining the binder, did not review the contents after a resident destroyed the original documents, leading to these deficiencies.
The facility failed to maintain RN coverage for 8 consecutive hours a day, 7 days a week, for three months, missing 22 weekend days. Despite attempts to hire a weekend RN, the facility relied on a PRN RN and an Employment Service Agency for coverage. No negative outcomes were reported, but the absence of an RN could risk resident care.
A CNA failed to follow proper infection control practices during incontinence care for a resident, leading to a deficiency in the facility's infection prevention program. The CNA did not perform hand hygiene before donning gloves, failed to change soiled gloves, and did not wash hands after removing gloves, despite recent training. The facility's policy emphasizes hand hygiene to prevent infection spread.
Failure to Complete Required Background and Registry Checks Before Hire
Penalty
Summary
The facility failed to implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property for 2 of 3 employees reviewed for employability. Record review showed the RN had a hire date of 05/06/2026, but there was no evidence the facility completed a criminal history check before hire. The BOM provided documentation showing the RN’s criminal history was checked on 05/28/2026 during the on-site investigation. The RN’s file also showed the Employee Misconduct Registry and Nurse Aide Registry were checked on 05/07/2026, after the hire date. Record review also showed the DON had a hire date of 04/28/2026, but there was no evidence the facility completed a criminal history check before hire. The BOM provided documentation showing the DON’s criminal history was checked on 05/28/2026 during the on-site investigation. During interviews, the RN said she had been employed at the facility for about three weeks, and the DON said she had been employed for about a month. The BOM stated she understood that criminal history and registry checks were to be completed before a person was hired and given access to residents, but said she was overwhelmed after the facility switched to a new payroll company. The facility policy required background screening and criminal conviction checks for applicants with direct access to residents, including registry checks for nursing staff and licensed professionals.
Inaccurate PASRR Level I Screening for Resident With PTSD and Anxiety Disorders
Penalty
Summary
The facility failed to ensure the accuracy of the PASRR Level I screening for one resident with documented mental illness. The resident, an adult female admitted in November 2025, had physician-documented diagnoses of generalized anxiety disorder, panic disorder, and post-traumatic stress disorder (PTSD), with the physician progress note indicating "PTSD on multiple meds." A quarterly MDS assessment showed an intact BIMS score of 15 and listed active diagnoses of anxiety, depression, and PTSD. Despite this documentation, the PASRR Level I Screening completed by the referring entity on 11/13/2025 indicated no primary diagnosis of dementia and no indicator of mental illness, resulting in a negative PASRR screen. During interviews, the resident reported having anxiety with panic disorder, PTSD, and depression, and stated she had not received any mental health services. The MDS Coordinator acknowledged that the resident had a mental illness diagnosis and that the PASRR screening should have been positive rather than negative, and stated that a corrected screening should have been completed and sent to the local authority for evaluation. The Administrator stated she expected PASRRs to be accurate and timely, and confirmed that the MDS Coordinator was responsible for PASRR accuracy. Facility policy required following Texas PASRR policy for all mandatory meetings and care coordination, including changes that may require a change in PASRR status, and state guidance identified PTSD and severe anxiety disorder as examples of mental illness that should trigger a PASRR Evaluation when suspected.
Failure to Provide Ordered Psychiatric Services for Resident With PTSD
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate behavioral health treatment and services to a resident with PTSD, depression, and anxiety, in accordance with the resident’s assessed needs and the facility’s own policy. The resident was a cognitively intact female, independent with ADLs, with active diagnoses of generalized anxiety disorder, panic disorder, depression, and PTSD. Her care plan identified behavior problems including verbal aggression, crying, and isolation related to PTSD, depression, and panic disorder, with interventions such as administering medications as ordered, anticipating needs, providing opportunities for positive interaction, and discussing and reinforcing why behaviors were inappropriate. Physician orders included behavior monitoring, psychoactive medication monitoring, and an order for psychiatric services to evaluate and treat, along with multiple psychotropic medications for depression, anxiety, and insomnia. Despite these orders and identified needs, the resident did not receive psychiatric services as ordered. The physician progress note documented that the resident had PTSD, was on multiple medications, and “probably needs psych follow up,” and the physician later stated he had been recommending mental health services for her. The resident reported that since admission she had not received psychiatrist services, had repeatedly requested a psychiatrist for her PTSD and depression from the Social Worker and Administrator, and that a counselor who had been visiting her stopped coming; she noted that the counselor could not adjust medications and only talked with her. A progress note documented that the resident made her own appointment with a psychiatrist and that the Administrator directed staff to inform the resident she could not schedule her own appointments and must coordinate with nursing, even though the appointment had already been set. Interviews with facility staff further demonstrated the lack of appropriate behavioral health services. The Social Worker stated that the resident had been receiving counseling services but that the counselor relocated and they had not had one “in a while,” and that he only comes once a week to visit the resident. The Administrator stated that the resident had refused to see the psychiatric NP who comes to the facility since admission but was unable to produce documentation of any such refusals and acknowledged not knowing why the facility had not attempted to obtain services from a different mental health entity. The Administrator also confirmed that the resident had made her own psychiatric appointment and would be going to it. The facility’s behavioral health services policy stated that residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and that residents exhibiting emotional or psychosocial distress receive services and support addressing their individual needs, but the facility did not follow this policy for this resident.
