Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hunters Pond Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with COPD had active orders for continuous oxygen and nighttime VPAP/BIPAP use, and staff documented that she used oxygen continuously and the device at night. However, the quarterly MDS and discharge MDS did not code the non-invasive mechanical ventilator, and the discharge MDS also did not reflect oxygen use. The MDS nurse and DON both acknowledged the assessments were not coded accurately.
The facility failed to report an influenza A outbreak to the state survey agency despite documented positive tests and isolation orders for 13 residents over several days. Multiple residents with comorbidities such as dementia, diabetes, heart disease, Parkinson’s disease, and schizophrenia developed symptoms including fever, cough, congestion, weakness, and changes in mental status, were tested for flu, and were confirmed positive. Some residents were evaluated in the ER and diagnosed with influenza A, including one with sepsis due to influenza. Facility records showed droplet isolation precautions and Tamiflu orders for affected residents, and care plans referenced influenza risk and monitoring, but review of the state’s reporting system showed no self-reported influenza outbreak. The report states that the DON and Administrator did not report these cases, and that this failure could put residents at risk of neglect, illness, communicable diseases, respiratory distress, and harm.
Delayed MDS Assessments and Transmissions: Quarterly MDS assessments were not completed or transmitted on time for several residents reviewed, including residents with diagnoses such as DM, dementia, Alzheimer’s disease, CHF, COPD, CKD, and prior stroke. The MDS Coordinator acknowledged the delays and said the assessments had not been completed on time because only two MDS coordinators were available, both had time off, and the facility had a large number of admissions and discharges.
Kitchen Food Storage, Logging, and Ice Machine Sanitation Deficiencies: Staff failed to label and date drinks, sandwiches, salads, and brown rice; boxes of food were stored on the freezer floor; required refrigerator and sanitizing sink logs were left incomplete; and the ice machine contained black and brown slimy buildup. The DM and Administrator stated staff were responsible for labeling foods, completing logs, and cleaning the ice machine.
A resident's MAR did not accurately show which LPN administered early morning GERD and thyroid meds, and two residents' bathing records did not match the care actually provided. One resident with COPD, narcolepsy, dementia, GERD, and other diagnoses had conflicting MAR documentation about who gave the meds, while two residents with ADL bathing needs had Task sheets marked Not Applicable even though shower sheets, skin notes, and interviews showed inconsistent or missing shower documentation.
Call Light Not Within Reach: A resident with hemiplegia/hemiparesis and dependence for transfers was left sitting in a wheelchair next to her bed without her call light within reach. She was heard yelling for help and stated she wanted to be put in bed and did not know where the call light was. CNAs found the call light clipped behind the resident on the privacy curtain, and the DON confirmed it should have been accessible for the resident to request assistance.
A resident with a UTI, bacteremia, urinary catheter, colostomy, and muscle weakness did not receive scheduled showers as documented, and bathing records repeatedly showed "Not Applicable" entries instead of clear shower or refusal documentation. The resident said he missed showers and was told staff did not have time, while CNA and RN interviews confirmed the bathing documentation was inconsistent and did not clearly show whether the showers occurred or were refused.
Improper Dumpster and Refuse Disposal: A dumpster was observed with its side door open and trash on the ground beside it, including a wipe, a used glove, and a plastic wrapper. The DM stated the dumpster should not be open because it can attract rodents or pests, and the Administrator stated staff are expected to keep the dumpster closed and trash off the ground.
Hand Hygiene Not Maintained During Wound Care Preparation: A nurse preparing supplies for wound care to a resident with a stage 4 sacral pressure ulcer touched her personal cell phone, did not sanitize her hands, and then handled a handful of clean gloves before providing care. The resident had diabetes, lymphedema, and an open sacral wound, and the facility policy required hand hygiene before handling dressings and after handling contaminated equipment.
A resident with severe cognitive impairments and mobility dependence fell and fractured both knees after a medication aide, working as a CNA, provided care without the required two-person assistance. The care plan lacked clear instructions, leading to the aide's incorrect assumption about the level of assistance needed, resulting in the resident's hospitalization.
A resident with severe cognitive impairment and multiple medical conditions fell and sustained fractures after a medication aide, working as a CNA, provided care alone despite the need for two-person assistance. The incident was not reported to authorities within the required timeframe, revealing deficiencies in the facility's reporting and communication processes.
A LTC facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment and total dependence on assistance for ADLs. The care plan did not specify the need for two staff members for bed mobility, despite the resident's diagnoses and occupational therapy evaluation indicating total assistance was required. This oversight led to inconsistencies in care delivery, as noted by facility staff.
The facility failed to maintain proper infection control practices, as evidenced by a CNA not performing hand hygiene between glove changes during incontinent care for a resident, and another resident's catheter bag being found on the floor without a cover. These incidents highlight lapses in following infection control protocols, potentially putting residents at risk for infections.
