Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lakeside Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with CHF, acute respiratory failure, acute kidney failure, and GAD had a new PRN Lorazepam oral concentrate order, with pharmacy records confirming delivery of a 30 mL bottle. The EMAR showed no administrations, and during a narcotic audit the prescription box was found in the narcotic refrigerator without the medication bottle. Interviews with the ADM, DON, LVNs, and a CMA revealed that narcotic counting practices were inconsistent, particularly for medications stored in the narcotic refrigerator, and required narcotic count sheets were missing for several days. Facility policy and verification forms required end-of-shift reconciliation of all controlled substances, but the lack of documented counts and failure to consistently include the refrigerator narcotics resulted in an unreconciled, missing controlled medication for this resident.
A resident with dementia, Parkinson’s disease, muscle weakness, and a high fall risk was found in bed without a call light within reach, despite being cognitively intact and care-planned to have the call light accessible and to receive prompt assistance. The call light cord was discovered wrapped and stored behind a roommate’s nightstand, and the resident reported not knowing it was there, while the roommate stated they would press their own call light when the resident needed staff. Multiple LVNs, the DOR, DON, and ADM confirmed the resident could use a call light, that all staff were responsible for ensuring call lights were within reach during rounds and room entries, and that facility policy required each resident to have a means to call staff from the bed and other areas, but this was not followed for this resident.
A resident with diabetes, osteoporosis, and a lumbar compression fracture experienced a significant unplanned weight loss of over 10% body weight within about one month after admission. The care plan called for maintaining weight within 3% of a target, monitoring intake each meal, and RD evaluation PRN, but the facility did not obtain weekly admission weights or a readmission weight as required by policy, and a large early weight drop was overlooked. The RD noted weight loss but made no recommendations and did not document a visit, and was not formally consulted despite policy requiring notification for significant changes. The resident reported losing more than sixteen pounds, limiting food choices due to blood sugar concerns, disliking some menu items, bringing her own protein shakes, and not being offered liquid supplements, while intake records showed multiple days with 50% or less meal consumption. Staff interviews confirmed inconsistent understanding and implementation of weight-monitoring procedures, leading to a failure to implement timely nutritional interventions for the resident’s significant weight loss.
A resident with spastic quadriplegic cerebral palsy was observed using a chest harness in a wheelchair without a physician order, consent, or documented evaluation, despite being unable to remove the device independently. Staff considered the harness a positioning device, but facility policy defined it as a restraint due to the resident's inability to remove it, and required a physician order and consent, which were not present.
A deficiency was cited for not ensuring a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or actions that led to this failure.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with a fractured patella and other conditions was prescribed Oxycodone/Acetaminophen for pain, but nursing staff failed to consistently document administration on both the MAR and narcotic count sheet. Additionally, two nurses did not properly report or witness the wastage of missing pills as required by policy, leading to discrepancies in medication records and unreported medication loss.
A resident with severe cognitive impairment and multiple medical and behavioral diagnoses did not have a comprehensive care plan addressing all identified needs, including cognitive loss, communication, urinary incontinence, behavioral symptoms, pressure ulcers, and the use of a wander guard. The care plan was incomplete despite facility policy and staff interviews confirming these areas should have been included.
Nine residents reported not having access to grievance forms, not knowing they could file grievances anonymously, and not being informed about the grievance procedure, with no postings or forms available in prominent locations. The ADM confirmed that forms were only available through staff and there was no process for anonymous submission, contrary to facility policy.
Two residents did not have their care plans updated or individualized to address vision, activities, and pressure ulcer risks, despite assessments indicating these needs. Staff interviews confirmed that care plans should be comprehensive and reflect all identified needs, but the required interventions and goals were missing or incomplete.
Multiple residents had triggered MDS items that were not included in their care plans, and care plans were not developed, reviewed, or revised by an interdisciplinary team within the required timeframe.
During a lunch meal, staff failed to follow proper hand hygiene and food handling procedures, including inadequate handwashing, handling food with bare hands, and serving food at unsafe temperatures. Several food items were served below the required holding temperature, and burnt food was provided to residents. Observations showed that much of the food was left uneaten, and staff interviews confirmed lapses in following established food safety and hygiene policies.
Staff failed to sanitize a blood pressure cuff between multiple residents and did not consistently perform hand hygiene or change gloves appropriately during incontinence care, despite having received training and facility policies requiring these infection control measures. Residents involved had complex medical histories, and these lapses were directly observed and confirmed in staff interviews.
A resident dependent on a mechanical lift for transfers was left in a wheelchair overnight due to a malfunctioning lift. Despite staff attempts to use the lift, it did not function, and the resident refused manual transfer, fearing for staff safety and his own. The resident's care plan required a mechanical lift, but there was no physician order for alternative methods. Staff interviews revealed a lack of training on alternative transfers and lift operation, highlighting communication and training issues.