RN Coverage and DON Staffing Deficiency
Penalty
Summary
The facility failed to use the services of an RN for 8 consecutive hours a day, 7 days a week, and failed to designate an RN as the DON on a full-time basis. Record review of the Monthly Nursing Attendance Calendar showed that in October 2025 there were 2 days with no RN coverage for 8 consecutive hours. In November 2025, there were 3 of 4 weeks with no DON and 11 days with no RN for 8 consecutive hours. In December 2025 through 12/18/2025, there were 2 of 3 weeks with no DON and 15 days with no RN for 8 consecutive hours. During interview, the AIT stated the facility did not have a DON or RN coverage for eight consecutive hours a day seven days a week. The AIT stated the facility had been trying to hire a DON and had recently added incentives to the posting, but there were no applicants at that time. The RDO stated he was aware the facility did not have RN coverage or an acting DON, expected an RN to work eight consecutive hours every day, and expected there to be an acting DON in the facility. He stated turnover in management staff led to the positions not being filled and identified the ADMIN as responsible for ensuring there was a DON and RN coverage. The facility policy titled, Nursing Services-Registered Nurse (RN), revised 01/01/2025, stated the facility would utilize the services of an RN for at least 8 consecutive hours per day, 7 days per week and designate an RN to serve as the DON on a full time basis.
Food storage, labeling, and temperature monitoring failures
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. During an observation on 12/16/2025 at 9:37 AM, the refrigerator contained an unopened package of food resembling corn tortillas that was not in the original box and had no label, opened date, or use-by date. The freezer contained 3 slices of an item that appeared to be garlic toast in an opened, unsealed package without a label or date, an opened bag of food items that appeared to be mixed fruit without a label or date, and an opened bag of food items that appeared to be frozen biscuits without a label or date. The refrigerator temperature was 33 F and the freezer temperature was 31 F at the time of observation. Record review showed the refrigerator temperature log had last been documented on 12/07/2025 at 40 F, with no further entries after that date. The freezer temperature log also had last been documented on 12/07/2025 at -2 F, with no further entries after that date. During interview, the DM stated temperatures were to be taken from the freezer and refrigerator twice a day and logged by kitchen staff, and that foods not in original packaging were to be placed in a sealed container or baggie with the opened date, use-by date, and description of the item. The DM also stated food temperatures were to be checked before being served by the cook and logged on food temperature logs. During an observation on 12/16/2025 at 12:15 PM, the Dietary Assistant took temperatures of food on the stove, including lima beans at 125 F, gravy at 100 F, carrots at 120 F, and chicken at 140 F, but dietary staff were not observed documenting the temperatures. The Admin stated food temperatures should be taken by dietary staff while being prepared and at the time of serving, and that temperatures were expected to be completed and logged during each meal. The Admin also stated the dangers of not having correct food storage temperatures could lead to food spoilage and foodborne illnesses and waste, and that improperly labeled and dated food could result in using spoiled or expired food or incorrect food and causing an allergic reaction or a foodborne illness.
Missing Pre-Employment Screening and Background Check Documentation
Penalty
Summary
The facility failed to implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property for 14 of 45 employees reviewed for employability. Record review showed that the facility did not have evidence that criminal history checks were completed before hire or before access to residents for multiple employees, including the AIT, SW, DM, Maint D, ADON, AD, DOR, RN A, LVN B, LVN C, LVN D, CNA E, CNA F, and CNA G. The facility also lacked evidence that EMR checks were completed before hire for the AIT, AD, DM, Maint D, CNA E, CNA F, and CNA G, and lacked evidence that NAR checks were completed before hire for CNA E, CNA F, and CNA G. Personnel record review identified missing screening documentation for each of the listed employees. The AIT had a hire date of 10/17/2025 with no evidence of a CHC or EMR check before hire. The ADON, hired 1/04/1994, had no evidence of a CHC. The SW, hired 3/01/2025, had no evidence of a CHC. The AD, hired 9/29/2025, had no evidence of a CHC or EMR check. The DM, hired 11/19/2025, had no evidence of a CHC or EMR check. The Maint D, hired 9/19/2023, had no evidence of a CHC or EMR check. The DOR, hired 5/08/2025, had no evidence of a CHC. RN A, hired 4/21/2025, had no evidence of a CHC. LVN B, hired 9/05/2022, had no evidence of a CHC. LVN C, hired 2/25/1987, had no evidence of a CHC. LVN D, hired 8/01/2025, had no evidence of a CHC. CNA E, hired 11/06/2025, had no evidence of a CHC, EMR check, or NAR check. CNA F, hired 1/09/2023, had no evidence of a CHC, EMR check, or NAR check. CNA G, hired 8/10/2017, had no evidence of a CHC, EMR check, or NAR check. During interviews, the AIT stated she expected all staff to have background checks before having contact with residents and said there had been a changeover in BO managers about two months earlier. She stated the current BO manager had been hired from housekeeping and was supposed to be trained by the corporate BO manager, but that training did not occur. The BO manager stated she had been in the position since the end of July, had only one day of in-person training, and remembered looking at some new hires' background checks but did not know she should have printed them out or could not show proof they had been reviewed. The RDO stated all staff should have background checks before hire, along with EMR/NAR checks for unlicensed employees, and attributed the failure to change in ownership and management. The facility policies titled Background Screening Investigations and Abuse, Neglect and Exploitation both stated that background, reference, and criminal checks were to be completed prior to employment and that documentation of the screening was to be maintained.
