Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 - Waxaha during CMS and state inspections, most recent first.
Two residents experienced failures in required notifications regarding significant changes in status and care decisions. One resident with dementia and other comorbidities was transferred to another facility’s memory care unit without prior notification to her RP; staff interviews showed that multiple staff assumed others had notified the family, and there was no documentation of timely communication. Another resident with severe cognitive impairment and multiple medical conditions was found on a floor mat by CNAs, who reported the event to the nurse; the nurse did not treat the event as a fall, did not notify the RP or MD, and did not document the incident. Days later, a nurse identified bruising and pain in the resident’s arm, notified the NP, and obtained x-rays that revealed an acute humeral head fracture, with the RP only informed of the injury and imaging, not the earlier fall.
Two residents did not receive care consistent with professional standards and facility policy. One resident with cellulitis and multiple chronic conditions was discharged home after completing IV antibiotics, but staff failed to obtain an order for and remove his PICC line, and the discharge assessment omitted any mention of the line. Another resident with severe cognitive impairment and identified fall risk was found on a floor mat by CNAs, who reported the event to the charge nurse; however, the nurse did not document the fall, perform or document a post-fall assessment, notify the provider or family, or complete an incident report. The fall was only discovered days later when a nurse noted bruising and pain in the resident’s arm, leading to imaging that revealed an acute humeral head fracture, contrary to the facility’s fall management policy requiring assessment, documentation, and notification after a fall.
Unlabeled and undated food items were found in the kitchen walk-in cooler, including mayonnaise, chicken salad with cranberries and pecans, and chopped dilled relish. Staff, the ADM, and the DON stated that all opened food items should be labeled and dated, and the facility policy required perishable foods to be dated, labeled, and stored according to safe food handling guidelines.
Failure to Employ a Qualified Full-Time Social Worker: The facility, licensed for 121 beds, did not have a qualified social worker employed on a full-time basis. The ADM stated the facility had been without a qualified SW since the prior one left, and the current ASW was not licensed and did not meet the educational requirements. Interviews also showed that grievances, discharge questions, PHQ-9s, and BIMS were being handled by the ASW, the DON, the ADM, and staff from sister facilities.
PASARR Level II Evaluation Not Coordinated for a Resident With MI: The facility failed to ensure a resident with bipolar disorder, severe cognitive impairment, and a PASARR Level 1 indicating MI was properly referred for a PASARR Level II evaluation. Staff stated an initial PL1 was incorrect, the corrected PL1 was not accepted by the system, and no follow-up occurred to ensure transmission, so the LMHA was not alerted to conduct the PE. The ADM acknowledged the missed transmission and noted the resident could miss additional services she may qualify for.
Expired lubricant eye drops labeled for a resident and two boxes of expired wound dressing were found on the 500-hall med cart during survey observation. Staff, including an LVN, ADON, DON, and ADM, stated that charge nurses and med aides were responsible for daily cart checks and removing expired or discontinued meds, but the expired items remained on the cart. Resident #13 had glaucoma, type 2 DM, acute embolism and thrombosis of the LLE, and severe cognitive impairment, and did not have an active order for the eye drops.
An insulin pen for a resident with DM was found on a 300-hall med cart without an open date. Staff stated insulin must be dated when opened and discarded after 28 days, and the facility policy required opened injectable medications to be labeled with the date opened and initials. Interviews also confirmed that nurses and medication aides were responsible for checking carts for proper labeling and expired medications.
A resident with multiple chronic conditions did not have several medications and treatments properly documented in the electronic medical record. Staff confirmed that medications and treatments, including insulin, pain management, and catheter care, were administered but not signed off in the MAR due to competing duties. The facility's policy requires complete and accurate documentation, and leadership acknowledged that unsigned records indicate care may not have been provided.
A resident with severe cognitive impairment and complex medical needs was found to have a Statutory Durable Power of Attorney (DPOA) executed with facility staff as agents and witnesses, creating a conflict of interest. The DPOA was implemented during a period when the resident's capacity to consent was in question, and no appropriate external agent or guardian was secured, despite legal and hospital staff concerns.
A resident with severe cognitive impairment and multiple diagnoses continued to have an active yeast infection listed on her care plan after treatment had ended. Facility staff, including the ADON, DON, and ADM, confirmed that the care plan was not updated to reflect the resolved condition, contrary to facility policy requiring timely and accurate care plan updates.
A resident with a history of mobility issues suffered a skin tear during a transfer due to inadequate staff assistance. After hospitalization, the facility failed to arrange a follow-up appointment with a wound care specialist as instructed in the discharge papers. This oversight led to the resident missing the appointment, resulting in an infection and increased anxiety about her condition. Interviews revealed a breakdown in communication and procedure for scheduling follow-up appointments.
A resident with Parkinson's disease and mobility issues was injured during a transfer from a wheelchair to a bed when a CNA attempted the transfer alone, contrary to the care plan requiring two-person assistance. The resident's leg was caught on the bed, resulting in a severe laceration that required hospitalization and a blood transfusion. The facility also failed to ensure the resident attended a follow-up wound care appointment.
