Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Legend Oaks Healthcare And Rehabilitation - Fort W during CMS and state inspections, most recent first.
A resident with severe dementia, poor trunk control, and dependence for all ADLs experienced multiple recurrent falls from a manual wheelchair over several months, most occurring in the dining room. Despite a documented high fall risk and repeated incident reports describing the resident sliding or falling from the wheelchair, staff interventions remained largely limited to repositioning, monitoring, and putting the resident to bed after meals. Therapy staff identified poor trunk control and lack of safety awareness but reported that alternative cushions, seat adjustments, or a reclining wheelchair were not implemented because they were believed to be restraints. This failure to address the root cause of the falls and to implement appropriate assistive devices resulted in repeated injuries, including head lacerations, a scalp hematoma, and a subacute to chronic nonunion rib fracture.
A resident admitted after a fall with a left arm fracture, stroke-related weakness, and a moderate Braden score for pressure ulcer risk spent most non-therapy time in bed, as staff considered the resident too unsteady to be out of bed. Although the care plan noted impaired mobility and risk for decreased tissue circulation, staff did not initiate heel off-loading or other specific preventive measures before a new left heel wound developed in-house, later documented as a stage III pressure ulcer. Nursing and therapy records showed the resident was largely bedbound outside of therapy sessions, and interviews revealed that heel protection and off-loading (bunny/foam boot) were only implemented after the heel wound appeared, despite the resident’s identified pressure ulcer risk and limited mobility.
Food Storage and Kitchen Fan Sanitation Deficiencies: The facility failed to keep opened food in the walk-in refrigerator completely covered and labeled, and kitchen fans were observed running with grease and dust or dust buildup on the grilles near the steam table and dish machine. The Dietary Manager stated opened food should be covered to keep contaminants out and that fans should be cleaned as needed; the Administrator stated opened food should be covered and labeled.
Improper dumpster and trash disposal was observed for 2 of 2 dumpsters. Surveyors found both dumpster doors and lids open, and a clear trash bag with soiled incontinent briefs and other trash partially underneath one dumpster. The Dietary Manager, Corporate Nurse, and Administrator all stated the doors and lids should be closed and trash picked up, and the Administrator said the facility did not have a policy for outside garbage and refuse disposal.
A resident with DM, PVD, and a CVA had multiple wound care entries left blank on the TAR for ordered treatments to the left Achilles tendon and right great toe. The resident stated dressings had not been changed as scheduled, and staff interviews confirmed treatments were supposed to be signed off and refusals documented, but the record did not show whether care was given or refused.
Missing Care Plan for Indwelling Catheter: A resident with an indwelling catheter had no catheter-related care plan, despite staff awareness that he had a catheter. The resident said he had to ask aides to check the catheter and usually emptied it himself. RN C, the ADON, DON, and MDS Coordinator all acknowledged the care plan did not reflect catheter use or care, and the facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes.
A resident with an indwelling catheter did not have a physician order for catheter use or care, and his MDS and care plan did not reflect catheter care. Staff observed the catheter bag hanging low from his wheelchair, and the resident said he had to ask aides to check it and usually emptied it himself. RN C could not find catheter orders, and the ADON and DON stated the resident should have had orders entered for proper catheter care.
A resident with HF and COPD was observed using a nasal cannula connected to a portable O2 tank and stated she was on 2 liters continuously, but the chart contained no physician order for supplemental oxygen. RN C could not locate an order and the DON stated the missing order was not known, while the care plan still referenced oxygen therapy as ordered by the physician.
Expired Famotidine, Benzocaine, and Glucosamine were found in the Station 2 med room during observation with the ADON. The ADON, DON, CNA A, RN B, and the Administrator gave differing accounts of who was responsible for checking med rooms for expired meds, and the facility policy required outdated meds to be immediately removed from stock.
A resident with severe cognitive impairment and a known elopement risk exited the facility unsupervised after following a visitor out the front door. Although the WanderGuard alarm sounded, the RN on duty turned off the alarm without checking outside, and the resident was not discovered missing until later. The resident was found by police several hours later, two miles from the facility.
Two residents with complex medical and behavioral histories, who were roommates, became involved in a physical altercation after a verbal dispute, resulting in one resident being pulled from bed and sustaining minor injuries. Staff and care plans did not identify or address any prior issues between the residents, and no interventions were in place to prevent the escalation, leading to a failure to protect residents from abuse.
