Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lily Springs Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease, MDD, and anxiety had a history of banging on the wall and was noted to be highly agitated and closed-fist banging during a shift, yet her care plan did not address the behavior or include interventions. Nursing notes and an investigative report also documented bruising and an injury of unknown origin, with the facility noting the wall-banging may have contributed to the forearm bruising. Staff interviews confirmed the behavior should have been care planned so caregivers would understand the resident's communication and safety needs.
Two residents with cognitive and mental health diagnoses were spoken to in a sharp, condescending manner by an LVN during a supervised smoking break when one resident attempted to share a cigarette and later tried to keep an unfinished cigarette. The LVN loudly prohibited sharing and taking the cigarette, causing visible anger and upset in both residents. In interviews, one resident reported feeling treated like a child and being used to that manner of speech at the facility, while the other stated the LVN always spoke to them that way and believed race was a factor. The LVN cited a rule against sharing cigarettes for infection control but could not recall receiving training on dignity, and facility in-service records showed no recent, specific training on treating residents with dignity and respect despite a policy affirming residents’ rights to dignity and personal choice.
A resident with Alzheimer's disease, COPD, and muscle weakness was left in bed with their call light pad placed out of reach for nearly two hours after care was provided. The resident was unable to call for assistance, and staff interviews confirmed awareness of the requirement to keep call lights accessible. Facility policy also mandated that residents have a means to call for help, but this was not followed in this instance.
A resident with severe cognitive impairment and multiple mental health diagnoses did not receive scheduled showers as documented in her care plan and EMR. Staff interviews and record reviews confirmed missed showers on several dates, despite facility policy requiring assistance with personal hygiene for dependent residents.
A resident with hemiplegia, muscle weakness, and a history of trauma and anger issues was not permitted to have a powered wheelchair, despite reporting difficulty using a manual wheelchair due to shoulder pain. Facility staff cited concerns about the resident's aggressive behaviors and potential safety risks, referencing past incidents of aggression and the need for further evaluation. The resident felt she was being unfairly denied the powered wheelchair, and the facility did not uphold her right to retain and use personal possessions.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation of the resident's care needs.
A resident with multiple medical conditions, including morbid obesity and legal blindness, was injured after falling from a bariatric shower chair during transport following a shower. The chair tipped when a CNA pushed it forward after the wheels became crooked, and the resident was not fully settled in the chair. The incident resulted in a right femur fracture and increased anxiety for the resident during shower times.
The facility did not provide sufficient activities to meet residents' interests and support their well-being, especially in the secured unit and on weekends. Observations and interviews showed that residents were often left without structured engagement, with staff unable to consistently provide activities due to interruptions and staffing limitations. The activities offered were limited, and residents and staff reported boredom and lack of stimulation, contrary to the facility's policy for individualized and comprehensive activity programming.
A secured memory care unit housing 14 residents with severe cognitive impairments was inadequately staffed, with only one or two staff members present at times. This resulted in residents being left unsupervised, leading to frequent incidents such as wandering, falls, aggression, and lack of engagement. Staff consistently reported that the staffing levels were insufficient to meet the residents' needs, and incident logs confirmed a high rate of accidents and behavioral issues in the unit.
Staff failed to follow Enhanced Barrier Precautions and hand hygiene protocols during high-contact care activities for two residents, including not donning gowns and not performing proper hand hygiene when changing gloves during peri-care and wound care, despite posted signage and prior training.
A resident with severe cognitive impairment and contracted hands was not provided with an accessible call light device, despite care plan requirements and staff awareness of the need for accommodations. Observations showed the call light was out of reach and no adaptive device was in place, and staff and leadership interviews confirmed the deficiency and its impact on the resident's ability to request assistance.
A resident with multiple health conditions sustained a right femur fracture after falling from a malfunctioning shower chair during transport. The facility did not report the incident to the State Agency as required by policy, and staff interviews revealed confusion about reporting requirements. The event was handled internally and not reported within the mandated timeframe, despite the injury's severity.
A resident with impaired vision and mobility needs sustained a femur fracture after falling from a shower chair, but the facility did not report the incident to the State Agency as required. Staff documented the event internally and notified the family and physician, but did not recognize the need for external reporting, despite facility policy mandating immediate notification for serious injuries.
A resident with severe cognitive impairment and multiple diagnoses had their Ativan discontinued by physician order, but the responsible party was not notified as required by facility policy. Staff interviews confirmed the expectation to notify the responsible party of significant treatment changes, but this did not occur, and documentation of notification was absent.