A resident with Parkinson's disease and reduced mobility was injured during a transfer by a CNA who did not use a gait belt or seek additional assistance. The resident's leg was lacerated, requiring hospitalization and a blood transfusion. The facility failed to report the incident to the state agency within the required timeframe, despite the resident's ability to articulate the event and the facility's policy mandating immediate reporting.
A resident with Parkinson's Disease and limited mobility was unable to reach the call light paddle due to improper placement by staff, leaving him unable to call for assistance. Despite facility policies requiring call lights to be within reach, the resident's call light paddle was consistently placed out of reach, leading to feelings of helplessness and reliance on staff for assistance.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in their documented speech clarity. One resident was observed to communicate only through gestures, while another was unable to respond verbally or with gestures, yet both were documented as having clear speech. These inaccuracies placed the residents at risk of receiving incorrect care.
The facility failed to implement comprehensive care plans for two residents, leading to potential risks. One resident's care plan lacked instructions for using a mechanical lift for transfers, while another's did not include required Enhanced Barrier Precautions. Staff interviews revealed confusion and reliance on informal communication methods, highlighting deficiencies in care planning and policy adherence.
A facility failed to monitor a resident for side effects of Apixaban, an anticoagulant medication. The resident, with multiple diagnoses, received the medication twice daily without any side effect monitoring in place. Interviews with staff revealed a lack of adherence to the facility's policy on monitoring blood thinner side effects, which is considered necessary to avoid classifying the medication as unnecessary.
A resident with multiple medical conditions reported receiving cold or lukewarm meals, with staff reluctant to reheat food, citing regulations. The resident spent significant money on outside food due to dissatisfaction. An LVN stated the procedure was to provide a new tray rather than reheating, and reheating was limited to kitchen staff during kitchen hours.
A long-term care facility failed to maintain an effective infection prevention and control program, resulting in deficiencies for two residents. A CNA did not follow proper hand hygiene protocols during perineal care for a resident, while another resident's room lacked signage and PPE for Enhanced Barrier Precautions. The facility's policies on infection control were not effectively implemented, posing a risk of cross-contamination and infection.
Two residents experienced neglect in a facility due to their soiled clothing not being taken to the laundry, leading to strong odors in their rooms. Despite requests for assistance, staff failed to address the issue, causing residents to feel neglected and embarrassed. Interviews revealed confusion among staff about laundry responsibilities, although facility policies indicated CNAs were responsible for laundry collection.
Two residents experienced neglect in maintaining a clean and homelike environment due to their soiled personal clothing not being taken to the laundry. Both residents' rooms had strong odors of urine and body odors, with overflowing laundry baskets identified as the source. Interviews revealed confusion among staff regarding the responsibility for laundry collection, contributing to the deficiency.
A resident in an LTC facility was mistakenly given three times the prescribed dosage of Requip, leading to symptoms such as dizziness and weakness. The error was due to a CMA misreading the order, and although the resident experienced distress, no significant adverse reactions were observed by the medical staff.
A resident with Alzheimer's and dysphasia choked and was hospitalized due to the facility's failure to assist and monitor her during meal service, despite clear hospice orders and family warnings.
The facility failed to develop and implement a comprehensive care plan for a resident requiring supervision or assistance while eating. Staff provided conflicting information about the resident's needs, and observations confirmed the resident was left to eat without necessary assistance. The care plan and care profile were not updated to reflect the resident's needs accurately.
Failure to Notify Physician and Responsible Party of Transfer and Fall Events
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with residents’ physicians and notify residents’ representatives of significant changes in condition and transfer decisions. For one resident with Alzheimer’s disease, hypertension, and atrial fibrillation, the facility transferred her to another nursing facility’s memory care unit without prior notification to her responsible party (RP). Progress notes showed that the resident was newly admitted, pleasantly confused, and exhibiting exit-seeking behavior, leading to placement of a Wanderguard. The following day, a nurse documented that the resident was discharged and transported to another facility, and that the family collected the resident’s belongings. However, the family member reported they were only called the morning of the transfer and told the resident was being moved and that they needed to pick up her belongings, with no prior notice or opportunity to participate in the decision. Interviews with staff confirmed that no one had clearly taken responsibility for notifying the RP about this transfer. The Admissions Director stated she spoke with the family when the resident was leaving but acknowledged she had not called the RP beforehand and had assumed another staff member had done so. The nurse who documented the discharge stated she did not call the RP because she believed the family was already aware, based on their presence later that day to collect belongings. A CNA who also worked as a social worker assistant stated she typically would contact the RP about transfers, discuss facility options, and send clinical information once a facility was chosen, but she was not aware of this resident’s discharge until after it occurred and had not contacted the RP or sent clinical information. The Administrator stated his expectation was that staff would have communicated with the RP prior to transfer or discharge, but he acknowledged there was no documentation of such communication. The deficiency also includes the facility’s failure to notify a resident’s RP and physician after a fall. A second resident, an older female with acute respiratory failure with hypoxia, type 2 diabetes, cognitive communication deficit, hypertension, muscle weakness, and severe cognitive impairment (BIMS score of 1), had a care plan identifying her as at risk for falls due to dementia, weakness, and an unsteady gait. A CNA reported finding this resident on her floor mat by the bed on an evening in mid-March and stated she notified the charge nurse, with another CNA corroborating that the nurse came into the room and saw the resident on the floor mat. The CNAs stated their role was to report falls to the charge nurse, who was then responsible for notifying the RP and medical providers. The nurse identified by the CNAs denied that the resident had fallen and stated he did not recall any such report, and therefore did not notify the RP or physician, complete an assessment, or initiate an incident report. Subsequently, another nurse performing a weekly skin assessment noted bruising and pain with movement in the resident’s right upper arm and notified the nurse practitioner, who ordered x-rays. The progress note documented that the RP was notified of the injury and x-ray order, but there were no notes indicating that the RP had been notified of a fall. Radiology results showed an acute right humeral head fracture in osteoporotic bone. The family member stated they were informed only of the bruising and x-ray and were unaware of the earlier fall until informed by the surveyor. The nurse practitioner and physician both reported they had not been notified of a fall at the time it occurred; the nurse practitioner stated she was only notified of the arm injury and ordered imaging, and the physician stated he learned of the fall after the fact. Facility policies on Resident Rights and Fall Management required immediate information to the resident when there is a decision to transfer or discharge, and required that the attending physician and resident representative be notified when a resident sustains a fall, but these procedures were not followed for these two residents.
