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 Lampstand Nursing And Rehabilitation during CMS and state inspections, most recent first.
Food storage and labeling deficiencies were identified in the kitchen. Surveyors observed multiple refrigerated items without proper labels or discard dates, including prepared foods and sandwiches, and found a black substance resembling mold on the dry storage wall, shelf, and floor. Staff interviews confirmed that dietary staff were responsible for dating and labeling food and that the dry storage area was supposed to be cleaned on a schedule.
Infection control failures were observed during care for three residents. An RN did not change contaminated gloves or wash hands appropriately during peri care for a resident with severe cognitive impairment and total dependence for toileting hygiene, another RN did not sanitize hands between glove changes during indwelling catheter care for a resident with a catheter and urinary infections, and an ADON/LVN did not sanitize the over-bed table or maintain sterile technique during tracheostomy care.
A resident with severe cognitive impairment and diagnoses including convulsions, major depressive disorder with psychotic symptoms, and schizophrenia was repeatedly observed wearing hospital gowns during the day while in common areas, therapy, and the dining room, even though his personal clothing was available in his room. His care plan directed staff to assist him in choosing comfortable clothing and to dress him in his own clothes. An RN said she did not know he had personal clothes available, a CNA said gowns were easier to put on, and the resident’s family said he preferred regular clothes and had plenty available.
Dirty Bathroom Floors: A resident with UTI, depression, and CKD reported that her bathroom was not cleaned properly on a daily basis, and observation showed a dirt ring and dark dirt/dried mud-like debris around the perimeter of the bathroom floor. A second bathroom was also observed with similar debris. The ADON, housekeeping manager, DON, and Administrator all stated the floors were not clean and that resident rooms and bathrooms were expected to be swept and mopped daily.
Care plans were not revised for two residents after activity preferences changed. One resident with dementia and intact cognition and another resident with dementia and severe cognitive impairment were both receiving in-room activities, but their comprehensive care plans did not reflect those current preferences. The Activity Director, DON, and MDS Coordinator LVN all stated the plans should have been updated to match the residents' activity needs.
Failure to Provide Needed Nail Care for Two Residents: Two residents who needed assistance with ADLs were observed with blackish/brownish substance under multiple fingernails, and one resident reported asking for nail cleaning days earlier without it being done. Records showed both residents had dementia and significant functional dependence, with care plans directing staff to assist with personal hygiene and to check, clean, and trim nails during bathing and as needed. Interviews showed staff understood nail care responsibilities were split between nurses for residents with DM and CNAs for others, but neither resident was known to have refused care.
Failure to Provide Planned Activity Programming: Two residents did not receive the in-room activity support reflected in their care plans and activity records. One resident with intact cognition and preferences for favorite activities and news reported wanting brief room visits instead of group activities, but said he had not received any activity visits. Another resident with severe cognitive impairment, dementia, contractures, and hemiplegia was observed lying in bed with no stimulation in his room, and his records also showed no in-room activities documented over several months.
Unlocked Housekeeping Cart With Chemicals Left Unsupervised: A housekeeping cart with chemical cleaners was observed unlocked near the 100 hall while the housekeeper was away from it and could not see it. The housekeeper stated the cart should be locked whenever she walked away, and the Administrator and Housekeeping Supervisor stated carts were expected to be locked when not in a staff member’s eyesight. The facility policy also stated housekeeping carts and chemicals must be locked when not within the eyesight of a staff member.
A resident with an indwelling Foley catheter and diagnoses including BPH, urinary retention, and obstructive uropathy complained of catheter pain, but the ordered catheter size was not immediately available. Staff discovered the wrong catheter size had been delivered, and the LPN waited for the correct supply to be located while the resident remained uncomfortable. Interviews showed the central supply process and communication between nursing and supply staff broke down, delaying catheter replacement.
A resident with a feeding tube, dysphagia, malnutrition, and aphasia had an enteral feeding pump audibly alarming with a flow error for about 45 minutes while the resident remained in bed. RN D, who was standing several rooms away, did not respond until questioned, despite facility leadership stating staff are expected to respond immediately to audible feeding pump alarms.
Medication Cart #1 was observed unlocked near the common TV area with its drawers accessible while the assigned med aide was in a resident room and no nursing staff were nearby. The med aide said she thought she had locked the cart and stated residents and visitors could access the medications. The DON stated carts were expected to be locked unless a nurse was actively administering meds, and the facility policy required medications and biologicals to be stored securely and accessible only to authorized personnel.
Pureed Diet Prepared to Incorrect Consistency: A dietary staff member prepared fish sticks for residents on a pureed diet by adding an unmeasured amount of broth and blending the food into a runny consistency instead of following the recipe. The DMA reviewed the recipe, which called for a measured amount of broth and a texture like applesauce to mashed potatoes, and the staff member then added bread to correct the consistency. Interviews with the dietary staff member, DMA, and DON confirmed that pureed foods should be prepared to the prescribed texture and that runny food was not appropriate.
Incomplete Documentation of Incontinent Care: A resident with severe cognitive impairment, schizophrenia, and total dependence for ADLs had a care plan requiring q2h checks, toileting assistance, and peri care after each incontinent episode. Review of the POC, nursing notes, and hourly check records showed multiple gaps in documentation of incontinent care over several days, and the DON and ADM stated CNAs were responsible for accurate shift documentation and that the missing entries were not acceptable.
A resident with severe cognitive impairment and multiple diagnoses did not have a comprehensive care plan that included dates of injuries or goals and interventions for schizophrenia. The care plan lacked measurable objectives and timeframes, and staff confirmed these omissions, resulting in incomplete clinical documentation.
A resident with severe cognitive impairment and non-verbal status was administered medication by a med aide who did not inform the resident of the medication name or purpose, contrary to facility policy requiring explanation of medications during administration. Staff interviews confirmed the omission, noting the resident's inability to understand but acknowledging the lapse in procedure.
A resident with a history of TBI and high fall risk was left in an unsafe position by a CNA who attempted to reposition the resident alone, contrary to the care plan requiring two-person assistance. The resident was left with legs hanging off a raised bed and the call light out of reach, while the CNA left the room to seek help. Facility leadership confirmed that proper procedures were not followed and the resident was not safely supervised.