A facility failed to update a resident's care plan to reflect a change in their Advanced Directive from DNR to full code, resulting in the resident not receiving CPR when they expired. The resident, who had intact cognition and communicated his wishes, was not provided with the care he desired due to a lack of responsibility and communication among staff. This deficiency was identified as an Immediate Jeopardy situation.
A resident with heart failure, diabetes, and hypertension requested a change from DNR to Full Code, but the facility failed to update his records. During a medical emergency, staff followed the outdated DNR status, and CPR was not administered, leading to the resident's death.
A Med Tech administered medications to four residents with an expired license, which was not tracked by the facility. Despite no medication errors occurring, the lapse in licensure compliance could have risked inadequate care. The facility's policy for license verification and tracking was not effectively implemented.
A resident's Advanced Directive was not followed, resulting in the resident not receiving CPR and expiring. The incident was not reported to the State Survey Agency as required. The resident had heart failure, diabetes, and hypertension, and was cognitively intact. The Administrator failed to report the incident, which was against facility policy and state law.
A resident was not administered hospital-ordered antibiotics upon admission to the facility, resulting in a delay of several days before receiving Levofloxacin and Metronidazole. The admitting nurse did not enter the orders, and the error was discovered later by another nurse. The facility's policy on medication reconciliation was not followed, leading to this deficiency.
The facility failed to document flu vaccinations for two residents, resulting in them receiving double doses. The oversight occurred because the flu shots given during a clinic were documented on paper but not uploaded to the electronic system. Interviews with staff and residents confirmed the lack of documentation and the subsequent double administration of the vaccines.
The facility failed to implement an admissions policy requiring inventory sheets for residents' personal belongings, affecting three residents. One resident reported missing items, which were reimbursed, while another alleged missing belongings but was noted to be confused. Staff acknowledged the importance of inventory sheets, but the practice was not followed.
The facility failed to keep the medication room locked and supervised, allowing unauthorized access. Observations showed the room was left unlocked, and interviews with staff confirmed that it should be locked at all times. This breach of policy could lead to medications being accessed by residents, posing a risk to their health.
A resident with Alzheimer's, polyarthritis, and dementia did not have a comprehensive care plan developed within the required timeframe due to the vacancy of the MDS Nurse position. The facility's staff, including the DON and ADM, acknowledged the absence of a comprehensive care plan, which left staff without guidance on providing necessary care.
A medication cart was found unsupervised and unlocked in a hallway, containing various medications and supplies. The responsible MA was not present, and the cart was in a busy area with staff and residents. Interviews with staff, including the MA, LVN, DON, and ADM, confirmed that the cart should have been locked when unattended to prevent unauthorized access and potential resident harm.
A resident with Alzheimer's, polyarthritis, and dementia did not have a comprehensive care plan developed within the required timeframe after admission. The MDS Nurse responsible for care plans had vacated the position, leading to a lapse in care planning. Interviews with staff revealed that without the care plan, there was no guidance for providing necessary care, including ADLs. The facility's policy required a baseline care plan until a comprehensive one was developed, but this was not followed.
A facility failed to implement a comprehensive care plan for a resident, addressing only the risk of wandering while neglecting other significant health concerns such as depression, cognitive impairment, and fall risk. The MDS Nurse did not complete or update the care plan due to unfamiliarity with the documentation system and unclear responsibilities, while the DON did not ensure proper oversight. This deficiency placed the resident at risk of unmet needs.
A resident with dementia exhibited signs of fear and pain during a mechanical lift transfer and incontinent care when two CNAs failed to identify themselves or explain the procedure. The CNAs engaged in personal conversation instead of communicating with the resident, who was unable to verbally communicate but understood when spoken to. The facility's DON had previously emphasized the importance of professional communication with residents.
The facility failed to provide scheduled showers to three residents, leading to a decline in hygiene and feelings of neglect. A cognitively intact male with mobility issues received only one shower in a month, while a female with moderate cognitive impairment and physical disabilities received four showers. Another male with physical disabilities received three showers. Staff interviews revealed a lack of communication and accountability for missed showers.
A resident with limited range of motion did not receive appropriate care as the facility failed to apply a prescribed hand contracture cushion. The resident, with dementia and osteoarthritis, was observed without the cushion, which was meant to prevent further contraction and skin issues. Nursing staff admitted to forgetting to replace the cushion after wound care, and the facility's policy did not emphasize the importance of following physician orders.