Failure to Remove PICC at Discharge and Failure to Assess and Report Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one male resident with cellulitis of both lower limbs, muscle weakness, hypertension, atrial fibrillation, chronic heart failure, and chronic kidney disease, the facility did not ensure removal of a peripherally inserted central catheter (PICC) line upon discharge after completion of IV antibiotics. His admission MDS showed a BIMS score of 13, indicating no cognitive impairment. The discharge summary and discharge assessment documented completion of IV antibiotics for cellulitis, no skin issues, and no special instructions, but did not mention the PICC line, and there was no order in the record for PICC removal. The resident’s care plan, which was closed shortly after discharge, reflected that he had been receiving IV antibiotics for cellulitis, but there was no documentation that the PICC was addressed at discharge. The attending MD later stated he was not aware the resident had been discharged with the PICC still in place until after the fact, and that standard of care is to remove PICC lines prior to discharge unless there is a specific reason to keep them. He stated the resident had completed antibiotic therapy and should have had the PICC removed prior to discharge. The DON reported she became aware the resident went home with the PICC still inserted and that she obtained a telephone order from the NP the following morning to remove it, then went to the resident’s home with another nurse to remove the line and assess the site. The family member reported noticing the PICC still in the resident’s arm that evening at home and calling the facility, and the resident himself stated he realized later that day that the PICC remained in his arm and then notified his family. The administrator stated his expectation that PICC lines be removed prior to discharge unless there is an order to keep them and that staff should have obtained an order to remove the line once antibiotics were completed. The nurse who completed the discharge assessment stated she knew the resident had been on IV antibiotics but did not remember or realize he still had a PICC line at the time of discharge. She reported that she did not see a PICC line when she discharged him and did not specifically look for one because he had completed his antibiotics, and she was not aware he went home with the line in place or that staff later went to his home to remove it. She stated that if a resident has a PICC at discharge, staff are supposed to notify the RN on duty because only RNs can remove PICC lines, but she did not notify the RN because she did not know the line was still present. The facility’s PICC line removal procedure, when requested, did not contain instructions or guidance on removal of PICC lines prior to discharge. The deficiency also involves the facility’s failure to assess, document, and report a fall and possible injury for a female resident with acute respiratory failure with hypoxia, type 2 diabetes, cognitive communication deficit, hypertension, and muscle weakness, whose BIMS score of 1 indicated severe cognitive impairment. Her care plan identified her as at risk for falls related to dementia, weakness, a foot ulcer, and unsteady gait/transfers, with a goal to minimize risk of injury. Progress notes from the period surrounding the alleged fall contained no entries documenting a fall or post-fall assessment. Several days later, a nurse performing a body assessment noted bruising on the resident’s right upper arm and pain with movement, documented these findings, and notified the NP and family, leading to x‑rays that showed an acute right humeral head fracture. A CNA reported finding the resident on her floor mat by the bed on an evening shift and hearing a thud just before discovering her on the floor. She stated she notified the charge nurse and that another CNA assisted in bringing the resident to the nurse’s station. Both CNAs reported that the nurse lifted the resident under her arms into a wheelchair and that they did not observe the nurse perform a physical assessment, take vital signs, or check pupils at that time. They stated the resident did not cry out or show facial expressions of pain and that they did not see visible bleeding. One CNA later informed the DON about the fall when she learned of the resident’s injury and discovered the fall had not been reported. The charge nurse involved stated he did not notify the MD, resident representative, or family about a fall because he believed the resident had not fallen and did not recall the CNA reporting a fall. He acknowledged that if a resident fell, the nurse would be responsible for notifying family and providers, completing an assessment, and doing an incident report, but reiterated he was unaware of any fall and therefore did not complete an assessment. The DON stated she learned of the fall from the CNA and that, during her interview with the nurse, he initially denied a fall had occurred and later said the resident had been found on her fall mat but he did not count it as a fall, so he did not report it or make notifications. The NP and MD both stated they were not informed of a fall at the time it allegedly occurred and described expectations that staff assess residents after falls and notify providers so that injuries can be identified and treated. The facility’s Fall Management System policy required that when a resident sustains a fall, a physical assessment be completed by a licensed nurse with results documented in the medical record, and that the attending physician and resident representative be notified of the fall and resident status.
