Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Le Reve Rehabilitation & Memory Care during CMS and state inspections, most recent first.
Care plans were not reviewed and revised for two residents with wounds. One resident’s care plan still listed an old sacral ulcer and did not reflect a right toe laceration, while another resident’s care plan had no interventions for a right thigh non-pressure ulcer. Staff said changes in diagnoses, orders, and care needs were discussed in morning meetings and were expected to trigger MDS and care plan updates.
Failure to Provide Scheduled Hygiene Care: A resident who was dependent on staff for bathing and grooming did not receive documented showers or bed baths as scheduled, and the shower log showed no hygiene care provided over an extended period. The resident’s family reported having to give bed baths themselves, while CNA and DON interviews confirmed that showers were expected on a set schedule and that missed care would leave the resident dirty and without proper hygiene.
Missing documentation of turn/reposition care was found for a resident with severe cognitive impairment, total dependence for bed mobility, and multiple pressure ulcers, including stage 4 ulcers. The EHR showed repeated missed charting on multiple shifts, while CNA, LPN, DON, and ADM interviews confirmed residents were to be checked/changed and turned every 2 hours and documented once per shift; the family member also stated the resident was not turned every 2 hours as required.
A resident with multiple serious diagnoses, including cancer and anorexia, was observed by a family member wearing both a wedding ring and an anniversary ring during a visit. Shortly after, the family member reported the anniversary ring missing, searched the resident’s bedding and clothing without success, and filed a grievance. An LVN reported the missing ring allegation to the prior DON, who indicated the administrator was handling it. The administrator documented that neither he nor staff could locate the ring and that the grievance could not be resolved, but no individual was identified as responsible. Despite facility policy requiring all alleged misappropriation of property to be reported to the State agency within 24 hours, a review of the State reporting system showed no intake for this allegation, demonstrating the facility’s failure to timely report the suspected misappropriation.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day on multiple days in a month after the prior DON, an RN, was terminated. Time card records showed no RN hours on several specific days, and the HR/Staffing Coordinator reported that, despite attempts to schedule RNs, shifts were sometimes covered by an LVN instead when no RN could be found. The new Administrator acknowledged the expectation for daily RN coverage and stated that a new DON had been hired but had not yet started. Facility policy required nursing services to be under the direct supervision of an RN, with the DON responsible for assessing each resident’s nursing needs and assisting the physician in planning care, and the Administrator stated that without an RN, the nurse may not be able to provide needed care.
A medication cart containing resident medications and narcotics was found unlocked and unattended on a hallway. An LVN assigned to the cart admitted forgetting to lock it, and both the DON and Administrator confirmed that the cart should always be locked when not in use, in accordance with facility policy.
A facility failed to maintain infection control when an LVN did not sanitize wound care items before and after use in a resident's room, risking cross-contamination. The LVN took a bottle of wound cleanser and a tube of medicated cream into the room without sanitizing them and returned them to the treatment cart unsanitized. The DON confirmed this was against the facility's infection control policy.
Two residents in a facility were found with inaccessible call lights, despite their high fall risk and need for assistance. One resident's call light was hung on a dresser, separated by a wheelchair and curtain, while another's was rolled up on the wall. Staff interviews revealed a lack of awareness and responsibility for ensuring call lights were within reach, and the facility lacked a specific policy on call light placement.
A resident with severe cognitive impairment and a history of falls was found in bed without the required fall mats, as specified in her care plan. Despite staff training on fall interventions, the mats were not placed, and staff interviews revealed uncertainty about the last training provided. The facility's policies on managing falls were reviewed, but the deficiency in implementing the care plan was evident.
A resident with severe cognitive impairment and a history of falls did not have fall mats placed beside her bed, as required by her care plan. Observations showed the mats were folded away from the bed, and staff interviews revealed confusion about responsibilities and training on fall interventions.
A resident with significant medical conditions experienced ant bites and pain, but the facility failed to notify the physician or family, violating its policy on change of condition notification. The incident was not documented, and no treatment was recorded, leading to an Immediate Jeopardy situation.
