Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Legacy Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction with frontal lobe deficit, psoas abscess, and aphasia was admitted without a baseline care plan being completed within 48 hours, contrary to facility policy. Record review showed no baseline care plan in the EMR and an incomplete MDS, while interviews with the DON and MDS Coordinator confirmed that the MDS Coordinator was responsible for baseline care plans, acknowledged the omission, and could not explain why the plan was not completed. Staff reported that in the absence of a baseline care plan, CNAs were expected to obtain needed care information from the nurse supervisor.
A resident with dementia, severe cognitive impairment, depressed mood, and a history of trauma-related beliefs and behaviors did not receive trauma-informed, culturally competent care. The resident’s record lacked a trauma screening, and the comprehensive care plan contained no focus area or interventions addressing his trauma history, fears, or behavioral triggers, despite multiple documented notes of paranoid beliefs, conflicts with a roommate, and repeated allegations involving staff and other residents. Social services, MDS staff, and the DON all acknowledged that such behaviors and triggers should be included in the care plan so staff could respond appropriately, but this was not done, resulting in a failure to follow professional standards and the facility’s own care planning policy.
A resident with dementia, prior hip fracture, and significant assistance needs for mobility and toileting experienced right leg pain during incontinence care, which was assessed by an LVN who found no visible abnormalities and administered PRN acetaminophen but did not document the event, notify the NP, or reliably communicate it to the next shift. Over the following days, staff reported being unaware of the prior pain episode, did not perform focused right leg assessments, and documented minimal or no pain until one day when a CNA observed the resident shivering in pain and an RN noted right leg pain without swelling, treated with acetaminophen, and reported to the oncoming nurse. Later that same day, another CNA found the resident in severe pain with marked swelling of the right leg, which the oncoming LVN assessed as significant edema and warmth before arranging transfer to the ED, where imaging revealed a distal right femur fracture from an unwitnessed ground-level fall. The absence of documentation, incomplete shift-to-shift communication, and lack of ongoing focused assessment of the resident’s right leg pain and condition led surveyors to cite a deficiency for failure to ensure adequate supervision and accident prevention.
Three residents with Parkinson's disease and other complex conditions did not receive their Carbidopa-Levodopa medications within the required timeframe, with doses administered late or missed entirely. Staff did not consistently document or report these late administrations, and interviews revealed that the informal practice of a one-hour administration window was not clearly outlined in facility policy. Leadership and clinical staff were unaware of the specific incidents at the time of the survey.
A resident with multiple medical conditions was left with dried blood splatters on the floor of her room following IV therapy. The blood was not cleaned up promptly, and neither housekeeping nor supervisory staff were notified, despite facility policy requiring immediate cleanup and disinfection of blood spills. Both the resident and a family member expressed concerns about the cleanliness and potential for contamination.
A resident with Parkinson's disease and autism did not receive recommended OT and PT services for several months after an IDT meeting due to the facility's failure to submit the required NFSS request form within the mandated timeframe. Staff interviews revealed a lack of training and understanding of PASRR documentation requirements, and the facility did not have a PASRR policy or protocol in place. Despite the delay, the resident's ADLs remained at baseline during this period.
Two residents with indwelling catheters did not have timely physician orders for catheter care after admission, resulting in a lack of documented catheter care orders for several days to over a month. Although staff reported providing catheter care as part of routine duties, the absence of formal orders was identified during order reviews and acknowledged by nursing and administrative staff.
A resident with significant mobility and cognitive impairments was left in a Geri-chair for approximately nine hours without being repositioned or provided with incontinent care, resulting in soiled clothing and skin redness. Staff did not perform required two-hour rounds or report care refusals to nursing, contrary to care plans and facility expectations.
Two residents with chronic pain did not receive consistent and effective pain management, including missed pain assessments, delays in medication administration, and lack of care plan documentation. One resident did not have her prescribed Fentanyl patch available due to delayed ordering, while another went without daily pain assessments for over a month. Nursing staff did not consistently document pain levels or monitor pain as required by facility policy.
Dietary staff prepared pureed foods by adding unmeasured amounts of liquid to carrots and roast, relying on estimation rather than following standardized recipes. The staff member had not received training on proper measurement and did not use the available recipe book, and no written protocol for pureeing food was provided by the dietary supervisor. This practice affected all residents receiving pureed diets.
Surveyors found that food items in the kitchen were not consistently labeled, dated, or discarded when expired, and cooking equipment such as the deep fryer and ovens were not properly cleaned. Dietary staff were observed working without required hair and beard restraints, and interviews revealed gaps in training and policy awareness. These failures in food storage, sanitation, and staff hygiene were directly observed and documented by surveyors.