A resident with a history of stroke, diabetes, and hypertension was found with an indwelling catheter but without physician orders for its use and care. The resident was unsure of the catheter's purpose, and staff interviews revealed a lack of clarity regarding its necessity and care instructions. The DON and Interim Administrator acknowledged the absence of orders and the potential risks, such as infection, due to this oversight.
A resident with a complex medical history, including dysphagia, was given medication by a CNA who was not certified to administer medications. The ADON, during a busy medication pass, prepared a Tylenol tablet and asked the CNA to administer it, citing the CNA's familiarity with residents. This action violated the facility's policy, which mandates that only licensed personnel administer medications.
A long-term care facility failed to maintain accurate drug records and reconcile controlled medications for a resident with dementia and Alzheimer's. Discrepancies in morphine administration were found, with staff not counting liquid morphine during shift changes, leading to an 8 ML discrepancy. The facility's policies did not explicitly require counting all medications, contributing to the oversight.
A long-term care facility failed to maintain an effective infection control program, as staff members did not adhere to enhanced barrier precautions during resident care. An LVN did not change gloves or wash hands during wound care and transfers, while CNAs failed to wash hands or wear gowns as required. Despite training, staff did not consistently follow infection control protocols, risking the spread of infections.
A resident with a surgical hip replacement did not receive wound care as per physician's orders, leading to a deficiency in care. The facility failed to perform daily dressing changes, resulting in blood-soaked dressings and sheets. Staff interviews revealed lapses in following procedures and documentation, contributing to the deficiency.
A facility failed to provide and document necessary wound care for a resident with a pressure ulcer, as per physician's orders. The resident, with multiple health conditions, required daily wound care, but there was no documentation of care on a specific date. Interviews revealed confusion among nursing staff about wound care responsibilities, and the DON confirmed that the absence of documentation indicated the care was not performed, placing the resident at risk for infection and worsening of the ulcer.
A resident with multiple medical conditions was not provided full privacy during peri and wound care by a CNA and ADON, leading to exposure. Despite training and facility policies, privacy curtains were not fully closed, and no sheet was used to cover the resident, resulting in a breach of privacy.
The facility failed to maintain an effective infection control program as CNAs did not adhere to hand hygiene protocols during incontinent care for residents. Despite training, CNAs neglected to wash hands before, during, and after care, increasing infection risk. Interviews confirmed staff awareness of protocols, yet routine habits led to non-compliance.
A resident with multiple health issues developed pressure ulcers that were not adequately treated according to physician orders. The facility failed to implement a comprehensive care plan, resulting in uncovered and untreated wounds. Staff interviews revealed a lack of awareness and inconsistent adherence to wound care schedules, despite training. The absence of a care plan policy further contributed to the deficiency.
A resident with multiple pressure ulcers was found with uncovered and improperly dressed wounds, despite physician orders for regular care. Staff interviews revealed a lack of awareness and adherence to the care plan, with some staff unaware of the resident's condition. The resident, who was in pain due to the open ulcers, denied removing the dressings. The facility's failure to follow physician orders placed the resident at risk of complications.
Failure to Reconcile and Account for Controlled Medication in Narcotic Refrigerator
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective system for acquiring, receiving, dispensing, administering, and reconciling controlled medications, specifically Lorazepam Oral Concentrate 2 mg/mL prescribed for one resident. The resident was an adult male admitted with diagnoses including unspecified diastolic congestive heart failure, acute respiratory failure, acute kidney failure, and generalized anxiety disorder. An order dated 03/18/2026 directed that 0.25 mL of Lorazepam oral concentrate be given by mouth every four hours as needed for anxiety, and the pharmacy shipment summary showed that a 30 mL bottle of this medication was delivered to the facility on that date. The Medication Administration Record from 03/18/2026 through 03/31/2026 showed no administrations of this PRN medication during that period. The Administrator reported that on 03/24/2026, following an audit of narcotic medications conducted by the DON and nursing staff, the prescription box for the resident’s Lorazepam was found in the narcotics refrigerator, but the bottle of medication was missing. Interviews with multiple LVNs revealed inconsistent practices regarding narcotic counts, particularly for medications stored in the narcotic refrigerator. Some LVNs stated they counted only the PRN narcotics on the medication carts and did not count the narcotics in the refrigerator, while others stated they believed they were counting all narcotics, including those in the refrigerator. One LVN, who assisted with the narcotic audit, stated that when she removed all items from the narcotic refrigerator, she discovered an empty box labeled for the resident’s Lorazepam without the corresponding bottle inside, and a subsequent search did not locate the medication. Further record review and interviews showed that the facility lacked completed narcotic count sheets for the period from 03/18/2026 to 03/24/2026, despite a policy requiring controlled substances to be reconciled upon receipt, administration, disposition, and at the end of each shift. The DON acknowledged that the narcotic refrigerator was not being consistently counted and that there was no specific system in place to ensure it was included in shift-to-shift reconciliations. The facility’s written policy and the Narcotic Book/EMAR Verification Sheet required that at each shift change both nurses verify all scheduled and PRN narcotics, document the actual number of cards, bottles, and patches, and turn in the form and any empty cards or bottles to the DON every shift without exception. The absence of narcotic count documentation for the relevant dates, combined with staff reports that the refrigerator narcotics were not always included in counts, led to the discovery that the resident’s newly received Lorazepam bottle was missing and could not be reconciled.
