Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Huebner Creek Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident’s medical records were released to a family member with another resident’s Administration Record included in the file. The misplaced document contained personal and insurance information, and staff stated it was likely accidentally scanned into the wrong profile. The MR staff member said she reviewed only part of each file before release, and the ADMIN later confirmed the error involved another resident’s confidential information.
The facility failed to ensure three diabetic residents received scheduled podiatry foot care to maintain proper toenail length, despite care plans directing referral to a podiatrist or foot care nurse and a contracted podiatry group visiting the facility. All three residents were on the podiatry list but were not seen during the most recent visit, and their last documented podiatry care had occurred several months earlier. One resident, cognitively intact and dependent for footwear, reported needing help with toenail cutting and had toenails extending beyond the toe with some curving toward the skin. Another cognitively intact resident who required substantial assistance with footwear stated he had not seen the podiatrist in a long time. A third resident with moderate cognitive impairment, who ambulated with a walker, reported asking staff about nail care, said her toenails were last cut the prior year, and described pain with wearing shoes and embarrassment; her toenails were visibly long. Staff interviews confirmed that the podiatry company did not see all residents on the last visit, could not return for several weeks, and that only the podiatrist trims toenails for residents with diabetes, consistent with facility policy. Leadership acknowledged that some residents did not receive foot care and that this placed them at risk for injury or infection and that long toenails can cause pain and be a fall hazard.
Two residents with intact cognition and documented needs for assistance with showering had incomplete ADL-bathing entries in the EMR, with multiple scheduled bath days lacking any recorded bath or refusal despite stated bathing preferences and observed clean, groomed appearances. CNAs reported that showers are required to be documented in the plan of care software but acknowledged that documentation is sometimes not completed when workloads are heavy, and one CNA suggested a resident likely refused showers without this being recorded. The DON confirmed that both showers and refusals must be documented and outlined a process for handling refusals that was not reflected in the residents’ records.
A resident with severe cognitive impairment, upper and lower extremity limitations, bowel incontinence, and a Foley catheter, and identified as high fall risk, experienced an unwitnessed fall next to her bed while her call light was in reach but not activated. The resident had been changed from a regular call light to a pressure bulb call light, yet observations and interviews showed she could not locate or trigger the device due to weakness, impaired upper body function, and cognitive decline, and she spoke in a faint voice from a room several doors away from the nurse station. Staff accounts conflicted on whether the resident could use the call light, and the Rehab Director acknowledged that no alternative adaptive call light devices or training had been implemented despite the resident’s decline. The facility’s fall and resident rights policies referenced call bells being within reach and supporting communication, but there was no specific policy governing the call light system.
Food Temperature and Thermometer Sanitization Deficiencies: A kitchen staff member sanitized the thermometer and then wiped it with a paper towel before taking food temperatures, rather than keeping it sanitized between items. During observation, cream of corn measured 106 degrees F and a smore parfait measured 46.8 degrees F, both outside the facility’s stated holding ranges. The DM confirmed hot foods should be over 140 degrees F, cold foods 40 degrees F and below, and the thermometer should be sanitized between each food item.
Infection Control Failures During Insulin Administration and Catheter Care: An LVN administered insulin to two residents without sanitizing the insulin pen rubber stopper and, in one instance, did not perform proper hand hygiene before care. In a separate event, a resident with an indwelling urinary catheter was observed with the drainage bag resting on the floor instead of being secured and kept off the floor as ordered.
Confidential Resident Information Left Visible on Computer Screen: An RN left a medication cart unlocked and walked away from a computer at the nursing station with a resident’s PHI displayed, including name, DOB, physician, location, code status, allergies, meds, and recent vitals. Other residents were nearby in the common area, and the ADON and RN acknowledged that the screen should not have been left visible.
A resident with acute kidney failure, UTI, HTN, type 2 DM with CKD, and hyponatremia had a discharge MDS that was completed but not transmitted to CMS within the required timeframe. The MDS Case Manager said transmission was her responsibility and another Case Manager’s, but she was unsure why it was not sent; the Regional Reimbursement Nurse stated a prior “do not send” setting from the managed care 5-day MDS likely remained in place and prevented transmission.
Missing Dialysis Care Plan Interventions: A resident with dementia, DM2, and ESRD was admitted receiving dialysis, and his MDS showed moderately impaired cognition and dialysis use while a resident. The care plan did not include dialysis services outside the facility until after the survey start date, even though physician orders specified dialysis M/W/F with scheduled chair and pickup times; the MDS Case Manager stated the omission meant nurses and aides would not receive alerts for the resident’s dialysis-related care needs.
Two residents who needed assistance with ADLs did not receive scheduled showers as planned. One resident with hemiplegia, seizures, and an above-the-knee amputation reported staff were not showering her and that she missed a shower because no one was available. Another resident with CHF, unsteadiness, and pain missed multiple scheduled showers and said she finally received one after nearly 8 days without bathing. Staff described the shower process as disorganized, with missed showers not reliably tracked and bathing duties not consistently assigned or documented.
Undated sterile water on an oxygen concentrator was found for a resident who used oxygen nightly and had an order for O2 by NC as needed. The resident said staff never dated the sterile water container, and an LVN, ADON, and DON all stated the nurse was responsible for dating it to show when it was placed and changed.
Dialysis communication and return assessments were not consistently maintained for a resident with ESRD receiving HD. The resident’s record showed ordered HD three times weekly with access-site monitoring, but the facility had only a few incomplete dialysis communication forms, many missing return notes, and no clear documentation of facility vitals or information sent to the dialysis center. The ADON and DON stated the wrong form was being used and that staff should have documented vitals, access checks, and return assessments in the chart.
Two residents received insulin lispro injections from an LPN without the insulin pens being primed, and the LPN also did not sanitize the pen rubber stopper before administration. One resident had dementia, type 2 DM, and ESRD; the other had type 2 DM and an insulin pump. The DON stated staff were expected to prime insulin pens, and the facility policy required a safety test before each injection to ensure an accurate dose.
Unlocked Medication Cart: The facility failed to keep a 600-hall med cart locked while an RN stepped away to clean a dropped liquid med top, leaving the cart unattended near a resident with severely impaired cognition and other nearby residents. The RN stated anyone could access the cart if it was unlocked, and the DON stated staff were not supposed to leave med carts unlocked because residents could get into them.
Improper trash disposal was identified in an outdoor refuse area when a bag of trash was observed leaning against the trash disposal container in a gated area. The DM stated the area should be clean, with nothing on the floor and the doors closed, to help prevent rodents and support infection control. Facility policy stated trash must be securely tied in leak-proof plastic bags and removed to the outdoor trash receptacle.
An LPN failed to disinfect a shared blood pressure cuff between two residents during routine blood pressure checks associated with medication administration. The LPN used the same cuff on two male residents with cardiovascular and other medical conditions, placing the cuff back on the medication cart after each use without wiping it with disinfectant wipes, despite existing infection control training and a facility policy requiring an infection prevention and control program to prevent the development and transmission of infections.
The facility failed to post required current daily nurse staffing and census information for an extended period, instead displaying an outdated staffing sheet in the lobby. The ADON, who was responsible for posting the information, acknowledged that although the daily postings were prepared and kept in a book, they were not actually posted and that there was no facility policy governing this process. The DON and ADMIN both stated their expectation that the daily staffing and census information be posted, while the ADMIN noted that some families accessed a staffing binder at the nursing station, which listed scheduled staff and assignments but did not replace the required public posting.
Surveyors found multiple dietary service deficiencies, including opened ham and cheese in the walk-in refrigerator without discard dates, boxes stored too close to the ceiling in the walk-in refrigerator and freezer, and bacon that was not fully covered. The CDM and a cook acknowledged that food items should be dated, properly wrapped, and stored at an appropriate distance from sprinkler heads for ventilation. A cook was also observed preparing a meal without a required beard restraint, despite prior training and facility policy mandating hair restraints for dietary staff with facial hair.
Surveyors found that MDS assessments did not accurately reflect the clinical status of two residents. One resident’s admission MDS incorrectly indicated no unhealed pressure ulcers, despite documentation of a pressure ulcer to the right buttock, a care plan addressing the ulcer, and physician orders and weekly wound assessments describing ongoing treatment. Another resident’s Medicare 5-day MDS incorrectly coded bladder status as having none of the listed devices, even though the care plan and physician orders documented an indwelling Foley catheter with shift-by-shift monitoring. The MDS nurse acknowledged both errors as coding mistakes, and the DON affirmed that MDS assessments are required by facility policy to accurately reflect each resident’s condition.