A resident with severe cognitive impairment and multiple medical conditions was found with ant bites, but the LTC facility failed to provide timely care and notify the physician or family. The CNA reported the incident to an RN, who moved the resident and performed a skin assessment but did not document the findings or communicate with the necessary parties. The facility's policies on change of condition and notification were not followed, resulting in a lack of appropriate care.
A resident with severe cognitive impairment and multiple medical conditions was found with ants and ant bites on her arm due to ineffective pest control measures in the facility. Despite previous reports of ants, the facility's pest control policy failed to prevent the infestation. Staff procedures for dealing with ants were in place, but the resident's family was not informed of the issue until they inquired.
The facility failed to maintain safe conditions for wheelchairs used by six residents, leading to cracked armrests, missing parts, and unclean conditions. Staff interviews revealed a lack of a formal process for reporting and repairing wheelchair issues, with no maintenance logbook available. The Director of Environmental Services and the Administrator were unaware of the deficiencies, and the facility's policy on maintaining assistive devices was not followed.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, on four occasions. This deficiency was identified through interviews and record reviews, revealing zero RN hours on specific days. The DON, newly employed, acknowledged the issue, noting that the night nurse's shift might not meet the 8-hour requirement. The facility's policy requires RN or LPN supervision at all times, and the owner confirmed the deficiency, citing last-minute staff call-ins as the cause.
The facility's kitchen failed to meet food safety standards, with issues such as a dirty ice machine vent, improperly labeled and stored food items, and personal items in food prep areas. These deficiencies could lead to food-borne illnesses and cross-contamination.
An LVN in a long-term care facility failed to disinfect a blood pressure cuff between uses on three residents, despite being aware of infection control protocols and having attended relevant in-service training. The residents involved had conditions such as hypertension, diabetes, and intracranial bleed, and required assistance with daily activities. The DON confirmed the expectation for equipment sanitization and noted the availability of disinfectant supplies, but there was a lack of follow-up competency reports to ensure compliance.
A resident with a suprapubic catheter experienced inadequate care due to the facility's failure to follow up with a physician after catheter leakage was reported. Despite the resident's condition, staff did not take timely action, leading to a urinary infection and hospital visit. The facility's policies on catheter care and change in condition were not followed, resulting in a deficiency.
A resident with a suprapubic catheter and moderate cognitive decline was not promptly treated for a UTI due to the facility's failure to notify the physician of abnormal urinalysis results. Despite signs of infection, the resident was only sent to the ER after surveyor intervention, where he was diagnosed and treated. The facility's communication and notification protocols were not followed, leading to a delay in care.
Care plans were not updated for two residents with wounds
Penalty
Summary
The facility failed to review and revise the person-centered, comprehensive care plan for 2 of 6 residents reviewed for comprehensive care plan revisions. Resident #7 had a comprehensive MDS assessment dated 03/11/2026 that reflected diagnoses including COPD, Parkinsonism, and a laceration of the right toe. Her skin and ulcer treatments included pressure-reducing devices for the chair and bed, turning/repositioning, and ointments/medications. However, her care plan dated 08/17/2025 still reflected a non-pressure ulcer to the sacrum and was not revised to reflect the laceration to her right toe, although she was receiving treatment per wound care physician orders. Resident #8 had a comprehensive MDS assessment dated 03/12/2026 that reflected diagnoses including a non-pressure ulcer of the right thigh. His skin and ulcer treatments included pressure-reducing devices for the chair and bed, turning/repositioning, and ointments/medications. His care plan was undated and reflected no care plan or interventions addressing the non-pressure ulcer to the right thigh, although he was receiving treatment per wound care physician orders. Staff interviews stated that new diagnoses, new orders, and changes in resident care needs were discussed in morning meetings and were expected to trigger updates to the MDS and care plans, and the DON stated care plans were expected to be accurate and person centered.