A newly admitted resident with chronic pain and multiple bone disorders did not have a baseline care plan developed within 48 hours that addressed her pain management needs. Despite physician orders and documented pain assessments, the care plan lacked instructions for pain control, leading to delays and issues in medication administration as reported by the resident and confirmed by staff interviews.
A resident with a history of intracranial injury, spastic hemiplegia, and contractures did not have a comprehensive care plan addressing management of right hand and neck contractures. Observations showed the resident without appropriate positioning devices or splints, and staff interviews revealed uncertainty and lack of individualized interventions in the care plan. The care plan only included basic ADL assistance and did not reflect therapy recommendations or address all contracture needs.
A resident with severe cognitive impairment and a history of falls, including a hip fracture, did not have her care plan updated to include effective fall prevention interventions such as fall mats or a low bed after multiple falls. Despite repeated incidents and staff awareness of her high fall risk and inability to use the call light appropriately, the care plan remained limited to encouraging call light use and did not reflect additional safety measures.
A resident with a history of spastic hemiplegia and contractures in the right hand and neck was not provided with individualized interventions or devices to manage these conditions. The care plan lacked specific contracture management, and staff were unclear about appropriate measures, resulting in the resident being observed multiple times without splints, hand rolls, or positioning devices as recommended by therapy and facility policy.
A resident with severe cognitive impairment and a history of falls, including a hip fracture, did not have effective fall prevention interventions such as a low bed or fall mats in place. Despite repeated falls and documented difficulty using the call light, the care plan and physician orders lacked appropriate fall precautions, and staff confirmed that interventions were limited to encouraging call light use. Observations showed the resident's bed was not kept low and no fall mats were present, contrary to facility policy for high-risk individuals.
A resident with chronic pain syndrome did not receive a timely replacement of a physician-ordered Fentanyl patch due to delays in obtaining the required order and lack of follow-up by the admitting nurse. The resident experienced a gap in pain management, and staff interviews revealed confusion about the process for ordering controlled substances, with facility policy lacking guidance on ordering timelines for narcotics.
A resident with severe cognitive impairment and a PEG tube was given the wrong dose and route of Aspirin, and did not have vital signs checked before receiving multiple antihypertensive medications. Staff failed to clarify medication orders or monitor blood pressure as required, resulting in a medication error rate above 5%.
Expired multivitamins and nicotine patches were found in a medication storage room, with the ADON confirming and removing the expired items during an observation. The DON and Administrator stated that monitoring for expired products is expected, and facility policy requires checking expiration dates before administration. This failure could result in residents not receiving the intended therapeutic benefits of their medications.
Staff and hospice personnel did not follow Enhanced Barrier Precautions when providing care to two residents with indwelling medical devices, such as a PEG tube and a urinary catheter. Despite clear care plans and signage requiring the use of gowns and gloves, staff were observed omitting gowns during medication administration and device care, and acknowledged not following the required precautions.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and complete a baseline care plan within 48 hours of admission for one newly admitted resident, as required by facility policy. Record review showed that this resident, a female with diagnoses including frontal lobe and executive function deficit following cerebral infarction, psoas abscess, and aphasia, was admitted on an identified date, but no baseline care plan was present in the electronic medical record as of 02/05/2026. The resident’s MDS assessment was also noted to be incomplete. The facility’s written Care Planning Policy and Procedure states that a baseline care plan will be completed within 48 hours of admission to provide a comprehensive plan of care addressing the resident’s needs, strengths, goals, and approaches. During interviews, the DON confirmed that a baseline care plan should be completed within 48 hours after admission and stated that the MDS Coordinator was responsible for completing these plans. The DON acknowledged that Resident #1 did not have a baseline care plan and stated she did not know why it had not been completed. The MDS Coordinator (LVN A) also confirmed responsibility for baseline care plans, acknowledged that the baseline care plan for this resident was missed, and stated she did not know why it was not completed. She indicated that baseline care plans are important for staff to follow for new admissions and that, in the absence of such a plan, CNAs were expected to ask the nurse supervisor if they needed to know what care a resident required.
