Average — CMS composite of the measures below.
The next survey window likely opens around May 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 Inspiration Hills Rehabilitation Center during CMS and state inspections, most recent first.
Failure to maintain an ordered fall mat for a resident at risk for falls. A resident with severe cognitive impairment, osteoarthritis, and multiple prior fractures had a care plan and active order for a floor mat while in bed, but surveyors repeatedly observed no mat beside the bed. CNAs and an LVN stated they were unaware of the fall mat need, while the DON stated that if ordered, the mat should be in place and that fall interventions are communicated by charge nurses.
Incorrect Zyprexa Dose Remained Active on MAR: A resident with psychotic disorder and hallucinations had a Zyprexa dose reduced per MD order, but the prior 10 mg order was not discontinued and both the 5 mg and 10 mg doses remained active on the MAR. The MAR showed both doses were administered daily until clarification was entered, and the LVN stated he entered the new order but thought the old order had been discontinued.
Medication administration error rates exceeded the allowed threshold when an MA gave scheduled meds to two residents after the ordered 9:00 a.m. time. One resident had dementia, HTN, atherosclerosis, and clotting-related diagnoses and received acetaminophen, warfarin, atenolol, and enalapril late; another resident with HTN, depression, anxiety, and chronic pain received amlodipine, duloxetine, gabapentin, and Gemtesa late. Staff interviews confirmed expectations for timely administration, and the facility policy reviewed did not include a specific medication-time policy.
Food Storage and Labeling Deficiencies: Surveyors found uncovered, unlabeled, and undated food items in the refrigerator and freezer, including a partially unwrapped pot roast with freezer burn. They also observed dented and damaged canned fruit on the rack. The Dietary Mgr said she was new in the role, was educating staff about labeling, and did not know why the cans were not dated or why the dented cans were present; the Admin stated there were no specific kitchen policies.
A resident with type 2 DM, anxiety, adult failure to thrive, and vascular dementia had a BIMS score of 04 and was not interviewable. Her representative requested access to her medical records, but staff denied the request because they questioned the validity of the MPOA/POA on file, and the DON and Administrator acknowledged delays in providing the records while the document was being reviewed.
Failure to Process Resident Grievances: A resident’s RP and the Ombudsman raised concerns about repeated denial of access to the resident’s medical records, but the facility did not generate grievance reports and treated the issue as a records request matter rather than a grievance. The RP also alleged the resident was injured by staff during incontinent care, and the DON stated no grievance or self-report was made. The resident had severe cognitive impairment, was not interviewable, and had diagnoses including DM2, anxiety, adult failure to thrive, and vascular dementia.
Failure to Report Alleged Abuse and Neglect: A resident with severe cognitive impairment and dementia sustained a deep gash/skin tear to a finger and bruising during incontinent care after becoming combative with a CNA. The RP accused staff of abuse and called law enforcement, but the DON and Administrator did not report the allegation to the State Survey Agency, stating the police investigation was sufficient.
The facility failed to complete person-centered care plans for three residents by not fully addressing activity preferences, in-room engagement, and wandering management. One resident who was bedbound and in pain wanted in-room activities, another resident signed himself out and left the facility daily but the care plan did not reflect that behavior, and a third resident’s care plan did not include psychiatric service recommendations for exercise, socialization, and cognitively stimulating activities.
Failure to Provide Ongoing Individual and Independent Activities: Two residents with significant medical and functional limitations did not have consistent documentation of individual or independent activities that matched their preferences and psychosocial needs. One resident with CAD, ESRD, DM, CVA, depression, pain, and bedfast status reported wanting in-room activities but said staff were too busy to offer them, while another resident with severe cognitive impairment, hemiplegia, anxiety, and wheelchair dependence preferred family visits, TV, snacks, and music and had limited activity documentation despite care plan directions and psych recommendations for social and cognitively stimulating engagement.
A resident with a Foley catheter was observed with the tubing not secured to the leg during care, and staff acknowledged it should have been secured to prevent pulling and injury. In a separate observation, two CNAs provided incontinent care to another resident with bowel incontinence and an indwelling catheter but did not clean the inner thighs or right buttock area before applying a clean brief, despite the care plan and facility policy requiring thorough perineal cleansing.
A resident with a G-tube, CVA, dysphagia, and severe cognitive impairment was observed receiving incontinent care with the HOB flattened while tube feeding continued to infuse. Two CNAs did not call the nurse to stop the pump before care, and the resident remained flat for 36 minutes while appearing uncomfortable. Interviews confirmed staff knew the pump should be stopped and that only nurses handle the tube and pump.
A resident receiving continuous O2 via nasal cannula had the cannula found on the floor while the concentrator was running. A CNA placed the cannula back on the resident’s face before an LVN identified it as contaminated and replaced the cannula and tubing. The resident had diagnoses including hypertensive heart disease and atherosclerotic heart disease, and the care plan called for O2 at 2 L/min to maintain O2 sats above 92%.