A resident with a seizure disorder and severe cognitive impairment did not receive two scheduled doses of Keppra due to lethargy and refusal, with staff failing to make additional administration attempts or notify the provider and responsible party as required. This resulted in the resident experiencing a seizure and hospital evaluation, with documentation and interviews confirming the missed doses and lack of appropriate notification.
A resident's legal representative requested that an LVN not provide care, but the LVN continued to care for the resident due to a lack of timely communication and updates to staff assignments. The resident, who was dependent on staff for mobility and ADLs and had multiple medical conditions, did not have their representative's wishes honored, as required by facility policy.
A bottle of Nystatin Topical Powder was found unattended and unsecured at the bedside of a resident with multiple medical conditions, despite facility policy prohibiting medications from being left in resident rooms. Staff interviews confirmed that no one was aware of the medication being left out, and all acknowledged that medications should be administered by licensed personnel and properly stored.
The facility did not provide all residents with notice of their rights, as required, with postings only available in one hallway and the resident rights document omitted from admission packets for several months. Interviews with multiple residents revealed they were unaware of their rights, and staff confirmed a lack of awareness and process to ensure this information was distributed.
Surveyors identified failures in food storage, labeling, and sanitation, including onions stored in water and leaking, undated and expired food items, improperly stored eggs, tea, and cake, and an ice machine with black slime. Dietary staff acknowledged not following protocols for labeling, dating, and cleaning, and were unaware of when the ice machine was last cleaned, contrary to facility policy.
Two medication aides failed to sanitize a blood pressure cuff between uses on multiple residents during medication administration, contrary to facility policy and infection control expectations. The aides acknowledged the oversight when questioned, and the DON confirmed that equipment should be cleaned between residents to prevent cross-contamination.
Essential kitchen equipment, including a coffee brewing system, oven, steam table, and heated delivery cart, were found to be nonfunctional or not maintaining proper temperatures. Staff interviews revealed these issues had persisted for months, with inconsistent reporting and follow-up, and maintenance logs lacked documentation for most equipment failures. Supervisory staff were not fully aware of the problems, and no facility policies for equipment maintenance were provided.
A dietary aide was allowed to work in the kitchen without completing required training, obtaining a food handler's certificate, or receiving proper supervision. Staff interviews and record reviews confirmed the aide had not been trained on key kitchen procedures, and facility leadership was unaware of the lack of training and oversight.
The facility failed to maintain proper hand hygiene during food preparation, as observed with a staff member who did not wash or sanitize her hands between tasks, leading to potential cross-contamination. The staff member handled food and kitchen utensils without gloves and touched various contaminated surfaces. Interviews with facility management confirmed the deficiency, and the facility's hand washing policy was not adhered to.
A resident with severe cognitive impairment and incontinence was found in a room with a strong urine odor and soiled sheets, indicating a failure to maintain a clean and comfortable environment. Staff interviews revealed a lack of awareness and action, as the assigned CNA did not recall the resident's condition, and another CNA noticed the issue but was unsure of responsibility. The facility's policy required immediate action to address such conditions, which was not followed.
A resident with chronic health conditions reported a grievance about delayed response to call lights, waiting over forty-five minutes for assistance. Despite the resident's clear communication, the grievance was not documented or investigated as per facility policy. The DON acknowledged the oversight, and the facility's grievance policy was not adhered to.
A resident with multiple sclerosis and dysphagia was not properly positioned during meals, leading to potential risks of choking and discomfort. Despite the resident's preference to sit up, he was observed lying in bed with the head slightly elevated while eating. Staff interviews confirmed the need for residents to be upright during meals to prevent choking, but the facility failed to consistently ensure this positioning.
A facility failed to maintain an effective infection control program, as staff did not consistently wear PPE or tie back long hair while providing care to a resident on enhanced barrier precautions. Video evidence and staff interviews confirmed these lapses, which increased the risk of cross-contamination and infection.
A resident with severe cognitive impairment and multiple medical conditions had their call light out of reach, contrary to their care plan. Observations confirmed the call light was under the bed, and staff interviews highlighted the importance of accessible call lights for resident safety. The facility lacked a specific call light policy.
A resident with cognitive impairment and blindness was unsafely discharged from an LTC facility and left unsupervised on a busy street. The facility failed to coordinate the discharge with the resident's family and did not wait for the completion of an appeal process. The resident's care plan indicated that discharge was not feasible due to dementia and elopement risk, yet the facility proceeded without ensuring a responsible party was present to receive the resident.
The facility failed to review and revise a resident's care plan within the required quarterly timeframe, missing the deadline by several weeks. The resident, with multiple diagnoses and moderate cognitive impairment, had his last care plan update in December 2023. Staff cited high admission rates and workload as reasons for the oversight.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store, label, and date food items in the walk-in refrigerator during kitchen observations. Surveyors found a storage bag containing slices of bread, crackers, cookies, pudding, and another unlabeled item with only a "lunch bag" label and a 4/5 date, but no use-by or discard date. They also observed a storage bag with several disposable cups of tartar sauce dated 3/27 without a use-by or discard date, a container with three prepared hamburger patties topped with melted cheese dated 4/7 with a use-by date of 4/17, and a container of leftover gravy dated 5/6 with a use-by date of 5/11/2026 while the observation occurred in April. During a follow-up tour of the dry food pantry, surveyors observed a large area behind the food storage racks on the wall with a black substance that resembled mold. The same substance was also seen on the bottom shelf of the storage rack and on the floor in the dry food storage area. On a later kitchen tour, surveyors observed a plastic storage container holding individually packaged sandwiches, including five meat sandwiches and one jelly/peanut butter sandwich, and the sandwiches did not have labels with a name, date, or discard date. Interviews confirmed that dietary staff were responsible for labeling and dating food items and that all items were supposed to have an open date and discard date. The DMA stated cooked foods were to be used within seven days and that the dry storage area was cleaned on a schedule, with shelves cleaned about once per month. The Maintenance Supervisor stated the black substance had been previously present on the kitchen wall, that prior contractors had repaired a hole in the wall, and that the cooler next to the dry storage area did not always close properly because of worn door gaskets, causing an improper seal.
