Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Kirkwood Manor during CMS and state inspections, most recent first.
MDS assessments were coded inaccurately for one resident’s fall history and for three residents’ PASRR status. A resident with dementia and a recent fall was marked as having no fall history on a quarterly MDS, while three residents with diagnoses including depression, PTSD, Down syndrome, schizophrenia, and intellectual disability were not coded correctly for PASRR despite records and care plans showing PASRR-related needs. Staff acknowledged the coding errors and stated the assessments were inaccurate.
Failure to preserve dignity during mealtime assistance: A CNA stood next to a resident while helping her eat in the dining area instead of sitting beside her. The resident had dementia, severe cognitive impairment, and required supervision assistance with meals. The CNA acknowledged the approach was not respectful, and the DON stated staff should sit next to residents when assisting with meals.
A resident with severe cognitive impairment, dementia, and diabetes was always incontinent of bladder and bowel, but the comprehensive care plan did not include any incontinence-related interventions or guidance. Staff confirmed the resident received incontinence care, and the MDS nurse acknowledged the care plan should have been developed but was overlooked.
A resident with severe cognitive impairment, dementia, traumatic subdural hemorrhage, and diabetes had a fall during a bed bath when she reached for the nightstand without asking for help. Although the IDT discussed the incident and staff reported bathing assistance was changed to 2-person assist along with other fall interventions, the written bathing care plan was not updated and still reflected extensive 1-person assistance.
Mechanical Lift Brakes Not Engaged During Transfer: A resident who required extensive 2-person assist with a Hoyer lift was transferred from a wheelchair to bed by two CNAs, but the lift brakes were not engaged while the resident was being lowered. The lift swung side to side during the transfer, and both the CNA and DON stated the brakes should have been engaged for safety. The resident had intact cognition and diagnoses including a femur fracture, muscle wasting and atrophy, and obesity.
Catheter Care and Peri-Care Not Provided as Observed: A resident with an indwelling urinary catheter had the drainage bag lifted above the bladder during catheter care, allowing urine in the tubing to drain back toward the bladder. In a separate observation, staff provided peri-care to a female resident who was incontinent of bowel and bladder but did not separate the labia or clean the suprapubic area. The DON stated the peri-care should have included those steps to prevent possible infection.
Respiratory care was not provided as ordered for two residents. One resident with COPD and chronic respiratory failure had AVAP oxygen tubing left detached and not bagged when not in use, and staff stated the tubing should have been stored in a bag to prevent contamination. Another resident with COPD and chronic hypoxia was observed with O2 concentrator settings below the ordered 3 L/min, and an LPN adjusted it after confirming the incorrect setting.
Expired blood glucose test strips were found in a nursing cart, and an LVN stated she had used them without checking the expiration date. The DON confirmed staff should have checked the strips before use. In a separate event, a resident with cerebral infarction, major depressive disorder, and anxiety did not have buspirone available during med pass because it had not been reordered in time; the MA and RN searched for the medication, and staff stated refills should have been ordered before the last dose was given.
Controlled Medication Box Not Permanently Affixed in Medication Refrigerator: A narcotic box containing Lorazepam injection pen was observed inside a medication refrigerator in Medication Room Station-2 for the 100 and 500 hall, but the box was attached to a shelf that was not permanently affixed to the refrigerator, allowing it to be removed freely. The ADON and DON both acknowledged the box was not permanently affixed, and the facility policy required controlled drugs to be stored in separately locked, permanently affixed compartments.
Wet insulated domes were placed on prepared meal trays before service, and water dribbled onto approximately 7 plates as the domes were turned over and applied. The Dietary Supervisor observed the issue and stated the domes should have been fully air-dried before use; staff also acknowledged that moisture could drip into food and allow bacteria growth. The facility policy required all items to air-dry after warewashing.
Unlabeled Food Stored in Resident Refrigerator: A resident’s personal refrigerator contained a small plastic container and foil-wrapped food brought by family, but neither item had a date or label. The resident said the food was apple pie from her daughter and did not know when it was brought in. The LVN stated the items were not dated or labeled, and the DON said nurses were responsible for monitoring the resident’s refrigerator daily and dating and labeling food brought in by family. The resident had pneumonia, dysphagia, and muscle wasting and atrophy, and her care plan included a regular diet with thin liquids.
Incomplete PASRR documentation was found in the EHR for two residents. One resident with major depressive disorder and PTSD had no PASRR level 1 screening or level 2 evaluation in the chart at the time of review, and another resident with Down syndrome had no PASRR level 2 evaluation, IP, or HSP in the record despite being listed as PASRR positive and receiving specialized services. The DON stated the HSP and IP should have been in the medical record.
A resident with severe cognitive impairment and multiple cardiac diagnoses was admitted with a hospital order for cloNIDine 0.1 mg to be taken PO twice daily PRN for HTN, but the facility entered the drug as a scheduled BID medication with hold parameters in the electronic record. The MAR reflected administration of cloNIDine according to the incorrect scheduled order, and the CMA reported giving all prescribed BP medications without awareness that one was intended as PRN. The admitting RN stated she entered the medications after NP approval and later learned the order had been entered incorrectly, while the NP confirmed the drug should have been PRN to allow dosing based on BP and pulse. The DON acknowledged that admitting nurses are expected to validate medication orders with the physician and that inaccurate order entry could lead to a change in condition, despite a facility policy requiring medications to be administered as prescribed by the attending physician.