A resident with acute kidney failure did not have vital signs checked immediately before dialysis, contrary to facility policy. Staff interviews revealed inconsistencies in understanding and executing the policy, with vital signs taken earlier in the day being used instead. This led to a deficiency in providing appropriate dialysis care.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS did not document hospice services despite being on hospice care, and another resident's discharge status was incorrectly recorded as being to a hospital instead of home. These discrepancies were acknowledged by facility staff, highlighting potential risks for improper care.
A facility failed to coordinate PASRR assessments for a resident with major depressive disorder, resulting in an inaccurate Level 1 Screening. The MDS nurse did not correct the discrepancy, missing the opportunity for psychiatric services. Interviews revealed staff were unaware of the PASRR process implications, despite the resident having medication orders for depression.
A facility failed to develop a comprehensive care plan for a resident, missing critical information on several health conditions and needs, such as nephrostomy catheter, urinary catheter, colostomy status, heart failure, and more. The MDS Coordinator confirmed the care plan was not updated after the resident's recent hospital readmission.
A long-term care facility was found to have an 8% medication error rate due to two incidents. One resident did not receive isosorbide mononitrate as the CMA was distracted by a missing medication and failed to dispense it, despite marking it as administered. Another resident received insulin aspart incorrectly because the LVN did not prime the pen, misunderstanding the procedure. Both incidents violated the facility's medication administration policies.
A facility failed to accurately document a resident's Major Depressive Disorder (MDD) diagnosis in their medical records, despite it being noted in hospital records and the resident being prescribed venlafaxine for depression. The MDS nurse and DON acknowledged the oversight, which could result in the resident missing necessary psychiatric services.
The facility failed to maintain an effective infection control program, as evidenced by two incidents involving staff. An LVN did not clean an insulin pen before administering insulin to a resident, risking contamination. Another LVN did not change gloves during nephrostomy care, potentially contaminating the site. The DON confirmed the need for proper procedures to prevent infection.
The facility failed to assist a resident with eating, leaving him waiting for at least 10 minutes, and did not honor another resident's food preferences, substituting her requested item without informing her. These actions led to feelings of frustration and being unheard among the residents.
The facility failed to document lactose allergies in the care plans and admission records of two residents with severe mental cognition impairment, despite dietary orders indicating the allergies. Interviews revealed a lack of awareness and adherence to facility policies on documenting dietary allergies.
The facility failed to accommodate the dietary restrictions and preferences of two residents. One resident with lactose intolerance was served dairy products, and another resident who disliked mixed vegetables was served them. Both errors were confirmed by staff, and the residents' records indicated their specific dietary needs.
The facility failed to follow the menu and recipe for a lunch meal, serving a Chicken Enchilada Casserole with mushrooms instead of the planned Chicken Quesadilla Casserole. The Dietary Supervisor admitted to not always following recipes, and the change was not documented as required by facility policy.
MDS Did Not Reflect Oxygen and BIPAP Use
Penalty
Summary
The facility failed to ensure Resident #1’s assessments accurately reflected her status on the quarterly MDS and discharge MDS. Resident #1 was a [AGE]-year-old female admitted with chronic obstructive pulmonary disease, and her record showed active orders for oxygen at 2-4 L/min continuously and use of a VPAP/BIPAP-type device at night. Her care plan also documented oxygen therapy and that she refused BIPAP at times. However, the quarterly MDS did not code non-invasive mechanical ventilator use, and the discharge MDS also did not reflect oxygen or BIPAP use at discharge. Record review showed Resident #1 continued to receive VPAP at night and oxygen during the day during the months before discharge, with documentation of nighttime VPAP use and continuous oxygen in the MAR. Staff interviews confirmed she used oxygen continuously until discharge and used VPAP/BIPAP at night. The MDS nurse stated the trilogy machine was not coded on the quarterly or discharge MDS and acknowledged she was responsible for ensuring MDS accuracy. The DON also stated the trilogy machine should have been coded on the MDS under non-invasive mechanical ventilator and confirmed it was not coded on either assessment.