A facility failed to follow physician orders for a resident's enteral feeding tube, setting the water flush rate at 145 mL every 4 hours instead of the prescribed 175 mL. The resident, with a history of cerebrovascular issues and dependent on tube feeding, was at risk of dehydration due to this oversight. Nursing staff admitted to not reviewing orders prior to connecting the resident to the feeding machine.
A resident with a PICC line did not have physician orders for dressing changes, flushing, or infection monitoring, leading to a failure in maintaining the line's integrity. The dressing was not dated, and staff interviews confirmed the absence of necessary orders, placing the resident at risk for infection. Facility policies require such orders and regular dressing changes, which were not followed.
A facility failed to ensure a resident requiring dialysis received appropriate pre- and post-dialysis assessments. Despite a care plan outlining necessary assessments, including vital signs and fistula checks, these were not consistently documented. Interviews revealed that while pre-dialysis vitals were taken, post-dialysis assessments were often missed. The ADON and DON were unaware of the incomplete documentation, indicating a lapse in oversight. This deficiency risked missing changes in the resident's condition, leading to inadequate post-dialysis care.
A resident with aphasia and right-sided hemiplegia left the facility unsupervised, traveling 1.5 miles away before being located by family using a tracking device. The resident, considered low risk for elopement, was frequently checked on while outside but managed to leave without staff knowledge.
A resident with a history of spinal surgery, diabetes, and high blood pressure did not receive compression socks as ordered to prevent blood clots. The order was not transferred to the TAR, and the socks were not consistently applied. The resident's family noted the socks remained on the dresser, and the resident did not recall them being applied until recently. The facility's investigation revealed the physician had not completed the order process, and the admitting nurse failed to ensure all orders were initiated.
The facility failed to ensure call lights were within reach for several residents, contrary to their care plans and facility policy. Observations showed call lights on the floor or out of reach, posing a risk to residents who required assistance. Staff interviews confirmed awareness of the policy, yet the deficiency persisted, highlighting a systemic issue in accommodating resident needs.
A facility failed to coordinate PASRR assessments and submit a request for NFSS for a resident with intellectual disabilities, leading to a deficiency. Despite recommendations for a customized wheelchair during the initial IDT meeting, the facility did not submit the request within the required timeframe. Interviews with staff confirmed the oversight, and the resident experienced difficulty maneuvering due to the lack of appropriate equipment.
Failure to Provide Adequate Supervision and Appropriate Wheelchair Seating to Prevent Recurrent Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and appropriate assistive devices to prevent accidents for a cognitively impaired male resident with Alzheimer’s disease, non-Alzheimer’s dementia, seizure disorder, anxiety disorder, difficulty walking, cognitive communication deficit, and muscle weakness. The resident’s MDS showed severely impaired cognition (BIMS of 0), unclear speech, dependence for all ADLs, use of a manual wheelchair, and a history of two or more falls since admission. The care plan, revised in mid-February, identified actual falls related to poor balance and unsteady gait and listed general interventions such as providing activities, assisting the resident back to bed after meals, repositioning in the wheelchair at the table, providing a fidget blanket, maintaining the bed in the lowest position with a floor mat, ensuring proper positioning in bed during rounds, and obtaining a therapy consult for strength and mobility. A fall risk evaluation in October identified the resident as high risk for falls. From November through February, multiple incident reports documented repeated falls, almost all occurring from the resident’s wheelchair, particularly in the dining room. On several occasions, nursing staff found the resident on the floor in front of or near his wheelchair, often unable to describe what happened. Specific incidents included falls from a chair in the dining room without injury, a fall in which the resident was found prone on the floor with his wheelchair behind him and a laceration to the top of the left eyebrow requiring sutures, and several episodes where staff observed or found him sliding out of his wheelchair to the floor. Another fall in early February resulted in an abrasion to the forehead, a scalp hematoma, and imaging that revealed a subacute to chronic nonunion fracture of the posterior left 11th rib. Despite this pattern of falls from the wheelchair, the documented interventions remained largely limited to repositioning, monitoring, and putting the resident to bed after meals. Interviews with CNAs, LVNs, RNs, therapy staff, and the MDS nurse confirmed that the resident repeatedly slid or