A resident with dementia, bowel and bladder incontinence, and multiple comorbidities did not receive complete perineal care during an observed incontinence episode. A CNA removed a soiled brief, cleaned only the groin, buttock, and rectal areas, but did not clean the suprapubic area or open the labia while cleansing the genital area, contrary to the facility’s perineal care policy requiring wiping across the pubis and proper cleansing of the labia majora from front to back. The CNA later stated she was nervous and forgot these steps, despite prior peri-care training, and the DON confirmed these actions should have been performed to prevent possible infection.
The facility did not provide individualized activities according to residents' care plans, particularly by restricting access to the activities room to limited weekday hours. Several residents with depression, PTSD, and intact cognition reported that they were unable to engage in preferred activities such as complex puzzles and art during nights and weekends, leading to complaints and feelings of isolation. Staff confirmed the restricted access and acknowledged its negative impact, while no activities policy was provided when requested.
A resident with quadriplegia and no cognitive impairment was found without access to a call light, as it had been left inside a nightstand by staff after care. The resident reported this was a recurring issue, and staff interviews confirmed the oversight. The care plan required encouragement to use the call bell, but the failure to ensure accessibility resulted in the resident being unable to independently request assistance.
A resident with dementia and depression was not provided adequate support to practice his Muslim faith, as his care plan lacked religious accommodations and staff were unaware of his preferences. The resident felt excluded from religious activities, was unable to watch religious programs due to a non-functioning TV, and did not receive meal accommodations for fasting, despite informing staff of his needs.
Two residents did not have their care plans updated to reflect important aspects of their care needs, including religious preferences and a PTSD diagnosis. One resident's care plan lacked documentation of his religion, resulting in missed opportunities for religious practice and staff being unaware of his needs. Another resident's care plan did not address his PTSD, despite staff knowing he was sensitive to noise and required specific accommodations. Staff interviews revealed confusion about responsibility for care planning and a lack of awareness of residents' individualized needs.
A resident with moisture associated skin damage did not have three scheduled wound care treatments properly documented in the electronic record. Nursing staff reported providing the care but failed to record it, especially during weekend shifts when the wound care nurse was absent. The lack of documentation was confirmed by review of the administration records and staff interviews, resulting in incomplete clinical records.
A CNA failed to sanitize hands after touching her face and eyeglasses and before assisting a resident with their meal, including handling utensils and cutting food. The CNA had not attended a recent in-service training on meal tray pass, and interviews confirmed she was unclear about hand hygiene procedures after touching personal items. Facility leadership stated their expectation for hand hygiene between each resident's tray delivery, and relevant policies emphasized its importance, but the meal service policy lacked specific guidance.
The facility did not post required contact information for State agencies and advocacy groups, including the LTC Ombudsman, in a manner accessible to residents and their representatives. Over several days, surveyors observed the absence of this information, and the DON confirmed both the missing posting and the lack of a facility policy or designated staff responsible for maintaining required postings.
The facility did not post required daily nurse staffing and census information for three days. Observations and interviews with the DON and ADON confirmed the postings were missing, and neither could determine how long this had been the case. The display case for the postings could not be found, and there was no facility policy regarding the required postings.
A CNA failed to perform hand hygiene between glove changes while providing peri-care to a resident who was fully dependent on staff for toileting and had multiple chronic conditions. After removing soiled gloves contaminated with stool, the CNA immediately donned clean gloves without using hand sanitizer or washing hands, contrary to facility policy and infection control standards. Interviews confirmed staff were aware of the required procedures, and records showed the CNA had been previously assessed as proficient in infection control.
The facility failed to provide a safe and clean environment for two residents. One resident with dementia was found in a room with a strong urine odor and soiled sheets, while another resident with mobility issues reported a wobbly toilet that was not fixed despite multiple complaints. Staffing shortages and inadequate communication regarding maintenance needs contributed to these deficiencies.
The facility failed to develop baseline care plans within 48 hours for two residents, one with dementia and other health issues, and another with severe cognitive impairment and multiple diagnoses. This oversight was confirmed by staff interviews, highlighting the importance of timely care plans for adequate resident care.
A facility failed to include a resident's mental health diagnoses and medication orders in her comprehensive care plan, despite her conditions of Depression, Generalized Anxiety Disorder, and Dementia. The MDS nurse acknowledged the oversight, and the DON confirmed that care plans should address all resident needs. The facility's policy emphasizes person-centered care plans to meet medical, physical, mental, and psychosocial needs.
A resident with dementia and unsteadiness experienced three falls in a short period, but the facility failed to update the care plan with new interventions. Despite discussions among staff and a hospital visit, the care plan remained unchanged, contrary to facility policy requiring updates after significant changes.
A resident with multiple health conditions did not receive consistent wound care and leg wrapping as per physician orders and care plan. Observations showed missing treatments on specific dates, and staff interviews revealed time constraints and workload issues as reasons for the lapses. The DON acknowledged the importance of following orders to prevent complications.
The facility failed to store medications securely, as observed in the medication room and on a nurse medication cart. Controlled substances were found unlocked in a refrigerator, and medications for a resident with diabetes were left unattended on a cart. The DON acknowledged the risk of drug diversion and confirmed that all medications should be locked according to facility policy.
The facility failed to maintain an effective training program for staff, with missing annual training in key areas for five employees. The HR Manager cited recent administrative changes as a reason for the oversight.
A resident with a history of Alzheimer's and suicidal ideation was found lethargic with an empty Tylenol bottle at their bedside, resulting in a 12,000mg overdose. The facility failed to monitor medications at the bedside and did not provide in-service training or assess other residents for safety following the incident.
A resident with a history of Alzheimer's and depression was found lethargic with an empty Tylenol bottle, leading to a 12,000mg overdose. Despite the seriousness of the incident, the facility failed to report the event to the state agency as required. Interviews revealed that the previous and current leadership were unaware if the incident had been reported, highlighting a lapse in following the facility's policy for reporting suspected neglect.
A resident with a history of suicidal ideation was found lethargic with an empty Tylenol bottle, leading to a 12,000mg overdose. The facility failed to investigate or report the incident to the state agency, as required by law. Staff interviews revealed a lack of awareness and action regarding the incident, and no documentation was provided to support that the facility had taken appropriate steps to address the situation.
An LVN failed to document a skin assessment and treatment for a resident with a rash, leading to incomplete medical records. The resident, with cognitive impairments and behavioral issues, was prescribed a steroid cream by a physician, but the order lacked specific application instructions. The facility's documentation policy was not followed, as confirmed by interviews with the LVN and DON.
The facility failed to provide privacy for three residents during care, as observed during a survey. A resident with a pressure ulcer did not receive privacy during wound care, as the LVN did not close the door or curtain. Another resident with a pressure ulcer was not provided privacy during wound care, with the LVN leaving the door, curtain, and blinds open. A third resident, requiring assistance with ADLs, was not given privacy during perineal care and dressing, as the CNA did not close the curtain or blinds. Staff interviews highlighted the importance of ensuring privacy to maintain resident dignity.
The facility failed to maintain complete and accurate medical records for three residents, leading to potential risks of improper care. A resident's records lacked documentation of wound care treatments on specific dates, despite confirmation of receipt. Interviews revealed inconsistencies in responsibility for documentation, with some staff unaware of who was responsible when the treatment nurse was unavailable. Another resident's records showed missing documentation for wound care treatments across several months, with staff admitting to not documenting treatments even if provided. Similarly, a third resident's records were incomplete, with missing documentation for wound care treatments. The DON was unaware of the missing documentation, assuming treatments were completed but not documented.
The facility failed to maintain effective infection control practices, as staff did not perform adequate hand hygiene, sanitize surfaces, or use PPE during wound care and personal hygiene for multiple residents. This included improper glove changes and neglecting Enhanced Barrier Precautions, increasing the risk of cross-contamination and infection.
The facility failed to ensure residents' rights to communication and visitor access due to a malfunctioning phone system at the nurse station, which did not alert staff to incoming calls. This issue, coupled with the absence of a weekend receptionist, potentially denied residents access to visitors, including family and physicians. The deficiency was observed when the surveyor found the main entrance secured without a doorbell and the phone system unresponsive.
Two residents in an LTC facility experienced issues with the call light system, leading to delays in receiving assistance. One resident was admitted without a call light, while another faced a malfunctioning system, resulting in a 36-minute wait for help with a burst colostomy bag. Staff failed to notice the alert due to a malfunctioning illuminator, causing prolonged discomfort for the resident.