A resident with severe cognitive impairment, incontinence, and multiple comorbidities received incontinent care during which a CNA failed to follow the facility’s hand hygiene and glove use practices. After initially washing hands, the CNA used bare hands to adjust the bed and then donned gloves without re-washing, handled clean wipes, performed perineal care, and then used the same soiled gloves to prepare a clean brief and bed pad before finally removing gloves and washing hands. The CNA later acknowledged this was inconsistent with facility policy, while the DON and ADON/Infection Preventionist confirmed that staff are required to perform hand hygiene before donning gloves, between glove changes, and after contact with room surfaces, as outlined in the facility’s written hand hygiene policy and prior staff training.
A resident with severe cognitive impairment and a history of combative and resistant behaviors during care did not have a comprehensive, person-centered care plan that addressed these issues. Despite multiple documented incidents of aggression, refusal of care, and self-injury, the care plan was not updated in a timely manner to include interventions or measurable objectives for managing these behaviors, contrary to facility policy and best practices.
Surveyors identified multiple failures in food storage and handling, including a dirty ice maker used for resident hydration, open and unlabeled food items in a medication refrigerator, and unrefrigerated thickened water and nutritional drinks on medication carts. Staff were unaware of manufacturer requirements for refrigeration after opening, and facility practices did not align with professional standards or internal policies.
Surveyors found that the facility did not develop or implement comprehensive care plans for multiple residents, including those on hospice, with wandering behaviors, or with contractures. For example, a resident on hospice had no care plan interventions for comfort, while others with orders for Wanderguard devices or psychotropic medications lacked specific care plan details and monitoring. Additionally, two residents with contractures did not have consistent or appropriate interventions documented or implemented.
Three dependent, cognitively impaired residents did not receive multiple scheduled showers, with documentation showing missed care and no evidence of refusals or rescheduling. Staff interviews revealed inconsistent communication and documentation practices, and the facility did not follow its policy requiring proper recording of showers and staff participation.
Surveyors found that hand sanitizer was stored in unsecured locations accessible to residents, including those with cognitive impairment, and that a resident with severe cognitive impairment and a recent fall was repeatedly observed in bed without required fall mats in place. These deficiencies placed residents at risk for injury due to inadequate supervision and lack of safety devices.
A resident with severe cognitive impairment and multiple physical diagnoses experienced a fall resulting in injury. Although the facility's investigation identified new interventions such as lowering the bed, ensuring the call light was within reach, and using fall mats, these were not incorporated into the resident's care plan. Observations confirmed that some interventions were implemented, but the care plan was not updated to reflect all planned changes.
A resident with diabetes, dementia, and vision problems did not receive timely ophthalmology evaluation after a missed appointment due to lack of family accompaniment. The facility failed to reschedule the appointment or ensure follow-up, resulting in continued vision difficulties and delayed care.
Two residents with significant contractures and severe cognitive impairment did not receive appropriate contracture management devices or interventions as ordered and care planned. One resident's left palm protector was not applied as required, and another resident with a right hand contracture had no assistive device in place, despite care plans and policies calling for such interventions. Staff interviews confirmed a lack of consistent application and monitoring of these devices.
Surveyors found that the facility's medication error rate was 8.11%, exceeding the acceptable threshold. Two residents were affected: one received medications for anxiety and personality disorder over an hour late due to staff scheduling practices, and another had a vitamin supplement documented as given but not actually administered, with no proper notation in the eMAR. These errors were attributed to staff scheduling, workload, and failure to follow documentation policy.
A resident with severe cognitive impairment and multiple medical conditions was given Carvedilol on several occasions when their blood pressure or heart rate was below the physician-ordered parameters. Nursing staff administered the medication despite these out-of-range vital signs, and facility leadership was either unaware or indicated that nurses could use their judgment in such cases, contrary to policy.
A CNA was observed leaving a resident's room wearing soiled gloves and carrying unbagged, soiled linen into the hallway, contrary to facility policy requiring linens to be bagged before transport and gloves to be removed before exiting. Additionally, a CMA used a reusable blood pressure cuff on two residents without cleaning it between uses, and no sanitizing wipes were found in the medication cart, despite facility policy requiring equipment to be cleaned between residents.
Failure to Maintain Ordered Fall Mat for a Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure Resident #41's floor mat was in place. Resident #41 was a [AGE]-year-old female admitted to the facility with diagnoses including unilateral primary osteoarthritis of the right knee, Alzheimer's disease, unspecified fractures of the lumbar vertebra, shaft of the left humerus, and right femur. Her quarterly MDS showed a BIMS of 5, indicating severe cognitive impairment. Her comprehensive care plan identified her as at risk for falls due to difficulty walking and documented a history of multiple falls, with interventions including that she may use a fall mat while in bed. Her order summary also showed an active order for 1-2 floor mats to be placed while in bed for safety. Survey observations found no floor mats placed next to Resident #41's bed while she was in bed on multiple occasions. During interviews, CNA D and CNA E stated they were not aware that Resident #41 needed a fall mat and said fall interventions are communicated by the nurse. LVN B stated she was not aware the resident was supposed to have a fall mat, while LVN A stated the resident's interventions included a low bed and fall mat but did not know why it was not in place on previous days. The DON stated that if there was an order for a fall mat, it should be in place, and later stated that fall interventions such as fall mats are communicated to CNA staff by charge nurses and followed according to orders and care plans.