A resident in a LTC facility experienced a violation of privacy and consent when placed in a room with electronic monitoring equipment that included audio capabilities, without her consent. The resident's personal property was also searched without permission. Facility staff acknowledged the lack of proper documentation and consent procedures, failing to adhere to policies on resident rights and personal property.
The facility failed to securely store medications, with drugs left unattended on medication and linen carts, and at residents' bedsides. Observations revealed unsecured medications on the 500 and 100 hall carts, and a medication cup with creams on a linen cart. Two residents with impaired cognition had medications improperly stored at their bedsides, contrary to facility policy. Staff interviews confirmed the lapses in following storage protocols, highlighting deficiencies in medication security and adherence to policies.
A resident with multiple health issues, including legal blindness and congestive heart failure, did not receive adequate bathing services as required by the facility's policy. Despite the resident's need for assistance with activities of daily living, the care plan did not address showering, and the resident reported only having three showers since admission. Interviews with the ADON and DON confirmed that wiping a resident's back and legs does not meet the facility's definition of a bath or shower.
The facility failed to ensure a safe environment by allowing unauthorized items on linen carts in two hallways, posing potential risks to residents. Observations revealed items like razors and creams on carts, which should only contain linens, briefs, and gloves. Staff interviews confirmed the oversight and lack of a specific Linen Cart policy contributed to the issue.
Failure to Care Plan Resident Wall-Banging Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a 90-year-old female resident with diagnoses including Alzheimer's Disease, major depressive disorder, and anxiety disorder. The deficiency involved the resident's behavior of banging on the wall of her room, which occurred on 05/05/2026 and on two other occasions, with the dates unknown. Review of the resident's care plan showed no focus or interventions addressing this behavior. Record review showed the resident's MDS dated 05/06/2026 indicated severe cognitive issues with a score of 5. Nursing notes dated 05/06/2026 documented that the resident was highly agitated during the shift and was closed-fist banging on the wall while continuing to not want staff in the room. A facility investigative report dated 05/12/2026 for injury of unknown origin noted bruising across the right eyebrow and bruising on the right forearm, with scabs over the centers of the bruises, and the resident was unable to describe what happened. The investigative summary reflected that banging her fist against the wall may have contributed to the bruising on the forearm. During interviews, an LVN stated the resident had a significant history of banging on the walls and had three known incidents, and said the behavior should have been care planned because it was the resident's form of communication. The CCS and ADON also stated the behavior should have been care planned so staff would be aware of it and understand how to care for the resident. Facility policy stated care plans are used to develop daily care routines, are available to staff responsible for care, and changes in condition must be reported so the assessment and care plan can be reviewed.
Failure to Maintain Resident Dignity During Supervised Smoking Break
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity during a supervised smoking break. A male resident with hypertension, schizophrenia, a history of traumatic brain injury, and mildly impaired cognition (BIMS 12) and a female resident with anxiety disorder, vascular dementia, depression, and severely impaired cognition (BIMS 6) were observed at a smoke break along with other residents. The LVN supervising the smoke break controlled the cigarettes and lighter. When the LVN reached the male resident, she told him she did not have cigarettes for him because staff had not been to the store; he became visibly upset, with a pursed brow, frown, and looking away, but did not speak. Shortly afterward, the female resident attempted to share her cigarette with him. In response, the LVN spoke in a sharp and condescending tone, loudly saying, “No! No! Yall can't be sharing. nuh-uh, no ma'am!” audible to all residents and the surveyor. When the female resident questioned when the rule had changed, the LVN replied, “It's just policy you cannot share. It's been a thing for a while,” and confirmed “Uh huh 100%” when the resident asked if she was serious. The male resident then made an angry facial expression and left the smoking area. The LVN further told the female resident, “No, ma'am, you cannot take that with you,” when she tried to pocket her unfinished cigarette, and held an ashtray out in front of her, after which the resident angrily threw the cigarette butt into the ashtray and left the area. In interviews, the male resident stated he was angry about what happened, felt he had been spoken to as a child, and that it made him feel “shitty,” adding that he was used to being spoken to that way at the facility. The female resident stated the LVN always spoke to them like that, had not reported it as a grievance because she thought it would make things worse, and believed the LVN did not like Black people and that this was why she spoke to them in that manner. She also stated she understood sharing a cigarette could be an infection control problem but had not known it was against the rules. The LVN reported she had been told residents could not share cigarettes due to infection control but could not recall who told her or any training on dignity or enforcing rules while maintaining dignity. Review of in-service records from October 2025 through January 2026 showed no specific in-service on treating residents with dignity and respect, and the facility’s policy on Rights of the Elderly stated residents have the right to be treated with dignity and respect for personal integrity without regard to race or other characteristics and to make their own choices regarding personal affairs, care, benefits, and services.