Failure to Provide Scheduled Hygiene Care
Penalty
Summary
The facility failed to ensure Resident #9 received the necessary assistance with personal hygiene, including scheduled showers and bed baths, despite being dependent on staff for showering/bathing, upper body dressing, and lower body dressing. Resident #9 was a [AGE]-year-old male with diagnoses including sequelae of cerebral infraction, hemiplegia and hemiparesis affecting the left non-dominate side, muscle weakness, lack of coordination, and cognitive communication deficit. His care plan, dated 12/24/2025, identified that he was totally dependent on staff for bed bath/shower care and listed shower days as Tuesday, Thursday, and Saturday. Record review of the shower sheet book from December 2025 through March 2026 showed no documentation that Resident #9 received a shower or bed bath. The grievance log reflected that in February 2026 and again in March 2026, the resident’s family member reported that no shower had been provided since admission. During interview, the family member stated she had to provide bed baths because staff would not provide them. CNA D stated that showers or bed baths should be documented on the shower sheet and that if a resident was not provided a shower, they would become dirty and had the right to be clean. The DON stated residents were expected to be on a shower schedule upon admission and that showers should occur on the scheduled days.
Missing Documentation for Turn/Reposition Care
Penalty
Summary
The facility failed to maintain accurate medical records for one resident by not documenting, at least once per shift, that turn/reposition care was completed. Resident #2’s quarterly MDS assessment showed severe cognitive impairment, dependence on staff for all functional abilities, and diagnoses including osteomyelitis of the vertebra, hemiplegia and hemiparesis following cerebral infarction, and multiple pressure ulcers, including two stage four pressure ulcers present on admission. The care plan identified the resident as totally dependent on staff for repositioning in bed as necessary. Record review of the resident’s electronic health record for the period reviewed showed missing documentation of the turn/reposition task on multiple shifts across several days, including second and third shifts on some dates and third shift on many others. During interviews, CNA D stated residents were to be checked and changed every two hours, turned and repositioned, and charted once per shift, and that missing documentation could mean the task was forgotten or not completed. The family member stated the facility did not turn the resident every two hours as required and may have turned him twice per shift, but not every two hours. The DON and ADM stated staff were expected to check/change and turn/reposition every two hours and chart once per shift, and that if it was not documented, it did not happen.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of resident property to the State Agency as required by regulation and facility policy. A resident with diagnoses including malignant neoplasm of the lung, asthma, Hodgkin’s lymphoma, hypothyroidism, cancer-related fatigue, and anorexia was admitted and remained in the facility for less than 72 hours before passing away. Progress notes showed the resident was admitted on an unspecified date and died on 01/26/2026. During a visit on 01/25/2026, the resident’s family member observed the resident wearing both a wedding ring and an anniversary ring. The family member later reported that the resident had lost weight due to cancer, making the ring easier to remove but not likely to fall off on its own. On 01/27/2026, the family member reported the anniversary ring missing and personally searched the resident’s bedding and clothing without finding it. LVN A stated that in January she received a call about the missing diamond ring and immediately informed the prior DON, who told her not to worry because the administrator was handling it; LVN A heard nothing further. The grievance log from January through March 2026 contained one grievance from the family member about the missing anniversary ring, with documentation by Administrator A that neither he nor staff could locate the ring and that the grievance could not be resolved because the ring remained missing and no responsible individual was identified. A review of TULIP on 04/22/2026 showed no intake for this allegation from the facility. The facility’s Abuse Investigation and Reporting Policy, dated July 2017, requires all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of property to be reported to the State licensing/certification agency and law enforcement immediately, but not later than 2 hours if involving abuse or serious bodily injury, or 24 hours if not. The allegation of misappropriation of the resident’s ring was not reported to the State Agency within the required 24-hour timeframe.