A nurse administered insulin from an unlabeled pen to a resident with diabetes and severe cognitive impairment. The pen, brought in by the resident's family, was not labeled with the resident's name as required by facility policy. The nurse identified the pen based on the resident's medication regimen but only labeled it after the incident was observed. Facility leadership confirmed that all insulin pens should be labeled and that this was not in accordance with established procedures.
An insulin flex pen used for diabetes management was found on a medication cart without a resident's name label. An LVN assumed the pen belonged to a resident with severe cognitive impairment and administered the medication. Staff interviews confirmed that insulin pens are usually labeled, but in this case, the pen was not, and the facility's policy requiring individual labeling and separate storage was not followed.
The facility failed to maintain a safe and comfortable environment, with water temperatures in shower rooms below the safe range, a hole around an electrical outlet in a resident's room, and broken tiles in a shower room. These issues persisted despite staff awareness and resident complaints, highlighting deficiencies in maintenance and safety protocols.
A LTC facility failed to maintain an effective infection control program, as evidenced by several deficiencies. An LVN did not sanitize hands between glove changes during colostomy care, another LVN failed to wear a gown while administering medications to a resident on Enhanced Barrier Precautions, and a Medication Aide did not clean a blood pressure cuff between uses. Additionally, a washcloth with feces was left in a shower room without proper sanitation. These actions increased the risk of infection among residents.
A facility failed to ensure accurate PASRR Level 1 Screening for a resident with bipolar disorder, as the screening did not indicate a mental illness despite the diagnosis and medication for mania. Staff interviews revealed uncertainty about the PASRR process, and the facility did not verify the accuracy of PASRRs against residents' diagnoses upon admission.
A facility failed to update a resident's care plan to reflect the current order for releasing a seatbelt and harness every 2 hours, instead of every 4 hours. Staff interviews revealed a lack of awareness of the updated order, and the Director of Nursing confirmed the care plan should match the most recent orders to ensure continuity of care.
A resident identified as a fall risk due to dementia and a history of falls was found without a required floor mat on the right side of their bed, as specified in their care plan and physician orders. The oversight was observed during a survey, and interviews revealed that the mat was not placed as required, compromising the resident's safety.
A resident with bowel and bladder incontinence did not receive proper care, as CNA-D failed to separate and clean the labia and did not fully clean a bowel movement, risking urinary tract infections. The resident had multiple health conditions and required assistance for transfers. The facility's perineal care policy was not adhered to, as confirmed by the DON.
The facility failed to provide appropriate respiratory care for two residents. One resident's oxygen tubing was not changed weekly as ordered, and another resident's nasal cannula and Bi-pap mask were left uncovered, risking infection. Interviews confirmed these practices did not align with physician orders or infection control standards.
A facility failed to discard an insulin Lispro pen 28 days after opening, as required by policy, for a resident with diabetes. The pen, opened on January 10, was still in use on February 19, despite the facility's policy to discard opened vials without an open date. This oversight was confirmed by the ADON and LVN, who acknowledged the potential for reduced medication effectiveness.
The facility failed to lock a medication cart on the 400-hall, leaving it unattended and accessible, and did not properly label a resident's insulin pen, which lacked an open date. The unlocked cart contained various medications, posing a risk of unauthorized access. The resident, with a history of diabetes and other conditions, was receiving daily insulin injections, but the LVN was unsure about discarding the undated insulin pen.
A facility failed to implement a policy for the use and storage of foods brought by visitors, leading to a deficiency. A resident's personal refrigerator contained an unlabeled and undated cup of hot sauce, which was supposed to be monitored daily by facility nurses. The resident had severe cognitive impairment and multiple health issues. The facility's policy required monitoring and education on safe food handling, which was not effectively enacted.
A resident missed three doses of Anastrozole due to the facility's failure to reorder the medication in a timely manner. The oversight was discovered during the resident's discharge process, revealing that the medication was unavailable for three consecutive days. The involved LVN did not report the issue, and the facility's medical director confirmed that the missed doses did not adversely affect the resident's condition.
The facility failed to ensure a resident received treatment and care according to professional standards and the care plan. Staff did not document vital signs before administering digoxin, failed to administer midodrine as ordered, and did not properly assess the resident's ongoing nausea. The resident was eventually discharged to the hospital and expired in the emergency room.
A resident with multiple diagnoses did not receive digoxin and midodrine as prescribed, leading to significant medication errors. The facility staff failed to hold digoxin per physician's parameters and did not administer midodrine when the resident's SBP was below 100, as required.
A facility failed to document vital signs before administering digoxin and midodrine for a resident with complex medical conditions. This lack of documentation occurred over multiple days, leading to incomplete medical records and potential risks for the resident.