Call Light Not Kept Within Reach for Resident with Cognitive and Physical Impairments
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, chronic obstructive pulmonary disease, lack of coordination, and muscle weakness was found to have their call light pad placed out of reach while lying in bed. The resident, who had moderate cognitive impairment and required varying levels of assistance with activities of daily living, stated that the CNA must have moved the call pad during care and did not return it to an accessible position. Observations confirmed that the call light remained out of reach for nearly two hours, during which time the resident was unable to call for assistance if needed. Interviews with staff, including a CNA, the ADON, and the ADM, revealed that all were aware of the policy requiring call lights to be within reach and acknowledged it was everyone's responsibility to ensure this. The facility's policy also specified that each resident must have a means to call staff for assistance from their bed, and alternative communication methods should be provided and documented if a resident is unable to use the standard system. Despite these policies and staff awareness, the call light was not returned to the resident's reach, resulting in a failure to provide reasonable accommodation for the resident's needs.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide care and services to assist a resident with activities of daily living, specifically in maintaining personal hygiene through scheduled showers. Record review showed that a female resident with severe cognitive impairment, dementia, generalized anxiety disorder, and major depressive disorder was dependent on staff for bathing and other ADLs. Despite a care plan and EMR documentation specifying a shower schedule, there was no evidence that the resident received showers or baths on several scheduled dates. The resident herself reported not having received a bath in a while, though she could not recall specific dates. Interviews with staff, including a CNA, the ADON, and the administrator, confirmed that the resident did not receive her scheduled showers on the identified dates. Staff acknowledged that missing scheduled baths or showers could result in odor or skin issues, and the facility's policy required staff to assist residents with personal hygiene to prevent such problems. The failure to follow the resident's care plan and shower schedule constituted a deficiency in providing necessary care and services for activities of daily living.
Failure to Allow Resident Use of Powered Wheelchair Due to Behavioral Concerns
Penalty
Summary
The facility failed to maintain a resident's right to retain and use personal possessions by not allowing a resident to have a powered wheelchair. The resident, a female with a history of hemiplegia, muscle weakness, difficulty walking, and other medical conditions, was admitted with intact cognition as evidenced by a BIMS score of 15. Her care plan included interventions for trauma, anger issues, and emotional regulation, and she was receiving therapy and medication management. Despite her expressed need for a powered wheelchair due to shoulder pain and difficulty self-propelling a manual wheelchair, the facility staff repeatedly told her she could not have one. Interviews with facility staff, including the DON, ADON, PsyD, and OTA, revealed concerns about the resident's history of aggression and the potential for her to use a powered wheelchair in a manner that could endanger herself or others. Staff cited incidents where the resident had been aggressive, including bumping into others with her manual wheelchair and being placed on 1:1 supervision for lashing out. The PsyD and OTA expressed concerns about her ability to safely operate a powered wheelchair, referencing her behavioral history and the need for further evaluation by therapy and the IDT before making a decision. The resident reported feeling that she was being denied the powered wheelchair due to perceived prejudice from therapy staff and her history of aggressive behavior. She described an incident where she fell while using a manual wheelchair, resulting in injury and involvement of EMS and law enforcement. The facility's policy on resident rights, which includes the right to a dignified existence and to retain personal possessions, was not upheld in this instance, as the resident was not allowed to have the powered wheelchair she requested.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Provide Safe Supervision and Equipment During Resident Transport Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and safe assistance devices to prevent accidents for a resident with significant medical needs. The resident, a male with a history of morbid obesity, legal blindness, chronic obstructive pulmonary disease, osteoarthritis, and previous right femur and tibia fractures, required extensive assistance for mobility and transfers. Despite these needs, the resident was transported in a bariatric shower chair after a shower, during which the chair tipped and the resident fell, resulting in a right femur fracture. The incident report and interviews revealed that the resident was still wet from the shower, the wheels of the chair became crooked, and the chair was pushed forward at an angle, causing the resident to fall and sustain injury. Interviews with staff indicated that the shower chair was believed to be appropriate for the resident's weight, and maintenance records showed the chair had been inspected and was within its weight limit. However, the incident occurred when the resident adjusted himself in the chair and indicated he was ready to be transported, but was not fully settled. The CNA transporting the resident did not stop to ensure the resident was properly positioned before moving, and when the chair's wheel got stuck while rounding a corner, the CNA pushed the chair forward, leading to the tip and fall. The resident reported immediate pain and gross deformity, and was subsequently hospitalized for a right distal shaft femur fracture. The facility's investigation initially ruled out abuse and neglect, citing that the fall was witnessed, the equipment was within weight limits, and the staff member had not acted improperly according to their policies. However, the investigation was later reopened, and it was found that the facility failed to provide adequate supervision and did not ensure the safe use of assistance devices during resident transport, directly resulting in the resident's injury. The event led to increased anxiety for the resident around shower times and a reduced quality of life.