Failure to Provide Trauma-Informed, Culturally Competent Care for a Resident With Severe Cognitive Impairment
Penalty
Summary
The deficiency involves the facility’s failure to provide trauma-informed, culturally competent care to a resident with a known history of trauma and severe cognitive impairment. The resident was an elderly male with dementia and altered mental status, with a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. His Minimum Data Set (MDS) assessment documented that he felt down, depressed, or hopeless nearly every day and that he was receiving an antidepressant. Despite these indicators of psychological vulnerability, review of his electronic medical record showed that no trauma screening assessment had been completed, and his care plan contained no focus area or interventions related to trauma history, behaviors, or triggers. Nursing and social services documentation reflected ongoing behavioral and psychological concerns that were not incorporated into the care plan. A nursing progress note described the resident making inappropriate verbal comments after medication administration and an episode where he accused a nurse of withholding medications, ranted at her, and threw a medication cup against the wall after taking his medication. A social services note documented that the resident believed other residents were out to get him, thought someone had a gun and was following him, and accused staff of showing him naked elderly women. The note indicated that he truly believed these allegations, that a psychologist had been notified, and that he refused to speak with the psychologist and was mean to her. None of these behaviors, beliefs, or potential triggers were reflected in the resident’s care plan. During interviews, the resident reported multiple distressing experiences and allegations involving his former roommate and various staff members, including threats from the roommate, seeing another resident unclothed, being pushed on the bed by an LVN, having his walker kicked by a male staff member, and having a male staff member run a finger across his back and put a finger in his ear. He also reported a background as an assistant warden in a prison and expressed strong feelings about men who hurt or kill women and children. The Social Services Director identified his family member as a trigger, described family conflict and restrictions on his visiting another family member before her death, and noted that the former roommate was large, bossy, and that the resident feared people having guns and believed the roommate had a gun. The Social Services Director, MDS Coordinators, and DON all stated that resident behaviors, fears, and triggers should be on the care plan so staff would know how to respond and monitor progress, and the DON specifically stated that this resident’s history of making allegations, fears, and triggers should absolutely be in his care plan. Despite this, the resident’s care plan and Kardex did not contain trauma history, behaviors, or triggers, and no trauma screening was present in the record, resulting in a failure to provide trauma-informed care in accordance with professional standards and the facility’s own care planning policy.
Failure to Assess and Communicate Right Leg Pain Leading to Unwitnessed Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assessment to prevent an accident and to identify and respond appropriately to a change in condition related to a resident’s right leg pain, which was later associated with a right femur fracture. The resident was an elderly female with dementia, a history of left femur fracture with surgical repair and left artificial hip joint, and other diagnoses including hypotension, iron deficiency, and pain. Her MDS showed severely impaired cognition (BIMS score of 01) and extensive physical assistance needs for bed mobility, transfers, and toileting, with full dependence for toilet transfer and incontinence care. Her care plan addressed pain related to a hip fracture with surgical repair, with interventions focused on administering ordered pain medication and observing for worsening pain symptoms to report to the physician. On one morning, a CNA observed the resident moaning and grimacing in pain when her right leg was moved during incontinence care and reported this to an LVN. The LVN assessed the resident and noted no visible abnormalities, deformities, swelling, or redness in the lower extremities, but confirmed that the resident moaned when the right leg was grasped during perineal care. The LVN administered PRN acetaminophen for pain but did not document the incident in the EHR, did not notify the NP, and was unsure if the information was communicated to the oncoming nurse at shift change. As a result, there was no documented follow-up assessment or monitoring of the right leg pain, and subsequent nurses and CNAs working the following shifts reported they were not aware of the prior pain episode and did not perform focused assessments of the right leg. Over the next several days, staff who provided care on various shifts reported no observed swelling, redness, or pain in the resident’s lower extremities during incontinence care, and there was no documentation in the EHR of ongoing pain assessment specific to the right leg. On a later date in the afternoon, a CNA observed the resident shivering and in apparent pain during lunch and reported this to an RN, who noted signs of pain in the right leg but no swelling or deformity, administered PRN acetaminophen, and reported the situation to the oncoming nurse. Later that same day, another CNA observed the resident moaning and grimacing in severe pain with significant swelling of the right leg from thigh to knee and reported this to the oncoming LVN, who assessed marked edema, warmth, and pain with palpation and movement, administered acetaminophen, and obtained an order to transfer the resident to the emergency department. Hospital records documented a distal right femur fracture from an unwitnessed ground-level fall at the facility, with radiology showing a dynamic hip screw in place and a midshaft comminuted impacted angulated spiral fracture below the implant. The NP and DON later stated they had not been informed of the initial right leg pain episode, and the DON acknowledged there was no evidence of continued assessment or communication regarding the resident’s right leg pain between the initial complaint and the later discovery of swelling and fracture. The facility’s abuse prevention and prohibition policy defined injuries of unknown origin and required a licensed nurse to examine the resident and notify the physician of any injuries noted when the source of injury was not observed or could not be explained by the resident. In this case, the hospital record identified the fracture as resulting from an unwitnessed ground-level fall at the facility, and staff interviews and record review showed no documented fall episodes for the resident in the month in question and no clear explanation from staff for how the injury occurred. The RP reported being informed by the hospital that the swelling might have been present for several hours before discovery and believed the fracture might have occurred during repositioning or care, while facility staff were unable to provide a definitive explanation. The lack of documentation, incomplete communication between shifts, absence of timely notification to the NP, and failure to conduct and document focused, ongoing assessments of the resident’s right leg pain and condition contributed to the deficiency in ensuring adequate supervision and accident prevention for this resident.