Resident Record Released With Another Resident’s Information
Penalty
Summary
The facility failed to ensure the confidentiality of a resident’s personal and medical records when another resident’s medical record was included in the records released to that resident’s family member. Record review showed one resident was admitted with diagnoses including sequelae of cerebrovascular disease, cognitive communication deficit, and cerebral infarction, and had a BIMS score of 11 with fluctuating inattention and disorganized thinking. Another resident’s admission record showed multiple admissions and discharge on 03/19/2026, and a family member was listed as an emergency contact. The family member of the second resident stated she requested the resident’s medical records and found a document belonging to another resident among the records she received. A photo of the USB showed the resident’s files dated 04/28/2026, and a printed copy of the other resident’s Administration Record was identified among those records. The document contained the other resident’s name, date of birth, admission dates, insurance type and policy number, and care provider names. During interview, the MR staff member stated she released the records to the family member after approval and said she reviewed only the first 15 to 17 pages of each file to confirm they were from the correct resident’s profile. She later re-reviewed the file after being notified of the error and found one document under physician’s orders that belonged to the other resident. The ADMIN stated the other resident’s Administration Record had probably been accidentally scanned into the second resident’s profile, and the DON stated the release of a resident’s medical information meant another person had access to information that should have remained confidential.
Failure to Provide Timely Podiatry Foot Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide podiatry foot care and treatment in accordance with professional standards of practice for three residents with diabetes who were care planned to receive podiatry services. All three residents had care plans indicating diabetes mellitus with an intervention to refer to a podiatrist or foot care nurse to monitor and document foot care needs and to cut long nails. A local podiatry group was scheduled to provide services on 3/4/26, and all three residents were listed to be seen, but they did not receive foot care during that visit. Record review showed that the last podiatry service date for each of these residents was 10/28/2025, despite their insurance allowing 4–6 podiatry visits per year. Resident #1 was an 82-year-old female with unspecified dementia, type 2 diabetes mellitus, and a need for assistance with personal care, who was dependent on staff for putting on and taking off footwear and had no cognitive impairment per a BIMS score of 15. During observation and interview, she reported needing help cutting her toenails, stated she could not do it herself, and that nurses did not cut her nails because she had diabetes and the podiatrist had to do it. She reported her last toenail trimming was about five months prior. Her toenails were observed to extend up to 1/4 inch beyond the flesh of the toes, with some nails curving toward the skin. Resident #2 was a male with spinal stenosis with neurogenic claudication, type 2 diabetes mellitus, and a need for assistance with personal care, who required substantial to maximum assistance with footwear and had a BIMS score of 15. He stated that a podiatrist usually cut his toenails but that he had not seen her in quite a while. Resident #3 was a female with unspecified dementia, type 2 diabetes mellitus, a need for assistance with personal care, and moderate cognitive impairment with a BIMS score of 7, who ambulated with a walker. She reported asking staff about getting her toenails cut and being told it would occur when the podiatrist came, stated her toenails were last cut the previous year, and reported pain with wearing shoes and embarrassment. Her toenails were observed to be 1/2 to 1 inch beyond the flesh of the toe. A family member reported that a hospital had noted her need for nail care and that the podiatrist had left before seeing her at the last visit. The SW confirmed the podiatry company could not see everyone on the March visit, could not return until late April, and that only the podiatrist provided toenail care for residents with diabetes, consistent with the facility’s nail care policy stating that nail care, especially trimming, is performed by a podiatrist in those with diabetes and peripheral vascular disease. The DON and ADON acknowledged that some residents did not receive foot care and that this put them at risk for injury or infections, and that long toenails can be a fall hazard and cause pain.
Incomplete ADL-Bathing Documentation for Two Residents
Penalty
Summary
Surveyors identified that the facility failed to maintain complete and accurate ADL-bathing documentation in the electronic medical record for two residents. For an 82-year-old female resident with dementia, type 2 diabetes, and a need for assistance with personal care, review of her quarterly MDS showed she had a BIMS score of 15/15 and was dependent on staff for showering/bathing. Her 30‑day task record reflected a preference for bathing on Tuesdays, Thursdays, and Saturdays, but there were no bath or refusal entries documented for multiple specified dates over February and March, despite her admission date of 1/1/2026. During observation, she appeared clean and groomed and reported that she was able to take showers on scheduled days but sometimes refused when offered early in the morning, preferring showers after dinner. A male resident with spinal stenosis, type 2 diabetes, and a need for assistance with personal care also had incomplete ADL-bathing documentation. His quarterly MDS showed a BIMS score of 15/15 and a need for substantial to maximum assistance with showering/bathing, with a documented preference for bathing on Tuesdays, Thursdays, and Saturdays. However, his 30‑day task record lacked bath or refusal entries for the same series of dates, despite a readmission date of 8/9/2025. During observation, he was in his room with clean clothes and a groomed appearance and stated he required help with showers. CNA A reported that showers were required to be documented in the plan of care but admitted that when work was very busy, she did not chart, even though she stated she always offered showers. CNA B stated that shower documentation was in the system and must be completed, and suggested the male resident probably refused scheduled showers. The DON stated that showers and refusals were required to be documented and described a process in which CNAs notify the nurse of refusals and attempts are made and documented, but the records for these residents did not reflect such documentation.
Failure to Provide Effective Call Light Access for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences regarding access to and use of the call light system. The resident was an 80-year-old female with sepsis, diabetes, dementia, hypertension, cognitive deficits, bowel incontinence, and a Foley catheter. Her MDS reflected a BIMS score of 02, indicating severe cognitive impairment, and she was dependent for transfers and mobility with impaired upper and lower range of motion. She had a history of falls and a fall risk score of 11, categorized as high risk. Her care plan included interventions such as a low bed, call light in reach, clutter-free room, and monitoring for risk of falls. On the date of the incident, the resident experienced an unwitnessed fall in her room, landing on the left side of the bed near the wall and sustaining scratches to the right side of her face. The fall assessment documented that the resident was disoriented and that neurological checks were initiated. A nurse note indicated that shortly before the fall, the resident had been given a pain medication, and when the LVN returned to administer night medications, the resident was found on the floor with the bed in a low position and the call light in reach but not activated. The resident was unable to provide a clear explanation for the fall. The resident’s room was located three rooms away from the nurse station, and she spoke in a faint voice, making it difficult for staff to hear her if she called out verbally. Observations and interviews showed that the resident could not effectively use the assigned pressure bulb call light due to upper body impairment and cognitive decline. The call light was tied to the left side of her nightgown, but her arms were crossed away from it, and she stated she could not reach or push the call light. The Rehab Director reported that the resident had previously used a regular call light effectively but had declined and was switched to a pressure call light; however, the Rehab Director was not aware that the resident could not use the squeeze pad requiring palm or pressure dexterity and acknowledged that no other adaptive devices or training had been tried. During direct observation, the resident was unable to locate or trigger the call light even when it was placed in her hand. Staff interviews were inconsistent: some staff stated the resident could not push the call light, while another LVN stated the resident was able to trigger it and that no further accommodations were needed. The DON stated that depending on the day and time, the resident could or could not activate the call light and that the resident’s door should have been open unless care was being given. The facility’s fall policy required call bells to be positioned within reach and responded to timely, and the resident rights policy addressed the right to communication and access to services, but the facility had no specific policy on the call light system.
Food Temperature and Thermometer Sanitization Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed. During kitchen observations, a staff member sanitized the thermometer and then wiped it with a paper towel before taking food temperatures, rather than keeping it sanitized between food items as described in the facility policy. The staff member took the temperature of mashed potatoes, then later took the temperature of cream of corn, which measured 106 degrees Fahrenheit, and also took the temperature of a corn item after again wiping the thermometer with a paper towel. During the same observation, the staff member took the temperature of a smore parfait, which measured 46.8 degrees Fahrenheit. In interview, the staff member stated hot items should be held at 130 degrees or above and cold items at 40 degrees or below, and stated the thermometer should be sanitized before each food item's temperature is taken. The DM stated hot items should be over 140 degrees and cold items 40 degrees and below, and confirmed the thermometer should be sanitized between each food item. The facility policy, Daily Food Temperature Control, stated the thermometer is to be sanitized between each food testing, hot foods are to be held at 140 degrees F or above, and cold foods are to be less than 41 degrees F.
Infection Control Failures During Insulin Administration and Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for three residents reviewed for infection control. For one resident with dementia, type 2 diabetes mellitus, and end stage renal disease, an LVN prepared and administered insulin lispro without sanitizing the insulin pen rubber stopper, placed a needle cap on the pen, dialed the dose, cleaned the resident’s arm, injected the insulin, and did not prime the pen. The resident’s record showed an order for insulin lispro by sliding scale, and the care plan directed administration of diabetes medications as ordered by the physician. For a second resident with type 2 diabetes mellitus and an insulin pump, the LVN washed the resident’s hands before obtaining blood glucose but only quickly rinsed the hands under water, used a bare hand to touch the sink handle and turn off the water, dried the hands with paper towels, put on gloves in the bathroom, and then touched the door with gloved hands. The LVN then prepared insulin lispro at the nurse cart and did not sanitize the insulin pen rubber stopper before placing the needle cap on the pen and dialing the dose. The resident’s record showed severe cognitive impairment for daily decision making and an order for insulin lispro before meals. For a third resident with neuromuscular dysfunction of the bladder, paraplegia, colostomy status, and a urinary tract infection diagnosis, the indwelling urinary catheter bag was observed resting directly on the floor next to the bed and was not in a privacy bag. The resident’s care plan directed that the catheter bag and tubing be positioned below the bladder and maintained off the floor, and the physician orders required the foley bag to be in a privacy bag while in bed or in a wheelchair. Staff interviews stated the drainage bag should be secured to the side of the bed, placed in a privacy bag, and kept off the floor.