Infection Control Failures During Peri Care, Catheter Care, and Tracheostomy Care
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 3 of 7 residents reviewed for infection control. For Resident #26, who had diagnoses including unspecified convulsions, major depressive disorder with psychotic symptoms, and schizophrenia, the quarterly MDS indicated severe cognitive impairment and total dependence for care tasks including toileting hygiene. During observed peri care, the RN Treatment Nurse did not change contaminated gloves between cleaning the front and back perineal areas, touched the resident’s clothes, body, bedding, and a clean incontinence brief with contaminated gloves while repositioning him, and did not wash her hands after removing the gloves before lowering the bed, moving the privacy curtains, and opening the door. She later sanitized her hands in the hallway, and stated she was supposed to change gloves between the front and back peri area and wash hands with soap and water after removing gloves and before leaving the room. For Resident #37, who had diagnoses including seizures, acute prostatitis, and acute cystitis without hematuria, the care plan called for catheter care every shift. During observed indwelling catheter care, RN B changed gloves but did not sanitize her hands between glove changes while performing the procedure. For Resident #76, during observed tracheostomy care, the ADON/LVN did not sanitize the over-the-bed table before placing supplies on it and turned her back to a sterile field multiple times while performing the care. The Administrator stated she expected staff to follow infection control protocols during tracheostomy care and did not consider turning away from the sterile field to be in accordance with infection control protocol.
Resident Dressed in Hospital Gowns Instead of Personal Clothing
Penalty
Summary
The facility failed to treat Resident #26 with respect and dignity by not assisting him to wear his preferred personal clothing during the day, even though his own clothes were available on-site. Resident #26 was an [AGE]-year-old male with diagnoses including unspecified convulsions, major depressive disorder severe with psychotic symptoms, and schizophrenia. His quarterly MDS dated 03/25/2026 indicated severely impaired cognitive skills for daily decision making and total dependence for dressing, bathing, toileting hygiene, oral hygiene, and eating assistance. The resident’s care plan, dated 09/12/2025, included an ADL self-care performance deficit focus with interventions to assist him to choose simple comfortable clothing and to dress him in his own clothing. However, observations on 04/08/2026, 04/09/2026, and 04/09/2026 showed Resident #26 wearing hospital gowns during the day while in the common area, attending therapy, and eating meals in the dining room. Nursing staff provided showers and dressed him in clean hospital gowns instead of his personal clothing, which was available in his room. During interviews, RN C stated she did not know the resident had personal clothes in his room, while CNA P stated she put a hospital gown on him because it was easier in the morning. The resident’s family member stated she regularly washed his clothes, that he had plenty of different clothes in his room, and that he preferred regular clothes and not a hospital gown. The ADON, DON, ADM, and Area Director of Operations all stated that residents have a right to choose their own clothing and that Resident #26 should be dressed in his own clothes if available. The facility’s Resident Rights policy stated residents have the right to retain and use personal possessions, including clothing, and the Dressing and Personal Grooming policy stated residents should be encouraged to choose their clothes and be dressed in their own clothing.
Dirty Bathroom Floors
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #10 by not keeping the bathroom floor free from dirt. Resident #10 was a [AGE]-year-old female admitted on [DATE] and most recently readmitted on [DATE] with diagnoses including UTI, depression, and chronic kidney disease. Her quarterly MDS, dated [DATE], showed a BIMS score of 13, indicating no cognitive impairment. During an interview and observation on 04/08/2026 at 1:55 PM, Resident #10 stated she was upset that her bathroom was not cleaned appropriately on a daily basis and pointed out a dirt ring around the perimeter of the bathroom floor. Observation revealed a dark colored dirt/dried mud like substance with debris around the perimeter of the bathroom. During a later observation on 04/10/2026 at 9:04 AM, Resident #33's bathroom floor also revealed a dark colored dirt/dried mud like substance with debris around the perimeter of the bathroom. The ADON LVN IPCP E stated she expected resident rooms, including bathrooms, to be swept and mopped daily and reviewed the pictures, stating she did not consider them to reflect a clean floor. The housekeeping manager stated staff were expected to sweep first and then mop, including all corners, of resident rooms every day, and she also stated the bathroom floor pictured was not clean. The DON and Administrator similarly stated they expected housekeeping to keep rooms clean and that the pictures did not meet their expectations.
Care plans not revised for residents' current activity preferences
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 2 residents reviewed for care plans. Resident #22, a male admitted with diagnoses including unspecified dementia, cognitive communication deficit, and lack of coordination, had an Annual MDS showing a BIMS score of 15 and activity preferences to participate in favorite activities and keep up with the news. His comprehensive care plan, dated 01/26/2026, was not revised to reflect his current activity preferences. Resident #52, a male admitted with diagnoses including unspecified dementia, contractures of both hands, limitation of activities due to disability, and hemiplegia/hemiparesis following cerebral infarction, had an Annual MDS with a BIMS score of 7 and a Quarterly MDS also showing a BIMS score of 7. His MDS reflected that he enjoyed participating in his favorite activities, but his comprehensive care plan, dated 04/07/2026, was not revised to meet his current activity preferences. Record review of the activity participation records for both residents showed they were to receive in-room activities in January, February, March, and April 2026. The Activity Director stated both residents were on in-room activity programs and that in-room activities needed to be added to their care plans. She also stated the care plans were not current. The DON and MDS Coordinator LVN both stated that when a resident's activity preference changed, the care plan was expected to be revised and that in-room activities were not on either resident's current activity care plan.