fell forward or sideways out of a standard manual wheelchair and that staff primarily responded by frequently repositioning him, watching him more closely, and laying him down after meals. The OT and Director of Rehab reported that the resident had poor trunk control, could sit upright only about five minutes, and lacked safety awareness due to impaired cognition, and that no additional equipment-based interventions (such as different cushions, seat adjustments, or alternative wheelchair types) were implemented because these were believed to constitute restraints. The MDS nurse stated she considered a reclining wheelchair a restraint and communicated this to the family and therapy, which contributed to the lack of implementation of such devices despite the resident’s ongoing falls. Staff interviews consistently indicated that no other significant interventions beyond repositioning, monitoring, and post-meal bed rest were put in place during the period when the resident experienced multiple falls from his wheelchair, leading to the cited failure to address the root cause of the falls, to implement therapy recommendations, and to implement effective interventions to prevent the resident from falling from his wheelchair. Additional observations later showed the resident seated in a padded high-back reclining wheelchair provided by hospice, in which he appeared more stable, with staff and family reporting that he had not had recent falls while using this chair. However, during the time frame covered by the deficiency (from November through February), the facility did not modify the resident’s wheelchair or seating system in response to his repeated falls, nor did it implement other therapy-recommended equipment changes due to concerns about restraints. The facility’s own fall management policy stated that it would provide an environment as free of accident hazards as possible and provide appropriate assessment and interventions to prevent falls and minimize complications, and that the QAA Committee would analyze fall trends and determine if further intervention was needed. Despite this, the documented pattern of frequent falls from the wheelchair, the resident’s known high fall risk, and his severe cognitive and physical limitations were not met with effective, individualized interventions to address the underlying causes of his falls during the cited period.
Failure to Implement Timely Pressure Ulcer Prevention Leading to Facility-Acquired Heel Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards and to prevent the development of a pressure ulcer in a resident identified as being at moderate risk. The resident was an adult male admitted after a fall at home with a left upper arm fracture, a wound to the left elbow, muscle weakness, stroke with left-sided involvement, and a history of falls. His admission MDS showed a BIMS score of 14 (cognitively intact), and his Braden Scale score was 14, indicating moderate risk for pressure ulcers. The admission assessment documented a skin issue on the right inner forearm and a fracture of the left humerus, but no heel issues were noted on admission. The care plan identified impaired physical mobility, risk of decreased tissue circulation, and an existing wound to the left elbow, and later reflected that he developed a pressure ulcer to his left heel. During his stay, therapy records showed that the resident participated in PT, OT, and ST in the gym daily on weekdays, but otherwise he spent most of his time in bed. According to the resident’s family member, therapy staff were the only ones who got him out of bed, and staff told the family that he was too unsteady to be out of bed and that it was safer for him to remain in bed or in a wheelchair, despite his prior independence and preference for using a walker. Nursing staff interviews indicated that the resident was sometimes confused, unsteady with his walker, and was encouraged to remain in bed to prevent falls. The LVN reported that because the resident could turn himself and was getting out of bed, staff did not necessarily implement precautionary measures for pressure ulcer prevention and that she did not recall when preventive measures were initiated. On 02/10/26, a new wound on the resident’s left heel was documented by nursing as an open blister acquired in-house, with partially intact, degloved skin. The Wound Care Nurse confirmed that the left heel wound was facility-acquired, likely related to lack of mobility and friction from the bed and sheets, and that off-loading practices such as a foam/bunny boot were not started until after the heel wound developed. Her first assessment measured the wound at 5.5 cm by 5 cm, and subsequent physician orders on 02/11/26 and 02/25/26 addressed cleansing, dressing changes, and use of a bunny boot to keep the heel off surfaces. Hospital records from a later admission documented a stage III pressure ulcer to the left heel measuring 6 cm by 6 cm. The DON and Wound Care Nurse acknowledged that heel protection was not implemented on admission because the resident was reported as ambulatory, and the DON could not confirm the accuracy of the Braden assessment without review, while the physician later stated the ulcer was unavoidable due to vascular issues and other medical problems.