Failure to Transmit Completed MDS Assessments
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS system within the required timeframe for 14 of 24 reviewed residents. The report states that multiple assessments, including admission, quarterly, entry, discharge return anticipated, and significant change MDSs, had been completed for residents #1, #4, #5, #7, #10, #11, #13, #14, #16, #19, #20, #21, #23, and #24, but remained in an export ready status and had not been transmitted as of 12/18/2025. Resident records showed that the affected residents had a range of diagnoses and care needs, including Alzheimer’s disease, dementia, schizoaffective disorder, epilepsy, intellectual disabilities, COPD, heart failure, chronic kidney disease, Parkinson’s disease, MRSA infection, and difficulty walking. The record review documented that each listed assessment had been completed, but the MDS assessments list showed they were not transmitted to CMS. Examples included Resident #1’s admission and multiple quarterly MDSs, Resident #10’s admission, quarterly, and discharge return anticipated MDSs, and Resident #16’s entry, admission, discharge return anticipated, and significant change MDSs. During interviews on 12/18/2025, the RCN, corporate DOMDS, ADON, and AIT stated the delay in transmission was related to a change of ownership and waiting for a new provider or contract number before the system would recognize the transmittal. The DOMDS stated the facility used an online program to upload completed MDSs for transmission to CMS and that the ADON was responsible for completing the MDS and preparing it for transmission. The DOMDS and ADON were unable to state any adverse effect on residents from the failure to transmit the MDSs. The facility policy, MDS Completion and Submission Timeframes, stated that resident assessments would be conducted and submitted in accordance with current federal and state submission timeframes.
Missing Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to complete annual performance reviews and competency evaluations for 2 of 3 CNAs reviewed, identified as CNA F and CNA G. Record review of the Personnel File Review completed on 12/18/2025 showed CNA F was hired on 1/09/2023 and CNA G was hired on 8/10/2017, and further review found that neither employee had a competency evaluation on file. The report also noted that the facility assessment dated 6/12/2025 stated that annual education, education upon hire, and competencies are developed for all staff based on their job title. During interviews, the BO manager stated on 12/17/2025 that she did not have any annual competencies on record for CNA F and CNA G. On 12/18/2025, the RCN stated he did not know where the CNA competencies would be filed if they were not in the employee files and was checking the DON's office and contacting the previous DON to locate any documentation. He stated CNAs should have training and competency checkoffs per regulation and that he would monitor that the DON was providing them, while also noting that the facility did not have a DON at that time and was actively attempting to hire one.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for 5 residents receiving hospice services, including communication with the hospice medical director, the attending physician, and others involved in care. Review of records for Resident #9, Resident #10, Resident #19, Resident #20, and Resident #23 showed hospice status in the MDS and physician orders admitting each resident to hospice services, but the clinical records did not contain evidence of documented communication between the facility and the hospice provider for any of these residents. For Resident #10, Resident #19, Resident #20, and Resident #23, the facility also did not maintain the required hospice forms and documentation, including the Hospice Election Form. Resident #10's care plan did not reflect hospice services or code status, despite an order to admit the resident to hospice services. Resident #19's care plan stated the resident had a terminal prognosis and had been admitted to hospice for Alzheimer's disease, and Resident #20's care plan stated the resident had a terminal prognosis related to Alzheimer's disease and included an intervention to consult with physician and social services for hospice care in the facility. Resident #23's care plan stated the resident had a terminal prognosis and was on hospice services for end-stage dementia. During interview, the Administrator stated there was no designated facility staff member to work with and communicate with hospice, that communication was done verbally with charge nurses, and that there was no documented communication. She also stated she was not aware this was a regulation and said the DON was responsible for ensuring hospice documents were in the facility, but since there was no DON, it would be the ADON. The facility policy titled Hospice Program stated that the facility was responsible for coordinating with hospice representatives, communicating with hospice providers and documenting such communication, and obtaining physician certification of terminal illness specific to each resident.