Failure to Provide Needed Nail Care for Two Residents
Penalty
Summary
The facility failed to ensure that two residents who were unable to complete activities of daily living received needed nail care to maintain grooming and personal hygiene. During observation, Resident #22 was found lying in bed with blackish/brownish substance under the fingernails of both hands, including the forefinger, middle, and ring fingernails on the right hand and the ring, middle, and fore fingernails on the left hand. Resident #22 stated he had asked someone to clean his nails several days earlier and that no one had come to do so. Resident #22’s record showed diagnoses including unspecified dementia, type 2 diabetes mellitus without complications, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and lack of coordination. His annual MDS indicated intact cognition with a BIMS score of 15, and he required supervision or touching assistance with personal hygiene, toileting hygiene, showers, lower body dressing, transfers, and bed mobility. His care plan identified an ADL self-care performance deficit and directed staff to assist with personal hygiene and to check nail length, trim, and clean nails on bath day and as needed. Resident #52’s record showed diagnoses including unspecified dementia, contracture of both hands, limitation of activities due to disability, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. His quarterly MDS showed a BIMS score of 7 and dependence on staff for personal hygiene, dressing, showers, toileting hygiene, and shower transfers. His care plan also identified an ADL self-care performance deficit and directed staff to assist with bathing and, during bathing, to check nail length, trim nails, and clean nails as needed. On observation, Resident #52 was lying in bed with blackish/brownish substance under the middle and ring fingernails of both hands and did not want to answer questions. Interviews with the Administrator, RN L, CNA M, and RN B indicated that nurses were responsible for nail care for residents with diabetes and CNAs were responsible for other residents, with nail care typically completed on shower days, Sundays, and as needed. Staff stated they were not aware of either resident refusing nail care. The facility’s nail care policy stated nail management includes cleansing, trimming, smoothing, and cuticle care, usually done during the bath, and is intended to promote cleanliness and skin integrity and prevent infection and injury.
Failure to Provide Planned Activity Programming
Penalty
Summary
The facility failed to provide an ongoing activity program that supported residents’ choices in facility-sponsored group activities, individual activities, and independent activities for two residents. Resident #22 was a male with diagnoses including unspecified dementia without behavioral disturbance, cognitive communication deficit, and lack of coordination. His annual MDS showed a BIMS score of 15, indicating intact cognition, and his activity preferences included participating in favorite activities and keeping up with the news. His comprehensive care plan was not revised to reflect his current activity preferences, and his activity participation records showed he did not receive in-room activities during January, February, March, and April 2026. Resident #22 was observed lying in bed during an interview and stated he did not enjoy group activities. He said he preferred someone coming to his room and talking with him, and reported he had not received any activity visits from anyone. He stated he had told someone a few months earlier that he wanted in-room activities, but he did not recall the person’s name. He said he would go out of his room, but wanted someone to visit him in his room for about 15 to 20 minutes about 4 days per week. Resident #52 was a male with diagnoses including unspecified dementia without behavioral disturbance, contractures of both hands, limitation of activities due to disability, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. His MDS assessments showed a BIMS score of 7, indicating severely impaired cognition, and he enjoyed participating in his favorite activities. His comprehensive care plan was not revised to meet his current activity needs, and his activity participation records showed he did not receive in-room activities during January, February, March, and April 2026. During observation, he was lying in bed with his television off and no stimulation in his room, and when interviewed he responded "no" when questions were attempted.
Unlocked Housekeeping Cart With Chemicals Left Unsupervised
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible when Housekeeping Cart #1 was left unlocked while unsupervised. On 04/08/2026 at 9:15 a.m., the cart was observed near the 100 hall with the chemical compartment unlocked and containing glass cleaner, disinfectant cleaner, tub and tile cleaner, and bio waste degrader. Housekeeper G was not standing near the cart and was at the end of the 100 hall, with no staff or residents near the cart at the time. During interview, Housekeeper G stated the cart was expected to be locked whenever she walked away from it and that she could not see the cart from the 100 hallway. She also stated she had a key but it was difficult to lock the cart. The Administrator and Housekeeping Supervisor later stated the cart was expected to be locked whenever the housekeeper was not obtaining an item or standing in front of it, and both stated housekeeping staff had been in-serviced on locking the carts. The facility’s Daily Common Area Cleaning policy stated housekeeping carts and chemicals must be locked when not within the eyesight of a staff member.
Delayed Foley Catheter Replacement Due to Supply Miscommunication
Penalty
Summary
The facility failed to ensure that a resident with an indwelling Foley catheter received appropriate treatment and services to prevent urinary tract infections when the resident complained of pain from the catheter and the correct catheter size was not immediately available. Resident #16 was admitted with diagnoses including type 2 diabetes mellitus, benign prostatic hyperplasia with lower urinary tract symptoms, urinary retention, and obstructive and reflux uropathy. His care plan identified that he had a 16 Fr 10 mL Foley catheter, with interventions to monitor and document pain or discomfort and signs and symptoms of UTI. On the day of the event, the resident was observed lying in bed, moaning, and crying with tears in his eyes while stating that he was in pain from his catheter and had been in pain for the past few days. He reported that he had told an aide, and a nurse came to his room and said she would change the catheter. The nurse later told him the facility did not have the ordered catheter size, but one was on the delivery truck. The resident remained waiting for the catheter to be located and changed while staff attempted to obtain it. Record review and staff interviews showed that the wrong size catheter had been delivered to the facility, and the correct catheter was not located until later in the afternoon. The Medical Record/Central Supply Manager stated she did not realize the catheter was needed immediately, did not ask whether it was urgent, and did not locate it when the nurse first requested it. The nurse stated she was waiting for the catheter to be brought to her and had not reported the issue to the DON at that time. The resident later stated the catheter was changed that night and then functioned better, and he was no longer in pain.
Delayed Response to Alarming Feeding Pump
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one resident with a feeding tube. The resident was admitted and readmitted with diagnoses including dysphagia following cerebral infarction, gastrostomy status, unspecified protein-calorie malnutrition, and aphasia. The resident’s orders directed enteral feeding with Diabetisource AC at 65 ml/hr continuous and water flushes at 25 ml/hr, and the care plan identified a need for tube feeding related to dysphagia and a risk for malnutrition with interventions to administer enteral feedings as ordered. On 04/08/2026, the resident’s feeding pump was observed alarming with a flow error indicating a clog in the line downstream of the pump. The alarm was first observed at 1:34 PM and continued through 1:48 PM, 2:03 PM, and 2:15 PM while the resident remained in bed. RN D was observed standing several rooms away and did not attend to the alarm until interviewed at 2:16 PM, at which time RN D stated she was filling in that day and did not know how long a feeding pump was supposed to alarm before being addressed. The ADON stated staff were expected to respond immediately to audible feeding pump alarms, the DON stated any staff member should attend to an alarming pump, and the Administrator stated staff should respond immediately if a feeding pump is alarming.