MDS Assessments Were Coded Incorrectly for Fall History and PASRR Status
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected resident status for four residents. The report identified errors involving fall history and PASRR coding on quarterly, annual, and admission MDS assessments. Facility staff acknowledged that the assessments were coded incorrectly and stated the inaccuracies could affect resident care and services. Resident #10’s quarterly MDS, signed as completed on 01/14/2026, was coded “No” to whether the resident had a fall in the last 2–6 months prior to admission, entry, or reentry. Record review showed the resident had a fall on 01/05/2026, and the incident report documented that the resident fell from the bed while a CNA was providing a bed bath. The care plan was updated after the fall, and the MDS nurse stated the assessment should have been coded “Yes” because the resident had fallen. Resident #13’s annual MDS and Resident #81’s admission MDS were both coded inaccurately for PASRR. Resident #13 had diagnoses including major depressive disorder and PTSD, and the annual MDS indicated the resident did not have a serious mental illness, with the Level II PASRR item left blank. Resident #81 had Down syndrome, unclear speech, severe cognitive impairment, and a care plan identifying PASRR services, but the admission MDS indicated the resident did not have an intellectual disability or related condition and left the Level II item blank. Resident #106’s annual MDS also coded PASRR as “No” despite diagnoses of undifferentiated schizophrenia and moderate intellectual disabilities, a PASRR care plan focus, and a prior PASRR screening showing mental illness, intellectual disability, and developmental disability. Staff interviews confirmed these MDS assessments were coded incorrectly.
Failure to Preserve Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to treat Resident #56 with respect and dignity during lunchtime assistance. Resident #56 was a female with dementia, muscle wasting and atrophy, and an extrapyramidal and movement disorder. Her quarterly MDS reflected a BIMS score of 0 out of 15, indicating severe cognitive impairment and inability to interview, and her care plan stated she required supervision assistance with meals and setup or clean-up assistance for eating. During an observation in the dining area, CNA-A was assisting Resident #56 with lunch while standing next to the resident. In an interview shortly afterward, CNA-A stated she should have been sitting down when assisting someone in the dining area and acknowledged that standing next to the resident was not a way of showing respect and dignity. The DON later stated staff should sit down next to residents when assisting them during mealtimes and that not sitting beside the resident to assist in eating did not uphold dignity and respect. The facility's Resident Rights policy stated residents have the right to be treated with consideration, respect, and full recognition of dignity and individuality.
Missing Care Plan for Bladder and Bowel Incontinence
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #115 that included measurable objectives and timeframes to meet the resident’s medical, nursing, and mental needs identified in the comprehensive assessment. Resident #115 was a female resident with diagnoses including senile degeneration of brain, type 2 diabetes mellitus, and dementia. Her admission MDS assessment showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. The record review showed Resident #115 was always incontinent of bladder and bowel, but her comprehensive care plan dated 01/20/2026 did not include any care plan related to bladder and bowel incontinence care. Staff interviews confirmed the resident had bladder and bowel incontinence and received incontinence care. The MDS nurse stated she should have developed the care plan because the resident was always incontinent, acknowledged she overlooked it, and stated it was her mistake.
Care Plan Not Updated After Fall and IDT Review
Penalty
Summary
The facility failed to review and revise Resident #10’s care plan after the comprehensive assessment and after an IDT meeting following a fall. Resident #10 was an 84-year-old female with diagnoses including traumatic subdural hemorrhage, dementia, and type 2 diabetes mellitus. Her quarterly MDS dated 01/14/2026 showed a BIMS score of 6 out of 15, indicating severe cognitive impairment, and Section GG indicated she was dependent for showering/bathing. Her comprehensive care plan, revised on 01/30/2025, listed bathing as requiring extensive one-person assistance. On 01/05/2026, the resident had an actual fall with injury when she fell from the bed while CNA-C was providing a bed bath and the resident reached toward the nightstand without asking for help. The care plan dated 01/05/2026 documented the fall and interventions such as a scooped air mattress, fall mat, grab bars, and monitoring for signs and symptoms after the fall. CNA-C stated that after the fall the facility updated care plans to include two-person assistance for showering/bathing, but the MDS nurse stated the care plan was not updated correctly after the IDT meeting and should have been changed from one-person to two-person assistance. The DON stated the IDT meeting occurred after the fall and that the updated care plans included two-person assistance for bathing, but the written bathing care plan remained at extensive one-person assistance.
Mechanical Lift Brakes Not Engaged During Resident Transfer
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible when staff did not engage the brakes of a mechanical lift during a transfer. Resident #39 was a 73-year-old female admitted with diagnoses of fracture of the lower and right femur, muscle wasting and atrophy, and obesity. Her admission MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and she was dependent for chair-to-bed and toilet transfers. Her care plan directed extensive 2-person assistance with a Hoyer lift for transfers. During an observation, CNA-D and CNA-E transferred Resident #39 from a wheelchair to a bed using a mechanical lift. After the resident was lifted and moved to the bed, CNA-E lowered the resident without engaging the lift brakes, and the lift swung a little bit from side to side while CNA-D held the resident. CNA-E stated she should have engaged the brakes for safety and said she had been trained on proper use of the mechanical lift in 2025. The DON also stated CNA-E should have engaged the brakes when lowering the resident. The facility policy for mechanical lift transfers stated that the base/legs should be opened completely while the lift is in motion, the brakes should be engaged after positioning, and the resident should be slowly lowered toward the receiving surface.