Incorrect Zyprexa Dose Remained Active on MAR
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of Resident #32 when the facility failed to discontinue an old Zyprexa 10 mg order after the dose was changed to 5 mg in the evening. Resident #32 was admitted with a diagnosis of psychotic disorder with hallucinations and was documented as rarely/never understood with severely impaired cognition. The resident’s care plan addressed psychotropic medication use and gradual dose reduction considerations, and a pharmacy recommendation was made to decrease Zyprexa from 10 mg to 5 mg in the evening, which was signed by the physician on 5/22/2026. The active order summary showed both Zyprexa 5 mg and Zyprexa 10 mg as active, and the MAR showed both doses were administered daily from 5/22/2026 until a clarification order was entered on 6/3/2026. During interview, LVN A stated he received the dose reduction order, notified the hospice provider, entered the new 5 mg order, and thought he had discontinued the 10 mg order, but did not know why it remained active. The DON stated the charge nurse was responsible for entering new orders into the MAR and later obtained clarification from hospice regarding the medication dose.
Medication Administration Times Not Followed
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5 percent. Surveyors observed a medication error rate of 32% based on 8 errors out of 25 opportunities, involving two residents and one medication aide during medication administration observations. The errors involved medications being administered outside the scheduled administration window for two residents. Resident #2 was an older male admitted with diagnoses including unspecified dementia, hypertensive heart disease, atherosclerosis of the aorta, and embolism and thrombosis of arteries of the extremities. His medication orders included acetaminophen, warfarin, atenolol, and enalapril, with scheduled administration times of 9:00 a.m. During observation, MA A began preparing and then administered Resident #2's medications at 10:30 a.m. to 10:36 a.m., after the scheduled time shown on the eMAR. MA A stated the medications were due at 9:00 a.m. and said she did not get there until 9:00 a.m. Resident #3 was an older female admitted with diagnoses including hypertensive heart disease, major depressive disorder, anxiety, and chronic joint pain. Her orders included amlodipine, duloxetine, gabapentin, and Gemtesa, with scheduled administration times of 9:00 a.m. for the daily medications and 9:00 a.m., 1:00 p.m., and 5:00 p.m. for gabapentin. During observation, MA A prepared and administered Resident #3's medications at 10:36 a.m. to 10:40 a.m., after the scheduled 9:00 a.m. time shown on the eMAR. Interviews with LVN C, LVN B, and the DON reflected that staff were trained on medication administration times and that medications should generally be given within one hour before or after the scheduled time, with notification to the MD, DON, ADON, and family if given late. The facility's policy titled Administering Oral Medications did not include a specific policy regarding medication administration times, and the referenced Administering Medications policy was not available.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety during a kitchen review. During an observation and interview on 06/01/2026 at 9:10 a.m., surveyors found food items in the commercial refrigerator and freezers uncovered, unlabeled, and undated. The commercial freezer also contained a pot roast that was partially unwrapped, unlabeled, and undated with freezer burn. Surveyors also observed canned foods that were dented and damaged, including 102-ounce cans of mangos and pineapples with deep dents. The Dietary Manager stated she was not sure why canned foods were not labeled with the date the supplier delivered them, said she was new in the role for four weeks, and stated she had been educating dietary staff about labeling foods. She stated she did not know why dented cans were on the rack and was observed removing them during the tour, adding that dented cans should have been thrown away. The Dietary Aide stated that labeling food helped with food safety and that dietary staff may have missed some food items. The Administrator stated there were no specific policies for the kitchen.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to provide Resident #30 and her representative access to her personal and medical records within 24 hours of request. Resident #30 was admitted and re-admitted to the facility, had diagnoses including type 2 diabetes, anxiety disorder, adult failure to thrive, and vascular dementia, and had a quarterly MDS assessment showing a BIMS score of 04, indicating severe cognitive impairment. She was documented as not interviewable during observation, and her medical power of attorney dated 01/03/2020 identified her representative as the person authorized to make health care decisions on her behalf. During interview, the representative stated she had contacted Medical Records, Social Worker, DON, and the Administrator about obtaining Resident #30's records and was told she was not the legal representative and that the MPOA/POA on file was not valid, so she would not have access to the records. The Ombudsman reported the facility was questioning the signed POA and denied the request based on concerns about validity. The DON and Administrator both acknowledged delays in providing the records because the MPOA was being reviewed for validity, and the DON stated the legal team had been reviewing the document.