Failure to Report Influenza Outbreak to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an infection prevention and control program that included required reporting to the state survey agency of an influenza outbreak affecting 13 residents. Complaint Intake Investigation Worksheet #1067849 alleged that multiple residents were diagnosed with influenza and that there was no self-report of the outbreak to the state agency. Review of the state’s TULIP system on 02/06/2026 showed no self-reported incidents regarding an active influenza outbreak, despite facility records documenting that 13 residents tested positive for influenza A between 01/26/2026 and 02/05/2026. The report states that the DON and Administrator failed to report these positive influenza cases to the state survey agency. Record review of the facility’s Symptomatic Testing log showed that 13 residents developed symptoms, were tested, and were confirmed positive for influenza A over a span of several days. One resident developed cough and congestion on 01/25/2026, was tested the next day, and was found positive for influenza A, with droplet isolation and antiviral treatment initiated. Two other residents developed fever and respiratory symptoms on 01/26/2026, were tested, and were later confirmed positive for influenza A, with isolation and Tamiflu ordered. Additional residents on the same hall and on another hall developed symptoms such as fever, cough, congestion, and changes in condition, were tested for influenza, and were confirmed positive, with droplet isolation precautions and antiviral therapy documented in their clinical records. Several residents were sent to the emergency room where they were also diagnosed with influenza A, including one resident who was transferred due to low blood pressure, tachycardia, and fever and was diagnosed with sepsis due to influenza A in the hospital. Another resident was evaluated in the ER after a fall and was diagnosed with influenza A there. Across all 13 residents, the facility’s records consistently documented positive influenza A test results, initiation of droplet isolation precautions, and orders for Tamiflu. Despite this cluster of confirmed influenza A cases and the presence of an active outbreak, there was no corresponding self-report of the outbreak in the state reporting system, as confirmed by review of TULIP, and the report explicitly states that the DON and Administrator did not report these cases to the state survey agency. The residents involved had multiple comorbidities, including paraplegia, dementia, schizophrenia, diabetes, hypertension, heart disease, Parkinson’s disease, malnutrition, and cognitive communication deficits. Some residents had received the influenza vaccine, while others had refused it, and care plans for many residents included monitoring for signs and symptoms of influenza. Nursing notes and physician orders documented changes in condition such as fever, cough, congestion, weakness, increased confusion, and abnormal vital signs, followed by testing and confirmation of influenza A. These documented clinical events and positive test results, combined with the absence of any self-reported outbreak in the state system, form the basis of the cited deficiency in the facility’s infection prevention and control program related to required reporting. The report states that this failure to report could put residents at risk of neglect, illness, communicable diseases, respiratory distress, and harm. The deficiency is specifically tied to the inaction of the DON and Administrator in not reporting the influenza outbreak to the state survey agency, despite clear evidence of an outbreak in facility records. The findings are based on observation, interview, and record review, and encompass all 13 residents reviewed for infection control reporting requirements.
Delayed MDS Assessments and Transmissions
Penalty
Summary
The facility failed to complete and transmit quarterly MDS assessments in a timely manner for 5 of 9 residents reviewed for timely completion of MDS assessments: Resident #47, #60, #62, #131, and #153. Record review showed Resident #47 had an annual MDS in progress dated 7/31/25 and a quarterly assessment in progress dated 8/2/25. Resident #60’s last completed MDS was dated 4/05/25, with the next quarterly assessment due 7/11/25 and still marked in progress. Resident #62’s last completed MDS was dated 4/11/25, with the quarterly assessment due 7/11/25 also in progress. Resident #131’s quarterly MDS was in progress dated 7/12/25, with the last quarterly MDS completed on 4/11/25. Resident #153’s quarterly MDS was overdue and dated 7/3/25, with the last quarterly MDS completed on 4/2/25. The residents had diagnoses including spinal stenosis, diabetes, lymphedema, cerebral infarction, dementia, Alzheimer’s disease, failure to thrive, cognitive communication deficit, heart failure, COPD, diabetes, absence of a left leg above the knee, and stage 3 CKD. During interview, the MDS Coordinator acknowledged that some MDS assessments had not been completed on time and stated, “We will make sure they get done immediately,” explaining that only two MDS Coordinators were available and both had taken time off in June and July, along with a large number of admissions and discharges.
Kitchen Food Storage, Logging, and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation, drinks in the reach-in refrigerator were not labeled or dated, two bags of sandwiches were open and not labeled, two prepared salads in the walk-in refrigerator were not labeled or dated, and a container labeled brown sugar contained brown rice. The walk-in freezer also had boxes of food stored directly on the floor, including three boxes on the floor. The Dietary Manager stated staff should have labeled and dated the foods, sealed the sandwich bags, and kept food off the floor; she also stated the brown rice would be discarded because the date it was added was unknown. The facility also failed to complete required kitchen logs and maintain the ice machine in a sanitary condition. The temperature log for the reach-in refrigerator did not include temperatures or staff initials for the night shift on three consecutive days, and the thermometer in the refrigerator read 40 F during the observation. The sanitizing sink log was not completed for breakfast, lunch, or dinner shifts across multiple days, including breakfast on the day of observation. In addition, the ice machine contained an unknown black and brown slimy substance inside the top of the machine and on the door mechanism. The Dietary Manager stated staff were expected to fill out the logs, and the Administrator stated kitchen staff were responsible for cleaning the ice machine and that contamination could get on the ice used by residents.