Catheter Care and Peri-Care Not Provided as Observed
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident with an indwelling urinary catheter. Resident #43 was a male with diagnoses including obstructive and reflux uropathy and benign prostatic hyperplasia with lower urinary tract symptoms. His care plan and physician orders called for catheter care every shift and for the urinary drainage bag and tubing to be positioned below the bladder. During observed catheter care, MA I lifted the urinary drainage bag by the hook and held it approximately 2.5 feet above the level of the resident’s bladder, and urine in the clear tubing drained back toward the bladder until surveyor intervention. The resident and CNA L both indicated the bag should be put back down, and the care was then completed. The facility also failed to ensure appropriate incontinent care for a resident who was always incontinent of bladder and frequently incontinent of bowel. Resident #108 was a female with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and urinary tract infection. Her care plan directed staff to check for incontinence and wash, rinse, and dry the perineum. During observation, CNA-F and CNA-C provided perineal care, but CNA-F cleaned the groin and genital area without separating the labia and did not clean the suprapubic area before turning the resident and cleaning the buttocks and rectum. During interview, CNA-F stated she did not clean the suprapubic area or separate the labia because she was nervous and forgot. The DON stated CNA-F should have cleaned the suprapubic area and separated the labia during peri-care to prevent possible infection. The facility policy for female peri-care directed staff to wash the genital area from front to back using a clean part of the washcloth or a clean wipe for each stroke, and then assist the resident on her side after cleansing the genital area.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who were receiving oxygen-related treatments. Resident #3 had diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and heart failure, and her MDS showed intact cognition. Her care plan and physician orders directed AVAP use at bedtime and off in the morning, with oxygen connected when the AVAP was applied. On 04/07/2026, Resident #3 was observed in bed wearing nasal cannula oxygen at 2 liters per minute, and the oxygen tubing attached to the AVAP machine was detached and lying on the floor next to the oxygen concentrator. On 04/08/2026, the tubing from the AVAP machine was observed looped up and stuffed in the handle of the oxygen concentrator rather than being bagged when not in use. During interview and observation, LVN M stated the green oxygen tubing that went to the AVAP machine should have been bagged when not in use and that bagging prevented contamination. LVN M also stated the tubing had been on the floor and removed it to replace it. The DON stated the oxygen tubing should have been stored in a bag when not in use to keep it clean and reduce contamination, and the Administrator stated the tubing was supposed to be bagged when not in use and that floor staff were responsible for ensuring it was stored properly. Resident #137 had diagnoses including chronic respiratory failure with hypoxia, COPD, and hypoxic ischemic encephalopathy, and her MDS showed borderline cognitive impairment. Her care plan directed oxygen therapy as ordered, and the physician order required oxygen at 3 L/min continuously via nasal cannula. On 04/08/2026, she was observed sitting in her wheelchair wearing nasal cannula oxygen while the concentrator was set at 2.5 liters per minute. Resident #137 stated it was supposed to be set at 3 liters per minute. LVN M checked the concentrator, confirmed it was set at 2.5 liters per minute, and adjusted it to 3 liters per minute. The DON and Administrator stated the facility needed to follow the physician order and that the nurse on the floor was responsible for ensuring the oxygen was at the proper setting.
Expired Test Strips and Missed Refill for Buspirone
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when expired blood glucose test strips were found in the 400-hall nursing cart. On observation, one bottle of blood glucose test strips was inside the cart, and the strips had expired. A red marker date was written on the bottle, and the LVN stated that date was the open date and that the strips had been used since then. The LVN said she did not check the expiration date and acknowledged it was her mistake. The DON stated the nurses should have checked the expiration date and should not have used expired strips to obtain accurate blood sugar values. The facility also failed to reorder Resident #134's buspirone hydrochloride 7.5 mg oral tablet in time, resulting in the medication not being available when it was due to be administered. Resident #134 was a male admitted with diagnoses including cerebral infarction, major depressive disorder, and anxiety disorder. His MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and his care plan identified him as at risk for depression with an intervention to administer medications as ordered and monitor for side effects and effectiveness. His physician order directed buspirone hydrochloride 7.5 mg by mouth twice a day for agitation related to major depressive disorder. During medication administration, the MA could not find the resident's buspirone in the cart. The RN searched the medication room and emergency kit but could not locate it, and the nurse planned to contact the physician and pharmacy. The MA informed the resident that the medication was not available and would be given when obtained. Staff stated the medication should have been reordered at least 5 days before it ran out, and the DON confirmed the medication had not been reordered per facility policy requiring refills to be ordered prior to the last dose being administered.
Controlled Medication Box Not Permanently Affixed in Medication Refrigerator
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 2 medication rooms reviewed, specifically Medication Room Station-2 for the 100 and 500 hall. During observation, a refrigerator used for medications was found in that medication room, and one narcotic box for controlled medications was inside the refrigerator. The narcotic box was affixed to a refrigerator shelf, but the shelf itself was not permanently affixed to the refrigerator, allowing the shelf and box to be removed freely. One medication, Lorazepam injection pen, was inside the narcotic box. During interview, the ADON stated the narcotic box inside the refrigerator was not permanently affixed and could be removed, and he said the box should have been permanently affixed to prevent possible diversion of medication. The DON also stated the narcotic box should have been permanently affixed to the refrigerator. Record review of the facility policy, Controlled Medications - Storage and Reconciliation, stated controlled drugs and other drugs subject to abuse are to be safeguarded using separately locked, permanently affixed compartments, with a limited exception for certain unit package medication distribution systems.