Failure to Process Resident Grievances
Penalty
Summary
The facility failed to ensure that a resident’s representative could voice grievances without discrimination or reprisal and failed to establish grievance reports for concerns raised by the resident’s representative and the Ombudsman. Resident #30 was an elderly female with diagnoses including type 2 diabetes, anxiety disorder, adult failure to thrive, and vascular dementia, and her quarterly MDS reflected a BIMS score of 04 indicating severe cognitive impairment. She was not interviewable during observation because she responded inappropriately to questions. The resident’s representative stated she had requested access to the resident’s medical records for two years and had been denied both times. She reported bringing her concerns to Medical Records, Social Worker, DON, and Administrator, but said there was no resolution and only delays. The Ombudsman also reported concerns about the representative’s denial of access to the medical records and stated the situation was ongoing and unusual. The Social Worker stated the representative wanted the records, was directed back to Medical Records, and was told to submit another request or ask for the denial reason, but the concern was not tracked as a grievance because it was viewed as a quick resolution. The DON stated the representative’s concerns were discussed during the care plan meeting, but she did not recall all details and believed there was no need to file a grievance. The Administrator stated the facility denied access to the records because of an invalid address and what she believed was an invalid POA in the chart, and later found an old POA in storage naming the representative to make all health care decisions. The report also states the representative contacted law enforcement alleging the resident was injured by facility staff after incontinent care, and the DON said no grievance or self-report was made about that incident.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that an allegation of abuse and neglect involving a resident with severe cognitive impairment was reported to the State Survey Agency within the required timeframe. Resident #30 was an elderly female with diagnoses including type 2 diabetes, anxiety disorder, adult failure to thrive, and vascular dementia. Her quarterly MDS reflected a BIMS score of 04, indicating severe cognitive impairment, and she was documented as requiring dependent assistance to supervision or touching assistance for functional abilities. On 05/19/2026, Resident #30 was involved in an incident during incontinent care in which staff reported that she became combative and pulled a CNA's hair. During the incident, blood was observed on her fingers, and she sustained a deep gash/skin tear to her right ring finger along with bruising on her hands and arms. The resident's representative later reported the injury to the DON and Social Worker and stated she was told the resident had become aggressive with the CNA. The representative also stated she did not receive follow-up after requesting information about what occurred. The record and interviews showed that the representative accused staff of abusing Resident #30 and called law enforcement to the facility. Law enforcement responded and investigated the matter, and the facility later stated the allegations were not substantiated. However, the DON and Administrator stated the incident was not reported to the State Agency because law enforcement had investigated it. The Administrator acknowledged she was the Abuse Coordinator, that allegations of abuse and neglect were to be reported to the State Agency within 2 hours after being reported to her, and that she did not investigate the incident further or report it to the State Agency.
Incomplete person-centered care plans for activities, room engagement, and wandering management
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that addressed the psychosocial needs and preferences of three residents. For one resident with CAD, HTN, ESRD, DM, CVA, depression, intact cognition, pain, and limited mobility requiring a manual wheelchair, the care plan included a goal to attend activities of choice and interventions to assist with activity participation, but it did not include additional comments or independent bedbound room activities. Records showed the resident was bedfast, preferred to stay in bed, and had been spending more time in bed due to incontinence and pain. During interview, the resident stated she could not participate in group activities because of lower-extremity pain and difficulty walking, and that she would enjoy in-room activities if offered. For another resident with CAD, HTN, DM, non-Alzheimer's dementia, and depression, the care plan addressed wandering/elopement risk and use of a WanderGuard, but it did not mention that the resident signed himself out of the facility and left into the community unattended. The care plan also did not reflect updates about the alarm being used to sound near exit doors and being turned off during the day. The interdisciplinary care conference documented that the resident was oriented and alert with some forgetfulness, used a walker, and signed himself out to visit girlfriends in the community from time to time. During interview, the resident stated he was allowed to leave on his own, signed out daily, took a bus around town, and was upset about being required to wear the WanderGuard. For a third resident with HTN, peripheral vascular disease, renal insufficiency, neurogenic bladder, DM, CVA, hemiplegia, anxiety disorder, and severe cognitive impairment, the care plan stated the resident attended activities of choice and should be encouraged to participate in activities, but it did not include additional comments or psychiatric treatment recommendations. The psychiatric services note recommended exercise, physical therapy if approved, social functions with friends and family, cognitively stimulating activities, reading the newspaper, and audiobooks or online brain exercises. During observation, the resident was lying in bed with a splint on the right hand and a Foley catheter at bedside, and an interview attempt showed speech difficulties and inability to be understood.