Failure to Keep Resident Call Light Within Reach at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system was available and within reach at a resident’s bedside as required by facility policy and the resident’s care plan. Record review showed the resident was an older male with unspecified dementia and Parkinson’s disease with dyskinesia, who was cognitively intact per a BIMS score of 14. His care plan identified an ADL self-care performance deficit due to muscle weakness related to Parkinson’s disease, a need for assistance by one to two staff for transfers, and a high risk for falls related to gait/balance problems and psychoactive drug use. The care plan specifically directed that his call light be kept within reach and that he receive a prompt response to all requests for assistance. During an observation and interview, the resident was found lying in bed without a call light within reach. He stated he had never had a call light in his room. The surveyor observed that the call light cord was wrapped and placed behind his roommate’s nightstand, approximately three feet from his bed, and the resident reported he did not know it was there. The roommate confirmed that the resident did not have a call light and that the roommate would press his own call light when the resident needed staff. When the roommate pressed his call light, an LVN entered the room in response, located the resident’s call light behind the nightstand, unwrapped it, and placed it within the resident’s reach, confirming it was functional and acknowledging it should have been within reach while the resident was in bed. Multiple staff interviews, including with the DOR, several LVNs, the DON, and the ADM, confirmed that the resident was capable of using his call light, even though he did not use it frequently and often sought staff by going out of his room. They each stated that the call light should always be within the resident’s reach while in his room for safety and that all staff were responsible for ensuring call lights were within reach during nursing rounds, every time staff entered a room, and as they walked down hallways. Review of the facility’s “Call System, Residents” policy stated that each resident is to be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor, and that the resident call system is to be routinely maintained and tested by maintenance. Despite these expectations and policies, the resident’s call light had been wrapped and stored behind the roommate’s nightstand, leaving him without an accessible means to call for assistance while in bed until it was discovered during the survey.
Failure to Monitor and Intervene for Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for a resident who experienced a significant, unplanned weight loss of 16.8 pounds, representing a 10% loss of body weight between early December and mid-January. The resident was an older adult female with diagnoses including a lumbar compression fracture, Type 2 diabetes mellitus, osteoporosis, and a cognitive communication deficit, but with intact cognition per an admission BIMS score of 15. Her admission MDS documented an admission weight of 158 pounds, no poor appetite, independent eating with setup assistance, and an LCS regular diet with thin liquids. The comprehensive care plan, initiated shortly after admission and later revised, identified a nutritional problem related to diabetes and set a goal for the resident to maintain weight within 3% of 145.8 pounds, with interventions to provide the ordered diet, monitor and record intake each meal, and have the RD evaluate and recommend diet changes as needed. Weight records showed the resident’s weight decreased from 158 pounds on admission to 145.8 pounds by early January and then to 141.2 pounds by mid-January, meeting the facility policy’s threshold for significant weight loss. The facility’s policy required residents to be weighed on admission, the next day, and weekly for two weeks, then monthly if no concerns, and to recheck any 5% or greater weight change the next day, with immediate written notification to the dietitian if confirmed. The DON later stated that newly admitted residents were usually weighed upon admission, weekly for four weeks, then monthly, and that residents should also be weighed upon readmission from the hospital. However, the resident was not weighed weekly upon admission, was not weighed upon readmission from a hospital stay in December, and the DON acknowledged being unsure why these weights were missed. The DON also stated he was not aware of the extent of the resident’s weight change and that the significant change noted on the early January weight was overlooked. The dietitian’s documentation and statements further showed that required nutritional follow-up was not completed or recorded in response to the resident’s weight changes. The dietitian reported seeing the resident shortly after admission and again in early January, noting some weight loss but believing the admission weight might be inaccurate based on the resident’s reported usual weight of 145–150 pounds. No recommendations were made at that time, and the dietitian did not enter a note in the electronic health record for the early January visit. The resident reported losing over sixteen pounds since admission, attributed her weight loss to limiting foods that might raise her blood sugar, described herself as a picky eater who did not care for some facility foods, and stated she brought her own protein shakes and was not offered liquid supplements by the facility. She also reported being weighed only once or twice a month and not recalling a dietitian visit since admission. Meal intake records showed variable intake, with multiple