Wet Insulated Domes Used During Meal Tray Preparation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when insulated domes used for plate covers were not properly air-dried before meal service. During observation on 04/09/2026 at 11:29 a.m., Dietary Aide N was seen placing prepared plates on trays and covering them with insulated domes that had pooling water inside; as the domes were turned over and placed on approximately 7 plates, water dribbled across the plates. The trays were then placed on a rack and sent to 600 hall. During the same observation, the Dietary Supervisor saw the wet domes being placed on plates and instructed Dietary Aide N to remove them from the serving area so they could be racked and allowed to dry thoroughly. The Dietary Supervisor stated the domes should be allowed to air dry totally and explained that this was to prevent residents from getting sick and prevent dishwater from getting on the food. Dietary Aide N stated that not drying the lids all the way could allow water to drip in the food and cause stomach upset, and Dietary Aide O stated the moisture could allow bacteria growth and possibly cause residents to get sick. The Administrator later stated the insulated domes should have been fully dried before use to prevent contamination issues, and the facility policy required machine warewashing techniques to air-dry all items because towels may contaminate items.
Unlabeled Food Stored in Resident Refrigerator
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors for Resident #1. On 04/07/2026, Resident #1’s personal refrigerator in her room contained a small plastic container and food wrapped in kitchen aluminum foil, and neither item had a date or label. The resident stated the food was apple pie brought by her daughter, but she did not know when it had been brought to the facility. Resident #1’s record showed she was a female admitted and readmitted to the facility with diagnoses of pneumonia, dysphagia, and muscle wasting and atrophy. Her MDS assessment indicated a BIMS score of 15 out of 15, showing intact cognition, and she required setup or clean-up assistance for eating. Her care plan included a regular diet, regular texture, thin liquids, and reinforcement to maintain the ordered diet. During interview, the LVN stated the food in the refrigerator was not dated or labeled and that the night nurses were supposed to check it daily. The DON stated facility nurses were responsible for overseeing the resident’s personal refrigerator, monitoring it daily, and dating and labeling food brought in by family members. The facility policy stated food or beverages brought in from outside sources for storage in facility or resident room refrigerators would be monitored by designated staff for food safety.
Incomplete PASRR Documentation in Resident Records
Penalty
Summary
Medical records were not complete or readily accessible for two residents because required PASRR documents were missing from the EHR at the time of survey review. For Resident #13, the record showed diagnoses of major depressive disorder and PTSD, and the annual MDS coded PASRR items without supporting documentation in the chart. Survey review found no evidence that a PASRR level 1 screening or PASRR level 2 evaluation had been completed in the resident’s medical record, although the resident’s PASRR negative level 2 evaluation dated 10/3/24 was later found uploaded on 4/10/26. For Resident #81, the record showed Down syndrome, unclear speech, severe cognitive impairment on BIMS, and a care plan noting PASRR services, a PASRR positive diagnosis, and a habilitation coordinator. However, the EHR reviewed on 4/9/26 and 4/10/26 did not contain the PASRR level 2 evaluation, IP, or HSP showing specialized services, even though the facility’s list identified the resident as PASRR positive and receiving specialized services. The DON stated the HSP and IP should have been in the medical record and was not sure why they had not been uploaded previously.
Incorrect Entry and Administration of PRN Antihypertensive Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate order entry and administration of medications for a resident with essential hypertension, heart failure, and atrial fibrillation. The resident, who had severe cognitive impairment with a BIMS score of 6/15, was admitted with hospital discharge paperwork indicating cloNIDine 0.1 mg to be taken by mouth twice daily as needed (PRN) for hypertension. However, the facility’s Order Summary Report listed cloNIDine HCl 0.1 mg as a scheduled medication to be given twice daily with specific hold parameters for blood pressure and pulse. The March MAR showed that cloNIDine HCl was administered on one date when the resident’s blood pressure was 142/52 and pulse 58. During interviews, the CMA who administered the medication stated she gave all prescribed blood pressure medications as ordered and was not aware of a PRN blood pressure medication or any parameters on the order. The RN who admitted the resident reported that she sent the hospital medication list to the NP for approval and then entered the approved medications into the electronic record, later learning that one medication had been entered incorrectly as scheduled instead of PRN. The NP confirmed that cloNIDine HCl should have been ordered as PRN to allow it to be held or staggered based on blood pressure and pulse readings. The DON stated that the admitting nurse should validate medication orders with the physician and acknowledged that inaccurate order entry could result in a resident having a change in condition. The facility’s medication administration policy stated that medications shall be administered as prescribed by the attending physician.
Unlabeled Insulin Pen Administered to Resident
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered insulin to a resident using an insulin pen that was not labeled with the resident's name. The insulin pen, which was for Aspart 100 units/mL, was found on the medication tray with an open date but no identifying label. The LVN stated she usually labels insulin pens but did not know why this one was not labeled. She identified the pen as belonging to the resident because the resident was the only one on the hall using that type of insulin. The Director of Nursing (DON) confirmed that insulin pens are required to be labeled and that the pen should not have been on the medication cart without a name. The Assistant Director of Nursing (ADON) indicated that insulin pens are logged and accounted for upon arrival, but in this case, the family had brought in the insulin and labeling was missed. The resident involved had multiple diagnoses, including cerebral palsy, type 2 diabetes mellitus, mild intellectual disabilities, and anxiety, and was severely cognitively impaired, requiring staff assistance for activities of daily living and daily insulin injections. The facility's policy and the LVN's training both required adherence to the six or seven rights of medication administration, including verifying the correct resident and medication. Despite this, the insulin was administered from an unlabeled pen, which was only labeled after the deficiency was observed.