Failure to Provide Ongoing Individual and Independent Activities
Penalty
Summary
The facility failed to ensure that residents received an ongoing program of activities that supported their choices and met their physical, mental, and psychosocial needs for 2 of 8 residents reviewed. The deficiency involved Resident #26 and Resident #34, both of whom had care plans that called for participation in activities of choice and invitations to group activities, but the record did not show consistent individual or independent activities being provided and documented during the review period. Resident #26 was a female with diagnoses including CAD, HTN, ESRD, DM, CVA, and depression. Her MDS showed a BIMS score of 13, indicating cognition intact, and she required dependent to setup or clean-up assistance and used a manual wheelchair. Her care plan included attending activities of choice, maintaining involvement in cognitive stimulation and social activities, and receiving assistance/escort to activities, but no additional comments were provided and independent bedbound room activities were not noted as an intervention. An activity progress note stated she participated in activities of choice weekly and that she preferred in-room activities such as her cell phone, social media, family phone calls, games, texting, and reading. A pressure ulcer risk evaluation identified her as bedfast and very limited, and a social service assessment noted she had been in bed more, preferred to stay in bed, and was on psych services for depression, anxiety, and mood disorder. During observation and interview, she was lying in bed watching TV and stated that pain in her lower extremities made it difficult to walk, that she could not participate in group activities, and that she did not believe staff provided in-room activities because they were constantly busy and in a hurry. Resident #34 was a male with diagnoses including HTN, PVD, renal insufficiency, neurogenic bladder, DM, CVA, hemiplegia, and anxiety disorder. His MDS showed a BIMS score of 07, indicating severe cognitive impairment, and he required dependent to substantial/maximal assistance and used a manual wheelchair. His care plan directed staff to encourage participation in activities and invite him to group activities. An activity progress note documented that he declined out-of-room programs and preferred family visits, TV, snacks, and music. Psychiatric services recommended exercise, social functions, and cognitively stimulating activities such as reading the newspaper and audiobooks. During observation, he was lying in bed, and an interview attempt showed difficulty with speech and inability to be understood. The Activity Director stated bedbound residents were provided in-room activities 3 times per week and that individual activities were documented in the EMR or daily activity roster, but she was unsure why Resident #26 had only one activity progress note over a 12-week period and why Resident #34 had only two activity progress notes over a 16-week period. She also stated she could not find the documentation in the hard copy roster and activity progress notes.
Unsecured Foley Catheter and Incomplete Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident with an indwelling Foley catheter. Resident #7 was admitted with obstructive and reflux uropathy, had an order for a Foley catheter with a leg strap to be monitored each shift and as needed, and had a care plan addressing catheter-related trauma and urinary infection prevention. During observed catheter care, the Foley catheter tubing was not secured to the resident’s leg. CNA D and CNA E both stated they did not notice the catheter was unsecured, and both acknowledged that the catheter should be secured to prevent twisting, pulling, and injury. The DON also stated that indwelling catheters should be secure to prevent pulling and possible injury. The facility also failed to provide complete incontinent care for a resident who was incontinent of bowel and had an indwelling catheter. Resident #34 had severe cognitive impairment, was dependent on staff for toileting and personal hygiene, and had a care plan directing staff to cleanse the perineal area with mild cleanser after each episode. During observed incontinent care, CNA J and CNA G cleaned the penis, scrotum, and catheter tubing, and cleaned the left buttock and perineum after the resident had a small bowel movement. However, after the soiled brief was removed and a clean brief was placed, neither CNA cleaned the resident’s inner thigh areas or the right buttock area. During interview, CNA J stated she was not aware that the inner thighs and right buttock had not been cleaned and said those areas should have been wiped. CNA G stated she had received training on incontinent care and acknowledged that if the inner thigh and buttock areas were not properly cleaned, the resident could get an infection. The facility’s perineal/incontinent care policy stated that for a male resident staff should wipe the perineal area including the penis, scrotum, inner thighs, and rectal area thoroughly, including under the scrotum, the anus, and the buttocks.
Feeding Tube Left Infusing While Resident Was Flat During Care
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a feeding tube when CNA G and CNA J lowered the head of the bed to a flat position while the resident’s enteral feeding continued to infuse. The resident, a male with a history of CVA, dysphagia, severe cognitive impairment, unclear speech, and dependence on staff for ADLs and mobility, had physician orders for NPO status and continuous tube feeding at 75 mL/hr with the head of bed elevated 30-45 degrees. During observed incontinent care, the CNAs did not contact the nurse to stop the tube feeding before flattening the bed. The feeding pump continued to infuse while the resident remained flat for 36 minutes as staff provided care. During this time, the resident grunted, patted the top of his head, grasped the handrail, groaned, and appeared uncomfortable while additional cleaning was needed after he had a bowel movement. In interviews, CNA J stated she should have called the nurse to stop the pump but forgot, and acknowledged prior training that the resident could choke if his head was lowered while feeding was running. LVN C stated the CNAs normally call her to stop the pump and that the pump must be off when the resident is flat or he could aspirate. Other CNAs and the DON stated they had been trained that only nurses handle the G-tube and pump and that the resident could potentially aspirate if the head of bed was flat while tube feeding was infusing. The facility policy also stated staff caring for residents with feeding tubes are trained on complications of enteral nutrition and that aspiration risk may be affected by improper positioning during feeding.