Infection Control Lapses During Incontinent Care and Ice Storage
Penalty
Summary
The facility failed to maintain an infection prevention and control program during incontinent care for a resident with severe cognitive impairment, bowel and bladder incontinence, and dependence on staff for toileting hygiene. The resident’s record showed diagnoses including Alzheimer’s disease, a BIMS score of 5, and a care plan noting extensive assistance for toileting and a history of UTI with hygiene-related interventions. During observation, CNA E and CNA I provided peri-care while the resident was positioned on a draw mat, and the resident’s soiled skin was placed back onto the draw mat without first changing it out. CNA E and CNA I also removed gloves and then continued care without performing hand hygiene before touching clean items or repositioning the resident. During the observed care, CNA E used disposable wipes to clean the resident, disposed of wipes into a plastic bag after each use, applied cream with her right hand, removed gloves, and then put on new gloves without performing hand hygiene before reaching into a drawer and continuing care. Both CNAs later stated they should have performed hand hygiene after glove removal and before touching other items, and they acknowledged that placing unclean skin on a clean draw mat and failing to clean hands could contaminate clean surfaces. The ADON stated staff needed more education on infection control and that not performing hand hygiene and other infection prevention steps during incontinent care could spread infection through cross contamination. The facility also failed to store the ice scoop outside of the ice chest. During observation, the ice chest in front of the nurses’ station had the scoop sitting inside the ice, and the ADON/IP stated the scoop should not have been left inside the chest. She stated she would have the ice dumped and refilled because the scoop being inside could cause infection from cross contamination. The RCN later stated the scoop should not be stored in the ice chest and that dirty items should not contaminate a clean environment.
Missing Required Staff Orientation Training
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for new and existing staff members. Record review showed that 9 of 15 staff reviewed, including the AIT, SW, AD, DM, DOR, RN A, LVN D, CNA E, and HK H, had no evidence of required orientation training on HIV, restraint reduction, or prevention of falls. The report stated these trainings were required upon hire, but the personnel records reviewed did not show completion for any of the identified staff. Personnel record reviews documented hire dates for each of the affected staff members and showed no evidence that they had completed the required HIV training, restraint reduction training, or fall prevention training. The AIT’s record reflected a hire date of 10/17/2025, the SW’s 3/01/2025, the AD’s 9/29/2025, the DM’s 11/19/2025, the DOR’s 5/08/2025, RN A’s 4/21/2025, LVN D’s 8/01/2025, CNA E’s 11/06/2025, and HK H’s 11/24/2025. The facility also did not provide a policy specifically requiring staff to be trained on HIV, restraint reduction, and prevention of falls. During interviews, the AIT stated staff should receive appropriate training during orientation and annually, and she said there had been a changeover in BO managers and that employee training from the prior ownership was not found in the payroll database. CNA E stated she thought she had received training on HIV, fall prevention, and restraint reduction before her re-hire. The BO manager stated she had not been aware of orientation training requirements, and the RDO stated he expected all staff to have orientation education on required topics and that the failure occurred due to changes in ownership and management.
Missing Effective Communication Training for Multiple Staff
Penalty
Summary
The facility failed to include effective communication as mandatory training for direct care staff members, including the AIT, SW, DM, DOR, RN A, LVN D, CNA E, and HK H. Record review showed each of these staff members had a hire date listed in their personnel records, but there was no evidence that they completed required effective communication training upon hire or while working at the facility. The report stated this affected 8 of 15 staff reviewed for training on effective communication. During interviews, the AIT stated she expected staff to have appropriate training during orientation and annually per regulation. She also stated there had been a changeover in BO managers about two months earlier, that the current BO manager had been hired from the housekeeper position with the understanding that the corporate BO manager would train her, and that she was told her job duty training did not occur. The AIT further stated she was not aware until the day before the interview that the facility did not have employee training loaded into the payroll database after the change in ownership in March 2025. The BO manager stated she had been in the BO role since the end of July 2025 and had not been aware of orientation training requirements until then. The RDO stated all staff were expected to have orientation with education on required topics, including effective communication, and said the failure occurred due to change in ownership and changes in management in both the DON and ADMIN. The facility’s orientation policy stated general orientation must be completed prior to formal contact with residents and that documentation must be maintained in personnel files, but the facility did not provide a policy specifically requiring staff to be trained on effective communication.
Failure to Train Staff on Resident Rights
Penalty
Summary
Staff members were not educated on resident rights and the facility’s responsibilities to properly care for residents for 9 of 15 staff reviewed. The staff reviewed included the AIT, SW, AD, DM, DOR, RN A, LVN D, CNA E, and HK H. Record review showed each of these employees had a hire date in 2025, and the facility provided no evidence that they completed required resident rights training upon hire or while working at the facility. Personnel record review showed no documentation of resident rights training for the AIT, SW, AD, DM, DOR, RN A, LVN D, CNA E, or HK H. The AIT stated she expected staff to receive appropriate training during orientation and annually, and said there had been a changeover in BO managers about two months earlier. She stated the BO manager told her job duty training did not occur, and that she was not aware until shortly before the survey that the facility did not have employee training. Additional interviews showed CNA E believed she had received training through in-services and thought resident rights training had occurred before her re-hire. The BO manager stated she had only one day of training and several computer training meetings, and had not been aware of orientation training requirements. The RDO stated all staff should have orientation with education on required topics including resident rights, and said the failure occurred due to change in ownership and management. The facility policy titled Orientation stated general orientation must be completed prior to employee contact with residents and that all documentation supporting completion of orientation must be maintained in the personnel file, but the facility did not provide a policy specifically requiring staff to be trained on resident rights.