Unlabeled Insulin Pen Found on Medication Cart
Penalty
Summary
A deficiency occurred when an insulin flex pen (Aspart) used for diabetes management was found on a medication cart without a resident's name labeled on it. The pen was assumed by an LVN to belong to a specific resident, who was a female with cerebral palsy, type 2 diabetes mellitus, mild intellectual disabilities, and severe cognitive impairment. The resident was dependent on staff for activities of daily living and received daily insulin injections as per physician's orders. The insulin pen was observed on the medication tray with an open date but lacked the required resident identification label. Interviews with staff revealed that the insulin pens were typically labeled with the resident's name, but in this instance, the pen was not labeled, and the staff could not explain how it ended up on the cart without proper identification. The Director of Nursing and other staff acknowledged that the pen should have been labeled and that it was not safe to have an unlabeled medication on the cart. Facility policy required medications to be labeled for individual residents and stored separately from floor stock, but this protocol was not followed in this case.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for its residents, as evidenced by several deficiencies observed during the survey. The water temperature in the 600 E and W shower rooms was found to be below the safe range of 100 to 110 degrees Fahrenheit, with temperatures recorded at 95.5 and 97.1 degrees, respectively. This issue persisted despite previous complaints from residents, including one who expressed dissatisfaction with the lukewarm water and the inability to take a hot shower. The Assistant Director of Nursing (ADON) and the Administrator confirmed the water temperature issues, and it was noted that the problem had been ongoing for several weeks, affecting multiple residents. Additionally, a safety hazard was identified in Resident #68's room, where a long hole was found around an electrical outlet beside the resident's bed. Although the resident was unaware of the hole, it posed a potential electrical danger. The Licensed Vocational Nurse (LVN) acknowledged the risk, and the Administrator admitted that the facility was unaware of the issue until it was pointed out. The facility's policy emphasized maintaining a safe environment, yet this hazard had not been addressed. Furthermore, broken tiles were observed in the 600 E shower room, which had been present for months. Staff members, including a Certified Nursing Assistant (CNA) and an LVN, were aware of the broken tiles but had not reported them to maintenance. The Maintenance Supervisor (MS) was also aware of the issue but had not prioritized its repair, considering it part of a future renovation plan. The facility's maintenance policy required work orders for repairs, but no such orders had been submitted for the broken tiles, which posed a risk of skin injuries to residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several observed deficiencies. One incident involved a Licensed Vocational Nurse (LVN-C) providing colostomy care to a resident without sanitizing or washing her hands between glove changes. This resident, who had intact cognition and a history of paraplegia and other medical conditions, was at risk of infection due to the improper hand hygiene practices of the nurse. The Director of Nursing (DON) confirmed that the nurse should have sanitized or washed her hands to prevent possible infection. Another deficiency was observed when an LVN (LVN-A) entered the room of a resident on Enhanced Barrier Precautions (EBP) and administered medications via a gastrostomy tube without wearing a gown. The resident had severe cognitive impairment and required tube feeding due to dysphagia. Despite the presence of a sign indicating the need for gloves and a gown during high-contact care activities, the LVN failed to comply, increasing the risk of infection. The DON acknowledged that the LVN should have worn a gown as per the EBP guidelines. Additionally, a Medication Aide (Medication Aide-I) failed to clean a blood pressure cuff before using it on another resident, which could lead to cross-contamination. The resident, who had intact cognition and a history of atrial fibrillation, was at risk due to the aide's oversight. Furthermore, a washcloth with feces was left in a shower room, and the area was not sanitized, posing a risk of infection transmission. The Assistant Director of Nursing (ADON) and DON both recognized the need for proper handling and sanitation of soiled linens and shower areas to prevent infection spread.
Inaccurate PASRR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure the accuracy of the PASRR Level 1 Screening for a resident diagnosed with bipolar disorder. The resident's PASRR Level 1 Screening did not indicate the presence of a mental illness, despite the resident having a diagnosis of bipolar disorder and being prescribed risperdal for mania. This oversight meant that the resident was not screened again for possible services, which could impact the resident's ability to receive necessary services to maintain their highest functional ability. Interviews with facility staff revealed a lack of clarity and understanding regarding the PASRR process for residents with mental illness. The Social Worker, Administrator, and Admissions Coordinator all expressed uncertainty about whether residents with mental illness should be screened for PASRR services. The Admissions Coordinator admitted that the facility did not verify the accuracy of PASRRs against residents' diagnoses upon admission. This lack of verification and understanding contributed to the deficiency in ensuring that residents with mental illness were appropriately screened and referred for necessary services.