Failure to Maintain Required Daily RN Coverage After DON Termination
Penalty
Summary
The facility failed to provide required RN coverage of at least 8 consecutive hours per day, 7 days a week, during March 2026. Review of the March 2026 Time Card Report for 03/01/2026 to 03/31/2026 showed zero hours worked by an RN on seven specific days: 03/05/2026, 03/06/2026, 03/11/2026, 03/17/2026, 03/18/2026, 03/23/2026, and 03/24/2026. During these days, there was no RN on duty, contrary to regulatory requirements and the facility’s own policy that nursing services be under the direct supervision of an RN. The deficiency was identified through record review and staff interviews. In an interview, the Human Resource/Staffing Coordinator reported that the previous DON, who was an RN, had been terminated on 02/28/2026 and that she was responsible for scheduling an RN at least 8 hours every day. She stated that although she attempted to schedule RN coverage, there were times she could not find an RN and instead scheduled an LVN to cover the shift. In a separate interview, the Administrator, who had started the day before the interview, stated that a new DON had been hired but had not yet started, and acknowledged that the expectation was to have an RN at least 8 hours per day every day. The Administrator stated that the risk to residents was that the nurse may not be able to provide the needed care. The facility’s policy on the Director of Nursing Services, dated August 2006, specified that the nursing services department is under the direct supervision of an RN and that the Director, a state-licensed RN, is responsible for assessing nursing requirements for each resident and assisting the attending physician in planning care. The Administrator was unable to provide a policy specifically addressing 8 hours of RN coverage prior to exit.
Unattended Unlocked Medication Cart
Penalty
Summary
A medication cart on hall 100 was observed to be left unlocked and unattended, allowing access to its contents. The surveyor was able to open the cart drawers, which contained wound care supplies, resident medications, and narcotics. LVN A, who was assigned to the cart, confirmed that he had forgotten to lock it and acknowledged that it should always be locked when unattended. The DON and Administrator both stated that the expectation is for medication carts to be locked when not in use or when staff are not directly working with them. Facility policy also requires that unlocked medication carts are not left unattended.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during wound care for a resident with a left ankle pressure ulcer. LVN A did not sanitize the bottle of wound cleanser, the bowl containing the medicated cream, or the tube of medicated cream before taking these items into the resident's room. Additionally, LVN A placed these items on the resident's bedside table without sanitizing the table first. After completing the wound care, LVN A returned the unsanitized items to the treatment cart, which contained supplies for other residents, thereby risking cross-contamination. The resident involved was an elderly male with a diagnosis of a left ankle pressure ulcer, and his care plan included interventions to prevent skin breakdown. Despite having experience in wound care, LVN A acknowledged the oversight and stated that the items should have been sanitized before and after use or placed in clean medication cups before entering the resident's room. The Director of Nursing confirmed that the facility's infection control policy was not followed, as the items should not have been taken into the resident's room and returned to the treatment cart without proper sanitization.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had reasonable accommodation for their needs and preferences, specifically regarding the accessibility of call lights for two residents. Resident #1, a female with a history of falls and significant medical conditions, was observed with her call light hung on a dresser drawer, separated from her by a wheelchair and privacy curtain, making it inaccessible. Despite being instructed to use the call light for assistance, Resident #1 was unaware of its location, and staff interviews revealed a lack of awareness and responsibility for ensuring the call light was within reach. Resident #2, also with a history of falls and severe cognitive impairment, was found with her call light rolled up and hung on the wall, out of her reach. Staff interviews indicated that the CNAs had recently put Resident #2 to bed but failed to place the call light within her reach. The facility's staff, including the Director of Nursing and other personnel, acknowledged the importance of having call lights accessible to residents to prevent accidents and ensure their needs are met. The facility lacked a specific policy addressing call light placement, although there were general policies on fall risk management and accident reporting. The deficiency in ensuring call light accessibility for these residents could potentially place them at risk of unmet needs and decreased quality of life, as they were unable to call for assistance when needed.