Failure to Train Staff on ANE and Dementia Care
Penalty
Summary
The facility failed to provide required staff training on abuse, neglect, and exploitation, misappropriation of resident property, reporting procedures for those incidents, and dementia management for 9 of 15 staff reviewed. The staff reviewed included the AIT, SW, AD, DM, DOR, RN A, LVN D, CNA E, and HK H. The report states these staff members had no evidence in their personnel records that they completed abuse, neglect, and exploitation training or dementia management training upon hire or while working at the facility. Personnel record reviews showed hire dates for each of the affected staff members, including the AIT, SW, AD, DM, DOR, RN A, LVN D, CNA E, and HK H, but no documentation of the required training. During interviews, the AIT stated staff should receive appropriate orientation training and annual training per regulation, and she said there had been a changeover in BO managers and that training had not occurred as expected. CNA E stated she had worked at the facility before, had just returned, and believed she had received some in-services, but thought they occurred before her re-hire. The BO manager stated she had been in the BO role since the end of July 2025 and had not been aware of orientation training requirements until the survey. The RDO stated all staff should have orientation with education on abuse, neglect, and exploitation so they would know what those issues are and how to protect residents, and that dementia management was important for caring for residents with dementia. The facility policy on Orientation required general orientation before resident contact and documentation in personnel files, but the facility did not provide a policy specifically requiring training on abuse, neglect, and exploitation or dementia management, and the staff list did not identify a Staff Development Coordinator.
Failure to Provide QAPI Orientation Training
Penalty
Summary
Mandatory training on the facility’s QAPI program was not provided for 9 of 15 staff reviewed, including the AIT, SW, AD, DM, DOR, RN A, LVN D, CNA E, and HK H. Record review showed each of these employees had a hire date in 2025 and had no evidence of completed QAPI training upon hire or while working at the facility. The report states the facility failed to ensure these staff members were educated on the QAPI program as part of orientation or ongoing training. During interviews, the AIT stated she expected staff to receive appropriate training during orientation and annually, and she reported there had been a changeover in BO managers about two months earlier. She stated the BO manager had been hired from the housekeeper position with the understanding that the corporate BO manager would train her, but that job duty training did not occur. The AIT also stated the corporate BO manager was supposed to load employee training into the payroll database after the ownership change in March 2025, and that prior to the day before the interview she was not aware the facility did not have employee training. The AIT later stated she had not received any orientation training on the QAPI program. The BO manager stated she had been in the BO role since the end of July 2025 and had not been aware of orientation training requirements until then. The RDO stated all staff were expected to have orientation with education on required topics, including QAPI, and said the failure occurred due to change in ownership and changes in management in both the DON and ADMIN. The facility’s Orientation policy required general orientation before resident contact, departmental orientation for job-specific competency, and documentation of orientation in personnel files, but the facility did not provide a policy specifically requiring staff to be trained on QAPI.
Failure to Provide Infection Control Training
Penalty
Summary
The facility failed to include mandatory infection prevention and control training as part of its infection prevention and control program for 8 of 15 staff reviewed, including the AIT, SW, DM, DOR, RN A, LVN D, CNA E, and HK H. Record review showed each of these employees had a hire date in 2025 and had no evidence of infection control training upon hire or while working at the facility. The report states the facility did not provide a policy that specifically required staff to be trained on infection control. Personnel record review for each of the identified staff members reflected no documentation of completed infection control training. The AIT, SW, DM, DOR, RN A, LVN D, CNA E, and HK H all lacked evidence of orientation or infection control education in their files. The facility’s Orientation policy, revised 1/02/2025, stated general orientation must be completed prior to an employee’s formal contact with residents, departmental orientation must continue until competency is demonstrated, and all documentation supporting completion of orientation must be maintained in the personnel file. During interviews, the AIT stated staff should receive appropriate training during orientation and annually per regulation, and she reported there had been a changeover in BO managers and ownership-related training issues. The BO manager stated she had not been aware of orientation training requirements until recently. The RDO stated all staff were expected to have orientation with education on required topics including infection control, and he attributed the failure to changes in ownership and management. CNA E stated she had returned to work at the facility and thought any training she received occurred before her re-hire.
Missing Compliance and Ethics Training for Multiple Staff
Penalty
Summary
The facility failed to include compliance and ethics as part of its compliance and ethics program through an effective training process or other practical method explaining the program’s standards, policies, and procedures. The facility also failed to provide annual training for all new and existing staff when the operating organization operated 5 or more facilities. Record review showed that 8 of 15 staff members reviewed, including the AIT, SW, DM, DOR, RN A, LVN D, CNA E, and HK H, had no evidence of compliance and ethics training upon hire or while working at the facility. Personnel records reflected hire dates for the AIT, SW, DM, DOR, RN A, LVN D, CNA E, and HK H, and the BO provided records showing no evidence that any of these staff had completed compliance and ethics training. The AIT stated she expected staff to receive appropriate training during orientation and annually, and she stated she had not received any orientation training on compliance and ethics. CNA E stated she had returned to work at the facility and remembered some training through in-services, but thought those occurred before her re-hire. The BO manager stated she had not been aware of orientation training requirements until the survey. The RDO stated he expected all staff to have orientation with education on required topics including compliance and ethics, and he acknowledged the organization operated more than 5 facilities. The facility’s Orientation policy required general orientation before resident contact, departmental orientation for job duties, and documentation in personnel files, but the facility did not provide a policy specifically requiring staff to be trained on compliance and ethics. The staff list provided by the facility did not identify a Staff Development Coordinator.