Contaminated oxygen tubing was placed back on a resident
Penalty
Summary
Resident #7, a female admitted on 05/14/2026 with diagnoses including hypertensive heart disease and atherosclerotic heart disease, was ordered to receive oxygen at 2 L/min via nasal cannula continuously every shift. Her MDS indicated that she was rarely/never understood and received oxygen therapy, and her care plan addressed impaired gas exchange related to respiratory failure with oxygen at 2 L/min via nasal cannula to maintain O2 saturations above 92%. During observation on 06/01/2026, Resident #7 was in bed with the head of bed elevated about 30 degrees. The oxygen concentrator was running at 2 L/min, but the tubing was above her head and the nasal cannula was lying on the floor. CNA C picked up the cannula from the floor and placed it back on the resident’s face. LVN A then entered the room and stated the cannula was contaminated and immediately changed it out. CNA C stated she had put the cannula back on because she did not think it had touched the floor, but also acknowledged that it could be contaminated and cause infection if it touched the floor. LVN A stated the cannula and tubing were changed because they had touched the floor and were contaminated. The DON stated the expectation was that tubing or a nasal cannula on the floor are to be changed out to prevent infection.
Failure to Follow Hand Hygiene and Glove Use Practices During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during incontinent care for one resident. The resident was an elderly female with multiple diagnoses, including unspecified cerebral infarction, contracture of the left hand, neuromuscular bladder dysfunction with incontinence, unspecified dementia with psychotic disturbance, and constipation. A quarterly MDS showed a BIMS score of 06, indicating severe cognitive impairment, and documented that she was dependent on staff for toileting hygiene and was frequently incontinent of bowel and bladder. Her care plan identified potential or actual skin integrity impairment related to fragile skin, incontinence, limited mobility, and hemiplegia, with an intervention to keep skin clean and dry, but did not include a specific focus or problem for incontinent care. During an observation of incontinent care, two CNAs provided care to the resident. CNA A initially washed her hands, then used bare hands to manipulate the bed control and bed frame to position the resident for care. Without washing her hands after touching these room surfaces, CNA A donned clean gloves and handled clean wet wipes, arranging them on a clean surface. After completing perineal care with those gloves, CNA A used the same soiled gloves to grab and prepare a clean brief and clean bed pad. Only after preparing these clean items did CNA A remove the soiled gloves and wash her hands, then don clean gloves to place the prepared brief and bed pad under the resident, and incontinent care was completed. In interviews, CNA A acknowledged that she should have washed her hands after touching the bed control and bed frame and before donning gloves, and that she should have removed gloves, washed hands, and applied new gloves before touching the clean brief and bed pad. She stated that facility policy required handwashing after every glove change and after touching room items, and that failure to follow this could lead to infections such as UTIs. The DON and the Assistant DON/Infection Preventionist both confirmed that staff were expected to wash hands before donning gloves, between glove changes, and after touching items in the resident’s environment, consistent with facility policy. Record review showed CNA A had prior competency evaluations in handwashing, PPE use, and pericare, and had completed an infection control training course. The facility’s hand hygiene policy required hand hygiene before and after resident contact, after contact with objects in the resident’s vicinity, and after removing gloves, which was not followed during this observed episode of care.
Failure to Timely Update Care Plan for Resident with Combative Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and a history of combative and resistant behaviors during care. Despite multiple documented incidents where the resident refused care, became aggressive, scratched, hit, and bit staff, and engaged in self-injurious behaviors, the care plan did not include specific focus areas or interventions addressing these behaviors. Progress notes and interviews confirmed repeated episodes of aggression and resistance, including refusal of showers, combative actions during nail care, and self-inflicted injuries, yet these issues were not incorporated into the resident's care plan in a timely manner. Staff interviews revealed that the care plan was not updated to reflect the resident's behavioral challenges until after several incidents had occurred. The social worker and MDS coordinator acknowledged that the care plan should have been revised to include interventions for resistance to care and combative behaviors, but this was delayed due to workload and oversight. The director of nursing also confirmed that the care plan should have been updated following a significant incident where the resident became combative and injured herself during nail care. The facility's own policy requires that comprehensive, person-centered care plans be developed and revised as residents' conditions change, incorporating identified problem areas and associated risk factors. However, the care plan for this resident did not meet these requirements, as it lacked measurable objectives, timeframes, and interventions to address the resident's medical, nursing, and psychosocial needs related to her aggressive and resistant behaviors.
Deficient Food Storage, Preparation, and Distribution Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, as evidenced by multiple observations and interviews. The ice maker was found to have a black substance build-up inside, despite a contracted cleaning company having recently serviced it and a policy stating it should be cleaned at least monthly. There was no internal schedule for cleaning the ice machine outside of the contracted service every six months, and both the DON and Administrator acknowledged the risk of illness from using ice from a dirty machine. Additionally, water pitchers and ice chests containing ice from the machine were observed being used for resident hydration. Further deficiencies were observed in the handling and storage of food and drink items. Two open, undated, and unlabeled food containers were found in the medication refrigerator, which the DON confirmed should not have contained food items. Multiple open containers of thickened lemon-flavored water and nutritional drinks intended for residents were found unrefrigerated on medication carts, despite manufacturer instructions requiring refrigeration after opening. Staff interviews revealed a lack of awareness regarding proper storage requirements, and the facility practice was to keep these items unrefrigerated on the carts. The DON disagreed with the need for refrigeration and deferred to the facility pharmacist, but no follow-up was provided before the survey concluded.