Food Storage and Kitchen Fan Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in its only kitchen. On 03/03/26 at 8:48 AM, a floor fan near the sink was observed running and pointed toward the steam table, with grease and dust accumulated on the front grille. On 03/03/26 at 8:53 AM in the walk-in refrigerator, one medium square container was not completely covered and contained pudding labeled and dated 2/28, and another medium square container was not completely covered and held an unknown item that appeared to be cheese sauce; this second container was dated 3/2 and had no label. The Dietary Manager stated the containers should be covered and labeled and removed them from the refrigerator. On 03/04/26 at 10:54 AM, the same fan near the sink was again observed running and pointed toward the steam table with grease and dust on the front grille. On 03/04/26 at 10:59 AM, another floor fan near the dishwashing area was observed running and pointed toward the dish machine, with dust accumulated on the front grille. During interviews on 03/05/26, the Dietary Manager stated opened food stored in the refrigerator should be completely covered to keep contaminants out and that fans should be cleaned as needed; she stated not cleaning the fans could cause contaminants to blow into the food. The Administrator also stated opened food stored in the refrigerator should be covered and labeled and that the fans should be cleaned as needed.
Improper Dumpster and Trash Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters, identified as dumpsters #1 and #2. During observation on 03/03/26 at 8:58 AM, surveyors found the doors open on both dumpsters, the lids on both dumpsters open, and a clear trash bag containing soiled incontinent briefs and other trash lying partially underneath dumpster #1. During interview at that time, the Dietary Manager stated the doors and lids should be closed and trash picked up to keep rodents and bugs away. Later interviews with the Corporate Nurse and Administrator confirmed that the doors and lids should be closed and that trash should be picked up, and the Administrator stated the facility did not have a policy for outside garbage and refuse disposal.
Incomplete TAR Documentation for Wound Care
Penalty
Summary
The facility failed to ensure Resident #3’s treatment administration record (TAR) was accurately documented for multiple wound care treatments. Resident #3 was a cognitively intact male with diagnoses including diabetes mellitus, peripheral vascular disease, and cerebrovascular accident. His care plan included nutritional problems related to a chronic ulcer to the left ankle, resistance to care related to a family member impeding care, and a diabetic ulcer to the left Achilles tendon related to vascular insufficiency. Review of the January TAR showed blanks for wound care treatments on 01/06/26, 01/10/26, and 01/20/26 for cleansing the venous wound to the left Achilles tendon with Vasha, applying alginate calcium with silver, and dressing changes every 48 hours. The January TAR also showed blanks for 01/22/26, 01/24/26, and 01/27/26 for wound treatments ordered for the left Achilles tendon and the right great toe, including cleansing with Vasha, applying collagen sheet, and covering with dry dressing three times a week and as needed. During observation, Resident #3 had a heel protector on the right heel and stated dressings had not been changed every other day in January. Staff interviews indicated wound care was supposed to be documented on the TAR, and refusals were supposed to be recorded, but blanks could mean the nurse forgot or the treatment may have been missed. One LVN stated she had provided wound treatment on one of the dates and remembered a refusal on another date, but did not recall the exact date. The Administrator and DON stated staff were expected to sign off treatments and document refusals, and that the risk was not knowing whether wound care was given and having inaccurate records.
Missing Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with an indwelling catheter. Resident #4 was an [AGE]-year-old male admitted and readmitted to the facility with diagnoses including benign prostatic hyperplasia, diabetes mellitus, anxiety disorder, bipolar disorder, and depression. His MDS assessment dated 01/07/26 showed a BIMS score of 15, indicating intact cognition, and he required supervision or touching assistance with toileting. However, the assessment did not include catheter use, and the undated care plan also did not reflect any use of or care for an indwelling catheter. The order summary report likewise did not show an order for catheter use or care. During observation on 03/03/26, the resident's catheter bag was hanging low and attached to his wheelchair, and the resident stated that communication "stinks" and that he had to ask aides to check his catheter because they would not check it on their own. He also stated that he usually emptied the catheter himself without facility assistance. On 03/05/26, RN C acknowledged awareness that the resident had a catheter and stated care plans were generated upon admission and updated by the MDS Coordinator. The ADON, DON, and MDS Coordinator each stated they were unaware the care plan did not include catheter use or care, and the DON and ADON stated the missing care plan information placed the resident at risk for infection and improper care. The facility policy stated the interdisciplinary team shall develop a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident's identified needs.