Failure to Update Care Plan for Resident's Restraint Schedule
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team to reflect the current orders. Specifically, the care plan did not reflect the updated order to release the resident's seatbelt and harness every 2 hours for 10 minutes, as opposed to the previous order of every 4 hours. This discrepancy was identified during a review of the resident's records, which showed that the order to release the seatbelt and harness every 2 hours was dated 01/09/2025, but the care plan printed on 02/20/2025 still stated every 4 hours. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Certified Nursing Assistant (CNA), and the Director of Nursing (DON), revealed a lack of awareness regarding the current order for the seatbelt and harness release schedule. The LVN and CNA were not aware of the specific frequency required by the order, and the DON acknowledged that the care plan should reflect the most recent orders to ensure continuity of care. The facility's policy on comprehensive person-centered care planning requires that the care plan be reviewed and revised by the interdisciplinary team after each assessment, but this was not adhered to in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. Specifically, nursing staff did not place a floor mat on the right side of a resident's bed, which was intended as a preventative device to reduce the risk of falls. This oversight was observed during a survey, where it was noted that the resident, who was identified as a fall risk, was lying in bed without the required floor mat in place. The resident in question had been admitted with a diagnosis of unspecified dementia and was assessed as a high risk for falls due to disorientation and a history of falls. The care plan and physician orders specified the use of a floor mat as an intervention to minimize injury risk. However, during interviews, it was revealed that the mat was not placed as required, and the Director of Nursing acknowledged the importance of using the mat to maintain resident safety. The lack of adherence to the care plan and physician orders contributed to the deficiency.
Inadequate Incontinence Care Poses Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident, leading to a potential risk of urinary tract infections. During an observation, CNA-D did not separate the resident's labia or clean the base of her labia while providing incontinence care. Additionally, CNA-D did not completely clean the resident's bowel movement, which was observed by a state surveyor who requested further cleaning. The CNA-D admitted to being nervous and forgetting to separate the labia, which resulted in incomplete cleaning. The resident involved was an elderly female with a history of atherosclerotic heart disease, transient ischemic attack, hypertension, pulmonary fibrosis, and gastroesophageal reflux disease. Her quarterly MDS indicated intact cognition and consistent bowel and bladder incontinence, requiring partial assistance for transfers. The facility's policy on perineal care, which emphasizes thorough cleaning to prevent infection, was not followed, as confirmed by the Director of Nursing. This oversight could lead to cross-contamination and increased risk of urinary tract infections.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in following physician orders and maintaining infection control standards. Resident #70, a female with a history of pulmonary fibrosis and other health conditions, had a physician's order to change her oxygen tubing and humidifier bottle every Wednesday night shift. However, observations revealed that the tubing was not changed as per the order, with the last change dated 02/03/2025. Interviews with the LVN and DON confirmed that the tubing should have been changed weekly to prevent possible respiratory infections, but the order was not followed. Resident #52, a female with chronic respiratory failure and other diagnoses, was observed to have her nasal cannula and Bi-pap mask left uncovered when not in use. The facility lacked a specific policy for covering these items, which could lead to potential infections. Interviews with the LVN and DON confirmed that the nasal cannula and mask should have been covered in plastic bags when not in use to prevent infections. The facility's policy on oxygen therapy did not address this specific issue, contributing to the deficiency.
Failure to Discard Insulin Pen After 28 Days
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the management of insulin medication. The resident, a female with a history of anemia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertension, and muscle wasting, was receiving insulin injections as per a sliding scale order. However, the insulin Lispro pen, which was opened on January 10, 2025, was not discarded after the required 28 days, as it was still found in use on February 19, 2025. This oversight was confirmed through observation and interviews with the Assistant Director of Nursing (ADON) and a Licensed Vocational Nurse (LVN), who acknowledged the error and the potential for reduced effectiveness of the medication. The facility's policy on medication access and storage mandates that any opened vial without an open date should be discarded immediately. Despite this policy, the insulin pen was not discarded as required, and the Director of Nursing (DON) confirmed that the nurses should have documented the open date to ensure timely disposal. The failure to adhere to these procedures could lead to inaccurate drug administration and inadequate therapeutic effects for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an unlocked and unattended medication cart on the 400-hall. During an observation, the 400-hall medication aide cart was found unlocked and unattended while the Medication Aide was passing medications. This allowed access to multiple medication blister packs, scissors, and bottles of medications. The Medication Aide admitted to not realizing the cart was left unlocked and acknowledged the importance of keeping it locked for the safety of residents, visitors, and staff. The Director of Nursing (DON) confirmed that the cart should not have been left unlocked, as it posed a risk of unauthorized access to medications. Additionally, the facility failed to properly label and store Resident #83's insulin flex pen (NovoLog) for diabetes. The insulin pen was found inside the 200-hall nursing cart without an open date, contrary to the facility's policy that requires opened and undated insulin to be discarded. Resident #83, a male with a history of cerebral infarction, type 2 diabetes mellitus, hemiplegia, hypertension, and muscle wasting, was receiving daily insulin injections. The Licensed Vocational Nurse (LVN) was unaware of when the insulin pen was opened and expressed uncertainty about whether it should be discarded due to the lack of an open date. This oversight could lead to the use of expired insulin, potentially affecting the resident's diabetes management.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement a policy regarding the use and storage of foods brought to residents by family and other visitors, which resulted in a deficiency. Specifically, a personal refrigerator in a resident's room contained a small plastic cup with red-colored food, identified as hot sauce, that was neither dated nor labeled. This oversight was observed during a survey, and it was noted that the facility nurses were supposed to check the refrigerator daily, but this was not done. The resident involved was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 0 out of 15. She had multiple diagnoses, including Parkinsonism, urinary tract infection, hypertension, muscle wasting, and gastroesophageal reflux disease. The facility's policy required that food brought from outside sources be monitored for safety, and that residents and individuals bringing food be educated on safe food handling and storage. However, this policy was not effectively enacted, as evidenced by the lack of labeling and dating of the food item in the resident's refrigerator.