Unlocked Medication Cart Exposed Medications
Penalty
Summary
Medication Cart #1 was found unlocked during an observation on 04/09/2026 at 1:03 pm. The cart was positioned against the wall by the common TV area, with the back of the cart against a half wall and the top open to the TV common area. The drawers faced the area near the nurse's desk, and the locking mechanism was protruding outward. The State Surveyor opened the drawers and took photos while the med aide responsible for the cart was in a resident's room on 100 hall, and no nursing staff were present in the area of the unlocked cart. At 1:15 pm, the med aide returned from the 100 hall toward the unlocked cart and stated she thought she had locked it before entering the hall, but could not believe it was unlocked. She stated she had the only set of keys for that cart and that residents and visitors had access to the medications in it. The DON stated the medication carts were expected to be locked unless the nurse was standing at the cart administering medications, with no exceptions if the cart was in the hallway and the nurse was not at it. The facility policy stated medications and biologicals are to be stored safely, securely, and properly, and accessible only to licensed personnel, pharmacy personnel, or staff lawfully authorized to administer medications.
Pureed Diet Prepared to Incorrect Consistency
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for 4 residents on pureed diets. During lunch service, [NAME] A placed an unmeasured amount of broth into the blender with fish sticks and pureed the food without using the measuring cup that was available. The resulting pureed fish was described as runny, and [NAME] A stated that pureed food should be creamy. The DMA then reviewed the recipe book, which called for a half cup of broth for 4 servings and instructed staff to add liquid as needed to obtain the desired consistency. [NAME] A then added bread to the mixture until it reached the corrected consistency. Interviews showed that [NAME] A had worked in dietary services for over 10 years and stated she had relied on her own judgment when preparing pureed diets. She acknowledged that if food was not the correct consistency, a resident could possibly choke. The DMA stated she monitored food preparation and tray line consistency, and the DON stated pureed consistency should not be runny but should resemble baby food. The facility policy required pureed foods to be prepared to an applesauce to mashed potatoes consistency and to be served at proper holding and serving temperatures.
Incomplete Documentation of Incontinent Care
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices that were completely and accurately documented for Resident #26. Resident #26 was a [AGE]-year-old male with diagnoses including unspecified convulsions, major depressive disorder with psychotic symptoms, and schizophrenia. His quarterly MDS dated 03/25/2026 indicated severely impaired cognitive skills for daily decision making and total dependence or need for 2 or more helpers for eating, oral hygiene, toileting hygiene, shower/bath, and dressing. His care plan dated 09/12/2025 included bowel and bladder incontinence interventions to check him every two hours, assist with toileting as needed, and provide peri care after each incontinent episode. Record review of the POC record showed missing documentation of incontinent care on multiple dates over the last 14 days, with only one or two entries on several days instead of the expected three entries per day. Nursing notes for the last 6 months did not reflect notes regarding provided incontinent care on those days. The DON stated CNAs were responsible for documenting incontinent care every shift and that not documenting care for a resident who required it was not acceptable documentation practice. The ADM stated CNAs were responsible for accurate and consistent documentation in the POC, with daily monitoring by nursing management, and that Resident #26 required every two-hour rounding with documentation in the POC and paper log at the nursing station. The resident’s Q1 hour checks paper record also indicated staff were to check for incontinence and assist with clean up as needed, and weekly pages showed multiple gaps in documentation of care.
Incomplete and Inaccurate Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex diagnoses, including traumatic brain injury, intellectual disability, schizophrenia, and seizures. The care plan did not include measurable objectives or timeframes to address the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, the care plan omitted the dates when the resident sustained bruises, such as a right lower leg bruise from swinging his leg over a chair and abdominal bruising from Lovenox injections. Additionally, there were no documented goals or interventions related to the resident's diagnosis of schizophrenia, despite the resident receiving medication for this condition. Record reviews and staff interviews confirmed these omissions. The resident was noted to have severe cognitive impairment, total dependence for mobility and transfers, and was non-communicative during observation. The facility's staff, including the Regional RN, ADO, and Administrator, acknowledged that the care plan and clinical records were incomplete and lacked necessary details to ensure continuity of care. The facility's documentation policy required complete and accurate records, but this was not followed in the resident's case.
Failure to Inform Resident of Medication During Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate administering of medications to meet the needs of a resident with severe cognitive impairment. Specifically, a medication aide administered Keppra Oral Solution to a non-verbal male resident with a BIMS score of 00, indicating severe impairment, and diagnoses including convulsions, schizophrenia, and a history of traumatic brain injury. The resident's care plan noted impaired cognitive function, non-verbal communication, and a need for staff to monitor and document changes. During medication administration, video footage showed the medication aide entering the resident's room, greeting him, and giving him the medication without advising him of the name or purpose of the medication. The aide ensured the resident swallowed the medication but did not explain what was being administered, despite facility policy requiring staff to explain the administration procedure to residents and adhere to the six rights of medication administration, including explaining the medication to the resident. Interviews with facility staff, including the medication aide, DON, and ADM, confirmed that the resident was not advised of the medication being given. Staff acknowledged that the resident was not cognitively capable of understanding the information, but also recognized that not advising residents of their medications is not appropriate and does not align with facility policy. The deficiency was identified through observation, interview, and record review, and was limited to this resident among those reviewed for pharmacy services.
Failure to Provide Required Supervision and Safe Positioning During Resident Repositioning
Penalty
Summary
A deficiency occurred when a resident, a 37-year-old male with a history of unspecified convulsions, schizophrenia, weakness, and traumatic brain injury, was not provided the required level of care and supervision to prevent accidents. The resident was care planned as a high fall risk and required two staff members for all bed mobility and repositioning. Despite this, a CNA attempted to reposition the resident alone, resulting in the resident being left in a diagonal position on the bed with both legs hanging off the side up to the knees, the bed in a raised position, and the call light out of reach. Video evidence showed the CNA making several unsuccessful attempts to reposition the resident, who exhibited muscle rigidity and resistance to movement. The CNA then left the resident unattended in this unsafe position, stating, "I can't be doing this all day," and exited the room. The resident remained unsupervised with the bed elevated and his legs off the bed until the CNA returned with another staff member. The care plan and Kardex clearly indicated the need for two-person assistance for repositioning, which was not followed. Interviews with facility leadership, including the DON, Administrator, and Corporate Administrator, confirmed that the CNA should not have attempted to reposition the resident alone or left the resident in an unsafe position. The staff acknowledged that the resident was at high risk for falls and that the actions taken were not in accordance with the resident's care plan or facility policy. The deficiency was identified as past noncompliance, and the incident was self-reported by the facility after review of the video evidence.