Failure to Administer Medications Within Required Timeframe
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for three out of five residents reviewed. Specifically, medications, including Carbidopa-Levodopa prescribed for Parkinson's disease, were not administered within the required timeframe for three residents. Medication administration records showed that doses were given outside the facility's stated one-hour window before or after the scheduled time, with some doses being administered significantly late. There were no supporting progress notes or documentation explaining the late administration for these instances. For one resident with severe cognitive impairment and multiple diagnoses including Parkinson's disease, hemiplegia, dysphagia, COPD, and dementia, Carbidopa-Levodopa was administered late on multiple occasions, with no documentation or notes to justify the delay. Another resident, with diagnoses including Parkinson's disease, urinary tract infection, hypertension, and soft tissue cancer, also received late administration of the same medication, again without supporting documentation. A third resident, who had Parkinson's disease, anxiety disorder, hypothyroidism, depression, and chronic pain syndrome, experienced both late and missed doses of Carbidopa-Levodopa, with no care plan in place and no documentation of the reasons for the missed or late doses. Interviews with medication aides and the DON revealed that staff followed an informal practice of administering medications within a one-hour window before or after the scheduled time, although this was not explicitly stated in the facility's policy. Staff admitted to giving medications late due to workload or being occupied on other halls, and often did not notify the charge nurse or document the late administration in the MAR. The DON, administrator, and nurse practitioner all expressed expectations that medication orders be followed as written and that any deviations be communicated to clinical staff, but were not aware of the specific late administrations at the time of the survey.
Failure to Clean Blood Spill After IV Therapy
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the presence of blood splatters on the floor of a resident's room following IV therapy. The resident, an elderly female with multiple medical diagnoses including metabolic encephalopathy, hypertension, atrial fibrillation, hypothyroidism, and vitamin deficiency, had received IV medications and fluids. Despite orders for monitoring signs of infection and maintaining a clean environment, several areas of dried blood were observed on the floor near the resident's bed the day after the IV was administered. Interviews revealed that the resident was aware of the blood on the floor and expressed concern about tracking it around the room with her wheelchair. A family member also noticed the blood and voiced concerns about cleanliness and the potential for spreading contaminants. The Housekeeping Supervisor stated she was not notified of the blood spill and confirmed that rooms are cleaned daily, but emphasized that blood spills should be cleaned immediately and reported to housekeeping for proper disinfection. The Director of Nursing and the Administrator both stated that their expectation is for blood spills to be cleaned up right away by staff and reported to the appropriate personnel. A review of the facility's policy on cleaning blood and body fluid spills indicated that all such spills should be cleaned and disinfected as soon as practical, with staff required to use appropriate personal protective equipment and approved disinfectants. The policy also states that all exposures should be reported to the infection control coordinator. In this instance, the failure to promptly clean and disinfect the blood spill and notify housekeeping was a direct violation of facility policy and infection control standards.
Failure to Timely Implement PASRR Recommendations and Submit Required Documentation
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and evaluation report into a resident's assessment, care planning, and transitions of care. Specifically, after an Interdisciplinary Team (IDT) meeting determined that a resident required occupational therapy (OT) and physical therapy (PT), the required Nursing Facility Specialized Services (NFSS) request form was not submitted within the mandated 20 business days. As a result, the resident did not receive the recommended therapies for several months following the IDT meeting. Record reviews showed that the resident had diagnoses including Parkinson's disease and autistic disorder, with intact cognition and independence in most activities of daily living (ADLs), requiring only supervision for showers. The care plan was updated to reflect the need for specialized therapies, and the IDT meeting included relevant staff and the resident's responsible party. However, the PASRR Comprehensive Quarterly Service plan form was not provided, and the NFSS request was not submitted in a timely manner, delaying the initiation of therapy services. Interviews with facility staff revealed a lack of understanding and training regarding the NFSS process and the required documentation for PASRR services. The MDS Coordinator and Director of Therapy were unaware of the need to submit the NFSS forms, and the Director of Nursing did not follow up to ensure the paperwork was completed. The facility also lacked a policy or protocol for PASRR, contributing to the delay. Despite the delay, staff and the resident reported no decline in the resident's ADLs during the period in question.