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 several residents, as identified through observations, interviews, and record reviews. For one resident receiving hospice services, the care plan did not include any focus area, goals, or interventions related to hospice care, despite orders indicating the resident was on hospice and staff acknowledging that such planning should be present. This omission meant that the resident's comfort and end-of-life needs were not addressed in the care plan. Another resident with a history of wandering and an order for a Wanderguard device did not have care plan interventions addressing the use or monitoring of the device, nor were there interventions for the resident's wandering tendencies. Documentation failed to reflect the presence or monitoring of the Wanderguard, and care plans for psychotropic medications lacked specificity regarding the medications, related diagnoses, and symptoms to monitor. Similarly, another resident with wandering behaviors did not have care planning related to wandering or increased observation, and their care plan also lacked specific details about medication management. For two residents with contractures, the facility failed to implement or identify appropriate care plan interventions. One resident had orders and therapy recommendations for a palm protector to prevent further contracture, but interviews revealed inconsistent application and lack of staff awareness regarding the intervention. The other resident had a contracture but no orders or restorative nursing program in place, and the care plan only included general interventions without specific devices or monitoring. These failures were contrary to facility policy and placed residents at risk of not receiving care and services related to their identified needs.
Failure to Provide Scheduled Showers and Document Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically personal hygiene and scheduled showers, for three residents who were dependent on staff for these tasks. Documentation showed that one resident missed 8 out of 13 scheduled showers, another missed 8 out of 13, and a third missed 4 out of 14 scheduled showers within a one-month period. All three residents were severely cognitively impaired, as indicated by their BIMS scores, and required total staff assistance for bathing according to their care plans. None of the care plans documented any behaviors of refusal related to showers or other care. Record reviews confirmed that the missed showers were not documented as refusals or rescheduled, and there was no evidence in the electronic health records or care plans to suggest that the residents declined care. Interviews with staff revealed that if a CNA was unable to provide a scheduled shower, the expectation was to communicate this to the nurse and document it, but this was not consistently done. The DON was unaware that residents were not receiving scheduled showers and stated that documentation was only available in the electronic health record, with no additional records to support that showers were provided or refused. Facility policy required that the date, time, and staff involved in showers or tub baths be recorded in the resident's ADL record or medical record. However, the lack of documentation for the missed showers indicated that the facility did not follow its own policy or ensure that dependent residents received the necessary care for personal hygiene as scheduled.
Failure to Prevent Accident Hazards and Ensure Use of Safety Devices
Penalty
Summary
Surveyors identified that the facility failed to ensure the resident environment was free from accident hazards and did not provide adequate assistance devices to prevent accidents. During observations, hand sanitizer bottles were found stored on top of EBP carts and in unlocked drawers, making them accessible to residents, including those with altered cognition. Staff and administration confirmed that this was the usual storage method, and there was no documentation of the hand sanitizer in the facility's MSDS book in case of ingestion. The facility relied on staff monitoring to prevent resident access to these hazardous substances, but no physical barriers or secure storage were in place. Additionally, a resident with severe cognitive impairment, muscle weakness, and a history of falls was observed multiple times in bed without fall mats present, despite a recent fall from bed that resulted in a facial injury and a hospital transfer. The care plan for this resident included interventions such as a lowered bed, call light within reach, and fall mats, but the fall mats were not in place during repeated observations. These failures were noted across all resident halls reviewed and placed residents at risk for injury due to inadequate supervision and lack of required safety devices.
Failure to Revise Care Plan After Fall Investigation
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident following a fall incident, despite conducting an investigation and identifying new interventions. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including muscle wasting, atrophy, and unsteadiness, experienced a fall from her bed that resulted in a facial injury. The facility's investigation after the fall identified interventions such as lowering the bed, ensuring the call light was within reach, and using fall mats. However, these interventions were not incorporated into the resident's care plan. Observations conducted after the incident showed that while the bed was lowered and the call light was within reach, fall mats were not present as planned. A review of the resident's care plan revealed that it had not been updated to include the new interventions identified during the investigation, with the most recent updates predating the fall. Interviews with the DON confirmed that changes were made in practice, but the care plan was not revised to reflect these interventions.
Failure to Reschedule Ophthalmology Appointment for Resident with Vision Impairment
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision abilities by not rescheduling an ophthalmology appointment after a missed visit. The resident, an older adult with diagnoses including type 2 diabetes mellitus, dementia, and cognitive deficits following cerebrovascular disease, had a standing order for ophthalmology evaluation and treatment. Documentation showed that the resident had previously been referred to an ophthalmologist for retinal and cataract evaluation due to complaints of blurred and watery vision, with diagnoses of cataracts and proliferative diabetic retinopathy with macular edema. The initial ophthalmology appointment was missed because the family member who was supposed to accompany the resident did not attend, and the facility was informed that the appointment would need to be rescheduled. Despite this, there was no evidence in the medical record that the appointment was rescheduled or that further action was taken to ensure the resident received the necessary evaluation. Interviews with facility staff revealed a lack of awareness regarding the missed appointment and the need for rescheduling. The resident continued to experience vision difficulties, impacting her ability to participate in activities, and was unsure about her vision care history. The absence of follow-up and coordination resulted in a delay in the resident receiving appropriate ophthalmology care as ordered.