Incomplete and Inaccurate Medication and Bathing Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 3 of 24 residents reviewed. For Resident #135, the MAR did not accurately reflect who administered early morning medications on 5/27/25. The resident had diagnoses including COPD, narcolepsy, dementia, GERD, Alzheimer's disease, acute kidney failure, and hypertension, and the quarterly MDS reflected a BIMS score of 11. The MAR showed levothyroxine and omeprazole were given at 4:00 AM and initialed by LVN A, while a nurse statement and staff interviews described that LVN B was involved in awakening the resident and giving the medications. The resident stated she had narcolepsy and that LVN B administered the medications, and LVN B stated she physically handed the medication to the resident and that the MAR should reflect who administered it. LVN A stated she documented the MAR even though LVN B gave the medication, and the DON stated the MAR should be documented by the nurse who gave the medication. For Resident #25, the bathing documentation did not accurately reflect whether the resident received a shower. The resident had diagnoses including UTI, bacteremia, lack of coordination, urinary retention, colostomy status, and muscle weakness, and the care plan called for showers on Monday and Friday per the resident's request, with additional bathing support due to ADL deficits and resistance to care. The Task bathing document showed multiple entries marked Not Applicable on several days, while one day showed Shower and another showed Resident Refused. The resident stated he was supposed to get a shower on Saturday but did not receive one, later stated he had not gotten a shower in four days, and said staff told him they had too many residents to shower that day. CNA C stated that checking Not Applicable was not supposed to be used when a shower was refused because it implied the task did not occur, and that based on the documentation it could not be determined whether the resident received a shower. For Resident #170, the bathing records also did not accurately reflect whether showers were provided. The resident had diagnoses including diabetes, TIA, anxiety disorder, and rheumatoid arthritis, and the care plan required one-staff assistance with bathing/showering three times per week and as necessary. The Task bathing document showed Not Applicable checked on multiple bathing days, while the skin observation document showed showers on those same dates. The resident stated she was supposed to get a shower on Friday and did not get it, and said she did not receive a shower for 5 days after admission. CNA D stated that Not Applicable implied the resident did not get a shower and that if the resident refused, Resident Refused should have been checked instead. RN E stated that if a resident refused a shower, staff were supposed to notify the charge nurse and the nurse was supposed to write a progress note after prompting the resident at least three times. The DON stated that if the resident did not get a shower, the CNA was supposed to complete the shower sheet and indicate on both the shower sheet and Task document that the resident refused.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure Resident #111 had the call light within reach. Resident #111 was a [AGE] year-old female with diagnoses including hemiplegia and hemiparesis following cerebral infarction, lack of coordination, and weakness. Her most current quarterly MDS indicated she was cognitively intact for daily decision-making and dependent on staff for transfers. Her care plan identified altered musculoskeletal status related to left-sided hemiparesis and included interventions to anticipate and meet her needs and to ensure the call light was within reach and staff responded promptly. During an observation and interview, Resident #111 was sitting in a wheelchair next to her bed and was heard yelling for help several times. Her call light had not been activated, and she stated she wanted to be put in bed and did not know where the call light was. CNA C and CNA D found that the call light was clipped to the privacy curtain behind the resident and not within reach. They stated the call light should have been given to her when she was taken to her room, but they did not know which staff member had assisted her to the room. The DON stated the resident liked to be put in bed as soon as lunch was over, could not determine who left her at the bedside without the call light, and confirmed the call light should have been within reach and accessible for her to ask for assistance.
Missed and Poorly Documented Scheduled Showers
Penalty
Summary
The facility failed to ensure Resident #25 received scheduled showers and other necessary ADL assistance to maintain personal hygiene. Resident #25 was a cognitively intact male with diagnoses including UTI, bacteremia, lack of coordination, urinary retention, colostomy status, and muscle weakness. His care plan directed extensive assistance for bathing and showers on Monday and Friday per his request, and also noted that he could be resistive to care and refuse showers and ADL care. Record review showed the bathing task documentation repeatedly marked bathing as "Not Applicable" on multiple days between 7/31/25 and 8/13/25, with only one shower entry on 8/5/25 and a later refusal entry the same day. Skin observation documentation showed refusals on 8/7/25 and 8/9/25, and a shower on 8/12/25, while documentation for 7/31/25 to 8/4/25 was not provided. During interviews, Resident #25 stated he was supposed to get a shower on 8/9/25 but did not know why it was not given, and later stated he had not received a shower in four days and had been told staff did not have time for him on 8/9/25. Staff interviews indicated the bathing documentation was inconsistent and did not clearly show whether showers were completed or refused. CNA C stated the "Not Applicable" entry should not have been used because it implied the task did not occur, and that refusals should have been documented as refusals on both the task document and shower sheet. RN F and the DON stated that when a resident refused, staff were to notify the nurse, encourage the resident, and document the refusal on the shower sheet and in a progress note. The facility policy stated residents were to receive grooming and dressing assistance as completed and showers or bed baths as scheduled and documented as indicated.
Improper Dumpster and Refuse Disposal
Penalty
Summary
Dumpster #1 was found with its side door open and trash on the ground beside it, including a wipe, a used glove, and a plastic wrapper. During interview, the Dietary Manager stated the dumpster should not be open because it can attract rodents or pests, and the Administrator stated staff are expected to keep the dumpster closed and trash off the ground. A trash policy was requested from the Dietary Manager and the Administrator but was not provided.