Failure to Provide Adequate Resident Activities and Engagement
Penalty
Summary
The facility failed to provide activities that met the interests and supported the physical, mental, and psychosocial well-being of all residents, particularly in the secured unit and on weekends. Observations revealed that residents were often left without structured activities, with some wandering the hallways or sitting idly at tables. The activities coordinator (ACT) was frequently the only staff member present to supervise and conduct activities, and was often interrupted to manage behavioral issues, leaving residents without consistent engagement. On weekends, there were no dedicated activities staff, and residents relied on limited options such as coloring, puzzles, or watching TV, with no formal activities provided. Interviews with staff and residents confirmed the lack of meaningful activities, especially during weekends and evenings. Residents described feeling bored and under-stimulated, with some expressing that all they did was smoke or play games they retrieved themselves. Staff members, including CNAs and LVNs, reported difficulty in providing activities due to staffing shortages and competing responsibilities, such as supervising residents or managing behaviors. The ACT and other staff noted that interruptions and lack of support made it challenging to keep residents engaged throughout the day. A review of the activities calendar showed that while some activities were scheduled, they were limited in scope and frequency, particularly on weekends. The facility's policy required a comprehensive activity program tailored to individual needs and interests, including social, physical, creative, and religious activities, offered at convenient times, including evenings and weekends. However, the observed and reported practices did not align with these requirements, resulting in unmet needs for resident engagement and well-being.
Insufficient Staffing in Secured Memory Care Unit Leads to Increased Incidents
Penalty
Summary
The facility failed to provide sufficient staffing with the necessary competencies and skills to meet the behavioral health needs of all 14 residents in the secured memory care unit. Observations revealed that at various times, only one or two staff members were present to supervise and care for residents with severe cognitive impairments, including Alzheimer's disease and dementia. Staff were frequently occupied with individual resident care tasks, leaving other residents unsupervised, which led to situations where residents wandered, entered other residents' rooms, or engaged in unsafe behaviors such as pushing wheelchairs or fighting over snacks. Staff interviews consistently indicated that the staffing levels were inadequate to provide the required supervision and care, especially given the residents' high needs for assistance with activities of daily living (ADLs) and behavioral management. Incident logs showed a disproportionate number of accidents and behavioral incidents in the secured unit compared to the rest of the facility. Of the total incidents recorded since the beginning of the year, 40% involved the 14 residents in the secured unit, who made up only 22% of the facility's population. These incidents included physical aggression, exit-seeking, bruises, and both witnessed and unwitnessed falls. Staff reported that many falls and incidents occurred when they were busy assisting other residents, and that the lack of supervision contributed to increased wandering and aggression among residents. The activity staff, who were intended to provide engagement, were frequently interrupted to address behavioral issues due to the lack of available nursing staff. Interviews with staff, including CNAs, LPNs, the activity director, and the psychiatric physician's assistant, all highlighted the challenges posed by insufficient staffing. Staff expressed concerns about resident safety, the inability to provide adequate supervision, and the increased workload leading to burnout. The facility's own policy required staffing levels to be based on resident needs and care plans, but the increase in resident numbers in the secured unit was not matched by an increase in staff. Overnight shifts were particularly understaffed, with only one CNA assigned to the secured unit and two nurses for the entire facility. The deficiency was further corroborated by the experiences of responsible parties and staff who reported frequent falls, increased aggression, and a lack of engagement for residents due to inadequate supervision.