Confidential Resident Information Left Visible on Computer Screen
Penalty
Summary
The facility failed to respect the confidentiality of a resident’s personal and medical records when RN A left a computer screen open and visible at the nursing station while stepping away from the medication cart. Resident #99, a female resident with diagnoses including aphasia following cerebral infarction, cerebral palsy, bipolar disorder, seizures, unspecified intellectual disabilities, and hemiplegia and hemiparesis following cerebral infarction, had severely impaired cognition for daily decision making. During medication administration, RN A dropped the top to a liquid medication, walked away to clean it up, and left the medication cart unlocked with the resident’s information displayed on the computer screen. The resident’s name, date of birth, physician, location, code status, allergies, medication list, and recent vital signs, including weight, were visible on the screen while four other residents were nearby in the common area. ADON B observed that RN A could not walk away with patient information displayed and instructed her to minimize the screen if she left. RN A stated it was not okay to leave resident information displayed because anyone could see or steal it. The DON stated staff were being in-serviced on HIPAA rights and that staff were not supposed to leave patient information displayed on the computer screen because others could see it. The facility policy stated residents have the right to secure and confidential personal and medical records.
Failure to Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit Resident #89’s discharge MDS assessment to CMS within 14 days of completion. Resident #89’s face sheet showed an admission date of 09/25/2026 and diagnoses including acute kidney failure, urinary tract infection, essential hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, and hypo-osmolality and hyponatremia. Review of the discharge MDS assessment dated 10/11/2025 showed that it had not been transmitted to CMS. During interview, the MDS Case Manager stated that completion and transmission of MDS assessments was her responsibility and that of another Case Manager who was on vacation, but she was not the one who completed Resident #89’s assessment and was unsure why it was not transmitted. The Regional Reimbursement Nurse stated the other Case Manager had completed and transmitted the admission and 5-day assessments, and because Resident #89 was managed care, the 5-day assessment had been marked not to send to CMS; she believed that setting remained marked when the discharge assessment was completed, so it was not transmitted. She stated the discharge assessment should have been transmitted to CMS and that the facility had 14 days from the date the RN signed the assessment as completed.
Missing Dialysis Care Plan Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #6 that included his dialysis services outside the facility. Resident #6 was admitted with diagnoses of dementia, type 2 diabetes mellitus, and end stage renal disease, and his admission MDS indicated that his cognition was moderately impaired for daily decision making and that he received dialysis while a resident. Record review showed the resident’s care plan, last revised 3/10/26, addressed dialysis related to renal failure with interventions such as not drawing blood or taking blood pressure in the arm with the graft, monitoring the access site, obtaining vitals and eight per protocol, and reporting significant changes in pulse, respirations, and blood pressure immediately. However, this care area was added after the survey start date. The physician orders also showed dialysis every Monday, Wednesday, and Friday with a chair time of 10:30 a.m. and pickup at 9:30 a.m. During interview, the MDS Case Manager stated audits found the resident was missing dialysis from his care plan, that it should have been included before 3/10/26, and that it needed to be added so nurses and aides would receive alerts about the tasks and care needs related to dialysis.
Missed Scheduled Showers for Two Residents
Penalty
Summary
The facility failed to provide scheduled showers for two residents who needed assistance with activities of daily living. Resident #45 was admitted with hemiplegia and hemiparesis following a cerebral infarction, seizures, and an above-the-knee left leg amputation. Her MDS showed she needed partial to moderate assistance with bathing and substantial to maximal assistance with tub/shower transfers. Her care plan called for one staff member to assist with ADLs and noted she preferred not to have male aides for incontinent care or showers. Her task record showed a shower schedule of Tuesdays, Thursdays, and Saturdays, but during observation she was in bed with slightly oily hair and stated staff were not showering her. She reported missing her Saturday shower because no one was available and was unsure whether she had last showered on the prior Tuesday or Thursday. Resident #80 was admitted and later readmitted with diagnoses including acute on chronic systolic heart failure, unsteadiness on feet, and pain. Her MDS indicated intact cognition and substantial to maximal assistance for transfers. Her care plan directed that she required two staff for transfers, sponge baths if a full bath or shower could not be tolerated, and one staff member to assist with bathing. Her March task record showed showers were scheduled for Tuesdays, Thursdays, and Saturdays on the 2 p.m. to 10 p.m. shift, but only one shower was documented. She stated she was supposed to receive a bath on Saturday but did not, and later reported she missed her scheduled shower on the following Tuesday because there was not enough staff. She said she finally received a shower around noon after almost 8 days without one. Staff interviews showed the shower process was not consistently organized or tracked. A CNA stated showers were a big mess, that nursing staff were not handling concerns about organizing showers, that residents did not always get showers on the assigned days, and that there was no method to track missed showers. Another CNA said morning staff were assigned bathing duties but she was assigned to weights instead. An RN stated aides were expected to document showers and notify nurses if a resident refused, while the DON stated staff were expected to document showers but some staff did not document them. The Administrator and DON stated they were not aware of residents missing showers and denied staffing shortages affecting bathing, despite the missed showers documented for both residents.
Undated sterile water on oxygen concentrator
Penalty
Summary
Safe and appropriate respiratory care was not provided for Resident #64 when the sterile water container attached to the resident’s oxygen concentrator was found without a date. Resident #64 was a readmitted [AGE]-year-old male with a primary diagnosis of spinal stenosis, lumbar region with neurogenic claudication. His MDS assessment dated 2/13/2026 showed a BIMS score of 15 out of 15, indicating intact cognition. The resident had an order allowing oxygen at 2-4 liters per minute by nasal cannula to keep saturation greater than 93% as needed for shortness of breath and feeling faint. During observations on 3/8/2026 and 3/9/2026, the sterile water container attached to the oxygen concentrator had no date. The resident stated he used the oxygen concentrator every night and staff never date the sterile water container. LVN K stated the sterile water container must be dated to show when it was placed on the oxygen concentrator and that the nurse was responsible for dating it. The ADON and DON also stated the sterile water should have been dated when it was changed out, and the DON stated the nurse who replaced it should have dated it.
Dialysis Communication and Return Assessments Not Maintained
Penalty
Summary
The facility failed to ensure that a resident who required dialysis received dialysis care and related communication consistent with professional standards of practice. Resident #6 was admitted with dementia, type 2 diabetes mellitus, and end stage renal disease, and the MDS indicated he received dialysis. His care plan and physician orders included dialysis every Monday, Wednesday, and Friday, assessment of the right arm access for bruit and thrill every shift, and monitoring for signs of infection, bleeding, bruising, pulsation, or aneurysm, with no needle sticks, blood pressure checks, or blood draws in the right arm. Record review showed the facility had only two dialysis communication forms available, and those forms contained only sections for the dialysis center to complete. No information was documented from the nursing facility to the dialysis center on those forms, and the vitals written at the top were unclear as to where they were obtained. Forms were not available for multiple dialysis trips, and progress notes were also missing for many returns from dialysis. The available nursing notes documented some returns from dialysis with stable vital signs and intact shunt dressings, but there was no documentation for numerous other dialysis days. During interviews, the resident stated he went to dialysis several days a week and was unsure whether staff assessed him when he returned. The ADON stated the facility sent communication forms with the resident, but they often came back without them, and staff should have documented vitals and return assessments in the computer. The DON stated the binder sent to dialysis included the resident’s information and medications, but after reviewing the forms, acknowledged staff were not using the correct communication form and that the form should include facility vitals and other information for the dialysis center. The facility policy required monitoring departures and returns from dialysis, documenting vital signs and general appearance, recording leave and return times, and assessing the access site every shift.