Unlabeled and Undated Food Items in Kitchen Cooler
Penalty
Summary
The facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. During an observation in the walk-in cooler, surveyors found 1 large plastic container of mayonnaise, 1 container of white meat chicken salad with cranberries and pecans, and 1 container of chopped dilled relish that were not labeled or dated. The facility’s staff and leadership stated that all food items opened in the kitchen should be labeled and dated, and that failure to do so could result in residents being served expired food. Interviews with kitchen staff, the ADM, and the DON confirmed that the expectation was for all food items to be labeled and dated when received or opened, using first in first out practices and checking expiration dates on all items. Review of the facility policy stated that perishable foods must be dated, labeled, and disposed of after 72 hours or by package expiration date, and that foods must be in original packaging, sealed, and dated from an approved vendor/store.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility with 121 licensed beds failed to employ a qualified social worker on a full-time basis. Review of the Facility Summary Report from TULIP dated 02/10/2026 showed the facility had a total licensed capacity of 121 beds, and review of the Key Staff Roster provided by the ADM showed no personnel listed next to the job title Social Services Director. The ADM stated in interview that the facility had been without a qualified social worker since the last week of January 2026 and that the prior social worker had been terminated for failing to become a licensed social worker. During interviews, the ADM stated the facility had an assistant social worker, but that person was not licensed and did not meet the educational requirements for a nursing facility social worker. The ASW stated she had worked at the facility for 8 years, served as ASW for 2 years, had previously worked as a CNA, and had a high school diploma with no bachelor's degree. She stated her duties included discharges, grievances, PHQ-9 assessments, and BIMS assessments, and that grievances were taken to the DON and/or ADM for follow-up. The ADM also stated the facility was looking for a qualified social worker through job postings and was conducting interviews, and that social work questions and social services assessments were being handled by staff from sister facilities.
PASARR Level II Evaluation Not Coordinated for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure proper coordination of PASARR assessments for one resident who had a PASARR Level 1 indicating a mental illness diagnosis. The resident’s quarterly MDS reflected diagnoses including aphasia, malnutrition, bipolar disorder, cognitive communication deficit, and senile degeneration of the brain, and her BIMS score was 07, indicating severe cognitive impairment. Her comprehensive care plan identified her as at risk for impaired cognitive function or impaired thought processes related to bipolar disorder and included psychosocial support interventions through social services, pastoral care, and psych services. During interview, the MDSC stated that two PL1s had been entered for the resident, that the first was incorrect, and that the second was not accepted by the system. She stated no one followed up to ensure the correct PL1 was transmitted, and because it was not transmitted, it did not alert the LMHA to conduct the PE. The ADM stated she was aware the corrected PASARR did not transmit through the system and acknowledged that the resident could lose out on additional services she qualified for. The facility’s PASRR manual stated that positive Preadmission PL1s are to be faxed to the LIDDA or LMHA and the LTC online portal is to be monitored daily for alerts.
Expired Medications Found on Nursing Medication Cart
Penalty
Summary
The facility failed to establish a system for accurate reconciliation and removal of expired or discontinued medications from the 500-hall nursing medication cart. During observation, the cart contained a box of lubricant eye drops labeled for Resident #13 with an expiration date of 01/2026, as well as two boxes of wound dressing with antibacterial silver with an expiration date of 07/01/2025. The expired items were found on the cart during survey review of medication storage and pharmacy services. Interviewed staff stated that charge nurses and medication aides were responsible for checking medication carts daily for expired or discontinued medications and removing them. LVN B said she had been trained to verify expiration dates before administering medications and during daily cart checks, and she stated expired wound dressing could reduce effectiveness in treating wounds. The DON, ADON B, and ADM A all stated that staff were expected to check carts for expired medications and remove them, and the DON stated expired medications should be removed from carts to reduce the risk of administering them to residents. Record review showed Resident #13 had diagnoses including acute embolism and thrombosis of the left lower extremity, type 2 diabetes mellitus, and unspecified glaucoma, with severe cognitive impairment on the MDS. Resident #13’s active orders did not include Systane lubricant eye drops.
Unlabeled Insulin Pen on Medication Cart
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles when an insulin pen for Resident #39 on the 300-hall nursing medication cart was found without an open date. The pen was observed during a medication cart review, and the deficiency involved 1 of 4 medication carts reviewed for medication storage. Resident #39 was a 79-year-old male with diagnoses including type 2 diabetes mellitus, alcoholic fatty liver, and cognitive communication deficit. His quarterly MDS assessment showed a BIMS score of 13, indicating intact cognition. His care plan documented diabetes management with medication administered as ordered, and his active order included insulin lispro sliding scale coverage before meals and at bedtime for hyperglycemia. During interviews, LVN A stated that insulin must be dated when opened and discarded after 28 days, and that unopened insulin was kept refrigerated until needed. ADON B and the DON stated that insulin should be labeled with the open date immediately when placed on the nursing med cart and that expired medication could provide less therapeutic benefit. The facility policy on preparation for medication administration required the date opened and initials on multidose injectable medications, and the in-service training report showed staff education on removing expired medications and dating insulin for 28 days.