Hand Hygiene Not Maintained During Wound Care Preparation
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #47 during wound care preparation. Resident #47 was an [AGE]-year-old female admitted with spinal stenosis, type 2 diabetes mellitus, and lymphedema. Her quarterly MDS assessment reflected intact cognition and identified one unhealed pressure ulcer. Her care plan documented a stage 4 sacral pressure ulcer with interventions to administer ordered treatments and monitor effectiveness. Physician orders required sacral wound care on Monday, Wednesday, and Friday, and the skin assessment documented a stage 4 sacral wound measuring 2.5 cm x 2.5 cm x 2.0 cm with 1.5 cm undermining. During observation, the treatment nurse prepared supplies for wound care, reached into her pocket for her personal cell phone, placed it on the treatment cart, did not sanitize her hands, and then grabbed a handful of gloves from a box and placed them on the bedside table before providing wound care to the resident’s open pressure wound. In interview, the nurse stated she thought she sanitized her hands after touching her phone but, if she had not, she would have contaminated the gloves she touched after touching the phone. The DON stated she could not say whether the gloves were contaminated and noted that if they were, the resident would be at risk of infection. The facility policy stated hand hygiene is the primary means to prevent the spread of infections and requires hand hygiene before handling clean or soiled dressings and after handling contaminated equipment.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to a significant accident. A medication aide, who was working as a CNA, provided incontinent care to a resident without assistance, despite the resident's care plan indicating a need for two-person assistance. During the care, the resident, who had severe cognitive impairments and was dependent on staff for bed mobility, fell from the bed and sustained fractures to both knees. The resident's care plan and Kardex did not clearly specify the number of staff required for assistance, leading to confusion among staff members. The medication aide believed the resident was a one-to-two-person assist and attempted to provide care alone. This misunderstanding, combined with the resident's use of an air mattress, which can be unstable, contributed to the accident. Interviews with staff revealed that the resident was known to require two-person assistance for bed mobility, as confirmed by occupational therapy evaluations. However, the care plan documentation was inconsistent, leading to the aide's incorrect assumption. The incident resulted in the resident being hospitalized with fractures, highlighting the facility's failure to provide adequate supervision and assistance devices to prevent accidents.
Removal Plan
- Medical Director notified of Immediate Jeopardy.
- Resident RP was notified of Immediate Jeopardy.
- Resident #1 was sent to the hospital and is no longer in the facility.
- In-services conducted: Abuse and Neglect at 100% for all staff, Review of Kardex to determine who is a 2 person assist with ADL-bed mobility to all licensed nurses, CNAs and CMAs at 100%, OT and PT were in-serviced at 100% on evaluating new admissions to determine ADL-bed mobility status, and all licensed nurses were in-serviced at 100% to refer to special instructions in resident's care profile to ensure ADL-bed mobility documentation is accurate.
- Any employee not receiving in-services will not be allowed to work their shift until in-services have been received.
- Audit of resident ADLs- bed mobility to identify residents who require 2 persons assist completed at 100% by nursing and therapy services.
- Any resident identified as 2 persons assist for ADLs-bed mobility will be added to the Kardex/Careplan and Special Instructions in the resident's care profile.
- CNA A was in-serviced 1:1 on 2 persons assist for ADLs- bed mobility and referring to Kardex for ADL- bed mobility status.
- Residents safe surveys were started and to be completed.
- DON/ADON started in-services on Abuse and Neglect at 100% for all staff, Review of Kardex to determine who is a 2 person assist with ADL-bed mobility to all licensed nurses, CNAs and CMAs at 100%, all licensed nurses were in-serviced at 100% to refer to special instructions in resident's care profile to ensure ADL-bed mobility documentation is accurate.
- Starting an audit of resident ADLs- bed mobility to identify residents who require 2 persons assist completed at 100% by nursing and therapy services.
- Starting any resident identified as 2 persons assist for ADLs-bed mobility will be added to the Kardex/Careplan and Special Instructions in the resident's care profile.
- Starting any new residents will be evaluated by therapy services to determine if a resident requires 2 persons assist with ADL-bed mobility and will ensure it is added to Kardex/Care Plan and to special instructions in resident's care profile.
- Starting any new hires, licensed and certified will receive all in-services before working their assigned shift.
- Two MDS nurses will verify that all new assessments careplan and Kardex correlate with the plan of care. A log with 2 verification signatures will be in place and will be ongoing.
- All nurses CNAs and CMAs will complete a Bed mobility competency prior to working the floor. The competencies will be completed.
- All new hires will receive a bed mobility competency prior to working the floor.
- DON/Designee will ensure any resident requiring 2 persons assist with ADL-bed mobility is added to care plan/Kardex and special instructions of resident's care profile.
- DON/Designee will review new admissions to ensure if a resident requiring 2 persons assist with ADL bed mobility it is added to the Kardex/Care Plan and special instructions of resident's care profile.