Failure to Ensure Timely Catheter Care Orders for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that residents with indwelling catheters had appropriate physician orders for catheter care during specific periods. For one resident, there were no catheter care orders from the time of admission until over a month later, despite the resident being admitted with a Foley catheter in place. The resident's care plan eventually included interventions for catheter care, but this was not reflected in the physician orders or the medication administration record (MAR) during the initial period. Documentation showed that catheter care was provided only after the appropriate orders were entered, and prior to that, there was no documentation of catheter care orders in the MAR. Another resident was admitted with a Foley catheter and was incontinent of bowel and bladder, but did not have catheter care orders for several days following admission. The care plan for this resident included interventions related to the presence of an indwelling medical device, but the physician orders for catheter care were not entered until several days after admission. Documentation of catheter care and monitoring only began after the orders were in place. Interviews with staff revealed that catheter care was generally provided as part of routine care and that CNAs and nurses were aware of the need for such care, even if it was not triggered in the resident's plan of care. However, the absence of formal physician orders for catheter care was acknowledged by nursing and administrative staff, who indicated that orders should have been entered upon admission. The lack of timely catheter care orders was identified during order reviews and audits, and staff recognized that this omission could result in inadequate monitoring and care for residents with catheters.
Failure to Provide Timely Repositioning and Incontinent Care
Penalty
Summary
A deficiency occurred when a male resident with a history of intracranial injury, spastic hemiplegia, contracture of the left hand, and moderate cognitive impairment was not provided with necessary assistance for activities of daily living, specifically repositioning and incontinent care. The resident was assessed as dependent on staff for transferring, bed mobility, and toileting, and was incontinent of bowel and bladder. His care plan included interventions for skin integrity, incontinence, and the need for regular repositioning and perineal care. On the day in question, the resident was observed in a Geri-chair from early morning until late afternoon, remaining in the same soiled clothing for several hours. Staff interviews revealed that the resident was not repositioned or provided with incontinent care every two hours as required. When finally assisted into bed, the resident was found to have a saturated brief with both urine and feces, and his skin showed slight redness. The CNAs and LVN assigned to his care admitted that rounds and care were not performed as scheduled, and that refusals of care were not reported to nursing staff as required by facility protocol. The facility's policy on incontinence care emphasized the importance of keeping skin clean and dry to prevent breakdown and infection, but did not specify the frequency of care. The Director of Nursing confirmed that it was expected for nurses and CNAs to make rounds and provide care every two hours, and that refusals should be reported and documented. However, on this occasion, the required care and monitoring were not provided, resulting in the resident being left in soiled conditions for an extended period.
Failure to Provide Consistent and Effective Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents requiring such services, resulting in deficiencies related to the evaluation, administration, and documentation of pain management. For one resident, a female with chronic pain syndrome and multiple bone disorders, the facility did not evaluate the effectiveness of her current pain medications and failed to have her prescribed pain medications available for administration. Upon admission, her pain was assessed at a level of 4/10, and she was prescribed a Fentanyl patch, Baclofen, and PRN oxycodone. However, the Fentanyl patch was not reordered in a timely manner due to a lack of follow-up by the admitting nurse, resulting in a period where the resident did not have access to her prescribed pain management. The resident reported severe pain, delays in receiving PRN medication, and expressed a preference for routine rather than PRN administration. Additionally, her baseline care plan did not include any entries related to pain or pain management, and staff interviews confirmed that the lack of a care plan could lead to inadequate pain management. For the second resident, a male with metabolic encephalopathy, dementia, pain, and a history of right shoulder surgery, the facility failed to conduct at least daily assessments of pain for 34 out of 49 days. Although his care plan identified the presence of pain and included interventions to evaluate pain using a 1-10 scale, it did not specify the frequency of assessments. There was no physician order for pain monitoring, and documentation of pain assessments was missing for numerous days. Observations and interviews revealed that the resident experienced ongoing pain, reported that pain medications were not effective, and was unable to recall details of conversations about his pain. Nursing staff confirmed that pain monitoring was not consistently documented and that there was no standing order to monitor pain, despite the resident's chronic pain condition. The facility's own pain management policy required pain assessments every shift and as needed, with documentation of pain levels and effectiveness of interventions. However, both residents experienced lapses in pain assessment, documentation, and timely administration of pain medications, contrary to professional standards of practice, the comprehensive person-centered care plan, and the residents' expressed choices. These failures were confirmed through record reviews, staff and resident interviews, and direct observations.