Insulin Pen Administration Errors Exceeded Medication Error Threshold
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent, with a documented rate of 5.88% based on 2 errors out of 34 opportunities involving 2 of 6 residents reviewed for medication administration. Both errors involved insulin lispro administration by LVN I and occurred when the insulin pens were not primed before injection. Resident #6 was an older male with diagnoses including dementia, type 2 diabetes mellitus, and end stage renal disease; his record showed he received insulin and had an order for insulin lispro by sliding scale. During observation, LVN I prepared and administered 6 units of insulin lispro to Resident #6 without sanitizing the pen stopper and without priming the pen. Resident #8 was an older female with diagnoses including type 2 diabetes mellitus without complications and presence of an insulin pump; her record also showed she received insulin and had an order for insulin lispro before meals. During observation, LVN I prepared and administered 5 units of insulin lispro to Resident #8 without sanitizing the pen stopper and without priming the pen. In interview, LVN I stated he should prime the insulin pen to push air out, acknowledged he forgot to prime the pens, and stated that without priming there could be air instead of the insulin the resident should be getting. The DON stated staff were expected to prime insulin pens prior to administration to ensure the accurate amount of units were provided. The facility policy for insulin pen use required a safety test before each injection and described that the test ensures an accurate dose by removing air bubbles.
Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments for 1 of 4 nurses' medication carts reviewed, specifically the 600-hall nursing medication cart. During an observation, RN A was administering medications to a resident at the nursing station when she dropped the top to a liquid medication and walked away from the medication cart to clean it up, leaving the cart unlocked. The resident was standing next to the cart and other unknown residents were nearby in a common area. The resident involved had a history of aphasia following cerebral infarction, cerebral palsy, bipolar disorder, seizures, unspecified intellectual disabilities, and hemiplegia and hemiparesis following cerebral infarction. The resident's quarterly MDS showed severely impaired cognition for daily decision making, and the care plan noted yelling out loud and difficulty being redirected at times, with interventions to protect the rights and safety of others. During interview, RN A stated it was not okay to leave the medication cart unlocked and that anyone could access it if unlocked. The DON stated staff were not supposed to leave medication carts unlocked because anyone could get into the cart and some residents needed supervision. The facility policy stated medication rooms, carts, and medication supplies are to be locked or attended to by authorized persons.
Improper Trash Disposal in Outdoor Refuse Area
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 1 of 1 trash disposal areas reviewed. During an observation, 1 bag of trash was seen leaning against the trash disposal container located outside the facility in a gated area. During an interview, the DM stated the trash area falls under her responsibility and that it should look clean, with nothing on the floor and the doors closed. The DM also stated that this is intended to prevent rodents and for infection control. Record review of the facility policy, Waste Control and Disposal, dated 2012, stated that trash must be securely tied in leak-proof plastic bags and removed from the department to the outdoor trash receptacle.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain its infection prevention and control program by not disinfecting shared blood pressure equipment between residents. On 02/13/2026 at 07:40 a.m., an LPN was observed taking one resident’s blood pressure prior to administering medications. After completing the blood pressure check, the LPN returned to the medication cart and placed the blood pressure cuff on the cart without sanitizing it. The LPN then administered medications to that resident. At 07:58 a.m. the same day, the LPN used the same blood pressure cuff to take another resident’s blood pressure, again returning the cuff to the top of the medication cart without disinfecting it. During a later interview, the LPN stated she forgot to wipe the blood pressure cuff between residents because she was nervous and acknowledged that failing to wipe the cuff with disinfectant wipes between residents was an infection control concern. She also stated that nursing staff received frequent training on hand hygiene and infection control. The first resident involved was an adult male with diagnoses including metabolic encephalopathy, essential hypertension, and paroxysmal atrial fibrillation, who was cognitively intact with no infections or antibiotic use noted in the seven days prior to the assessment. The second resident was an adult male with anemia, atherosclerotic heart disease, and essential hypertension, who was moderately cognitively impaired and also had no infections or antibiotic use in the seven days prior to the assessment. Facility leadership, including the ADON, DON, and Administrator, each stated in interviews that staff were expected to disinfect blood pressure cuffs between residents using disinfectant wipes and acknowledged that failure to do so was an infection control concern. The facility’s Infection Control Plan policy stated that the facility would establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection.
Failure to Post Daily Nurse Staffing and Census Information
Penalty
Summary
The deficiency involves the facility’s failure to post required daily nurse staffing and census information for a continuous period of 20 days. Surveyors observed on multiple occasions that the only staffing document displayed in the front lobby was dated several weeks earlier and labeled for a prior day, even though it contained census and scheduled staffing information for various shifts. The required current daily posting, which must include the facility name, current date, total number and actual hours worked by RNs, LPNs/LVNs, and CNAs directly responsible for resident care per shift, as well as the resident census, was not posted for any of the days reviewed. During interviews, the ADON stated he was responsible for posting the daily census and nurse staffing information and acknowledged that he had not been posting it, despite having the prepared postings kept in a book. He explained that he had “just not put them out” and had “forgot” to post them, and also reported that the facility did not have a policy on posting the daily census and nurse staffing. The DON stated her expectation was that the information be posted daily and confirmed the ADON was responsible for this task, but she was unsure why it was not posted on one of the observed days. The Administrator also stated his expectation that the posting be done daily, acknowledged it was a requirement, and noted that some families were aware they could review a nurse staffing binder at the nursing station, which contained staffing schedules and assignments, but this binder was separate from the required public posting.
Food Storage, Labeling, and Hair Restraint Lapses in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper food storage, labeling, and staff attire in the kitchen. During observation of the walk-in refrigerator, they found an opened package of ham and an opened package of cheese without discard dates. The Certified Dietary Manager (CDM) stated that once opened, these items should be discarded after 14 days and acknowledged responsibility for ensuring proper labeling. Surveyors also observed boxes stored in both the walk-in refrigerator and freezer less than 18 inches from the ceiling, contrary to facility policy requiring storage 18 inches or more from sprinkler heads to allow appropriate ventilation and air flow. The CDM confirmed she was responsible for putting boxes away and agreed the boxes were too close to the ceiling. Additional observations showed bacon in the walk-in refrigerator that was not fully covered, which the CDM stated should have been properly covered by another staff member earlier that day to prevent contamination. During meal preparation, a cook was observed working without a beard restraint while cooking dinner, despite acknowledging he had been trained to wear one and understood its importance in preventing hair from getting into food. Another cook later confirmed that boxes should be kept a certain distance from the ceiling for proper circulation, that discard dates are important for prepared foods, and that bacon must be fully wrapped so it does not go bad. Review of facility policies on food storage and dress code showed requirements for food and supplies to be stored six inches above the floor and 18 inches or more from sprinkler heads, and for dietary staff with facial hair to wear hair restraints or nets.
Inaccurate MDS Coding for Pressure Ulcer and Indwelling Catheter
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents’ clinical status for two residents reviewed. For one resident, the admission MDS coded Section M (Skin Conditions) as “No” to the question of whether the resident had one or more unhealed pressure ulcers/injuries. However, the resident’s comprehensive care plan documented an actual unstageable pressure ulcer to the right buttock, and a Weekly-Ulcer Assessment described a Stage II pressure ulcer in the right buttock area near the sacrum, with corresponding physician orders for daily wound care using normal saline and triad. The MDS nurse later acknowledged that, because the resident had a pressure ulcer in the sacral area during the assessment period, Section M should have been coded “Yes” and stated that the inaccurate coding was a mistake by a former MDS nurse. For a second resident, the Medicare 5-day MDS coded Section H (Bladder and Bowel) as “None of the above” for urinary elimination status, despite facility records showing the resident had an indwelling urinary catheter at readmission. The resident’s comprehensive care plan identified the presence of an indwelling urinary catheter with an intervention for catheter care as ordered, and physician orders directed staff to monitor the Foley catheter every shift for leakage, blockage, sediment buildup, or low output. The MDS nurse confirmed that “Indwelling catheter” should have been selected instead of “None of the above” and described this as a coding mistake. The DON stated that all MDS assessments should be coded accurately to provide appropriate care, and the facility’s MDS policy requires that assessments accurately reflect the resident’s status.
Inadequate Perineal Care for Incontinent Resident
Penalty
Summary
The facility failed to provide appropriate incontinence and perineal care to a female resident who was frequently incontinent of bladder and bowel and had multiple comorbidities, including a hip fracture, type 2 diabetes mellitus, dementia with moderate cognitive impairment (BIMS score 8/15), and chronic kidney disease. Her comprehensive care plan documented bowel and bladder incontinence related to dementia, hospice status, weakness, impaired mobility, and pain, with interventions to check her every two hours, assist with toileting as needed, and provide peri care after each incontinent episode. During an observation, CNA-B removed the resident’s soiled brief and cleaned only the right and left groin areas, then turned the resident to her right side and cleaned the buttock and rectal area before applying a clean brief. The observation further showed that CNA-B did not clean the resident’s suprapubic area and did not open the labia while cleaning the genital area, contrary to the facility’s perineal care policy, which directs staff to wipe across the pubis area and, for female residents, to wipe one side of the labia majora from front to back to avoid contaminating the urethral area. In a subsequent interview, CNA-B acknowledged she did not clean the suprapubic area or open the labia, stating she was nervous and forgot, and confirmed she had received peri-care training in the prior year. The DON also stated that CNA-B should have cleaned the suprapubic area and opened the labia area to prevent possible infection and confirmed responsibility for providing peri-care training and monitoring skill checkoffs.