Incomplete Documentation of Medication and Treatment Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards and practices. Specifically, there were multiple instances where medication administration and treatments were not documented in the electronic medical record (PCC) for a resident with significant medical needs, including diabetes, muscle weakness, hypertension, and congestive heart failure. The resident's care plan included interventions for diabetes management, pain control, and suprapubic catheter care, all of which required consistent documentation to ensure continuity of care. Record reviews revealed that several medications and treatments, such as insulin administration, lidocaine patch application, air mattress checks, barrier cream application, and suprapubic catheter care, were not signed off as completed on the Medication Administration Record (MAR) on specific dates. Interviews with the involved staff confirmed that these medications and treatments were administered, but the staff failed to document them at the time of administration. The staff cited being occupied with other duties as the reason for the lack of timely documentation. The facility's policy on documentation and charting emphasizes the importance of maintaining a complete account of resident care, including medications and treatments, to guide physicians, measure quality of care, and serve as a legal record. Both the Director of Nursing (DON) and the Administrator acknowledged that failure to sign off on the MAR indicates that the medication or treatment may not have been given, which could have implications for the resident's care. The resident interviewed did not report any missed medications or treatments and expressed satisfaction with the care received.
Improper Execution of DPOA and Conflict of Interest in Resident Rights
Penalty
Summary
The facility failed to ensure a resident's rights to self-determination and a dignified existence by improperly executing a Statutory Durable Power of Attorney (DPOA). The DPOA was completed with facility staff members named as agents and witnesses, which created a conflict of interest and a dual relationship between the resident and staff. The DPOA was implemented during a period when the resident's capacity to consent was in question, as evidenced by medical documentation indicating severe cognitive impairment and a medical opinion recommending guardianship due to incapacity. Despite this, staff proceeded with the DPOA process without prior legal consultation and without securing an appropriate external agent or guardian. The resident involved had a complex medical history, including a recent femur fracture, type 2 diabetes with a foot ulcer, cerebral infarction, and a cognitive communication deficit. The resident was admitted from an acute care hospital and was listed as his own financial responsible party, with a niece and other contacts declining to serve as POA due to personal or religious reasons. The resident's cognitive status was noted to fluctuate, and assessments showed severe cognitive impairment. Despite these factors, facility staff members were named as agents in the DPOA, and the document was witnessed and notarized by another staff member, further compounding the conflict of interest. Interviews with facility staff revealed that the DPOA was not reviewed by the legal department until after its execution, and the hospital social worker raised concerns about its legality. The facility's legal counsel later advised that guardianship should have been sought instead of staff serving as agents. Documentation also showed that no formal guardianship application had been filed, and the staff members named in the DPOA continued to be listed as legal agents. The facility's own policies emphasized residents' rights to self-determination and participation in care decisions, but these were not upheld in this case due to the improper handling of the DPOA and failure to secure an appropriate decision-maker for the resident.
Failure to Update Care Plan After Resolution of Yeast Infection
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, specifically neglecting to update the care plan to reflect the resolution of a yeast infection. The resident, an elderly female with diagnoses including essential primary hypertension, unspecified dementia, and depression, had a severe cognitive impairment as indicated by a BIMS score of 1. Her care plan continued to list an active yeast infection even after the prescribed course of Terconazole vaginal suppositories was completed, and treatment had ended. Interviews with facility staff, including the ADON, DON, and ADM, confirmed that the care plan was not updated to indicate the yeast infection had resolved. The ADON acknowledged responsibility for updating the care plan and admitted to missing this update. The DON and ADM both stated it was expected for the care plan to be updated to reflect the resident's current condition. Facility policy requires the interdisciplinary team to develop and maintain comprehensive care plans with measurable objectives and timeframes, but this was not followed in this instance.
Failure to Arrange Follow-Up Wound Care Appointment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically by not arranging a follow-up appointment with a wound care specialist. The resident, who had a history of muscle weakness, reduced mobility, and Parkinson's disease, suffered a skin tear during a transfer from a wheelchair to a bed. This incident occurred because only one staff member was present, despite the resident requiring assistance from two people for transfers. The resident was subsequently hospitalized, received a blood transfusion, and was discharged with instructions to follow up with a wound care specialist. Upon discharge, the resident was supposed to have a follow-up appointment with a wound care doctor, but the facility failed to arrange this appointment. The resident's discharge papers clearly indicated the need for a follow-up on a specific date, but the facility did not read the discharge papers thoroughly and did not schedule the appointment. As a result, the resident missed the appointment, which led to the development of an infection in the wound. The resident expressed anxiety and concern over the missed appointment and the condition of her leg, which was exacerbated by the delay in receiving appropriate wound care. Interviews with facility staff revealed that there was a breakdown in communication and procedure regarding the scheduling of follow-up appointments. The nursing staff were responsible for reviewing discharge documentation and coordinating with the transporter to schedule appointments, but this process was not followed correctly. The facility's Director of Nursing acknowledged the importance of follow-up appointments for continuity of care but could not confirm if the missed appointment directly caused the infection. The deficiency highlights a failure in the facility's processes to ensure residents receive timely and necessary medical follow-up care.