Failure to Measure Liquids in Pureed Food Preparation
Penalty
Summary
Dietary staff failed to prepare pureed foods according to measured recipes, as observed during meal service. Specifically, a dietary staff member added unmeasured amounts of liquid from cooked carrots and pan juices to pureed carrots and roast, respectively, without following any standardized measurement or recipe. The staff member admitted to guessing the amount of liquid to add and stated she had not received training on proper measurement for pureed diets. She was also unaware of the exact number of servings being prepared, only estimating the amount needed for all residents on pureed diets. Further review revealed that while a recipe book was available in the kitchen, the dietary staff member had not been utilizing it for preparing pureed foods. The dietary supervisor confirmed the existence of the recipe book but was unable to provide a written policy or protocol for pureeing food at the time of the survey. This lack of adherence to standardized recipes and absence of a clear protocol had the potential to affect all residents receiving pureed diets prepared in the facility's kitchen.
Deficiencies in Food Storage, Sanitation, and Staff Hygiene in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and sanitation. During several tours, food items in the walk-in refrigerator and dry food pantry were found to be unlabeled, undated, and in some cases, expired. Specific items such as coleslaw, scrambled egg mix, dessert cups, bread, rolls, rice, corn syrup, and Italian dressing were not properly labeled or dated, and expired items remained in storage even after initial findings were communicated to staff. The facility's own policies required all time and temperature control for safety (TCS) leftovers to be labeled, covered, and dated, and for expired foods to be discarded, but these procedures were not consistently followed. In addition to food storage issues, the kitchen's cooking equipment, including the deep fryer and ovens, was found to be unclean, with excessive grease, food debris, and charred residue present. The cleaning schedule provided by the Dietary Supervisor indicated that equipment should be cleaned regularly, but interviews revealed inconsistencies in cleaning frequency and adherence to the schedule. The Dietary Supervisor acknowledged that unclean equipment could pose fire hazards and increase the risk of illness for residents. Surveyors also noted that dietary staff were not consistently wearing required hair and beard restraints while working in the kitchen. Several staff members with beards were observed without beard restraints, and interviews revealed confusion and lack of training regarding the requirement for beard restraints. Some staff stated they had not been provided with beard restraints or were unaware of the policy, despite the facility's written procedures mandating hair restraints for all kitchen staff. These lapses in food safety and sanitation practices could place residents at risk of foodborne illness, as directly stated in the report.
Failure to Develop Baseline Care Plan Addressing Pain Management Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted female resident with chronic pain syndrome and multiple bone disorders. Upon admission, the resident was assessed with a pain level of 4/10 and had physician orders for pain management, including a Fentanyl patch, Baclofen, and PRN oxycodone. Despite these documented needs, the baseline care plan did not include any entries related to pain or pain management. The resident reported experiencing significant pain, delays in receiving pain medication, and issues with medication administration, such as the removal of her Fentanyl patch without timely replacement and receiving Baclofen at undesired times. Interviews with the resident, MDS Coordinator, and DON confirmed that the baseline care plan was not completed as required and did not address the resident's immediate needs, particularly pain management. The facility's care planning policy did not specifically address baseline care plans, and staff acknowledged that the lack of a comprehensive baseline care plan could result in staff not knowing how to manage the resident's pain effectively.
Failure to Develop and Implement Comprehensive Care Plan for Contractures
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs, specifically omitting individualized interventions for contractures in the resident's right hand and neck. The resident, a male with a history of intracranial injury, spastic hemiplegia, and contractures, was assessed to have functional limitations in range of motion in both upper and lower extremities. Despite these documented conditions, the care plan only included basic interventions for assistance with activities of daily living and did not address specific contracture management for the right hand or the neck. Multiple observations revealed that the resident was consistently without appropriate positioning devices or splints for his right hand and neck contractures while in his Geri-chair and bed. Staff interviews confirmed that the resident previously had a pillow for his neck and a splint or hand roll for his hand, but these were no longer in use. A CNA reported uncertainty about whether to use a rolled-up washcloth in the resident's hand due to the lack of an order, and the MDS Coordinator acknowledged that the care plan lacked individualized interventions for the contractures, particularly for the neck, which she had not considered a contracture. Therapy staff indicated that the resident had not received therapy since the previous year, and the occupational therapy discharge summary had recommended the use of a palmar guard for the right hand. The Director of Nursing stated that staff are expected to identify contractures and develop individualized care plans, but this had not occurred for the resident's neck contracture. The facility's care planning policy requires comprehensive plans that address all resident needs, but this was not followed in this case.