Failure to Provide Behavioral Health Training Upon Hire
Penalty
Summary
The facility failed to provide behavioral health training consistent with 483.40 and the facility assessment for 8 of 15 staff reviewed: the AIT, SW, DM, DOR, RN A, LVN D, CNA E, and HK H. Record review showed each of these staff members had a hire date in 2025 and had no evidence of behavioral health training upon hire or while working at the facility. The report states the facility did not provide a policy that specifically required staff to be trained on behavioral health. Interviews reflected that the AIT expected staff to receive appropriate training during orientation and annually, and stated there had been a changeover in BO managers about two months earlier. She stated the BO manager had been hired from the housekeeper position with the understanding that the corporate BO manager would train her, but that job duty training did not occur. The AIT also stated the corporate BO manager was supposed to load employee training into the payroll database because of the change in ownership in March 2025, and that prior company training was not found in the payroll database. She stated she was not aware until the day before the interview that the facility did not have employee training. Additional interviews showed CNA E said she had worked at the facility in the past and had just started back on 11/06/2025, and thought any in-service training occurred before her re-hire. The RDO stated all staff should have orientation with education on required topics including behavioral health, and identified change in ownership and changes in DON and ADMIN as reasons for the failure. The facility policy titled Orientation stated general orientation must be completed prior to formal contact with residents, departmental orientation continues until competency is demonstrated, and documentation must be maintained in the personnel file. The facility assessment stated annual education upon hire and competencies are developed for all staff based on job title, but the staff list provided did not identify a Staff Development Coordinator.
Incomplete Care Plans for Hospice and Diabetes Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 2 of 12 residents reviewed. For Resident #10, the record showed a readmission with diagnoses including Alzheimer's disease, fracture of vertebra, and adjustment disorder, and a Quarterly MDS with a BIMS score of 06 indicating severe cognitive impairment. Section O of the MDS showed the resident was on hospice care, and physician orders included admission to hospice services dated 09/11/2025, but the Comprehensive Care Plan last revised 12/15/2025 contained no evidence of hospice services or code status. For Resident #15, the record showed diagnoses including dementia, anxiety, depression, and diabetes, with a Quarterly MDS showing a BIMS score of 13 indicating intact cognition. Section I identified diabetes, Section N showed insulin injections, and physician orders included Basaglar Kwik Pen 30 units subcutaneously daily related to Type 2 Diabetes, dated 03/05/2025, but the Comprehensive Care Plan last revised 10/23/2025 contained no evidence of diabetes or insulin. During interview, the RCN stated hospice services, diabetes, and insulin should have been on the care plan and that he was responsible for ensuring care plans were current and accurate.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The activities program was not directed by a qualified professional because the facility’s activity director, hired on 9/29/2025, did not have evidence in the employee file of certification or training as a qualified therapeutic recreation specialist or as an activities professional meeting state licensing requirements. Record review of the unsigned activity director job description stated that the activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable, and who is eligible for certification by a recognized accrediting body or has completed a state-approved training course. During interviews, the RDO stated he expected staff to have appropriate education and certification for their roles and expected the activity director to have the required experience or certification to provide an effective activities program. The AD stated she had been a CNA before becoming the activity director, had been hired as an activities assistant because the facility did not have an activities director, and said the previous ADMIN had planned to get her into the appropriate training course before leaving. The AIT stated the AD was not certified but was working on certification and said she would provide the job description, while also stating she did not know what the previous ADMIN had done to ensure the AD had appropriate certification.