Inadequate Supervision During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for Resident #162 during a transfer from a wheelchair to a bed, resulting in a significant injury. The incident occurred when a CNA attempted to transfer the resident alone, despite the resident's care plan indicating the need for two-person assistance. During the transfer, the resident's leg was caught on the bed, leading to a severe laceration that required hospitalization, a blood transfusion, and stitches. Resident #162, a woman with Parkinson's disease and other mobility issues, was admitted to the facility with a care plan that required substantial assistance for transfers. On the day of the incident, the CNA attempted to transfer the resident without the necessary support, leading to the resident's leg being injured on the bed's mobility bar. The resident was on anticoagulant therapy, which exacerbated the bleeding from the wound. The facility's failure to follow the care plan and provide adequate supervision during the transfer placed the resident at risk of physical harm. Additionally, the facility did not ensure the resident attended a follow-up appointment with a wound care doctor, as indicated in the hospital discharge papers. This oversight further contributed to the resident's risk of complications from the injury.
Failure to Report Neglect After Resident Injury
Penalty
Summary
The facility failed to report an incident of neglect involving a resident who required assistance with transfers due to multiple medical conditions, including Parkinson's disease and reduced mobility. On the day of the incident, a CNA attempted to transfer the resident from a wheelchair to a bed without the required assistance of a second staff member. During the transfer, the resident's leg was injured, resulting in a significant laceration that required hospitalization and a blood transfusion. The facility did not report this incident to the state agency within the required two-hour timeframe. The resident, who had a BIMS score indicating no cognitive impairment, reported that the CNA did not use a gait belt initially and did not heed her warnings about her leg being caught during the transfer. The resident's medical records indicated she was on anticoagulant therapy, which contributed to the severity of the bleeding from the laceration. Despite the resident's ability to articulate the events, the facility did not consider the incident as neglect or mistreatment, and thus did not report it as required by their policy. Interviews with staff and observations of the equipment involved in the transfer revealed discrepancies in the accounts of how the injury occurred. The maintenance director and other staff inspected the mobility bar and found no sharp edges that could have caused the injury, yet the CNA suggested the injury might have been caused by the bed frame. The facility's policy required immediate reporting of such incidents, but this was not adhered to, placing residents at risk of continued neglect.
Resident Unable to Access Call Light Paddle
Penalty
Summary
The facility failed to ensure that Resident #23's call light paddle was placed within reach, which compromised the resident's ability to call for assistance. Resident #23, diagnosed with Parkinson's Disease and moderate cognitive impairment, had limited mobility and was dependent on staff for most activities of daily living. Despite the resident's physical limitations, the call light paddle was consistently placed out of reach, rendering the resident unable to summon help when needed. Observations on multiple occasions revealed that the call light paddle was positioned near the top outer edge of the resident's right shoulder, a location inaccessible due to the resident's limited range of motion in both arms. Interviews with the resident confirmed feelings of helplessness and reliance on staff to check on him, as he was unable to activate the call light paddle independently. The facility's policy required that call lights be within reach, yet this was not adhered to, as evidenced by the resident's inability to access the call light paddle. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), highlighted the importance of ensuring call lights are accessible to residents, especially those with physical limitations. Despite this understanding, the facility's safeguards, such as regular room rounds and spot checks, failed to ensure the call light paddle was within reach for Resident #23. This oversight placed the resident at risk of unmet medical needs and psychosocial harm, as he was unable to call for assistance when necessary.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. Resident #18's MDS inaccurately reflected her speech clarity as clear, despite observations and interviews indicating she could only make unarticulated sounds and relied on gestures for communication. Her care plan acknowledged her communication challenges due to aphasia, yet the MDS did not align with her actual condition as observed by the surveyor and reported by staff. Similarly, Resident #58's MDS inaccurately documented her speech clarity as clear, while observations showed she was unable to respond verbally or with gestures. Her care plan noted her risk for communication problems due to aphasia and other conditions, but the MDS did not accurately reflect her severe communication impairments. Interviews with staff confirmed her inability to speak due to her medical conditions, and her recent SLUMS assessment indicated severe cognitive impairment. These inaccuracies in the MDS assessments for both residents placed them at risk of receiving incorrect care and services, as the assessments did not accurately reflect their communication abilities and needs. The facility's policy requires comprehensive and accurate assessments, yet the discrepancies in the MDS documentation for these residents highlight a failure to adhere to these standards.