Failure to Update Care Plan with Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to review and update the care plan for a resident with a history of falls and severe cognitive impairment. The resident, an elderly female with diagnoses including dementia, diabetes, hypertension, and a history of fractures, experienced multiple falls during her stay. Despite these incidents, the care plan was not revised to include appropriate safety interventions such as fall mats or a low bed, even after unwitnessed and witnessed falls occurred on several occasions. Clinical records and progress notes indicated that the resident had at least three falls, including one resulting in a hip fracture and others without injury. Observations over several days confirmed that the resident's room did not have fall mats and the bed was not kept in a low position. Staff interviews revealed that interventions prior to the most recent fall were limited to encouraging call light use and keeping the call light within reach, despite the resident's severe cognitive impairment and inability to use the call light appropriately. Physical therapy assessments noted the resident's high fall risk and difficulty with transfers but did not recommend specific fall precautions. The facility's care planning policy requires that care plans remain current and address residents' needs, but the care plan for this resident was not updated with effective fall prevention interventions after repeated falls, as confirmed by staff and record review.
Failure to Provide Contracture Management for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decrease in range of motion (ROM) for a resident with documented contractures. The resident, who had a history of intracranial injury, spastic hemiplegia, and contractures affecting both the right hand and neck, was observed multiple times without any splint, hand roll, or positioning device in place for his contractures. The care plan for the resident did not include individualized interventions for contracture management of the right hand or address the neck contracture, despite clear evidence of these conditions. Staff interviews revealed a lack of awareness and guidance regarding the management of the resident's contractures. A CNA reported that devices previously used for the resident's neck and hand were no longer available, and she was unsure whether to use alternatives like a rolled-up washcloth due to the absence of specific orders. The MDS Coordinator acknowledged that the care plan contained only basic interventions and did not address the resident's specific contracture needs, particularly for the neck, which she had not considered a contracture. Therapy staff confirmed that the resident had not received therapy for his contractures since the previous year, and the occupational therapy discharge summary had recommended the use of a palmar guard for the right hand. Facility policy required assessment and appropriate treatment for loss of voluntary movement and limitation in ROM, including the neck, but these were not implemented for the resident. Observations consistently showed the resident without necessary devices to manage his contractures, indicating a failure to follow policy and provide individualized care.
Failure to Implement Adequate Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of appropriate assistance devices to prevent accidents for a resident with a history of multiple falls and significant cognitive impairment. The resident, an elderly female with diagnoses including dementia, diabetes, hypertension, and a history of fractures, experienced three falls—two unwitnessed and one witnessed—over a three-month period. Despite these incidents, the care plan did not include interventions such as fall mats or a low bed, and physician orders lacked fall precautions or increased monitoring. The only intervention added after the second fall was education and encouragement to use the call light for assistance, despite documentation and staff interviews indicating the resident was unable to use the call light appropriately due to severe cognitive impairment. Observations conducted over several days revealed that the resident's bed was not kept in the low position and no fall mats were present in her room, even after multiple falls. Staff interviews confirmed that prior to the most recent fall, interventions were limited to encouraging call light use and keeping the call light within reach. Both nursing and CNA staff expressed that the resident was not capable of using the call light effectively and that fall mats would have been an appropriate intervention given her fall history. Physical therapy assessments noted the resident's high fall risk and difficulty with transfers but did not recommend specific fall precautions or interventions. The facility's fall prevention policy requires that all residents at high risk for falls have individualized care plans with appropriate interventions, yet this was not followed for the resident in question. The incident log lacked detailed outcomes for the falls, and the care plan was not updated with effective interventions after repeated incidents. The lack of timely and appropriate fall prevention measures contributed to the resident experiencing multiple falls, including one resulting in a hip fracture.