Failure to Follow Menu and Communicate Dietary Changes
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs, as observed during a lunch meal review. On the specified date, the facility did not follow the posted menu, which included baked pork chop, cheesy grits, broccoli and cauliflower, cornbread, and frosted cake. Instead, residents were served baked pork chops, mashed potatoes, a biscuit, and frosted cake. There was no substitution list available for residents to review, and the dietary manager (DM) admitted that the menu was not followed due to a delay in grocery delivery. Resident #5, who has a history of dietary calcium deficiency and other health issues, expressed a desire to know the menu in advance to make informed choices. Resident #13, who has dietary restrictions due to diabetes and other conditions, reported dissatisfaction with the food quality and lack of menu communication. The resident also mentioned that the food served did not match the dietary ticket, and substitutions were not satisfactory. The dietary manager confirmed that the menu changes were not communicated to the residents or approved by the dietician. The facility's policy requires that any menu changes be approved by the dietician and recorded on a Menu Substitution Approval Form. However, the administrator (ADMN) acknowledged that the dietician was not consulted about the menu change, and the meal served was based on resident preferences rather than nutritional guidelines. The dietician confirmed that menus should be followed and any changes should be approved, but there was no follow-up communication from the dietician before the survey exit.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The deficiencies included improper storage and labeling of food items in the freezer and refrigerator, as well as a lack of up-to-date temperature logs for these storage units. Specifically, items such as tamales, breaded meat patties, oatmeal raisin cookie dough, egg rolls, yellow cheese slices, and lettuce were found either unsealed, unlabeled, or undated. Additionally, temperature logs for the freezer and refrigerators were not maintained for the current month, which could lead to undetected spoilage if the equipment malfunctions. Furthermore, the facility did not ensure that dietary staff adhered to hygiene protocols, as one of the dietary staff members was observed not wearing a hair net while preparing and serving meals. This lapse was attributed to a shortage of hair nets in the facility. The dietary aide acknowledged the potential risk of hair contaminating food, which could deter residents from eating and potentially lead to weight loss. Interviews with the dietary manager and administrator confirmed these issues, with the administrator noting the importance of maintaining temperature logs to prevent food spoilage and the necessity of hair coverings for staff in the kitchen.
Deficiency in Staff Communication Training
Penalty
Summary
The facility failed to ensure that employees received the required training in effective communication, which is mandatory for staff members. This deficiency was identified for 7 out of 19 employees reviewed, including the Director of Nursing (DON), Maintenance (MAINT), Transport (TRNS), Certified Occupational Therapy Assistant (COTA), Dietary Manager (DM), Certified Nursing Assistant (CNA C), and Housekeeping (HSKP F). The facility did not provide evidence that the DON, MAINT, TRNS, and COTA completed the effective communication training during their orientation. Additionally, the DM, CNA C, and HSKP F did not complete the training annually as required. These lapses in training could potentially place residents at risk of miscommunication and social isolation. Interviews with staff revealed a lack of clarity and accountability regarding the tracking and documentation of training completion. The TRNS and MAINT stated they completed the training but could not provide documentation. The DM and HSKP F were unsure of who was responsible for maintaining training records. The COTA mentioned that her records had not been transferred from a sister facility. The facility's recent transition from paper to electronic records and changes in leadership were cited as contributing factors to the lack of documentation. The HR director, who was also the Business Office Manager, acknowledged the requirement for training but was unaware of how to locate the missing records.
Deficiency in Staff Training on Resident Rights
Penalty
Summary
The facility failed to ensure that five staff members, including a Dietary Manager (DM), a Licensed Vocational Nurse (LVN G), and three housekeeping and transport staff (HSKP E, TRNS, and HSKP F), received the required training on resident rights in a timely manner. This deficiency was identified through interviews and record reviews, which revealed that the employee files of these staff members did not contain any record of training on resident rights. The hire dates for these staff members ranged from August 2022 to September 2023, yet there was no documentation of the required training in their files. Interviews conducted with staff members and facility leadership highlighted issues with the tracking and documentation of training. The DM mentioned that training was conducted online, but he was unaware of how incomplete training could affect residents. The Certified Registered Nurse (CRN) and the Assistant Director (AD) indicated that a recent transition from paper to electronic records and changes in leadership contributed to the lack of documentation. The CRN also noted that the Human Resources Director was responsible for tracking completed training, but the AD, who also served as the HR Director, was unable to locate the missing records.
Deficiency in Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to provide adequate training to their staff on critical topics such as abuse, neglect, exploitation, and misappropriation of resident property, as well as dementia management. This deficiency was identified through interviews and record reviews, which revealed that two employees, DM and HSKP F, did not have documentation of having received this essential training. The absence of training records for these employees, who were hired in August 2022 and April 2023 respectively, indicates a lapse in the facility's staff development program. Interviews with staff members highlighted a lack of clarity and responsibility regarding training records. The DM mentioned that training was conducted online, but could not explain the impact of incomplete training on residents. HSKP F, despite claiming to have completed all required training, was unaware of who managed the training records. The CRN attributed the lack of documentation to a transition from paper to electronic records and a change in leadership. The AD, who also served as the HR Director, acknowledged the requirement for training but was unable to locate the missing records. This situation suggests systemic issues in the facility's training and documentation processes, potentially placing residents at risk of harm from untrained staff.