Deficiencies in Care Planning for Resident Transfers and Precautions
Penalty
Summary
The facility failed to implement a comprehensive care plan for two residents, which could potentially compromise their care and safety. For one resident, the care plan did not specify the use of a mechanical lift for transfers, despite the resident's need for substantial maximal assistance due to conditions such as spastic hemiplegia and muscle weakness. Observations and interviews revealed that staff were unclear about the resident's transfer status, and the care plan lacked specific instructions on the level of assistance required. This lack of clarity could lead to unsafe transfers, as noted by staff members who expressed concerns about the potential for injury or falls. Another resident's care plan failed to include Enhanced Barrier Precautions (EBP) as ordered, despite the resident's medical conditions that warranted such precautions, including an indwelling catheter and a skin condition. The order for EBP was active, yet the care plan did not reflect this requirement, which was crucial for preventing infection and ensuring the resident's safety. Interviews with staff, including the DON, indicated that while there were informal methods to communicate EBP needs, such as stickers on resident names, the care plan itself did not provide the necessary guidance. The facility's policies on care planning and mechanical lift usage were not adequately followed, leading to these deficiencies. The interdisciplinary team was responsible for updating care plans to reflect residents' needs, but this was not done effectively. The lack of specific instructions in the care plans for both residents could result in inadequate care and increased risk of harm, as staff relied on incomplete or informal communication methods rather than comprehensive, documented care plans.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was adequately monitored and free from unnecessary drugs. Specifically, the facility did not monitor a resident for side effects or adverse reactions related to the use of Apixaban, an anticoagulant medication. The resident, a female with diagnoses including muscle weakness, hyperlipidemia, abnormalities of gait, and hypertension, was receiving Apixaban twice daily. However, there was no order for side effect monitoring of the medication, and the Medication Administration Record for November showed no monitoring for side effects was in place. Interviews with facility staff revealed a lack of awareness and adherence to the policy regarding monitoring for side effects of blood thinners. The Administrator admitted to not being familiar with the general risks associated with not monitoring blood thinner side effects, while the Director of Nursing stated that floor nurses should include side effect monitoring when receiving an order for a blood thinner. The facility's policy on Pharmacy Services, revised in January 2022, indicated that medication ordered without adequate monitoring is considered an unnecessary drug.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food was served at an appetizing temperature for a resident, leading to dissatisfaction and additional expenses for the resident. The resident, a female with multiple medical conditions including neuromyelitis optica, paraplegia, and legal blindness, reported that meals served in her room were often cold or lukewarm. Despite her requests for reheating, staff were reluctant or refused to accommodate her preferences, citing federal and state regulations as the reason. The resident noted that scrambled eggs and toast were frequently served at undesirable temperatures, impacting her ability to enjoy the meals. Interviews with the resident revealed that the issue persisted throughout her stay, although there was some improvement during the state surveyors' visit. The resident had to spend a significant amount of money on outside food due to the unsatisfactory quality and temperature of the facility's meals. An interview with an LVN indicated that the facility's procedure was to provide a new tray rather than reheating food, and that any reheating was to be done by kitchen staff during kitchen hours. The facility's policy required food to be served at a temperature above 135°F, but this standard was not consistently met for the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident #52, a CNA did not adhere to proper hand hygiene protocols while performing perineal care. The CNA failed to wash her hands or use an alcohol-based hand sanitizer between changing gloves from handling a soiled brief to applying a clean one. This lapse in protocol was acknowledged by the CNA, who admitted forgetting to wash her hands, and by the facility's administration, who confirmed the expectation for staff to follow infection control policies to prevent the spread of bacteria and potential infections. For Resident #82, the facility did not ensure that Enhanced Barrier Precautions (EBP) were properly communicated and implemented. There was no signage or indication outside the resident's room to alert staff and visitors of the need for EBP, nor was PPE readily accessible. The resident's room was observed to have a foul odor and multiple soiled towels, which the resident used to manage fluid leakage from his legs. The resident expressed a preference for managing his towels due to concerns about availability, which was not addressed in his care plan. The facility's Director of Nursing (DON) stated that EBP should be communicated through rounds and spot checks, but there was no consistent system in place to ensure PPE availability or proper signage. The facility's policies on infection prevention and control, including hand hygiene and transmission-based precautions, were not effectively implemented. The lack of proper environmental cleaning and disinfection in Resident #82's room, combined with the absence of clear communication and availability of PPE, posed a risk of cross-contamination and infection. The facility's failure to adhere to its own policies and procedures contributed to the deficiencies observed during the survey.