- The plan will be reviewed with all nurse managers who will monitor staff when making rounds to ensure the plan is being followed.
- The DON /Administrator will observe 10 staff members a week for verification of proper use of care plans and Kardex.
- The DON/ ADON will verify MDS verification log is accurate by reviewing the log weekly.
- DON/designee will observe 5 nursing staff weekly complete proper bed mobility.
- Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.
Failure to Report Resident Fall and Injury
Penalty
Summary
The facility failed to report an incident involving a resident who required two-person assistance for bed mobility but was provided care by a single staff member, resulting in a fall and serious injury. The resident, a female with severe cognitive impairment and multiple medical conditions, including cerebral palsy and a stage 4 pressure ulcer, was dependent on staff for all activities of daily living. Despite this, a medication aide, who was working as a CNA, attempted to provide incontinent care alone, leading to the resident falling from the bed and sustaining fractures to both knees. The incident was not reported to the State Survey Agency or other relevant authorities within the required timeframe. The facility's policy mandates that any allegations of abuse, neglect, or mistreatment, including injuries of unknown source, be reported immediately, or within two hours if serious bodily injury occurs. However, the facility did not adhere to this policy, as evidenced by the lack of a self-report in the TULIP system and the delay in notifying the appropriate parties. Interviews with staff revealed a lack of clarity and communication regarding the resident's care requirements. The care plan and Kardex did not specify the need for two-person assistance, leading to confusion among staff. The Director of Nursing acknowledged the oversight and the potential for accidents due to the lack of clear instructions. Despite the incident being witnessed, the facility did not take immediate steps to report the injury, highlighting a significant deficiency in their reporting and communication processes.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. Specifically, the care plan did not address the resident's need for two staff members to assist with bed mobility, despite the resident's severe cognitive impairment and total dependence on assistance for activities of daily living (ADLs). The resident, a female with multiple diagnoses including encephalopathy, cerebral palsy, and a stage 4 pressure ulcer, was admitted with a requirement for total assistance with bed mobility, as noted in her occupational therapy evaluation and daily skilled progress notes. The care plan, last revised in December, failed to specify whether one or two staff members were needed for assistance, leading to inconsistencies in care delivery. Interviews with facility staff revealed that the electronic medical records system provided prepopulated interventions, which may have contributed to the oversight. The Director of Nursing acknowledged that the care plan and Kardex did not clearly indicate the number of staff required for assistance, which could lead to accidents. The facility's policy mandates the development of a comprehensive care plan by the interdisciplinary team within seven days of completing the Resident Minimum Data Set (MDS), but this requirement was not met in this case.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a CNA provided incontinent care to a resident without performing appropriate hand hygiene between glove changes. The CNA removed gloves after wiping the resident's peri area but did not sanitize her hands before putting on new gloves. Additionally, the CNA applied medicated cream and put on a clean brief without changing gloves, which could lead to infection. The CNA admitted to forgetting to use hand sanitizer due to nervousness and was unsure about the hand hygiene protocol between glove changes. In the second incident, a resident's catheter bag was found lying on the floor without a cover, which is against the facility's infection control policy. The resident, who required assistance to move, was unaware of how the catheter bag ended up on the floor. Staff members acknowledged that the catheter bag should not be on the floor due to infection risks. Despite multiple staff interactions with the resident that day, the catheter bag was not properly managed, indicating a lapse in following the facility's policy for catheter care. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) provided conflicting information regarding hand hygiene protocols, with the ADON stating that staff should sanitize hands between glove changes. The facility's policy on hand hygiene was not provided during the survey, highlighting a potential gap in staff training and policy enforcement. These deficiencies in infection control practices could place residents at risk for infections due to improper care practices.
Failure to Ensure Timely Vital Sign Checks Before Dialysis
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards. The deficiency involved a resident with acute kidney failure, type 2 diabetes, and hypertension, who was scheduled for hemodialysis every Monday, Wednesday, and Friday. On a specific date, the resident's vital signs were not checked immediately before leaving for dialysis, as required by the facility's policy. Instead, the vital signs recorded were from earlier in the day, which could have changed by the time of the dialysis appointment. Interviews with staff revealed inconsistencies in the understanding and execution of the facility's policy regarding the timing of vital sign checks before dialysis. The Director of Nursing (DON) stated that vital signs should be taken within 30 minutes to an hour before the resident leaves for dialysis. However, the Licensed Vocational Nurse (LVN) and Medical Assistant (MA) involved did not adhere to this timeframe, with the LVN using morning shift vital signs and the MA unable to recall obtaining the vital signs. This lack of adherence to the policy and communication among staff led to the deficiency in providing appropriate dialysis care.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their Minimum Data Set (MDS) records. For Resident #95, the Quarterly MDS assessment did not document that the resident was receiving hospice services, despite the care plan and hospice physician recertification indicating hospice admission due to a terminal diagnosis of cardiac arrest and anoxic brain injury. The MDS Coordinator acknowledged that hospice services should have been marked to ensure proper care planning. For Resident #104, the Discharge MDS assessment inaccurately recorded the discharge status as being to a Short-Term General Hospital, while the discharge progress note indicated the resident was discharged home with their daughter. The MDS Nurse confirmed the discrepancy, acknowledging that the MDS was coded incorrectly and should have reflected the resident's discharge to home. These inaccuracies in the MDS assessments could risk improper or incorrect care for the residents.