Failure to Provide Individualized Activities and Access to Activities Room
Penalty
Summary
The facility failed to provide individualized activities based on comprehensive assessments and care plans for three residents, particularly during nights and weekends. Observations and interviews revealed that the activities room was only open for limited hours on weekdays, restricting access to preferred activities such as complex puzzles, drawing, and painting. Residents expressed that the closure of the activities room outside of these hours prevented them from engaging in meaningful activities, which they found stimulating and comforting, especially during the evening and night. Residents with intact cognition and diagnoses including depression and PTSD reported that access to the activities room was important for their mental well-being. One resident with PTSD and a traumatic brain injury stated that working on puzzles at night in the activities room helped him cope with his trauma. Another resident described feeling lost and depressed when unable to access the room after hours, as she did not enjoy alternative activities like watching TV and found it difficult to transport her complex puzzles. Staff interviews confirmed that residents had complained about the restricted access to the activities room, and the Activities Director acknowledged the negative impact of the limited hours. The facility did not provide a policy for activities when requested, and the care plans for the affected residents included interventions that could not be implemented due to the restricted access. The lack of individualized activities and limited access to the activities room led to unmet physical, mental, and psychosocial needs for the residents involved.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, muscle wasting and atrophy, and acute respiratory failure was found without access to their call light. The resident, who was cognitively intact and required full assistance from two staff members, had a care plan intervention to encourage use of the call bell for assistance. During an observation, the call light was discovered inside the nightstand, out of the resident's reach. The resident reported that staff frequently left the call light inaccessible, causing distress and forcing him to call the facility's phone number for help. Interviews with staff confirmed the call light was not accessible to the resident. The assigned CNA admitted to forgetting to place the call light within reach after returning the resident to bed following a shower. The LVN acknowledged that the call light was not accessible and stated this was not good nursing practice, as the resident would be unable to call for help. The DON and ADON both emphasized the importance of call light accessibility and stated that staff are trained on this procedure, but there was no formal policy addressing the issue.
Failure to Support Resident's Religious Practices and Self-Determination
Penalty
Summary
The facility failed to ensure that a resident's right to self-determination and religious practice was honored. The resident, a male with dementia and depression, had informed staff of his Muslim faith and expressed a desire to practice his religion within the facility. Despite this, his care plan did not include any mention of his religious preferences or related activities, except for a selective menu for certain meals. The resident reported feeling excluded because he could not participate in religious activities relevant to his faith, while other residents could attend Bible study. He also stated that he was unable to watch religious programs on his TV due to it not working, an issue the facility was aware of but had not resolved. Interviews with staff, including an LVN, the Activities Director, and the DON, revealed a lack of awareness or effective support for the resident's religious needs. The Activities Director acknowledged attempts to support the resident's religion, but these efforts did not meet his expectations. The resident also noted that he did not receive food before fasting periods and felt unable to request accommodations due to the facility's set meal times. The facility's policy requires respect for resident rights and individuality, but documentation and staff actions did not reflect adequate support for this resident's religious practices.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by regulation. For one resident with dementia and depression, the care plan did not include any mention of his religious preferences or needs, despite the resident being Muslim and having communicated this to staff. The only reference to his religion was a dietary note about a selective menu, but there was no documentation regarding his desire to practice his religion or participate in religious activities. Interviews revealed that the resident felt excluded from religious activities and was not provided alternatives to practice his faith, and several staff members were unaware of his religious background or how to accommodate his needs. For another resident with a diagnosis of PTSD and a history of traumatic brain injury, the care plan did not address his PTSD diagnosis or related care needs. The resident reported that engaging in puzzles at night helped him cope with his trauma, and staff interviews confirmed that he was sensitive to loud noises and required accommodations to avoid being triggered. However, this information was not reflected in his care plan, and some staff were unaware of his PTSD diagnosis or how to support him appropriately. Record reviews and staff interviews indicated a lack of communication and clarity regarding responsibility for updating care plans to reflect residents' religious and psychosocial needs. The facility's policy required person-centered care plans that addressed each resident's preferences and needs, but in these cases, the care plans were incomplete and did not provide measurable objectives or time frames for addressing the identified needs. This failure was confirmed through interviews with residents and staff, as well as review of facility documentation.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for one resident reviewed for clinical records. Specifically, wound care treatments for a resident with moisture associated skin damage (MASD) to the sacral area were not properly documented on the Wound Administration Record (WAR) for three scheduled treatments out of thirty-nine reviewed. The treatment order required cleansing the sacral area and applying Triad cream every day and evening shift, but the WAR showed blanks for three specific shifts, indicating missing documentation. Interviews with nursing staff revealed that the wound care nurse was not present on weekends, and direct care nurses were expected to provide and document wound care in her absence. One LPN recalled providing the treatment but admitted she did not document it, while another LPN, new to the facility, stated she may not have noticed the order in the electronic record and therefore did not mark it as completed. The Director of Nursing confirmed that a blank in the administration record typically indicates a missed administration or lack of documentation, which impacts the ability to monitor whether orders are being followed. The resident involved was cognitively intact, dependent for all self-care and mobility, and at risk for pressure ulcers, with a history of MASD. The resident could not recall if wound care was provided on the dates in question. Facility policy required that the person administering a treatment document it at the time of administration, but this was not consistently followed, resulting in incomplete clinical records for the resident.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
A certified nursing assistant (CNA) failed to perform proper hand hygiene while serving and assisting residents with their meals. During observation, the CNA was seen leaving a resident's room after delivering a meal tray, adjusting her eyeglasses, and then proceeding to handle another resident's meal tray and utensils without sanitizing her hands. The CNA touched her face and personal glasses multiple times before assisting a resident with their meal, including cutting up the resident's food, without performing hand hygiene in between these actions. Record review showed that the CNA did not attend a recent in-service training on meal tray pass, which included hand hygiene expectations. Interviews with the CNA revealed she was aware of the need for hand hygiene between serving residents but was unclear about the procedure after touching her glasses. Both the Director of Nursing (DON) and the Administrator confirmed their expectations for staff to use hand sanitizer before and between each resident's tray delivery, including after touching their face or glasses. Facility policies emphasized hand hygiene as a primary means of infection prevention, but the policy on nursing responsibilities at meal service did not address hand hygiene during meal service.
Failure to Post Required State Agency and Ombudsman Contact Information
Penalty
Summary
The facility failed to post, in an accessible and understandable manner, the required list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the Office of the State Long-Term Care Ombudsman program. This deficiency was observed over a three-day period, during which surveyors noted the absence of the required information in public postings on multiple occasions. The lack of posting was confirmed during interviews and observations, with no information available for residents or their representatives to access. During interviews, the DON acknowledged the missing ombudsman contact information and was unable to provide a timeline for how long the posting had been absent. The DON also stated that there was no facility policy regarding required postings and was unable to identify any staff responsible for ensuring the postings were maintained. The absence of this information could impact residents' ability to contact advocacy resources and exercise their rights, as noted by the DON during the interview.
Failure to Post Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to post daily nurse staffing and census information for three consecutive days, as required. Observations on multiple occasions revealed that the information regarding the facility name, current date, total number and actual hours worked by RNs, LPNs, and CNAs per shift, as well as the resident census, was not publicly posted. Interviews with the DON and ADON confirmed that the postings were missing and that neither could determine how long the information had not been posted. The DON stated that the responsibility for posting was assigned to the ADON and the weekend supervisor, but the display case used for posting could not be located. Both the DON and ADON indicated they were unaware of any inquiries from residents or families regarding the posting and did not believe the absence of the posting had an impact. Further, the DON revealed that the facility did not have a policy regarding the required postings. The ADON confirmed that while the facility maintained the procedure of creating, updating, and preserving the daily census and nurse staffing documents, the actual public posting had not occurred for an undetermined period. No specific residents or patient conditions were mentioned in relation to this deficiency.