Failure to Provide Contracture Management Devices and Interventions for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) for two residents with limited ROM. For one resident, who had a history of cerebral palsy, contractures, and severe cognitive impairment, the care plan and physician's orders specified the use of a left palm protector to address a left hand contracture. Despite these orders and documentation indicating the device should be applied five times per week, multiple observations over several days revealed that the palm protector was not in place. Interviews with CNAs confirmed that they did not apply any device to the resident's hand to prevent further contracture, and the restorative nursing program for this intervention had only recently been initiated. For another resident with a history of CVA, apraxia, and severe cognitive deficit, the care plan included passive and active ROM exercises to prevent contractures, but there was no evidence of an occupational therapy program or physician's orders for a contracture management device. Observations showed the resident had a right hand contracture with no assistive device in place. The facility's contracture prevention policy required risk assessment, care planning, and implementation of prevention programs, but these steps were not fully carried out for this resident. Interviews with facility staff, including the DON and DOR, revealed a lack of consistent monitoring and implementation of contracture management interventions. The DON acknowledged that not utilizing a palm protector could increase contractures and that a device for the second resident had been requested but not obtained. The failures in applying and monitoring prescribed devices and interventions contributed to the deficiency in providing appropriate care for residents with limited ROM.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8.11% based on three errors out of 37 opportunities. Two residents were directly involved in these errors. In one instance, a certified medication aide (CMA) administered Fingolimod HCl and Sertraline HCl to a resident for personality disorder and anxiety, respectively, at 9:34 AM, despite both medications being ordered for administration at 8:00 AM. The delay was attributed to the facility's practice of timing routine morning medications for 9:00 AM due to CMA work schedules, although the physician orders specified an earlier time. The Director of Nursing (DON) and the administrator confirmed that CMAs' schedules and budgetary constraints contributed to the delay, and that nursing staff were expected to assist if delays were anticipated. In another instance, a CMA documented the administration of Cholecalciferol 1000 units for vitamin deficiency to a resident at 9:49 AM, but this medication was not observed as administered during the medication pass. The facility's policy requires that any dose withheld, refused, or given at a time other than scheduled must be properly notated in the electronic medication administration record (eMAR) and explained in the resident's progress notes, which was not done in this case. These actions and inactions resulted in residents not receiving medications as prescribed or not receiving them at all, as observed and documented by surveyors.
Medication Administered Outside Physician Parameters
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dysphagia, cerebral infarction, and HIV, was administered Carvedilol outside of the physician-ordered parameters. The resident's care plan included monitoring and recording medication side effects, and the medication order specified that Carvedilol should be held if the systolic blood pressure (SBP) was less than 110 or the heart rate (HR) was less than 60. Despite these instructions, the medication administration record showed that Carvedilol was given on three occasions when the resident's SBP or HR was below the specified thresholds. Interviews with facility staff revealed that the ADON was unaware of medications being given outside of parameters, while the DON stated that if vital signs were out of range, the nurse could use their judgment to administer the medication but must notify the physician. The facility's policy required obtaining and recording vital signs as necessary prior to medication administration. The failure to adhere to these parameters resulted in the resident receiving medication inappropriately, as documented by the surveyors.
Infection Control Breaches in Linen Handling and Equipment Cleaning
Penalty
Summary
A certified nursing assistant (CNA) was observed exiting a resident's room while wearing soiled gloves and carrying unbagged, soiled linen into the hallway. The CNA acknowledged the breach, stating that the facility's process is to bag soiled linens before leaving a resident's room and to avoid wearing soiled gloves in the hallway. The CNA explained that the presence of the survey team caused him to act quickly and not follow proper procedures. The Director of Nursing (DON) confirmed that the facility's expectation is for linen to be bagged prior to exiting a resident's room and acknowledged awareness of the incident. Additionally, a certified medication aide (CMA) was observed using a reusable blood pressure cuff on two residents consecutively without cleaning or sanitizing the device between uses. The CMA stated that she typically cleans the device every two to three residents and was unsure of the facility's policy regarding cleaning between residents. The Assistant Director of Nursing (ADON), who also serves as the Infection Preventionist, stated that equipment should be cleaned between every resident and that sanitizing wipes are available and should be stored in the medication carts. However, no cleaning agent was found in the medication cart during the observation. Facility policies reviewed indicated that reusable equipment should not be used for another resident until appropriately cleaned and that gloves should be removed promptly after use, with soiled linen handled in a way that prevents contamination.
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 931 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) |
|---|---|---|---|---|
| Morningside Manor | 1.7 mi | ★★★★★ | 9 | 1 |
| Oak Park Nursing And Rehabilitation Center | 2 mi | ★★★★★ | 25 | 0 |
| Golden Estates Rehabilitation Center | 2.4 mi | ★★★★★ | 12 | 0 |
| The Atrium Rehabilitation Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Sorrento | 2.8 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.