Failure to Maintain Dignified Environment Due to Laundry Neglect
Penalty
Summary
The facility failed to maintain a dignified environment for two residents by not ensuring their soiled personal clothing was taken to the laundry. Resident #2, a male with Alzheimer's Disease and Chronic Respiratory Failure, reported that his laundry had not been taken for eight days despite requesting assistance from nursing staff. His room had a strong odor of urine and body odors, with an overflowing laundry basket identified as the source. The resident expressed feelings of anger and neglect due to the situation. Similarly, Resident #3, a male with heart failure, experienced a similar issue with his laundry not being taken to the laundry room. He reported that he had asked staff to take his clothes but was told it was not their responsibility. The resident expressed feelings of sadness, loneliness, and neglect, and refrained from having his grandchildren visit due to the odor in his room. Observations confirmed the presence of strong odors and a full laundry basket in his room. Interviews with various staff members, including CNAs, LVNs, and the Director of Nursing, revealed confusion and miscommunication regarding the responsibility for laundry collection. While the facility's policies indicated that CNAs were responsible for collecting and transporting dirty laundry, some staff members were unaware of this duty. The facility's administration expected CNAs to follow the schedule and ensure a homelike environment, but the issue of dirty laundry buildup was not previously observed by the administration.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents, as observed during a survey. Resident #2, a male with Alzheimer's Disease and Chronic Respiratory Failure, reported that his soiled personal clothing had not been taken to the laundry for eight days, despite requesting assistance from nursing staff. The resident's room had a strong odor of urine and body odors, with a laundry basket overflowing with dirty clothing, which was identified as the source of the odor. The resident expressed feelings of anger and neglect due to the situation. Similarly, Resident #3, a male diagnosed with Heart Failure and in need of personal care, experienced a similar issue with his laundry not being taken to the laundry room. The resident's room also had strong odors of urine and body odors, with a basket of dirty clothes filled to the top. The resident expressed feelings of sadness, loneliness, and neglect, and mentioned that he avoided having his grandchildren visit due to the unpleasant smell in his room. Interviews with various staff members, including CNAs, LVNs, and the Director of Nursing, revealed a lack of clarity and communication regarding the responsibility for collecting and transporting residents' dirty laundry to the laundry room. While the facility's policies indicated that CNAs were responsible for this task, there was confusion among staff, with some believing it was the responsibility of laundry personnel. This lack of adherence to established procedures contributed to the deficiency in maintaining a clean and homelike environment for the residents.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medication to a resident, leading to a medication error. The resident, a woman diagnosed with restless leg syndrome, anxiety disorders, and COPD, was prescribed Requip, ropinirole HCI, 3 MG at bedtime. However, on one occasion, the resident was mistakenly administered three tablets of Requip, totaling 9 MG, instead of the prescribed single 3 MG tablet. This error was identified through a medication error report and confirmed by the CMA who administered the medication, acknowledging the mistake of misreading the order. Following the administration of the incorrect dosage, the resident experienced symptoms such as dizziness, weakness, and difficulty speaking, which led her to seek assistance from the nursing staff. Vital signs were monitored, and an ECG/EKG was performed, revealing a prolonged QT interval, although no immediate harm was noted. The resident expressed feeling scared and angry about the situation, and it took her several days to feel normal again. Despite the resident's reported symptoms, the facility's medical director and nursing staff did not observe any significant adverse reactions or changes in vital signs. Interviews with facility staff revealed that the medication error was attributed to the CMA misreading the order, and the CMA was subsequently educated on the error. The facility's policy required medication errors to be reported and addressed, but the administration did not consider this incident a significant medication error. The facility had procedures in place for medication administration, including multiple checks to prevent errors, but these were not effectively followed in this instance.
Failure to Monitor Resident During Meal Service
Penalty
Summary
The facility failed to assist and monitor a resident during meal service despite a hospice order stating that she should be assisted with meals and not left alone with food. The resident, who had Alzheimer's disease, heart failure, dysphasia, and required a mechanically altered diet, choked on her meal and was subsequently sent to the ER where she was diagnosed with aspiration pneumonia and remained hospitalized for several days. This incident occurred despite previous warnings and meetings with the family and hospice staff about the resident's need for assistance and the risk of choking. The resident's care plan and hospice orders clearly indicated that she required supervision while eating and should not be left alone with food. However, on multiple occasions, the resident was observed eating alone, and her meal trays included items that were not suitable for her condition, such as bread. The family had repeatedly expressed their concerns to the facility's staff, including the DON and ADM, but these concerns were not adequately addressed, leading to the resident's hospitalization. Interviews with the family and staff, as well as a review of the resident's medical records, revealed that the facility did not follow the prescribed care plan and hospice orders. The DON admitted to not being aware of the specific orders for assistance with meals, and there were lapses in communication and verification of meal trays. This failure to provide adequate supervision and follow dietary restrictions placed the resident at significant risk and resulted in a serious health incident.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan for a resident who required supervision or touching assistance while eating was incomplete. This deficiency was identified during a review of the resident's records and interviews with staff members, revealing inconsistencies in the documentation and understanding of the resident's needs for assistance during meals. The resident, a [AGE] year-old male with diagnoses including hypertensive emergency, muscle weakness, hyperlipidemia, and hypothyroidism, was assessed to require supervision or touching assistance while eating. However, the care plan did not reflect this need accurately. Staff members provided conflicting information about the resident's need for assistance, with some stating that the resident did not require supervision while others acknowledged the need for assistance. Observations confirmed that the resident was left to eat without the necessary assistance, struggling to cut food and expressing a need for help. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the resident was on a high-risk list for nutrition and hydration and required staff assistance during meals. Despite this, the care plan and care profile were not updated to reflect the resident's needs accurately. The DON and ADON acknowledged the importance of updating care plans to ensure staff are aware of and can meet residents' needs, but this was not done in this case, leading to the identified deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 365 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waxahachie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care Of Waxahachie | 2.8 mi | ★★★★★ | 11 | 1 |
| Pleasant Manor Healthcare Rehabilitation | 5.8 mi | ★★★★★ | 13 | 0 |
| Red Oak Health And Rehabilitation Center | 7.1 mi | ★★★★★ | 2 | 0 |
| Midtowne Meadows Health & Rehab | 9 mi | ★★★★★ | 1 | 0 |
| Midlothian Healthcare Center | 9.2 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.