days where she consumed 50% or less of meals, despite the care plan goal of consuming at least 75% of three meals daily. These actions and inactions in monitoring weights, confirming significant changes, notifying the dietitian, and implementing timely nutritional interventions led to the resident’s significant weight loss. Staff interviews corroborated that the facility’s processes for weight monitoring and nutritional follow-up were not consistently implemented for this resident. The CNA responsible for passing lunch trays stated the resident usually consumed 75–100% of meals and was receiving sandwiches as snacks, and that she would notify the kitchen and offer alternatives if residents complained about food. The LVN stated that CNAs on day shift were responsible for obtaining monthly weights and that she believed new residents were weighed on admission and monthly, with the DON responsible for notifying the physician of changes. The DON stated that a transportation aide obtained weights and turned them in for entry into the electronic record, and he was unsure why the resident was not weighed weekly or upon readmission. The administrator stated he was not aware of the resident’s significant weight loss until a care plan meeting and that he and the DON were ultimately responsible for ensuring weights were monitored and significant changes were addressed. The facility’s written policy on weight assessment and intervention, including thresholds and required actions for significant weight loss, contrasted with the actual practice documented for this resident, resulting in a failure to implement appropriate monitoring and interventions to prevent or address her significant weight loss.
Failure to Obtain Physician Order and Consent for Use of Chest Restraint
Penalty
Summary
A deficiency was identified when a resident with spastic quadriplegic cerebral palsy and a history of falls was observed using a chest harness in his wheelchair. The resident required substantial to maximal assistance with positioning, mobility, and transfers, and was cognitively moderately impaired. Despite the use of the chest harness, there was no physician order, consent, or documented evaluation of need for the device in the resident's medical record. The quarterly MDS assessment did not indicate the use of a trunk restraint, and the comprehensive care plan lacked any mention of a restraint or the chest harness. Staff interviews revealed that the chest harness was used daily to prevent the resident from falling, and the resident was unable to remove the harness independently. Both the LVN and the DON acknowledged that the resident could not unbuckle the harness himself. The DON and ADM stated that the harness was considered a positioning device rather than a restraint, and therefore did not require the same documentation or physician oversight. However, the facility's own policy defined a restraint as any device that the resident could not remove easily and that restricted freedom of movement, which applied to the chest harness in this case. Further review of facility documentation showed that the use of the chest harness was noted as a stability device to prevent the resident from slipping out of his chair. Despite this, there was no evidence of a risk assessment, consent, or physician order for its use, as required by facility policy. The policy also specified that restraints should only be used upon written physician order, with documented consent and ongoing evaluation, none of which were present for this resident.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Accurately Document and Report Administration and Wastage of Controlled Substances
Penalty
Summary
The facility failed to provide proper pharmaceutical services for a resident who was prescribed Oxycodone/Acetaminophen 10/325MG, resulting in multiple documentation and reporting errors by nursing staff. Specifically, one nurse did not document the administration of the medication on the Medication Administration Record (MAR) after giving it to the resident. Additionally, two other nurses failed to record the administration of the same medication on the Narcotic Record Count Sheet after giving it to the resident. These lapses led to inconsistencies between the MAR and the narcotic count sheet, making it unclear how many doses were actually administered and how many pills should have remained in inventory. Further compounding the issue, one nurse failed to notify the Director of Nursing (DON) or Assistant Director of Nursing (ADON) about a discrepancy involving two missing pills, as required by facility policy. Instead, the nurse documented the pills as wasted on the narcotic count sheet and had another nurse sign as a witness, even though the witnessing nurse did not actually observe the medication being wasted. This was contrary to facility policy, which requires two nurses to witness and sign off on the destruction of controlled substances. Interviews with staff revealed confusion and lack of adherence to proper procedures for documenting, counting, and reporting discrepancies with controlled medications. The resident involved was an older female admitted with a fractured patella, muscle weakness, and lack of coordination, and had an order for Oxycodone/Acetaminophen as needed for pain. Documentation reviews and staff interviews confirmed that the required records for administration and wastage of the medication were incomplete or inaccurate, and that staff did not consistently follow the facility’s policies for handling controlled substances. The discrepancies in documentation and failure to report missing medication were directly observed and verified by facility administration during the investigation.
Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical and psychosocial needs. The resident, an elderly female with diagnoses including benign intracranial hypertension, mixed hyperlipidemia, Type 2 diabetes with hyperosmolar hyperglycemic coma, intermittent explosive disorder, cognitive communication deficit, and unspecified dementia, was admitted with significant cognitive impairment as evidenced by a BIMS score of 00. The comprehensive assessment identified several care areas requiring attention, such as cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, falls, nutritional status, pressure ulcers, and psychotropic drug use. Despite these identified needs, the resident's care plan did not address several critical areas, including cognitive loss/dementia, communication, urinary incontinence, behavioral symptoms, and pressure ulcers. Additionally, the care plan failed to include the physician's order for a wander guard or the rationale for its use, and did not address the resident's behaviors related to her diagnoses. Observations confirmed the presence of a wander guard and ongoing behavioral symptoms, such as repeated tapping, yet these were not reflected in the care plan. Interviews with staff revealed a lack of awareness regarding the incomplete care plan and uncertainty about whether all required care areas were included. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for each resident. However, the care plan for this resident was incomplete and did not reflect all areas identified in the comprehensive assessment. Staff interviews indicated that care plans were supposed to be updated upon admission, quarterly, and as changes occurred, but the process was not fully implemented, resulting in the omission of essential care planning for the resident.
Failure to Provide Grievance Information and Access to Residents
Penalty
Summary
The facility failed to provide information to residents and their representatives regarding their rights to file grievances or concerns. During a Resident Council meeting, nine residents who had been in the facility for over six months reported that they did not have access to grievance forms, were unaware they could file grievances anonymously, and had never had the grievance procedure discussed during council meetings. These residents also stated they had not seen postings of the grievance procedure in prominent locations and did not know where to acquire a grievance form, who to submit it to, or what the process entailed after filing. Observations confirmed that the facility did not have instructions regarding the grievance procedure posted in prominent locations, and grievance forms were not readily available nor was there a method to submit grievances anonymously. The Administrator, who served as the Grievance Officer, stated that grievance forms were kept in staff offices and residents could not obtain them without asking staff. Staff typically completed the forms for residents, and there was no established procedure for anonymous submissions. The grievance policy, last updated in 2017, required that information on filing grievances be made available to residents, but this was not being implemented as described.
Failure to Develop and Update Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, specifically neglecting to address their vision, activities, and pressure ulcer risks. For one resident, the care plan was not revised or updated to include interventions and goals related to vision, despite documentation indicating vision impairment and risk for pressure ulcers. The Minimum Data Set (MDS) and Care Area Assessment (CAA) summaries identified these issues, but the care plan did not reflect them. For the second resident, the care plan lacked documentation and interventions for visual function, activities, and pressure ulcers, even though the resident's assessments indicated impaired vision, use of corrective lenses, and risk for pressure ulcers. The relevant sections of the MDS were either incomplete or not addressed in the care plan, and the CAA summaries triggered concerns that were not care planned. Interviews with facility staff, including the Administrator, DON, and MDS Coordinator, confirmed that care plans are intended to be individualized and updated based on assessments and resident needs. However, the care plans for these residents were not updated or individualized as required, and the facility's policy mandates that care plans include measurable objectives, timeframes, and interventions for all identified needs.
Failure to Develop and Update Care Plans for Triggered MDS Items
Penalty
Summary
Several residents were found to have discrepancies in their care plans, specifically with care plan items not being developed as required. Record review revealed that for at least three residents, there were multiple triggered Minimum Data Set (MDS) items that were not addressed in their care plans. The care plans were not completed within the required timeframe following the comprehensive assessment, nor were they prepared, reviewed, and revised by a team of health professionals as mandated.
Failure to Provide Palatable, Safe, and Properly Handled Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature during a lunch meal observation. Kitchen staff member A was observed not following proper handwashing procedures, often rinsing hands with water only and not washing for the required 15 seconds with soap. The staff member also handled food with bare hands, picked up food items directly, and then donned gloves without proper hand hygiene. Additionally, the staff member used gloved hands to pick up brisket from the serving bar and returned it to the steam table, served burnt rolls, and handled rolls and potatoes with bare hands while serving residents. Hot dog buns were left open in their package for an extended period. Temperature checks of the food revealed that several items were not maintained at appropriate temperatures. For example, the roast on a regular plate was measured at 120°F, potatoes at 101.8°F, and carrots at 122.9°F, all of which are within the temperature danger zone for food safety. Pureed and mechanical diet items also showed inconsistent temperatures, with some items above and others below the required holding temperature of 135°F. Observations further indicated that ten plates of food were left uneaten on the table, suggesting issues with food palatability and temperature. Interviews with staff confirmed a lack of adherence to food safety and hand hygiene policies. Kitchen staff member A acknowledged being trained years ago and recognized that not following policy could negatively impact residents' health and nutrition. The administrator and kitchen supervisor both stated expectations for compliance with food safety and hand hygiene protocols, referencing facility policies that require proper handwashing, glove use, and maintenance of safe food temperatures. Record reviews of facility policies supported these requirements, emphasizing the importance of hygiene and temperature control in food preparation and service.