Failure to Perform Hand Hygiene Between Glove Changes During Peri-Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to perform proper hand hygiene during peri-care for a female resident who was totally dependent on staff for toileting and incontinent. The resident, who had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, congestive heart failure, and generalized muscle weakness, required total assistance for toilet hygiene. During an observed episode of peri-care, the CNA removed soiled gloves after handling a large volume of stool and immediately donned clean gloves without performing hand hygiene in between, despite her gloves being visibly contaminated. Interviews with the CNA, the Assistant Director of Nursing (ADON) who also served as the facility's Infection Preventionist, and the Director of Nursing (DON) confirmed that the facility's expectation and policy required staff to perform hand hygiene after removing gloves and before putting on new gloves, especially during peri-care. The CNA acknowledged awareness of the correct procedure but failed to follow it during the observed care. Facility records indicated the CNA had previously been assessed as proficient in both peri-care and infection control awareness. Facility policies reviewed also specified the necessity of hand hygiene before and after glove use, particularly when gloves are visibly soiled.
Failure to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents. One resident, who had dementia and was frequently incontinent, was found in a room with a strong urine odor and soiled sheets containing urine and feces. Despite having a care plan that included regular incontinent care, the resident's needs were not met due to staffing shortages, as only one CNA was available during the shift. The maintenance supervisor noted that the urine odor persisted due to absorption into the flooring, and the housekeeping supervisor identified stains on the walls, indicating inadequate cleaning. Another resident, who was legally blind and had difficulty walking, reported a wobbly toilet in her restroom that had been loose since her admission. Despite informing several staff members, the issue was not addressed, and the toilet remained unstable, posing a safety risk. The maintenance supervisor was unaware of the problem due to a lack of work orders from staff, although the resident had previously reported an overflowing toilet, which was fixed. The facility had a system for maintenance requests, but it was not utilized effectively by the staff. The facility's policies on resident rights, linens, and housekeeping emphasize the importance of maintaining a clean and safe environment. However, these policies were not followed, leading to deficiencies in the care provided to the residents. The lack of adequate staffing and communication regarding maintenance needs contributed to the failure to address the residents' environmental concerns.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure proper care and continuity of services. Resident #12, a woman with dementia, dehydration, chronic respiratory failure with hypoxia, and generalized anxiety disorder, was admitted on 12/12/2024. Her baseline care plan was not completed until 18 days after her admission, on 12/30/2024. She was assessed with a BIMS score of 13, indicating intact cognition, and required assistance with mobility and toileting hygiene. Similarly, Resident #29, a woman with dementia, type 2 diabetes, depression, and anxiety disorder, was admitted on 11/21/2024, but her baseline care plan was not completed until 11 days later, on 12/02/2024. She had a BIMS score of 5, indicating severe cognitive impairment, and was dependent on assistance for personal hygiene and bathing. Interviews with facility staff, including the MDS-A and the DON, confirmed the oversight and acknowledged the importance of completing baseline care plans within the required timeframe to provide adequate care for newly admitted residents.
Failure to Address Mental Health Needs in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is consistent with resident rights and includes measurable objectives and time frames to meet the resident's mental, nursing, and psychosocial needs. Specifically, the care plan for a resident with diagnoses of Depression, Generalized Anxiety Disorder, and Dementia did not address these conditions or the active orders for anti-anxiety and anti-psychotic medications. This oversight was identified during a record review and interview, where it was noted that these diagnoses and medications should have automatically triggered a Care Area Assessment (CAA) but were missed. The resident's comprehensive care plan, initiated on a specific date, lacked focus areas addressing her mental health diagnoses and medication orders. The MDS nurse acknowledged the omission and stated that these should have been included in the care plan. The facility's Director of Nursing (DON) and other staff confirmed that comprehensive care plans should address all nursing, mental, and psychosocial needs, including necessary interventions and services. The facility's policy on comprehensive care planning emphasizes the development and implementation of person-centered care plans to meet residents' medical, physical, mental, and psychosocial needs.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to review and revise the care plan for a resident after experiencing three falls within a four-hour period. The resident, who has a history of dementia, overactive bladder, hearing loss, and unsteadiness on feet, was admitted to the facility with a moderate cognitive impairment. Despite the falls being unusual for the resident, the care plan, which had not been updated since July 2024, was not revised to include new interventions or assessments following the incidents. The falls resulted in a skin tear and a hospital visit, but no new medical orders were issued upon the resident's return. Interviews with facility staff revealed that the falls were discussed in a morning meeting, and it was agreed that the resident should receive an Occupational Therapy evaluation in addition to ongoing physical therapy. However, these interventions were not documented in the resident's care plan, which is a requirement according to the facility's policy. The Director of Nursing, who was responsible for updating the care plan, was no longer with the facility, and the new Director of Nursing acknowledged the oversight. The facility's policy mandates that care plans be reviewed and revised after significant changes, such as falls, to ensure all staff are informed of the resident's needs.
Failure to Provide Consistent Wound Care and Leg Wrapping
Penalty
Summary
The facility failed to provide appropriate wound care and leg wrapping for a resident, as per the physician's orders and the resident's care plan. The resident, an elderly woman with intact cognition, was admitted with conditions including Lichen Simplex Chronicus, obesity, and mobility issues. She was dependent on assistance for personal care and had moisture-associated skin damage. The care plan included daily wound dressing and leg wrapping to manage her conditions. However, observations revealed that these treatments were not consistently applied, with specific dates noted where the treatments were not documented as completed. Interviews with facility staff, including the Treatment Nurse and the Director of Nursing (DON), confirmed the lapses in care. The Treatment Nurse admitted to not completing the treatments due to time constraints and workload, and there was no coverage in her absence. The DON acknowledged the issue and emphasized the importance of adhering to physician orders to prevent slow healing and infection. The facility's policy on skin integrity management required wound care to be performed as ordered, highlighting a failure to comply with established protocols.
Failure to Secure Medications in Locked Compartments
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed in the medication room and on a nurse medication cart. During an observation, it was found that the compartment inside the refrigerator designated for controlled substances was unlocked and contained lorazepam, a controlled medication. The Director of Nursing (DON) acknowledged that this oversight could lead to drug diversion and confirmed that the bin should have been locked. The facility's policy mandates that all controlled medications be stored under double lock and checked for accountability at each shift change. Additionally, medications for a resident with a history of hemiplegia, hemiparesis, and Type 2 Diabetes Mellitus were found unattended on top of a medication cart outside the nurse's station. The medications included Tradjenta, Metformin, and Potassium Chloride. A Licensed Vocational Nurse (LVN) admitted to being distracted and forgetting to secure the medications back into the cart, which should have been locked at all times. The DON confirmed that leaving medications unsecured could result in them being taken by anyone, including residents, staff, or visitors. The facility's policy requires medication carts to be locked when not in use or under direct supervision.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for both new and existing staff members, as evidenced by the lack of required annual training for five employees: CNA G, LVN H, LVN I, LVN J, and PT. The personnel records for these staff members showed missing documentation of annual training in critical areas such as Resident Rights, Dementia, Behavioral Health, HIV, Falls, Restraints, and Emergency Preparedness, among others. The HR Manager, during an interview, acknowledged the oversight in training due to recent changes in administration and staffing. The deficiency was identified through a review of personnel records and interviews, revealing that the facility relied on an online system, RELIAS, for training, which was not effectively utilized to ensure compliance with training requirements. The Nursing Policy and Procedure Manual indicated that the facility was supposed to provide ongoing in-services on issues related to abuse/neglect prohibition practices, but this was not adhered to, leading to the deficiency.
Failure to Monitor Resident Medications Leads to Overdose
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that residents received adequate supervision to prevent accidents. This deficiency was identified when a resident was found lethargic and difficult to arouse with an empty Tylenol bottle at the bedside. The resident was assessed with a 12,000mg Tylenol overdose, significantly exceeding the harm threshold of 4,000mg over 24 hours. The resident was transported to the emergency room for evaluation and treatment, where they were stabilized and later discharged back to the facility. The resident involved had a history of Alzheimer's disease, depression, and encephalopathy, and was assessed with a BIMS score indicating no cognitive impairment. Despite this, the resident's care plan noted suicidal ideation, and the resident had recently returned from a hospital stay after a suicide attempt involving an overdose of over-the-counter Tylenol provided by family. The facility failed to monitor the resident for medications at the bedside, which contributed to the overdose incident. Interviews with facility staff, including the previous Director of Nursing (DON) and Registered Nurse (RN) involved, revealed that there was no in-service training provided to staff regarding the incident or the presence of medications at the bedside. Additionally, there was no evidence that the facility assessed other residents for safety or conducted a sweep for medications at the bedside following the incident. The current Administrator and DON, who were not in leadership at the time of the incident, acknowledged the lack of in-service training and safety assessments for peer residents.