Failure to Prevent Significant Medication Error for Seizure Disorder
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder and traumatic brain injury did not receive two out of three scheduled doses of the anticonvulsant medication Keppra (Levetiracetam) as ordered. The medication was not administered on two occasions: once because the resident was lethargic and staff felt it was unsafe to administer, and once because the resident refused by keeping his mouth closed. Documentation shows that staff did not make multiple attempts to administer the medication, nor did they notify the provider or responsible party of the missed or refused doses, as required by facility policy. The resident was categorized as severely cognitively impaired and nonverbal, with a care plan indicating the need for seizure medication as ordered and monitoring for side effects and effectiveness. Despite this, staff did not follow up with additional attempts to administer the medication or escalate the issue to medical providers or the resident's representative. The lack of notification and follow-up led to the resident missing critical doses of his seizure medication. Subsequently, the resident experienced a seizure, which was documented by staff and confirmed by hospital records showing an undetectable Keppra level. Interviews with staff and medical providers confirmed that the missed doses and lack of notification were not in accordance with facility policy and expectations for care of residents with seizure disorders. The incident was self-reported by the facility, and staff interviews indicated knowledge of the policies, but these were not followed in this instance.
Failure to Honor Resident Representative's Refusal of Specific Caregiver
Penalty
Summary
The facility failed to ensure that a legal surrogate, designated as the resident's representative (RP), could exercise the resident's rights as provided by state law. Specifically, the RP instructed LVN F not to provide care to a resident after a verbal request was made through a camera in the resident's room. Despite this request, LVN F continued to provide care to the resident on the same day and was also assigned to the resident's hall the following day. The RP's request was not communicated to the appropriate facility staff in a timely manner, resulting in the continued assignment of LVN F to the resident. The resident involved was a 37-year-old male with diagnoses including unspecified convulsions, schizophrenia, weakness, and a history of traumatic brain injury. He was dependent on staff for all forms of mobility and required significant assistance with activities of daily living. The RP's request for LVN F to be removed from the resident's care was made verbally via the room camera, citing concerns related to social media. However, the facility's staff, including the ADON and administrative personnel, were not promptly informed of the restriction, and the staff assignment sheets continued to list LVN F as responsible for the resident's care. Interviews with facility staff revealed a lack of awareness regarding the restriction, and the list of staff not permitted to care for the resident was not available to all relevant personnel prior to the second day. The facility's policy states that the decisions of a resident representative must be treated as the decisions of the resident, but this was not followed in practice. As a result, the resident's right to have their care decisions made by their legal surrogate was not honored.
Unsecured Medication Found at Resident Bedside
Penalty
Summary
A bottle of Nystatin Topical Powder was found unattended and unsecured at the bedside of a female resident with diabetes mellitus Type 2, mild cognitive impairment, pituitary gland disorder, and obesity. The resident had an order for Nystatin Powder to be applied topically for a yeast rash, and her care plan included medication administration as an intervention for pressure ulcer prevention. The medication was observed on the resident's bedside table during a survey, and the resident stated she had an order for medications to be left at her bedside. Multiple staff interviews, including those with the LVN, ADON, RN, and DON, revealed that none were aware of the medication being left at the bedside, and all confirmed that facility policy did not allow medications to be left in residents' rooms. The facility's Medication Administration Procedures required all medications to be administered by licensed personnel, and there was no policy permitting bedside medications. The presence of the medication at the bedside was not in accordance with professional principles or facility policy, and staff acknowledged the responsibility to ensure medications are properly stored and not left accessible in resident rooms.
Failure to Provide Notice of Resident Rights to All Residents
Penalty
Summary
The facility failed to provide residents with a notice of their rights, rules, services, and charges during their stay, as required. Information regarding residents' rights was only posted in one hallway (Hallway 4), making it inaccessible to residents in other areas of the facility. Additionally, the resident rights document was not included in admission packets since November 2023, despite the facility's policy requiring that this information be provided both orally and in writing to residents or their representatives upon admission and during their stay. Interviews with multiple residents from different hallways revealed that none were aware of their rights, had not been given a document listing their rights, and had not seen any postings about resident rights, ombudsman information, or complaint procedures. Residents expressed that knowing their rights was important and would help them understand what they could expect from the facility. Cognitive assessments indicated that at least one resident had intact cognition, while others had moderate cognitive impairment, yet all were unaware of their rights due to the lack of communication and documentation provided by the facility. Staff interviews confirmed that the staff member responsible for admissions was unaware that the resident rights document needed to be included in the admission packet and had never included it since starting in the role. The administrator also acknowledged that the postings were not accessible to all residents and that there was no process in place to ensure residents received all required information. Observations during a facility tour corroborated that resident rights postings were only present in one hallway, further limiting access to this essential information.
Deficient Food Storage, Labeling, and Sanitation Practices in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and sanitation practices. In the dry storage room, a 50-pound bag of yellow onions was found sitting in water and leaking, while undated red onions were sprouting greens. A large can was present without a label or date, and a box of potatoes was found with an expired date. Cold eggs were left sitting on the stove top in a pan with a spatula, and a pitcher of tea and a pan of cake were left in a food warmer that was turned off. The tea and cake were not refrigerated as required. Additionally, the inside of the ice machine had an unknown black slime by the internal dispenser, indicating improper cleaning. Interviews with dietary staff revealed a lack of adherence to food safety protocols, including failure to label and date food, dispose of expired or questionable items, and properly clean the ice machine. Staff admitted to not removing cans without labels or dates and not knowing when the ice machine was last cleaned. The new temporary dietary manager and other staff confirmed that these practices did not align with facility policy or the Texas Food Code. Record review of facility policies confirmed the requirements for food labeling, dating, and ice machine cleaning, which were not followed.