Failure to Follow Infection Control Protocols for Equipment and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not following established protocols for cleaning and hand hygiene. During medication administration, a medication aide (MA) used a blood pressure cuff on several residents consecutively without sanitizing the equipment between uses, despite having been trained to do so. The aide acknowledged awareness of the protocol but stated she forgot to disinfect the cuff, which was confirmed by direct observation and staff interviews. Additionally, certified nursing assistants (CNAs) did not adhere to proper hand hygiene practices during incontinence care. One CNA changed gloves without performing hand hygiene between glove changes, while another failed to change gloves and perform hand hygiene before placing a clean brief on a resident. Both CNAs had received training on infection control and recognized the importance of these practices but admitted to forgetting the required steps during care. The residents involved had significant medical histories, including conditions such as cerebral infarction, type two diabetes, urinary tract infection, major depressive disorder, and cerebrovascular disease. Facility policy required cleaning and disinfection of non-critical resident care items, such as blood pressure cuffs, and mandated hand hygiene before moving from contaminated to clean body sites and after glove removal. Despite these policies and recent staff training, the observed lapses in infection control protocols led to the identified deficiencies.
Resident Left in Wheelchair Overnight Due to Inoperable Mechanical Lift
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was dependent on a mechanical lift for transfers due to muscle weakness, neuropathy, and other conditions, was left in his wheelchair overnight because the mechanical lift was reportedly inoperable. Despite multiple attempts by staff to use the lift, it did not function properly, and the resident refused manual transfer due to concerns about staff safety and his own fear of being dropped. The resident's care plan indicated that he required a mechanical lift with two staff assistance for transfers, but there was no physician order for the use of a mechanical lift or alternative transfer methods. On the night in question, the staff did not report the malfunctioning lift to the appropriate personnel, and the resident remained in his wheelchair until the following morning. The resident expressed discomfort but did not experience pain or require immediate medical attention during the night. Interviews with staff revealed a lack of training on alternative transfer methods and mechanical lift operation. The facility had only one mechanical lift, and there was confusion among staff about the appropriate number of personnel required for a manual transfer if the lift was not operational. The incident highlighted a breakdown in communication and training, as well as a failure to adhere to the resident's care plan and ensure his comfort and safety.
Lack of Physician Orders for Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident with a urinary catheter had the necessary physician orders for its use and care. The resident, a female with a history of cerebral infarction, type 2 diabetes, essential hypertension, and a urinary tract infection, was observed with an indwelling catheter but without corresponding physician orders. The resident, who had an intact cognitive status, was unsure of the reason for the catheter's placement, and staff interviews revealed a lack of clarity regarding the catheter's necessity and care instructions. The Director of Nursing (DON) and Interim Administrator acknowledged the absence of physician orders and the potential risks associated with this oversight, such as infection or inadequate catheter care. The DON, new to the facility, was uncertain about the catheter's origin, suspecting hospice involvement, but could not confirm the diagnosis necessitating the catheter. The facility's policy required documentation of clinical indications for catheter use, which was not adhered to in this case, leading to a deficiency in providing appropriate catheter care and increasing the risk of urinary tract infections for the resident.
Improper Medication Administration by Uncertified Staff
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate dispensing and administration of drugs, as evidenced by an incident involving the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA). On a hectic day, the ADON prepared a Tylenol Extra Strength tablet for a resident and handed it to the CNA, who was not certified to administer medications, to give to the resident. This action was prompted by the ADON's need for assistance during a busy medication pass, and the CNA's familiarity with the residents was cited as a reason for this decision. The resident involved had a complex medical history, including acute respiratory failure, epilepsy, insomnia, anxiety, depression, dysphagia, cerebral palsy, and congenital hypertonia. The resident required substantial assistance with eating and was on a mechanically altered diet with thickened liquids due to swallowing difficulties. Despite these needs, the medication administration record showed no documentation of the Tylenol being given on the day in question, raising concerns about the accuracy and safety of medication administration. Interviews with staff and observations confirmed the incident, with multiple staff members expressing concern about the risks associated with an uncertified person administering medications. The ADON acknowledged the mistake and stated it was a spur-of-the-moment decision. The CNA, who administered the medication, also recognized the error and stated it would not happen again. The facility's policy clearly states that only licensed or state-permitted personnel may prepare and administer medications, highlighting the deviation from standard procedures in this case.