Failure to Report Resident's Overdose Incident
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency in a timely manner, as required by regulations. On February 24, 2024, a resident was found lethargic and difficult to arouse with an empty Tylenol bottle at their bedside. The resident was transported to the emergency room and diagnosed with a 12,000mg Tylenol overdose, which significantly exceeded the harm threshold of 4,000mg over 24 hours. Despite the seriousness of the incident, there was no evidence that the facility reported the suicide attempt or the presence of medications at the bedside to the state agency. The resident involved had a history of Alzheimer's disease, depression, and encephalopathy, and was assessed with a BIMS score indicating no cognitive impairment. The resident's care plan noted suicidal ideation, and the resident had recently returned from a hospital stay after taking over-the-counter Tylenol provided by family. The resident's representative and family had been present at the hospital, and it was noted that the resident felt more depressed after their visit. Interviews with facility staff revealed that the previous Director of Nursing (DON) and the current Administrator and DON were not aware if the incident had been reported to the state agency. The previous DON recalled the incident but did not remember if it was reported. The current Administrator and DON, who began their roles in April 2024, stated they had minimal knowledge of the incident and acknowledged that it should have been reported. The facility's policy required immediate reporting of suspected abuse, neglect, or exploitation, but there was no documentation to support that this was done in this case.
Failure to Investigate and Report Tylenol Overdose Incident
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and reported in accordance with state law. This deficiency was identified in the case of a resident who was found lethargic and difficult to arouse with an empty Tylenol bottle at their bedside. The resident was subsequently diagnosed with a 12,000mg Tylenol overdose, which significantly exceeded the harm threshold of 4,000mg over 24 hours. Despite the severity of the incident, there was no evidence that the facility investigated or reported the incident to the state agency within the required timeframe. The resident involved in the incident had a medical history that included Alzheimer's disease, depression, and encephalopathy, and was assessed with a BIMS score indicating no cognitive impairment. The resident was admitted for long-term care and was generally independent in daily activities. However, the resident's care plan noted a history of suicidal ideation. On the day of the incident, the resident was found with an empty bottle of Tylenol, which had been provided by family members, and was transported to the emergency room for treatment. Interviews with facility staff revealed a lack of awareness and action regarding the investigation and reporting of the incident. The previous Director of Nursing (DON) and the current Administrator and DON were unable to confirm whether the incident had been reported to the state agency. Additionally, there was no documentation to support that the facility had taken steps to investigate the incident or assess the safety of other residents. This lack of action and documentation highlights a significant deficiency in the facility's handling of the incident.
Failure to Document Skin Assessment and Treatment
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding a skin assessment and subsequent treatment. An LVN assessed a resident with a rash on their forearms but did not document the assessment, the communication with the physician, or the detailed physician's order. The physician prescribed a steroid skin cream, but the order lacked specific instructions on where to apply the medication. This lack of documentation could lead to inaccurate medical records. The resident involved was admitted for long-term care with diagnoses including hemiplegia, hemiparesis following cerebral infarction, restlessness, agitation, and cognitive communication deficit. The resident's care plan included the use of antipsychotic medications for behavior management. The facility's documentation policy requires accurate and complete recording of all information related to resident care, but this was not adhered to in this instance, as confirmed by interviews with the LVN and the DON.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to provide personal privacy for three residents during care, which was observed during a survey. Resident #2, who had a pressure ulcer on the left hip, did not receive privacy during wound care as the Licensed Vocational Nurse (LVN) did not completely close the door or the privacy curtain. This lack of privacy was acknowledged by the LVN during an interview, where she stated the importance of ensuring the resident was covered and the door and curtain were closed. Similarly, Resident #4, who had a pressure ulcer on the left buttock, was not provided privacy during wound care. The LVN did not close the door, privacy curtain, or blinds while performing the procedure. In an interview, the LVN admitted she had not noticed the door was open and emphasized the importance of closing the door, curtain, and blinds to maintain resident dignity and privacy. Resident #6, who required assistance with activities of daily living (ADLs) due to severe cognitive impairment, was also not provided privacy during perineal care and dressing. The Certified Nursing Assistant (CNA) closed the door but failed to close the privacy curtain or blinds. Interviews with the CNA, Registered Nurse (RN), and other staff members highlighted the importance of ensuring privacy by closing the door, blinds, and curtains during care to protect the residents' dignity and prevent embarrassment.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to potential risks of improper care. Resident #1's medical records lacked documentation of wound care treatments on specific dates, despite the resident confirming receipt of the treatments. Interviews with staff revealed inconsistencies in the responsibility for wound care documentation, with some staff unaware of who was responsible when the treatment nurse was unavailable. Resident #3's records also showed missing documentation for wound care treatments on multiple occasions across several months. Interviews with staff indicated a lack of clarity regarding who was responsible for wound care on weekends, with some nurses admitting to not documenting treatments even if they were provided. The facility's procedure required documentation of treatments, but this was not consistently followed, leading to gaps in the resident's medical records. Similarly, Resident #4's records were incomplete, with missing documentation for wound care treatments on specific dates. The Director of Nursing (DON) was unaware of the missing documentation and assumed treatments were completed but not documented. Interviews with staff highlighted a lack of clear responsibility for ensuring documentation was completed, with some staff indicating that the weekend supervisor or assigned nurse was responsible for wound care. The facility's administrator acknowledged the need for a system to monitor documentation but was unsure of the current arrangements.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper infection control practices during wound care and personal hygiene for multiple residents. For instance, during wound care for a resident with a pressure ulcer, a registered nurse (RN) did not perform adequate hand hygiene, failed to sanitize surfaces before placing treatment supplies, and did not change gloves appropriately. The RN also neglected to clean the resident's genital area thoroughly during perineal care, which left the resident feeling unclean and uncomfortable. Another resident with a pressure ulcer received wound care from a licensed vocational nurse (LVN) who did not don personal protective equipment (PPE) and failed to perform hand hygiene between glove changes. The LVN also placed treatment supplies on unsanitized surfaces, increasing the risk of cross-contamination. Similarly, during toileting assistance for a resident, a certified nursing assistant (CNA) did not perform hand hygiene between glove changes and failed to assist the resident with hand hygiene after using the restroom. The facility also did not ensure compliance with Enhanced Barrier Precautions (EBP) for residents requiring such measures. Staff members, including an RN and LVNs, did not wear the necessary PPE when providing care to residents on EBP, which included those with wounds and other conditions requiring additional precautions. Interviews with staff revealed a lack of adherence to proper infection control protocols, such as hand hygiene, glove changes, and the use of PPE, which could lead to cross-contamination and increased infection risk among residents.
Failure to Facilitate Resident Communication and Visitor Access
Penalty
Summary
The facility failed to protect and facilitate the residents' right to communicate with individuals and entities both within and external to the facility. This deficiency was identified during an observation where the facility's main entrance was found to be secured without a doorbell, and a sign was posted with the facility's phone number for assistance. However, the phone at the nurse station did not ring to alert staff of incoming calls, which could potentially deny access to visitors, including family members and physicians. The surveyor observed that pulling on the door for an extended period triggered an automatic release mechanism, allowing entry and sounding an alarm. Further investigation revealed that the facility did not have a weekend receptionist, and staff were expected to answer calls to allow entry for visitors and care providers. During a tour, the surveyor demonstrated the issue to the Manager on Duty (MOD), who confirmed that the phone was not alerting staff to incoming calls. The Administrator and the Director of Nursing (DON) were unaware of the phone issue and acknowledged the lack of a weekend receptionist. The facility's policy on resident rights emphasized the residents' right to receive visitors and have reasonable access to communication, which was not upheld due to the phone system failure.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that a working call system was available for residents to alert staff for assistance, which was observed in two cases. Resident #4 was admitted without a call light system in place, leaving him unable to alert staff for help or emergencies. This resident, who had severe cognitive impairment and was assessed as a high fall risk, was found in his room calling out for help without a functioning call light system. Resident #2 experienced a malfunctioning call light system, which resulted in a significant delay in receiving assistance. Despite using his call light to request help with a burst colostomy bag, the call was not recognized by staff due to a malfunctioning illuminator outside his room. This resident, who required total assistance with personal hygiene, was left in a soiled state for 36 minutes until a surveyor intervened. The facility's call light system was not adequately monitored, as evidenced by staff failing to notice the alert for Resident #2. The call light system box at the nurse's station was visually and audibly alerting a call for assistance, but staff did not recognize it. This oversight led to prolonged wait times for Resident #2, who reported frequent delays in receiving colostomy care, causing discomfort and feelings of neglect.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 926 citations issued within 25 miles in the last 12 months — including the 20 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 San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort San Antonio, Llc | 0.2 mi | ★★★★★ | 18 | 0 |
| Mesa Vista Inn Health Center | 0.5 mi | ★★★★★ | 24 | 0 |
| Northgate Health And Rehabilitation Center | 0.5 mi | ★★★★★ | 29 | 0 |
| Remington Transitional Care Of San Antonio | 0.8 mi | ★★★★★ | 3 | 0 |
| Sorrento | 1 mi | ★★★★★ | 17 | 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.