Failure to Ensure Timely Availability of Physician-Ordered Fentanyl Patch
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with chronic pain syndrome and other bone disorders by not ensuring the timely availability of a physician-ordered Fentanyl patch. Upon admission, the resident had a Fentanyl patch in place, but it was removed when it expired, and a replacement was not available due to delays in ordering the medication. The admitting nurse did not follow up with the physician to obtain the required triplicate order for the Fentanyl patch, and the nurse practitioner clarified that only the physician could order this medication. As a result, the resident went without the prescribed Fentanyl patch for an extended period, during which time she reported severe neck pain related to her medical condition. Documentation in the electronic medical record and medication administration record confirmed the gap in Fentanyl administration, with nursing notes indicating the medication was not available and was pending delivery from the pharmacy. Interviews with nursing staff and the director of nursing revealed a lack of clarity and training regarding the process for ordering controlled substances, specifically the need for physician involvement and timely follow-up to ensure medication availability. The facility's medication ordering policy did not address timelines or procedures for ordering narcotics, contributing to the delay in the resident receiving her prescribed pain management.
Medication Error Rate Exceeds 5% Due to Incorrect Dose, Route, and Lack of Monitoring
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with four errors identified in 35 opportunities, resulting in an error rate of 11.43%. One staff member, an LVN, administered 325 mg of Aspirin crushed via PEG tube to a resident, despite the order specifying 81 mg chewable Aspirin to be given by mouth. The same resident, who had a history of cerebral infarction, dysphagia, aphasia, and essential hypertension, was also not assessed with vital signs such as blood pressure and pulse prior to receiving multiple antihypertensive medications, as required by accepted standards and the resident's care plan. The resident involved was severely cognitively impaired, non-verbal, and on an NPO diet due to dysphagia, requiring all medications to be administered via PEG tube. Despite this, the medication order for Aspirin was not clarified or updated to reflect the appropriate route, and the incorrect dose was given. Staff interviews revealed that nurses did not consistently check or document vital signs before administering blood pressure medications, and there was a lack of clarity among staff and pharmacy regarding the need for blood pressure parameters and monitoring for such residents. Facility policy required staff to verify medication orders, be aware of contraindications, and consult with prescribers if there were concerns about medication administration. However, these procedures were not followed, as staff failed to review and clarify the medication orders, did not monitor vital signs as indicated, and did not communicate concerns to the physician or pharmacy. The failure to adhere to these protocols resulted in medication errors involving incorrect dose, route, and lack of necessary monitoring for a resident with significant medical vulnerabilities.
Expired Medications Found in Medication Storage Room
Penalty
Summary
Expired and/or discontinued medications were found in one of two medication storage rooms during an observation and interview. Specifically, six bottles of multivitamins with an expiration date of 01/2024 and one box of nicotine patches with an expiration date of 04/2024 were present in the medication storage closet on Hall 100. The ADON present at the time confirmed the presence of these expired medications and removed them from the room. Interviews with the DON and Administrator revealed that the facility's expectation is for the supply person to monitor expiration dates when restocking supplies, and that expired products should be disposed of. The facility's Medication Administration Policy and Procedure requires that the individual administering medication ensures the expiration date has not been exceeded before administration. The failure to remove expired medications from storage could result in residents not receiving the intended therapeutic benefits of their medications.
Failure to Follow Enhanced Barrier Precautions During Device Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically by not ensuring that staff and hospice personnel followed Enhanced Barrier Precautions (EBP) during care of residents with indwelling medical devices. Observations revealed that licensed vocational nurses (LVNs) and a hospice registered nurse (RN) did not wear required personal protective equipment (PPE), such as gowns, when providing care involving a PEG tube and a urinary catheter, despite clear signage and care plans indicating the need for EBP. One resident, a male with severe cognitive impairment, cerebral infarction, dysphagia, and a PEG tube, had physician orders and a care plan requiring EBP, including the use of gowns and gloves during device care. On two separate occasions, LVNs administered medications and tube feeding through the PEG tube while only wearing gloves, omitting the gown. Both the signage on the resident's door and the care plan specified the need for both gown and gloves during such care. The LVNs acknowledged in interviews that they did not follow the required precautions and recognized the importance of doing so. Another resident, also with severe cognitive impairment and a suprapubic catheter, was observed receiving catheter care from a hospice RN who wore gloves but not a gown, contrary to facility policy and posted instructions. The hospice RN stated that this was not standard practice for hospice in home settings, but the facility's contract and policies required adherence to facility infection control protocols. Interviews with facility leadership confirmed that hospice staff are expected to follow facility policies regarding infection control when providing care within the facility.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 96 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bryan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestview Retirement Community | 0.5 mi | ★★★★★ | 0 | 0 |
| St. Joseph Manor | 0.5 mi | ★★★★★ | 10 | 0 |
| Lampstand Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 20 | 2 |
| Five Points Nursing & Rehabilitation Of College St | 5.1 mi | ★★★★★ | 10 | 3 |
| Fortress Nursing And Rehabilitation | 5.9 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.