Missing catheter orders and care for a resident with an indwelling catheter
Penalty
Summary
The facility failed to ensure a resident with an indwelling catheter had appropriate treatment and services to prevent urinary tract infections based on the resident’s comprehensive assessment. Resident #4, an adult male with a BIMS score of 15, was admitted and readmitted to the facility with diagnoses including benign prostatic hyperplasia, diabetes mellitus, anxiety disorder, bipolar disorder, and depression. His MDS assessment did not include catheter use, his care plan did not reflect indwelling catheter care, and the order summary did not show an order for catheter use or care. During observation, Resident #4’s catheter bag was hanging low from his wheelchair, and he stated he had to ask aides to check his catheter because they would not check it on their own, and that he usually emptied the catheter himself without staff assistance. RN C later observed the resident with the catheter secured to his leg but could not identify the catheter size and confirmed she could not locate an order for catheter use or care. The ADON and DON stated the resident should have had orders entered and that without them he was at risk of improper care and infection. The facility’s indwelling urinary catheter policy required orders for catheter size, care, monitoring, and catheter changes.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #83 by not having a physician order for her supplemental oxygen. Resident #83 was a [AGE]-year-old female with diagnoses including heart failure, hypertension, and COPD, and her MDS reflected that she had shortness of breath or trouble breathing when lying flat. Her clinical record contained no physician orders for oxygen treatment, even though her care plan addressed COPD with potential for respiratory decline and included interventions for oxygen therapy as ordered by the physician. During observation on 03/03/26, Resident #83 was sitting in her room in a wheelchair with a nasal cannula in place connected to a portable oxygen tank, and she stated that she had been using oxygen for some time and was on 2 liters continuously. On 03/05/26, RN C stated she could not locate a physician order for the oxygen and said the order may have been deleted when the resident returned from the hospital. The DON stated she was not aware of the missing oxygen order and confirmed that not reviewing physician orders for accuracy placed residents at risk of missing treatments or receiving incorrect amounts of treatment.
Expired Medications Left in Station 2 Medication Room
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring expired medications were removed from the Station 2 medication room. During observation with the ADON, two boxes of Famotidine 10 mg were found with an expiration date of 02/25, along with Benzocaine 20% and Glucosamine 500 mg, both with expiration dates of 01/26. The ADON opened the Famotidine boxes to confirm the expiration date and stated it was her responsibility to ensure there were no expired medications in the storage rooms. She also stated she was new to the facility and had not yet completed weekly audits of the medication rooms. Interviews with the DON, CNA A, RN B, and the Administrator showed differing expectations about who was responsible for checking medication rooms for expired medications. The DON stated the ADON was expected to check the medication rooms weekly, that Central Supply also checked when restocking, and that nurses were only responsible for checking their carts and medications before administration. CNA A stated she and a nurse restocked the medication rooms weekly and did spot checks for expired medications, but the last time this was done was 02/26/26. The facility policy stated outdated medications are to be immediately removed from stock and disposed of according to medication destruction procedures.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, and a high risk for elopement exited the facility unsupervised. The resident was equipped with a WanderGuard device and had a care plan identifying elopement risk, including interventions such as monitoring the WanderGuard device and documenting wandering behavior. On the evening of the incident, the resident was last seen following a nurse during medication pass and was later observed on camera following a visitor out the front door. Despite the WanderGuard alarm sounding at the main entrance, the registered nurse on duty turned off the alarm without immediately investigating outside to determine if a resident had exited. The nurse and a CNA began searching for the resident only after noticing his absence from the hallway and rooms. The facility initiated a code white and staff searched both inside and outside the building, but the resident was not located until approximately nine hours later by local police, two miles away from the facility. Interviews and record reviews confirmed that the resident was known to pace the hallways and follow people, and had a history of elopement risk. The nurse on duty did not respond to the WanderGuard alarm as required, and the resident was able to leave the facility by following a visitor, which was not immediately detected by staff. The failure to provide adequate supervision and to respond appropriately to the WanderGuard alarm resulted in the resident's prolonged absence from the facility.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, neglect, misappropriation of resident property, and exploitation, as evidenced by an incident involving two residents who were roommates. On the night of the incident, one resident, who had a history of heart failure, diabetes, stroke, and respiratory failure with moderately impaired cognition, was pulled out of bed and hit by his roommate, who had diagnoses including end stage renal disease and Huntington's disease but was cognitively intact. The altercation began after verbal exchanges related to personal habits and derogatory remarks, escalating to physical aggression when one resident pulled the other from bed and struck him, resulting in minor lacerations and scratches that required in-house treatment and a hospital evaluation for one resident. Prior to the incident, there were no documented behavioral issues or altercations between the two residents, and staff interviews indicated that neither resident had previously expressed dissatisfaction with their roommate arrangement. Staff members, including nurses and CNAs, reported that both residents generally kept to themselves and did not display aggressive behaviors or complain about each other. The care plans for both residents noted the potential for behavioral issues, but no specific interventions or monitoring were in place to address escalating tensions or prevent resident-to-resident altercations. The incident was discovered when staff responded to a call light and sounds of banging from the room. Upon entering, staff found one resident on the floor with visible injuries and the other resident pacing in the room. Both residents confirmed the physical altercation during interviews, and staff immediately separated them. The facility's records showed no prior incidents between the two, and the event was considered isolated by staff and administration. However, the failure to identify and address the potential for conflict between the residents led to a situation where one resident was not protected from abuse by another resident.