Inadequate Infection Control Training Documentation
Penalty
Summary
The facility failed to ensure that its infection prevention and control program was adequately implemented, as evidenced by the lack of training records for three staff members: DM, HSKP E, and HSKP F. These staff members were reviewed for training compliance, and it was found that they did not receive the required infection control training in a timely manner. The DM's employee file, with a hire date of August 3, 2022, lacked any record of infection control training. Similarly, HSKP E, hired on August 5, 2024, and HSKP F, hired on April 1, 2023, also had no records of such training in their files. Interviews conducted with the staff revealed a lack of clarity and responsibility regarding the tracking and documentation of training. The DM mentioned that training was conducted online, with notifications sent via email and group text, but could not explain the impact of incomplete training on residents. HSKP F claimed to have completed all required training but was unaware of who maintained the records. The CRN indicated that the HR director was responsible for tracking training but cited a transition from paper to electronic records and a change in leadership as reasons for the missing documentation. The AD, who also served as the HR director, admitted to not knowing where to find the missing records, acknowledging the requirement for reviews.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, which is a requirement to ensure effective and person-centered care. The resident, a male with moderate cognitive impairment, was admitted without a baseline care plan being completed or a summary provided to him or his representative. This oversight was identified during a record review and interviews with facility staff, who confirmed the absence of the required documentation and discussions. The facility's policy mandates that a baseline care plan be completed within 48 hours of admission to promote continuity of care and communication among staff, as well as to inform the resident and their representative of the initial care plan. Despite this policy, the responsible staff, including the Director of Nursing and registered nurses, did not complete the baseline care plan for the resident, which could disrupt the continuity of care. The facility's interdisciplinary team, which includes the DON, ADON, and ADMN, is expected to monitor the completion of these plans, but the reason for the oversight was not determined.
Failure to Conduct Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to conduct a performance review of each Certified Nursing Assistant (CNA) at least once every 12 months, specifically for one of the three CNAs reviewed for annual competency evaluations. This deficiency was identified during a personnel file review, which revealed that CNA C did not have a competency evaluation on file. The absence of these evaluations could potentially affect residents by placing them at risk of not receiving consistent and appropriate interventions necessary to meet their needs. Interviews conducted during the investigation revealed that the Director of Nursing (DON) was responsible for conducting and documenting nursing training and staff performance reviews. However, the DON was unavailable for an interview as they were out of state. The facility had recently transitioned from paper to electronic records and experienced a change in nursing leadership, which were cited as reasons for the missing documentation. Additionally, the Business Office Manager, who also served as the Human Resources Director, was unaware of the location of the missing records but acknowledged the requirement for these reviews.
Failure to Properly Post Survey Results and Protect Resident Privacy
Penalty
Summary
The facility failed to post the results of the most recent survey, including any plans of correction, in a place readily accessible to residents, family members, and legal representatives. During an observation, it was noted that the last survey results were placed in a binder outside the administrator's office, but the plan of corrections was missing. Additionally, the binder contained a form that identified residents by their resident identifier numbers, which could potentially violate residents' privacy rights. The administrator admitted responsibility for placing the survey results in the binder and explained that a resident had destroyed most of the pages over the weekend. In a hurried attempt to replace the information, the administrator did not review the contents provided by corporate before placing them back in the binder. This oversight resulted in the absence of the plan of corrections and the inclusion of resident identifiers, which were not supposed to be part of the publicly accessible documents.
Deficiency in RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for three months (October, November, and December 2023). This deficiency was identified through a review of the CMS' PBJ Staffing Data Report, which showed no RN coverage on Saturdays and Sundays for a total of 22 days during these months. Interviews with the HR Coordinator, Administrator, and Director of Nursing (DON) confirmed the absence of RN coverage on weekends, despite attempts to hire a weekend RN. The facility relied on a PRN RN and an Employment Service Agency to provide RN assistance if needed. The facility's policy, revised on September 28, 2023, states that it should provide sufficient nursing staff to ensure resident safety and well-being. However, the lack of RN coverage on weekends could potentially place residents at risk, as decisions requiring an RN's expertise might not be made. Despite this, the HR Coordinator, Administrator, and DON reported no negative outcomes for residents due to the absence of an RN on weekends, citing the availability of alternative resources.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nurse Aide (CNA) during incontinence care for a resident. The resident, a 91-year-old female with diagnoses including diarrhea and rash, required moderate assistance with activities of daily living and was occasionally incontinent of bladder. During an observation, the CNA did not perform hand hygiene before donning gloves, failed to change gloves after they became visibly soiled with urine and fecal matter, and did not wash hands or perform hand hygiene after removing the gloves. This lapse in infection control practices occurred despite the CNA having received infection control training two weeks prior. The facility's policy on hand hygiene, revised in January 2023, emphasizes the importance of hand hygiene in preventing the spread of infections. The policy requires handwashing with soap and water when hands are visibly soiled and after contact with residents with infectious diagnoses. It also mandates the use of an alcohol-based hand rub and performing hand hygiene before donning and after doffing gloves. The interim Director of Nursing (DON) acknowledged awareness of infection control concerns and stated that staff are expected to follow the facility's policy, which includes annual and periodic training as needed.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 2 citations issued within 25 miles in the last 12 months — 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
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Illustrative
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Nursing homes near Hamlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonewall Living Center | 19.7 mi | ★★★★★ | 2 | 0 |
| Harmony Care At Stamford | 20.4 mi | ★★★★★ | 0 | 0 |
| Merkel Nursing Center | 28.9 mi | ★★★★★ | 34 | 5 |
| Avir At Haskell | 29.4 mi | ★★★★★ | 0 | 0 |
| Sweetwater Healthcare Center | 31.5 mi | ★★★★★ | 7 | 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.