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, identified as Resident #2, to meet her medical, nursing, and mental and psychosocial needs. Resident #2, a female with severe cognitive impairment and a history of falls, was observed in bed without the required fall mats on either side, as specified in her care plan. The care plan indicated that fall mats should be placed beside her bed due to her tendency to crawl from the bed to the floor to sleep. However, during an observation, the fall mats were found folded and leaned against the window wall, not in use as intended. Interviews with facility staff, including an LVN, a social worker, a CNA, and the DON, revealed a lack of adherence to the care plan and uncertainty about the last training provided on fall interventions. The LVN acknowledged the absence of fall mats and the CNA admitted to not knowing why they were not placed, despite being trained on their necessity. The DON confirmed the expectation for staff to ensure fall interventions were in place and to round every two hours to check on residents' safety. The facility's policies on managing falls and investigating accidents were reviewed, but the deficiency in implementing the care plan for Resident #2 was evident.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall mats were placed on either side of Resident #2's bed, despite her being at high risk for falls. Observations revealed that the fall mats were folded and leaning against the window wall, rather than being positioned beside the bed. This oversight occurred even though Resident #2 had a history of crawling from her bed to the floor to sleep, as noted in her care plan. Interviews with staff, including an LVN, a social worker, a CNA, and the DON, confirmed that fall mats were required for Resident #2's safety due to her fall risk. Resident #2, a female with severe cognitive impairment and multiple diagnoses including acute kidney failure, hemiplegia, diabetes, and dementia, was dependent on staff for daily activities and had a history of falls. Her care plan specifically indicated the need for fall mats as a preventive measure. Despite this, staff interviews revealed a lack of clarity on who was responsible for placing the mats, and there was uncertainty about when the last training on fall interventions was conducted. The facility's policy on managing falls emphasized the need for interventions based on resident-specific risks, which were not adhered to in this case.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician when a resident experienced ant bites and pain, which was a change in the resident's condition. The incident involved a resident who was non-verbal and had significant medical conditions, including aphasia, hemiplegia, and diabetes. On the morning of the incident, a CNA discovered ants on the resident's arm, which resulted in welts and pain. The CNA reported the situation to an RN, but the RN did not notify the physician or the resident's family about the change in condition or the room move due to the ant infestation. The resident's medical records showed no documentation of the ant bites, skin assessments, or any treatment provided. There was also no record of communication with the resident's family or physician regarding the incident. Interviews with the staff revealed that the RN did not remember documenting the incident or contacting the necessary parties. The facility's policy required notification of significant changes in a resident's condition to the physician and family, which was not followed in this case. The lack of communication and documentation could have led to the resident not receiving necessary medical care for the ant bites. The facility's failure to adhere to its policy on change of condition and notification resulted in an Immediate Jeopardy situation, indicating a serious breach in the standard of care expected in such facilities.
Failure to Provide Timely Care for Ant Bites
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. A resident, who was severely cognitively impaired and required extensive assistance for daily activities, was discovered with ants and ant bites on her body. The incident occurred when a CNA found between 20 to 30 ants on the resident's right arm, which had noticeable welts. The CNA informed an RN, who then moved the resident to another room and performed a skin assessment but did not document the findings or notify the physician or the resident's family. The facility's communication breakdown was evident as the ADON and DON were not informed of the incident, and there was no documentation of the ant bites or room change in the resident's records. The pest control log indicated that ants were sighted in the resident's room, but treatment was delayed. Interviews with staff revealed that the incident was not properly communicated, and the necessary medical assessments and notifications were not conducted. The facility's policies on change of condition and physician/family notification were not followed, leading to a failure in providing appropriate care and treatment. The lack of documentation and communication among staff members resulted in the resident not receiving timely medical attention for the ant bites, which could have led to complications given the resident's medical history, including diabetes and hemiplegia.