Failure to Timely Reorder Medication for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident undergoing chemo treatment. The resident, a female with a history of type 2 diabetes mellitus, atrial fibrillation, heart failure, chronic kidney disease stage 3, and hemiplegia, missed three doses of Anastrozole due to the medication not being reordered in a timely manner. This lapse occurred over three consecutive days, during which the medication was unavailable. The deficiency was identified when the Director of Nursing (DON) discovered the missed doses during the resident's discharge process. The resident's Medication Administration Record indicated that the Anastrozole was not administered because it was not available. The facility's Medication Error Report confirmed the oversight, noting that the medication was not reordered in advance as required by the facility's policy. Interviews with the involved staff revealed that the Licensed Vocational Nurse (LVN) responsible for administering the medication did not recall the specific reason for the oversight, as it occurred nearly a year prior. The LVN, who was an agency nurse, failed to report the unavailability of the medication to the DON or Assistant Director of Nursing (ADON). The facility's medical director confirmed that the missed doses did not adversely affect the resident's condition, as the medication was intended for prophylactic purposes.
Failure to Administer Medications and Assess Change of Condition
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The staff administered digoxin to the resident without documenting the required blood pressure and pulse readings for 23 days and failed to hold the medication as ordered on two specific dates. Additionally, the staff did not administer midodrine as ordered when the resident's systolic blood pressure was below 100 on five instances. These actions were not in line with the physician's orders and the resident's care plan, leading to a lack of proper monitoring and medication administration. The facility staff also failed to assess the resident for a change of condition related to continued complaints of nausea over several days. Despite the resident's ongoing symptoms, there was insufficient documentation and assessment of the resident's condition. The resident was eventually discharged to the hospital by EMS and expired in the emergency room. The lack of timely and appropriate assessment and intervention contributed to the resident's deteriorating condition. The deficiencies in care included not documenting vital signs before administering medications with specific parameters, not administering medications as ordered, and failing to properly assess and respond to changes in the resident's condition. These failures placed the resident at risk of critically low pulse and blood pressure, inadequate blood flow, missed signs and symptoms of illness, hospitalization, and death.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was reviewed for medication errors. The staff did not hold the resident's digoxin medication as per the physician's ordered parameters on two occasions. Additionally, the staff failed to administer midodrine as ordered on five separate instances when the resident's systolic blood pressure (SBP) was below 100. These failures were identified through interviews and record reviews, which showed discrepancies between the physician's orders and the actual administration of medications as documented in the electronic medical records (EMAR) and electronic health records (EHR). The resident involved had multiple diagnoses, including heart failure, atrial fibrillation, atherosclerotic heart disease, and acute kidney failure. The resident's care plan included specific instructions for digoxin therapy and the administration of midodrine for low blood pressure. Despite these instructions, the facility's staff did not adhere to the prescribed medication administration guidelines, leading to potential risks for the resident. The facility's policy on medication administration, which mandates that medications be given as prescribed by the physician, was not followed in these instances.
Failure to Document Vital Signs for Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for a resident, specifically regarding the administration of digoxin and midodrine. The staff did not document blood pressure and pulse readings before or after administering digoxin, which had specific parameters to hold the medication if the readings were outside the set limits. This lack of documentation occurred over multiple days in February and March, leading to incomplete medical records for the resident. Additionally, the staff failed to document blood pressure readings every 8 hours as required for the administration of midodrine, a medication used to treat low blood pressure, throughout February and part of March. The resident involved had a complex medical history, including osteomyelitis, atrial fibrillation, atherosclerotic heart disease, and acute kidney failure. The resident's care plan included specific interventions for digoxin therapy and monitoring of an indwelling Foley catheter. Despite these detailed care plans, the facility's electronic medical records (EMAR) and electronic health records (EHR) showed significant gaps in the required documentation of vital signs, which are crucial for the safe administration of the prescribed medications. Interviews with the Director of Nursing (DON) and other staff members revealed that the facility was aware of the documentation issues and had started in-service training to address them. However, the DON was still investigating how the vital sign entry was dropped from the MAR. The physician acknowledged that while it would be ideal to have the vital signs documented as ordered, the lack of documentation did not contribute to the resident's hospitalization. The facility's policy on medication administration emphasized the importance of following the physician's orders and the resident's service plan, which was not adhered to in this case.
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 467 citations issued within 25 miles in the last 12 months — including the 9 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 New Braunfels
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eden Home | 2.5 mi | ★★★★★ | 23 | 0 |
| Sundance Inn Health Center | 4.6 mi | ★★★★★ | 16 | 0 |
| Avir At New Braunfels | 4.8 mi | ★★★★★ | 38 | 2 |
| Legend Oaks Healthcare And Rehabilitation - New Br | 5.8 mi | ★★★★★ | 11 | 0 |
| Avir At Schertz | 9.7 mi | ★★★★★ | 41 | 2 |
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.