Failure to Sanitize Blood Pressure Cuff Between Residents During Medication Pass
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two medication aides not sanitizing a blood pressure cuff between residents during medication administration. Specifically, one medication aide used the same blood pressure monitor on two residents consecutively without cleaning it in between, despite being trained to do so. The aide acknowledged the lapse when interviewed and subsequently cleaned the equipment after being prompted. The residents involved had various medical conditions, including anemia, chronic viral hepatitis C, hypertension, congestive heart failure, and atrial fibrillation, with cognitive assessments ranging from intact to moderate impairment. A similar incident occurred with another medication aide, who also failed to sanitize the blood pressure monitor between two residents during medication pass. This aide admitted forgetting to clean the equipment due to focusing on the medication pass. The Director of Nursing confirmed that the facility's expectation and policy require blood pressure cuffs to be cleaned between residents to prevent cross-contamination. The facility's infection control policy specifies that non-invasive resident care equipment should be cleaned between uses, and documentation of cleaning should be maintained.
Failure to Maintain Safe and Functional Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as observed and confirmed through staff interviews and record review. Multiple pieces of equipment, including the coffee brewing system, the left side of the double oven, one well on the steam table, and a mobile heated delivery cart, were found to be nonfunctional or not maintaining proper temperatures. Observations revealed the heated delivery cart was only reaching 75 degrees, the coffee pot displayed a heating element malfunction error, the left well of the steam table was not working, and the left side of the oven was not heating. Staff interviews indicated that these issues had been ongoing for several months. Dietary staff reported that the warmer and steam table had been working intermittently or not at all, and that the coffee pot had been out of service for over a week. Maintenance staff were aware of some of the issues but had not completed repairs, citing reasons such as waiting for outside companies or believing the problems were electrical rather than equipment-related. Communication lapses were evident, with some staff unsure of who was responsible for reporting or following up on repairs, and maintenance requests were not consistently documented or tracked. The administrator and other supervisory staff were not fully aware of the extent or duration of the equipment failures until recently. Maintenance logs only documented the coffee pot issue, with no records available for the other broken equipment. No facility policies regarding equipment maintenance were provided for review. The lack of timely repair and inadequate documentation contributed to the ongoing deficiency in maintaining safe and functional kitchen equipment.
Failure to Ensure Dietary Staff Training and Competency
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. One dietary aide (DA B) was hired and began working in the kitchen without having completed mandatory online training, receiving training from facility management, or obtaining a food handler's certificate. Record review of DA B's employee file showed only her application and background check, with no documentation of training or certification. Interviews revealed that DA B was not trained on essential kitchen procedures, such as using the dishwasher, understanding appropriate temperatures, or proper food labeling and storage. She expressed uncertainty about her duties and concern about making mistakes due to lack of training. Other staff interviews confirmed that DA B had not received the required training or oversight before working independently in the kitchen. The traveling dietary manager and other facility leaders were unaware of DA B's lack of training and certification. The HR representative acknowledged that no further training was coordinated after DA B was hired, and the administrator assumed that traveling dietary managers were providing necessary training. No facility policies on training new dietary employees were provided, and there was no evidence of competency checks or supervision by a dietary manager prior to DA B working alone in the kitchen.
Failure in Hand Hygiene During Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene, during food preparation in the kitchen. During an observation, [NAME] C, a staff member, was seen preparing food without wearing gloves and failed to wash or sanitize her hands between tasks. She touched various surfaces, including her clothes and a utility cart, which were considered contaminated, and then proceeded to handle food and kitchen utensils without proper hand hygiene. This lack of hand hygiene was observed over a period of approximately 30 minutes, during which [NAME] C did not wash her hands until prompted by the Dietary Manager. Interviews with the Director of Operations and the Dietary Manager confirmed the observations, acknowledging that [NAME] C did not follow expected hand hygiene practices, which could lead to cross-contamination of food. [NAME] C admitted to not washing or sanitizing her hands between tasks and recognized the potential risk of contaminating food, which could result in foodborne illness for residents. The facility's hand washing policy, dated 2012, emphasized the importance of proper hand hygiene, yet the in-service training records requested were not provided at the time of the survey exit.
Failure to Maintain a Clean and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, leading to a deficiency in care. The resident, an elderly male with severe cognitive impairment and multiple diagnoses including Parkinson's disease and dementia, was found in a room with a strong urine odor and soiled sheets. Observations revealed that the sheets were partially wet and partially dried with urine, and the odor was particularly strong near the resident. The resident, who required substantial assistance with activities of daily living and was always incontinent of bowel and bladder, did not respond to questions or conversations during the observation. Interviews with staff members revealed a lack of awareness and action regarding the resident's condition. A CNA not assigned to the resident's care noticed the urine odor and soiled sheets but was unsure of who was responsible for the resident. Another CNA, who was assigned to the resident, did not recall the condition of the room or the resident's sheets during her rounds. The Director of Nurses stated that staff were expected to make rounds every two hours and change any soiled sheets immediately, but this protocol was not followed in this instance. The facility's policy on resident rights emphasized the importance of maintaining a safe, clean, and comfortable environment, which was not upheld in this case.
Failure to Document and Investigate Resident Grievance
Penalty
Summary
The facility failed to ensure prompt documentation and investigation of a grievance reported by a resident regarding delayed response to call lights. The resident, a male with chronic obstructive pulmonary disease, polyneuropathy, and morbid obesity, reported using the call light for assistance after a bowel movement and waiting at least forty-five minutes for staff to respond. Despite the resident's intact cognition and ability to communicate his needs, his grievance was not documented by the Director of Nurses as required by the facility's policy. The Director of Nurses acknowledged receiving the grievance from the resident and stated that she intended to document and investigate it on the same day. However, the grievance was not recorded in the facility's grievance records. The Director of Operations confirmed that grievances should be documented immediately and investigated promptly, with the Director of Nurses responsible for grievances related to call lights. The facility's policy outlines specific steps for documenting and investigating grievances, which were not followed in this instance.