Ant Infestation in Resident's Room Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an ant infestation affecting a resident. The resident, a female with severe cognitive impairment and multiple medical conditions including aphasia, hemiplegia, and diabetes, was found with ants and ant bites on her arm. The resident was non-verbal and required extensive assistance for daily activities. The incident was discovered by a CNA who noticed the resident indicating pain in her arm, which led to the discovery of ants in the crook of her arm. The facility's pest sighting log revealed that ants had been reported in the facility on multiple occasions, including in the resident's room. Despite these reports, the pest control measures were not effective in preventing the recurrence of the ant infestation. The facility's pest control policy stated that pest control services were to be provided frequently, with emphasis on areas prone to infestation, but the policy did not prevent the incident from occurring. Interviews with staff indicated that there was a procedure in place for dealing with ants, which included assessing the resident for bites, cleaning the room, and notifying pest control. However, the family of the resident was not informed of the ant problem or the room change until they inquired about it. The Director of Environmental Services stated that pest control visits occurred twice a month and that staff were instructed to report any pest sightings, but there was no record of residents being bitten by ants prior to this incident.
Failure to Maintain Safe Wheelchair Conditions
Penalty
Summary
The facility failed to ensure that all assistive devices, specifically wheelchairs, were maintained and free of hazards for six residents. Observations revealed that several wheelchairs had cracked armrests with exposed foam, missing armrests, and dried food substances on the wheels and rims. These deficiencies were noted for residents with varying degrees of cognitive impairment and physical disabilities, including conditions such as Alzheimer's disease, cerebral infarction, and end-stage renal disease. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), indicated a lack of a formal process for reporting and repairing wheelchair issues. The LVN mentioned that staff were supposed to report wheelchair repairs to the maintenance supervisor, but there was no maintenance logbook available at the nurse's station. The CNA was also unaware of any maintenance logs, stating that she would inform a nurse if a wheelchair needed repair. The Director of Environmental Services and the Administrator were both unaware of any wheelchairs requiring repair and acknowledged the absence of a formal process for maintenance checks or repairs. The Director admitted that no random checks were conducted, and the Administrator stated that a system would be implemented to monitor and report wheelchair conditions. The facility's policy on assistive devices and equipment, revised in January 2020, was not being followed, as it required devices to be maintained on schedule.
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 4 out of 90 days reviewed. Specifically, there was no RN coverage on the dates of 10/21/23, 11/14/23, 11/20/23, and 11/26/23. This deficiency was identified through interviews and record reviews, which showed zero hours worked by an RN on these specific days. The Director of Nursing (DON), who was newly employed at the facility, acknowledged the issue and explained that the night nurse's shift, which starts at 10:00 PM and ends at 6:00 AM, might not be considered as 8 consecutive hours for a single day. The DON was not employed at the facility during the time of the deficiency. The facility's policy, dated August 2006, requires that nursing services be supervised by a registered or licensed practical/vocational nurse at all times. The policy also mandates that an RN be employed as the Director of Nursing Services, with a nurse supervisor or charge nurse responsible for supervision in the absence of the DON. During interviews, the facility's administrator and owner confirmed the lack of RN coverage on the specified dates, attributing it to last-minute staff call-ins. The owner acknowledged that the facility had been cited for this issue during the last inspection and stated that no hours had been missed since then.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. The ice machine vent was found to be dirty, with dust particles present, which could lead to contamination. Additionally, food items in the refrigerators, freezer, and dry storage were not properly labeled with item descriptions, opened dates, or consume-by dates, as required by the facility's policy. This lack of proper labeling and storage could result in the use of expired or unsafe food products. During the inspection, several food items were found to be improperly stored. For instance, a block of butter was left exposed to air, and various food items such as cheese, lunchmeat, and apple juice were not labeled with clear opened or consume-by dates. In the freezer, items like frozen squash, pancakes, and meatballs were exposed to air, and some had developed ice crystals, indicating potential spoilage. The dry storage room also contained dented cans and improperly labeled items, which were not stored in designated areas for dented goods. Interviews with the Director of Culinary Services revealed inconsistencies in labeling practices, with some items marked with a received date rather than a use-by or expiration date. The facility's policy requires that opened food items be discarded after three days, and liquids after seven days, but this was not consistently followed. Personal items were also found in food preparation areas, which could lead to contamination. These deficiencies in food storage and labeling practices could place residents at risk for food-borne illnesses and cross-contamination.