Failure to Coordinate PASRR Assessments for Resident with Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for a resident, leading to a deficiency in ensuring accurate PASRR Level 1 Screening. The resident, a male with diagnoses including depression and insomnia, was admitted with a hospital record indicating a diagnosis of major depressive disorder (MDD). However, the PASRR Level 1 Screening completed prior to admission did not reflect this mental illness diagnosis. This oversight was not corrected by the facility, as the MDS nurse did not notice the discrepancy and failed to contact the hospital to amend the PASRR screening. Interviews with facility staff revealed a lack of awareness and responsibility regarding the PASRR process. The MDS nurse acknowledged the missed opportunity to provide the resident with necessary psychiatric services due to the incorrect PASRR screening. The Director of Nursing (DON) was also unsure of the implications of not listing the MDD diagnosis as active, despite the resident having medication orders for depression. The facility's policy required designated individuals to follow up on PASRR screenings and coordinate with local authorities for Level II evaluations if needed, but this was not effectively implemented in this case.
Incomplete Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, which was identified during a survey. The resident, who was admitted with diagnoses including paraplegia, hypotension, and gastro-esophageal reflux disease, had a care plan that was missing critical information. The care plan did not address several of the resident's health conditions and needs, such as nephrostomy catheter, urinary catheter, colostomy status, heart failure, acute and chronic kidney disease, enhanced barrier precautions, the need for a pressure-reducing bed and wheelchair, and the use of hydrocodone. During an interview, the MDS Coordinator confirmed that the care plan was incomplete and acknowledged that it had not been fully updated following the resident's recent readmission from the hospital. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan for each resident, but this was not adhered to in this case, leading to a deficiency in the resident's care planning.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8% due to errors involving two residents. The first incident involved a resident with chronic heart conditions who was not administered isosorbide mononitrate as prescribed. The Certified Medication Aide (CMA) responsible for the administration was distracted by the unavailability of another medication, apixaban, and failed to dispense the isosorbide mononitrate, although it was marked as administered in the electronic medication record (EMR). This oversight was discovered during a surveyor's observation, where the CMA admitted to the error after being prompted to recount the medications. The second incident involved a resident with type 2 diabetes mellitus who was administered insulin aspart incorrectly. The Licensed Vocational Nurse (LVN) did not prime the insulin pen before administration, which is a necessary step to ensure the correct dosage is delivered. The LVN was unaware of the need to prime the pen with each use, believing it was only necessary upon first opening. This misunderstanding was clarified during an interview with the Director of Nursing (DON), who confirmed that priming is required to avoid dosage errors. The facility's policies on medication and insulin administration were not adhered to in these instances. The medication administration policy requires verification of medications against the resident's Medication Administration Record (MAR) before administration, which was not followed by the CMA. Similarly, the insulin administration policy mandates priming the pen before each use, a step that was neglected by the LVN. These procedural lapses contributed to the medication errors observed during the survey.
Failure to Document Major Depressive Disorder Diagnosis
Penalty
Summary
The facility failed to maintain accurate medical records for a resident diagnosed with Major Depressive Disorder (MDD). The resident's medical records did not reflect this diagnosis, despite it being documented in hospital records and the resident being prescribed venlafaxine for depression. The omission was identified during a review of the resident's admission record, quarterly MDS assessment, and physician's orders, which only listed depression and not MDD. This discrepancy was noted during interviews with the MDS nurse and the Director of Nursing (DON), who acknowledged the oversight but were unsure of the potential implications for the resident's care. The MDS nurse admitted to reviewing the hospital paperwork but did not recall seeing the MDD diagnosis, which she would have added if noticed. The DON confirmed that the charge nurse was responsible for entering medical information, with the MDS nurse following up to ensure accuracy. The facility's policy requires maintaining a health record for each resident, including current diagnoses, but this was not adhered to in this case. The failure to document the MDD diagnosis could lead to the resident missing out on necessary psychiatric services.
Infection Control Deficiencies in Insulin and Nephrostomy Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving staff members. In the first incident, a Licensed Vocational Nurse (LVN) did not clean the rubber stopper on an insulin pen before administering insulin to a resident with type 2 diabetes and hemiparesis. The LVN admitted to not cleaning the pen in the resident's room, which could lead to contamination and infection. The Director of Nursing (DON) confirmed that the insulin pen should be cleaned before use to prevent infection. In the second incident, another LVN did not change gloves while providing nephrostomy care to a resident with a history of genitourinary issues and urinary tract infection. The LVN failed to change gloves between removing a dirty bandage and applying a clean one, which could contaminate the site. The DON acknowledged that gloves should be changed to prevent infection, although the facility did not have a specific policy for nephrostomy care. The facility's existing policies for insulin administration and nephrostomy tube management were not followed, contributing to these deficiencies.