Resident Not Properly Positioned During Meals
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain functional abilities. Specifically, the facility did not place a resident in a safe and comfortable position while eating, which placed the resident at risk of discomfort and choking/aspiration. The resident, a male with a history of multiple sclerosis, dysphagia, and cognitive communication deficit, was observed lying in bed with the head slightly elevated while eating breakfast. Despite the resident's preference to sit up while eating, he was seen struggling to lift his head and see his food. Interviews with staff and the resident's responsible party confirmed concerns about the resident's positioning during meals. The staff acknowledged that residents should be in an upright position to prevent choking and aid digestion. The Assistant Director of Nursing noted that the resident's position in the video was unsafe, and the Administrator admitted the resident did not look comfortable. Despite this, the Administrator and Administrator in Training mentioned the importance of respecting the resident's wishes, even though the resident expressed difficulty eating while lying down.
Infection Control Deficiencies in PPE Use and Hair Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to enhanced barrier precautions (EBP) for a resident with specific care needs. A video observation revealed a staff member in the resident's room handling linens and the resident's diaper without wearing the required personal protective equipment (PPE), such as gowns and gloves. Interviews with various staff members, including a CNA, LVN, MA, and the ADON, confirmed that they were aware of the EBP requirements, which include wearing PPE during high-contact activities to prevent infection transmission. However, the staff did not consistently follow these protocols, as noted in the video and corroborated by the resident's statement that staff did not always wear gowns during care. Additionally, another video observation showed a housekeeping supervisor and a CNA providing care without gowns, despite the resident being on EBP. The housekeeping supervisor's long hair was not tied back, and it came into contact with dirty linens and the floor, posing a risk of cross-contamination. Interviews with the RN, ADON, and the ADM confirmed that long hair should be tied back to prevent infection risks. The facility's policy on dress code and grooming also required employees providing direct care to keep their hair pulled back, which was not adhered to in this instance.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents who require assistance with activities of daily living. This deficiency was identified during observations on a specific date when the call light for a resident with severe cognitive impairment and multiple medical conditions, including cerebral infarction and dysphagia, was found underneath the bed and out of reach. The resident's care plan specifically included the need for a safe environment with a working and reachable call light due to their dependency on staff for various activities of daily living. Interviews with facility staff, including a CNA and the DON, confirmed that call lights should always be within reach to allow residents to call for assistance. The CNA acknowledged that if a call light is not accessible, residents might attempt to get help on their own, potentially leading to falls. The DON emphasized the importance of CNAs ensuring call lights are in place during rounds. The ADM stated that rounds should be conducted at least every two hours, and staff should ensure residents are comfortable and have their call lights within reach. However, it was noted that the facility did not have a specific call light policy in place.
Unsafe Discharge of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide and document an effective discharge planning process for a resident, leading to an unsafe discharge. The resident, who was blind and moderately cognitively impaired, was discharged from the facility and left unsupervised on the front porch of a home located on a busy street. The resident was at risk for elopement and had a history of elopement, making the situation particularly dangerous. The facility did not ensure that a responsible party was present to receive the resident, and the discharge occurred despite an ongoing appeal process. The resident's care plan indicated that discharge was not feasible due to the resident's dementia, inability to care for himself, and risk of elopement. Despite this, the facility proceeded with the discharge, citing ongoing behaviors as the reason. The facility attempted to find alternative placements, including a behavioral psychiatric hospital, but these efforts were unsuccessful. The decision to discharge the resident to the family was made without confirmation from the family, and the resident was left unattended, leading to a situation where the resident was confused and at risk of harm. Interviews with facility staff revealed that the discharge process was not coordinated with the resident's responsible parties, and the facility did not wait for the appeal process to be completed. The staff left the resident's medications and aftercare instructions on the porch, and the resident was left sitting outside with his belongings. The facility's actions were not in compliance with their discharge policy, which requires coordination with family representatives and ensuring a safe discharge environment.
Failure to Review and Revise Care Plan Quarterly
Penalty
Summary
The facility failed to review and revise the care plan for one resident, identified as Resident #1, within the required quarterly timeframe. Resident #1's care plan was last reviewed and revised on 12/29/23, but the next quarterly review, due by 03/29/24, was not completed. This oversight was discovered during a record review and interviews conducted on 04/25/24. Resident #1, a male with multiple diagnoses including unspecified dementia, major depressive disorder, and chronic obstructive pulmonary disease, had a moderate cognitive impairment with a BIMS score of 8 and required varying levels of assistance with daily activities. The failure to update his care plan could potentially impact his health, safety, and well-being, as his care needs may not be adequately met in a timely manner. Interviews with the facility staff, including two MDS Coordinators and the Director of Nursing (DON), revealed that the care plans were supposed to be reviewed and revised quarterly, as well as during significant changes in the resident's condition or as needed. Both MDS Coordinators and the DON acknowledged the importance of timely care plan reviews to ensure residents' needs are met. However, they were unaware that Resident #1's care plan had not been updated since December 2023. The MDS Coordinators cited high admission rates and workload as reasons for the oversight, with one coordinator mentioning that she had not been working full-time until after the missed deadline. The facility's policy on Comprehensive Care Planning mandates that care plans be reviewed and revised after each admission, quarterly, annually, and during significant changes in the resident's condition. Despite this policy, the facility failed to adhere to the required schedule for Resident #1, leading to a lapse in the care planning process. The DON mentioned that corporate oversight and training were in place, but it was unclear when the last in-service training for the MDS Coordinators occurred. This deficiency highlights a gap in the facility's adherence to its own care planning procedures, potentially affecting the quality of care provided to residents.
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What surveyors actually found near you
We read the 81 citations issued within 25 miles in the last 12 months — including the 8 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
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Illustrative
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Nursing homes near Bryan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Joseph Manor | 0.2 mi | ★★★★★ | 10 | 0 |
| Crestview Retirement Community | 0.4 mi | ★★★★★ | 0 | 0 |
| Legacy Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 5 | 0 |
| Five Points Nursing & Rehabilitation Of College St | 5.7 mi | ★★★★★ | 10 | 3 |
| Fortress Nursing And Rehabilitation | 6.5 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.