Inadequate Disinfection of Blood Pressure Cuff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A, who did not disinfect the blood pressure cuff between resident uses. This deficiency was observed during blood pressure checks for three residents, including a female resident with hypertension and diabetes, and a male resident with hypertension and a non-traumatic intracranial bleed. Both residents were moderately cognitively impaired and required assistance with activities of daily living. Despite being aware of the requirement to sanitize equipment and having attended in-service training on infection control, LVN A neglected to clean the blood pressure cuff, potentially risking cross-contamination. The Director of Nursing (DON) confirmed that the expectation was for staff to sanitize all reusable equipment between each resident use, and acknowledged that failing to do so could lead to cross-contamination of infections. The facility had adequate supplies of EPA-registered disinfectant wipes available on medication carts, and recent in-service training had been conducted on infection control and equipment cleaning. However, there were no follow-up competency reports available to verify the effectiveness of the training, indicating a gap in ensuring compliance with infection control protocols.
Failure to Provide Adequate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with urinary incontinence who had a suprapubic catheter. The resident, a male with a history of hemiplegia, chronic kidney disease, urine retention, and Down Syndrome, was admitted with an indwelling catheter. Despite the resident's condition and the presence of a suprapubic catheter, the facility staff did not follow up with the physician after leakage was reported on the catheter. This issue persisted from the initial report of leakage until the surveyor intervened. Observations and interviews revealed that the resident's catheter was not draining properly, leading to urine-soaked briefs and potential skin irritation. The resident's catheter care orders included regular cleaning and monitoring, but these were not adequately followed. The staff, including the LVN, DON, and ADON, failed to notify the physician promptly or take corrective action when the catheter was not functioning correctly. The resident was eventually sent to the hospital, where a urinary infection was diagnosed, and the catheter was replaced. The facility's policies on catheter care and change in resident condition were not adhered to, as evidenced by the lack of timely communication with the physician and inadequate documentation of the resident's condition. The DON and ADON were not informed of the resident's change in condition, and the facility's communication system with the physician was ineffective, as there was no follow-up on the initial notification of the catheter issue. This deficiency placed the resident at risk of harm due to the potential for infection and other complications.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results for a urinalysis (UA) conducted on a resident, which suggested a urinary tract infection (UTI). The UA results were reported on June 28, 2024, but the physician was not informed, leading to a delay in care. The resident, a male with a history of hemiplegia, chronic kidney disease, urine retention, and Down Syndrome, was admitted to the facility with a suprapubic indwelling catheter and required substantial assistance with activities of daily living. The resident's cognitive assessment indicated moderate cognitive decline. On June 29, 2024, the resident was observed with signs of a potential UTI, including cloudy urine and leakage around the catheter site. Despite these observations, there was no documentation of physician notification regarding the abnormal UA results. The resident was eventually sent to the emergency room after surveyor intervention, where he was diagnosed and treated for a UTI, and his catheter was replaced. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) were not informed of any changes in the resident's condition prior to this intervention. Interviews with facility staff revealed that the DON expected nurses to notify the physician and leadership of any changes in a resident's condition, including signs of infection. The ADON confirmed that nurses were responsible for catheter care and should report any concerns to the physician. However, there was no record of communication with the physician regarding the UA results, and the facility's protocol for lab result notification was not followed. An in-service training on lab reporting and physician notification was conducted after the incident, but the deficiency highlighted a failure in the facility's communication and notification processes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Leaves | 2 mi | — | 0 | 0 |
| Golden Acres Living And Rehabilitation Center | 2.8 mi | ★★★★★ | 23 | 0 |
| Palomino Place | 3.2 mi | ★★★★★ | 13 | 1 |
| C C Young Memorial Home | 4.1 mi | ★★★★★ | 6 | 0 |
| Willowbend Nursing And Rehabilitation Center | 4.2 mi | ★★★★★ | 19 | 0 |
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