Failure to Follow Physician Orders for Enteral Feeding Tube Flush
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via an enteral feeding tube received the appropriate treatment and services to prevent complications. Specifically, the facility did not follow the physician's orders for the resident's feeding tube to be flushed with 175 cc of water every 4 hours. Instead, the water flush rate was set at 145 mL every 4 hours, which was not in accordance with the prescribed orders. This discrepancy was observed during a survey, and the nurse assigned to the resident admitted to not reviewing the physician's orders prior to connecting the resident to the feeding machine. The resident involved was a male with a history of non-traumatic intracerebral hemorrhage, respiratory failure, dysphasia, aphasia, paraplegia, and gastro-esophageal reflux disease. The resident was dependent on tube feeding due to dysphagia following a cerebrovascular accident. The failure to provide the correct water flush amount placed the resident at risk of dehydration, as acknowledged by the nursing staff and administration during interviews. The facility's Quality of Care policy required adherence to physician orders for tube flushing, which was not followed in this instance.
Failure to Maintain PICC Line Integrity and Obtain Necessary Orders
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids for a resident, specifically in maintaining the integrity of the resident's Peripherally Inserted Central Catheter (PICC) line dressing. The resident, a male with a history of hemiplegia, hemiparesis, and other medical conditions, was readmitted to the facility and required IV antibiotic therapy. However, the facility did not have physician orders to change the PICC line dressing, flush the line, or monitor for infection and infiltration, which are essential practices to prevent infection and ensure the effectiveness of the IV therapy. Observations revealed that the resident's PICC line dressing was not dated, and the dressing had not been changed since the resident's admission. Interviews with the nursing staff, including the RN and ADON, confirmed that there were no physician orders for the necessary PICC line maintenance procedures. The RN acknowledged the absence of orders and the lack of a date on the dressing, which is crucial for tracking when the dressing needs to be changed. The ADON and DON also confirmed that it was the responsibility of the admitting nurse to obtain the necessary orders and ensure the dressing was dated. The facility's policies require that all drug and treatment orders be obtained from a licensed professional and that PICC line dressings be changed every seven days or as needed. The failure to adhere to these policies and obtain the necessary physician orders for the resident's PICC line care placed the resident at risk for infection and other complications. The nursing staff's actions and inactions, including not obtaining the required orders and not dating the dressing, contributed to this deficiency.
Failure to Complete Pre- and Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate pre- and post-dialysis assessments, as per professional standards of practice. The resident, a male with end-stage renal disease, diabetes mellitus, and hypertension, was admitted to the facility and required dialysis three times a week. Despite having a care plan that outlined the need for pre- and post-dialysis assessments, including checking vital signs and the condition of the arteriovenous fistula, these assessments were not consistently documented or completed. Interviews with the resident and staff revealed that while the resident's vitals were checked before leaving for dialysis, it was rare for them to be taken upon return. The nursing staff, including RN B, acknowledged the responsibility to complete these assessments but admitted that they were not always done. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were unaware of the incomplete documentation until it was brought to their attention, indicating a lapse in oversight and communication within the facility. The facility's policy on dialysis care required the completion of pre- and post-dialysis assessments to monitor the resident's condition and ensure the patency of the dialysis access. However, the lack of completed documentation on several occasions, including missing forms, highlighted a failure to adhere to these policies. This deficiency posed a risk of not detecting changes in the resident's condition, which could lead to inadequate post-dialysis care.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident who was aphasic and had right-sided hemiplegia, resulting in the resident leaving the facility without staff knowledge. The resident, who was considered a low risk for elopement, managed to leave the facility and travel approximately 1.5 miles away with the assistance of a bystander. The resident was out of the facility for about two hours before being located by family members using a tracking device placed on the resident's shoe. The resident had a history of sitting outside the facility and had never previously attempted to leave the premises. On the day of the incident, the resident was last seen by staff in his room and later at the nurses' station. However, after a family member could not find him in his usual places, the staff began searching for him. The resident was eventually found unharmed, being pushed by a young man near his old neighborhood. Interviews with staff revealed that the resident was frequently checked on when sitting outside, and it was believed he was safe to be outside on his own. The staff was unaware of the tracking device placed by the family, and the resident had not been identified as an elopement risk prior to the incident. The facility's policy aimed to provide a safe environment through appropriate assessment and supervision, but the lack of awareness and monitoring led to the resident's unsupervised departure.