Medication Reconciliation Failure in LTC Facility
Penalty
Summary
The facility failed to ensure that the drug records for a resident were in order and that an account of all controlled drugs was maintained and periodically reconciled. This deficiency was identified during a review of the medication administration records for a resident diagnosed with dementia, Alzheimer's disease, and altered mental status. The resident was prescribed morphine sulfate for pain management, but discrepancies were found in the medication administration records and the actual amount of morphine present in the facility. The investigation revealed that the facility did not monitor, review, or reconcile the resident's medication administration record from April to October 2024. The medication administration logs showed inconsistencies in the documentation of morphine administration, with missing doses and discrepancies between the recorded and actual amounts of morphine. Interviews with staff, including the DON, ADON, and various LVNs, indicated that the liquid morphine was not being counted during shift changes, and the staff had become relaxed in the process, relying on verbal confirmations rather than physical counts. The facility's policies on medication administration and documentation did not explicitly require the counting of all medications, including liquids, during shift changes. The lack of adherence to proper medication reconciliation procedures led to an 8 ML discrepancy in the morphine count, which was discovered by a new nurse. The failure to maintain accurate medication records and perform regular counts placed residents at risk of not receiving prescribed medications and potential drug diversion.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions and inactions of staff members during the care of two residents. Specifically, LVN D did not adhere to enhanced barrier precautions, failed to change gloves, and neglected to wash her hands or use alcohol-based hand rub (ABHR) during wound care for two residents and during the transfer of one resident to bed. Additionally, LVN D did not wear the appropriate personal protective equipment (PPE) during these procedures, which is a requirement under the facility's infection control policy. CNA G and CNA H also failed to follow enhanced barrier precautions. Both CNAs did not wash their hands or use ABHR before entering and after exiting a resident's room. Furthermore, CNA H did not wear a gown while transferring a resident to bed, despite the facility's policy requiring gloves and gowns for high-contact resident care activities. These lapses in protocol were observed despite the presence of signage indicating the need for enhanced barrier precautions. Interviews with the staff, including LVN D, CNA G, CNA H, the Director of Nursing (DON), and the Administrator, revealed a lack of adherence to the facility's infection control policies. Although the staff had been trained on enhanced barrier precautions, they did not consistently apply this training in practice. The DON and Administrator acknowledged the deficiencies and recognized the potential for the spread of infections due to these lapses in infection control practices.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident received wound care in accordance with physician's orders and professional standards of practice. The resident, a female with a history of surgical hip replacement, epilepsy, end-stage renal disease, and major depressive disorder, was admitted to the facility with specific orders for daily dry dressing changes to her left hip incision. However, the facility did not adhere to these orders, as evidenced by the lack of documentation for a dressing change on one of the specified dates. On a particular day, a CNA discovered the resident with blood-soaked dressings and sheets, indicating that the wound care had not been performed as required. The charge nurse confirmed that the dressing had not been changed for two days, despite the presence of old and new blood and a foul odor emanating from the dressing. The nurse acknowledged that the dressing should have been changed daily, as per the physician's orders, and reported the issue to the on-call ADON. Interviews with facility staff, including the DON and the administrator, revealed that the failure to perform and document the dressing changes was due to a lapse in following the established procedures. The DON admitted that if there was no documentation, the care was likely not provided, and emphasized the importance of adhering to physician's orders to prevent potential negative outcomes such as infection or wound deterioration. The facility's policy on wound care documentation was not followed, contributing to the deficiency.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure ulcer, as per the physician's orders. The resident, a cognitively intact female with multiple health conditions including multiple sclerosis and schizoaffective disorder, had a documented pressure ulcer on the coccyx. The physician's orders required daily wound care, which included cleansing, drying, applying triad, and covering with a dressing. However, there was no documentation of the wound care being performed on a specific date, indicating a lapse in following the prescribed treatment plan. Interviews with the nursing staff revealed a lack of clarity and communication regarding wound care responsibilities. The charge nurse and medication nurse both stated they did not perform the wound care for the resident on the specified date. The Director of Nursing (DON) acknowledged that due to low census, the medication nurse was responsible for wound care between medication passes, and all staff had been notified of this change. However, the absence of documentation suggested that the wound care was not completed, which the DON confirmed should have been documented with date, time, and initials. This failure to follow physician's orders and document care placed the resident at risk for infection and worsening of the pressure ulcer.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to respect a resident's right to personal privacy during care procedures. Specifically, a CNA did not provide full privacy for a resident during peri care by not completely closing the privacy curtains or using a towel or sheet to cover the resident. This resulted in the resident's body being exposed during the procedure. Additionally, the ADON also failed to ensure privacy during wound care by not fully drawing the privacy curtain and not providing a sheet to cover the resident, leading to exposure while care was being administered. The resident involved was a female with multiple medical conditions, including metabolic encephalopathy, urinary tract infection, hyperlipidemia, depression, high blood pressure, anemia, type 2 diabetes, fibromyalgia, Sjogren syndrome, and acid reflux disease. The resident had a BIMS score indicating moderate cognitive impairment. During the care procedures, a camera was present in the room, allowing the family to view the resident, and a CNA entered the room while the resident was exposed. Interviews with the ADON, DON, and CNA confirmed that privacy protocols were not followed, despite training and facility policies emphasizing the importance of maintaining resident privacy.