Failure to Assist with Eating and Honor Food Preferences
Penalty
Summary
The facility failed to provide Resident #2 with assistance during his lunch service, leaving him waiting for at least 10 minutes with an untouched meal tray in front of him. Resident #2, who has moderate mental cognition impairment and requires assistance with eating due to lack of coordination and muscle weakness, expressed his hunger and frustration during the wait. Despite his care plan indicating the need for assistance, staff were not immediately available to help him, and the Director of Nursing (DON) was unaware of his need for assistance. Speech Therapy and the Director of Rehab confirmed that Resident #2 required physical assistance with eating, which was not promptly provided on the observed date. The facility also failed to accommodate Resident #3's food preferences, leading to her receiving tater tots instead of the potato chips she had requested. Resident #3, who has intact cognition and a history of cognitive communication deficit, felt upset and unheard due to this oversight. The Dietary Supervisor acknowledged the importance of following residents' preferences to ensure their happiness and nutritional intake but admitted that the facility ran out of potato chips and substituted them without informing Resident #3. This failure to honor her food preferences contributed to her feeling of being disregarded by the facility.
Failure to Document Lactose Allergies in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, specifically regarding their lactose allergies. Resident #1, who has severe mental cognition impairment and a history of gastrointestinal issues, did not have their lactose allergy documented in their care plan or admission record. Similarly, Resident #5, who also has severe mental cognition impairment and a diagnosis of moderate protein calorie malnutrition, did not have their lactose allergy documented in their care plan or admission record. Despite the absence of weight loss in both residents, the lack of documentation could lead to potential allergic reactions, as noted by the dietary orders on their meal tray tickets. Interviews with the Director of Nursing (DON) and MDS Coordinators revealed a lack of awareness and adherence to the facility's policy on documenting dietary allergies in care plans and admission records. The DON was unaware that allergies should be listed on care plans, while the MDS Coordinators confirmed that dietary allergies needed to be care planned and documented to prevent allergic reactions. A CNA/MA also emphasized the importance of listing allergies in the admission record to avoid negative reactions. The facility's policies on menu planning and comprehensive person-centered care planning were not followed, leading to this deficiency.
Failure to Accommodate Dietary Restrictions and Preferences
Penalty
Summary
The facility failed to ensure that Resident #1 received food that accommodated her lactose intolerance. On 03/21/24, Resident #1 was served 1% low-fat milk and sausage with gravy containing dairy products, despite her meal tray ticket indicating a lactose allergy and a preference for lactose-free milk. The Resident Care Coordinator and Dietary Supervisor confirmed the error, and the nursing staff monitored Resident #1 for any adverse effects. Resident #1's records showed severe mental cognition impairment and no weight loss since admission, but her dietary restrictions were not properly followed during the breakfast meal on 03/21/24. The facility also failed to accommodate Resident #4's food preferences. On 03/21/24, Resident #4 was served mixed vegetables for lunch, despite his meal tray ticket indicating a dislike for mixed vegetables. The Dietary Supervisor acknowledged the mistake and offered a substitute, which Resident #4 declined. Resident #4's records showed a diagnosis of protein-calorie malnutrition and relatively stable weight, except for weight changes due to an amputation. The Dietary Supervisor admitted to sometimes not following recipes strictly, which led to the oversight of Resident #4's food preferences.
Failure to Follow Menu and Recipe
Penalty
Summary
The facility failed to ensure the menu was followed for one of the three meals observed. Specifically, the lunch meal on 03/21/24 included mushrooms in a Chicken Enchilada Casserole, which was not part of the recipe. The facility's menu for that day indicated that Chicken Quesadilla Casserole was to be served. During an observation and interview, the Dietary Supervisor confirmed the inclusion of mushrooms and admitted to sometimes not following recipes to 'elevate' the food. The facility's policy requires any changes to the planned menu to be noted, which was not done in this instance. This failure could affect residents by contributing to dissatisfaction, poor intake, and weight loss.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 711 citations issued within 25 miles in the last 12 months — including the 11 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.
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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Mccullough Hall Nursing Center Inc | 1.5 mi | — | 0 | 0 |
| Legend Oaks Healthcare And Rehabilitation Center - | 1.8 mi | ★★★★★ | 17 | 0 |
| Avir At San Antonio | 2.5 mi | ★★★★★ | 6 | 0 |
| San Jose Nursing Center | 3.1 mi | ★★★★★ | 1 | 0 |
| Harbor Valley Health And Rehabilitation | 4.8 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.