Failure to Apply Compression Socks as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not apply the resident's compression socks as ordered by the physician. The resident, a cognitively intact male with a history of spinal surgery, diabetes, and high blood pressure, was admitted to the facility with an order to wear compression socks to prevent blood clots due to decreased activity. However, the order was not transferred to the Treatment Administration Record (TAR), and the compression socks were not consistently applied as required. Interviews and observations revealed that the resident's compression socks were not applied upon admission and remained on the dresser, despite the family's presence and reminders. The CNA claimed to have applied the socks daily, except for one day when the resident refused, but the resident did not recall this until the previous afternoon. The facility's investigation indicated that the physician had not completed the order process, leading to the omission from the TAR. The Director of Nursing (DON) stated that the admitting nurse was responsible for ensuring all physician's orders were placed and initiated, which did not occur in this case.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that the call lights were within reach for five residents, which is a critical aspect of accommodating their needs and preferences. Observations revealed that the call lights for Residents #2, #3, #4, #5, and #6 were not accessible, being found on the floor or in positions that the residents could not reach. This oversight was contrary to the care plans of these residents, which emphasized the importance of having call lights within reach to prevent falls and ensure a safe environment. Resident #2, a male with a BIMS score indicating severe cognitive impairment, was dependent on staff for all activities of daily living and at risk for falls. His care plan included the use of a call light for assistance, yet it was found on the floor under his bed. Similarly, Resident #3, with a history of stroke and chronic pain, had a care plan that required the call light to be within reach to manage pain and meet needs promptly, but it was found under the bed. Resident #4, who had intact cognition but required assistance with ADLs, had her call light positioned between her bed and the wall, out of reach. The facility's policy, revised in October 2022, mandates that call lights be within reach to facilitate communication with nursing staff. Interviews with staff, including a CNA and the ADON, confirmed awareness of this policy and acknowledged the risk posed by inaccessible call lights. The DON reiterated the necessity of having call lights within reach, even for residents believed incapable of using them, to ensure that family and staff can call for help if needed. Despite this policy, the observations indicated a systemic failure to adhere to these guidelines, placing residents at risk of unmet needs.
Failure to Coordinate PASRR Assessments and Submit NFSS Request
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program effectively, leading to a deficiency in the care of a resident. The resident, a male with a history of intellectual disabilities, anemia, coronary artery disease, heart failure, and hypertension, was identified as PASRR level II positive. Despite recommendations made during the initial Interdisciplinary Team (IDT) meeting for a customized wheelchair, the facility did not submit a request for Nursing Facility Specialized Services (NFSS) in the LTC Online Portal within the required 20 business days. This oversight was confirmed during interviews with the PASRR Habilitation Coordinator, the facility Social Worker, the Director of Rehabilitation, and the MDS Coordinator, all of whom acknowledged the failure to complete the necessary documentation and processes. The deficiency was further highlighted by the resident's difficulty maneuvering around the facility due to the lack of a customized wheelchair. The Director of Rehabilitation admitted to contacting a vendor for an assessment, but the process was not completed, and the NFSS form was not submitted. The facility's policy required the initiation of specialized services by submitting the request within 20 business days after the initial IDT meeting, a step that was not taken, potentially placing residents at risk of not receiving necessary services to prevent conditions such as skin breakdown and pressure sores.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 970 citations issued within 25 miles in the last 12 months — including the 40 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.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Keller
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Harrison At Heritage | 1.2 mi | ★★★★★ | 11 | 0 |
| Heritage House At Keller Rehab & Nursing | 2.6 mi | ★★★★★ | 7 | 1 |
| Green Valley Healthcare And Rehabilitation Center | 5.1 mi | ★★★★★ | 4 | 1 |
| North Pointe Nursing And Rehabilitation | 5.3 mi | ★★★★★ | 1 | 1 |
| Discovery Village At Southlake | 5.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.