Inadequate Hand Hygiene Practices in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNAs who did not adhere to hand hygiene protocols during the provision of incontinent care to residents. Specifically, CNA A did not wash her hands before or during the care of Resident #2, who had multiple pressure ulcers and was incontinent. Despite being trained in infection control practices, CNA A only washed her hands for 10 seconds after completing the care, contrary to the facility's policy of washing hands for at least 15 seconds. Similarly, CNA A did not wash her hands before, during, or after providing incontinent care to Resident #3, who had a history of sepsis and other serious health conditions. The CNA assisted the resident with toileting and cleaning without performing hand hygiene, increasing the risk of cross-contamination. This lack of adherence to hand hygiene protocols was also observed in the care of Resident #4, where both CNA A and CNA B failed to wash their hands before, during, and after providing care, despite the resident's cognitive intactness and need for extensive assistance due to incontinence. Interviews with the CNAs, ADON, DON, and the Administrator revealed that the staff had been trained in infection control practices, including handwashing, through regular in-services and competency checks. However, the CNAs admitted to not following the protocols due to routine habits and nervousness. The facility's policies clearly outlined the importance of hand hygiene in preventing the spread of infections, yet the staff did not consistently apply these practices, leading to the identified deficiencies.
Failure to Implement Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple pressure ulcers, which were not adequately treated according to physician orders. The resident, a male with a history of lung cancer, anemia, and other health issues, was admitted without pressure ulcers but was at risk of developing them. Despite verbal orders for wound care to the coccyx, left hip, and left thigh, the care plan did not address the resident's tendency to remove his own dressings, leading to uncovered and untreated wounds. Observations revealed that the resident's pressure ulcers were not properly covered, with one dressing hanging off and another wound completely uncovered. Interviews with staff, including CNAs and the ADON, indicated a lack of awareness and inconsistent adherence to the wound care schedule. The ADON and DON acknowledged the orders for wound care but could not explain why the dressings were not applied as required. The resident expressed pain due to the open wounds and stated that he had not removed any bandages himself. The facility's failure to follow physician orders and ensure proper wound care was compounded by the absence of a care plan policy, as confirmed by the DON. Despite training provided by the DON, the staff did not consistently report or address uncovered pressure ulcers, potentially leading to infection and worsening of the resident's condition. The administrator and DON both emphasized the importance of following physician orders, yet the deficiency persisted, highlighting a gap in the facility's care planning and implementation processes.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to uncovered and improperly dressed pressure ulcers. Observations revealed that the resident's pressure ulcer on the left thigh was uncovered, and the dressing on the coccyx was hanging off, exposing the ulcer. The dressing was soaked with drainage, and there was blood on the resident's gown and bedding. These observations were made despite physician orders for the ulcers to be cleaned and covered every night shift. Interviews with staff indicated a lack of awareness and adherence to the care plan. A CNA stated she was unaware of the uncovered ulcers and had seen them uncovered before. The ADON acknowledged the orders for cleaning and covering the ulcers but was unsure why they were not followed. The LVN, who was working PRN, was unaware of the resident's wounds and planned to address them after completing medication pass. The DON and Administrator both expected staff to follow physician orders and cover the ulcers promptly. The resident, who was moderately cognitively impaired and incontinent, reported being in pain due to the open ulcers. The resident denied removing the dressings himself. The facility's failure to ensure the resident's pressure ulcers were properly dressed and covered as per physician orders placed the resident at risk of complications, including infection and worsening of the ulcers.
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 144 citations issued within 25 miles in the last 12 months — including the 14 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 Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lubbock Health Care Center | 0.1 mi | ★★★★★ | 6 | 0 |
| Southern Specialty Rehab & Nursing | 0.4 mi | ★★★★★ | 13 | 2 |
| Mi Casita Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 15 | 0 |
| Mesquite Post Acute Care | 0.6 mi | ★★★★★ | 11 | 0 |
| The Mildred & Shirley L. Garrison Geriatric Educat | 1.4 mi | ★★★★★ | 14 | 5 |
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.