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices during care provided to two residents. Certified Nursing Assistants (CNAs) did not consistently perform hand hygiene when changing gloves during peri-care and wound care. Specifically, during Foley catheter care for a resident with a stage 4 sacral pressure ulcer and other significant medical conditions, the CNA and Assistant Director of Nursing (ADON) did not don gowns as required by Enhanced Barrier Precautions signage. The CNA also changed gloves without performing hand hygiene, and soiled wipes were observed in a trash bag at the foot of the bed, with some wipes touching the resident's top sheet and the resident's feet coming into contact with the soiled wipes. During wound care for the same resident, the Licensed Vocational Nurse (LVN) and Registered Nurse (RN) donned gowns and gloves as required, but the LVN removed gloves and handled a wound dressing with bare hands before sanitizing and re-gloving. For another resident with colon cancer and a neuromuscular bladder dysfunction, two CNAs provided peri-care without donning gowns, despite Enhanced Barrier Precautions signage. One CNA was observed applying hand sanitizer in a haphazard manner while holding a glove, and then donning the glove without proper hand hygiene. Interviews with the CNA, ADON, and Director of Nursing (DON) confirmed that staff were aware of the requirements for hand hygiene and the use of gowns and gloves during high-contact care activities for residents on Enhanced Barrier Precautions. Facility policies and CDC guidance were reviewed, indicating that hand hygiene and proper use of personal protective equipment (PPE) are required during high-contact care activities, and that supplies should be readily accessible. In-service records showed that the involved CNA had received training on infection control and Enhanced Barrier Precautions prior to the observed deficiencies.
Failure to Provide Accessible Call Light Device for Resident with Contractures
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the needs and preferences of a resident with severe cognitive impairment and multiple physical disabilities, including contractures of the hands and wrists. The resident required extensive assistance with all activities of daily living and had a care plan specifying that the call light should be within reach and that staff should encourage its use for assistance. Despite this, observations on multiple occasions revealed that the call light button was out of reach, either lying on the floor or clipped to the side of the bed, making it inaccessible due to the resident's contracted hands. There was no evidence of an alternative call light device, such as a call light pad button, being provided during these observations. Interviews with staff confirmed that the resident would benefit from a call light pad button device placed on the chest, as the original call light system was not feasible for the resident's physical limitations. Staff acknowledged that the resident had not previously used the original call light system and that the lack of an appropriate device could prevent the resident from requesting assistance. The responsible party also indicated that a call light pad button would be easier for the resident to use, given the contractures. Facility leadership, including the DON and Administrator, stated that staff are responsible for ensuring call light devices are within reach and appropriate for each resident's needs. They confirmed that the original call light device was not suitable for this resident and that the care plan required individualized accommodations. Facility policies reviewed also required that adaptive devices be provided and documented for residents unable to use standard call systems, but these accommodations were not in place at the time of the observations.
Failure to Report Major Injury and Implement Abuse Reporting Policy
Penalty
Summary
The facility failed to develop and implement abuse reporting policies as required, specifically in the case of one resident who experienced a significant injury. The resident, a male with multiple medical conditions including legal blindness, morbid obesity, and a history of fractures, fell out of a shower chair while being transported back to his room after a shower. The incident resulted in a right femur fracture, and the resident was subsequently hospitalized. Documentation indicated that the shower chair's wheels malfunctioned, contributing to the fall, and the resident reported hearing a loud pop and experiencing immediate pain and inability to bear weight. Despite the severity of the injury, the facility did not report the incident to the State Agency as required by their abuse prohibition policy. Interviews with staff revealed confusion and lack of clarity regarding what constitutes a reportable event, with some staff believing that any fracture should be reported, while others deferred to internal investigations that ruled out abuse or neglect. The incident was not reported within the required two-hour window, and the facility's abuse coordinator and administration determined in-house that the event was not suspicious and did not meet their criteria for neglect or abuse, despite the major injury. Further review showed that the facility's policy required reporting all allegations and substantiated occurrences of abuse, neglect, or misappropriation, especially those resulting in serious bodily injury, to the state agency immediately or within two hours. However, the incident involving the resident's fall and fracture was not reported as mandated. The lack of reporting was confirmed through interviews and record reviews, and a complaint was later filed by the resident alleging neglect due to the injury.
Failure to Timely Report Serious Injury Following Resident Fall
Penalty
Summary
The facility failed to ensure that all allegations involving abuse, neglect, or serious bodily injuries were reported immediately, but not later than 24 hours after the allegation was made. Specifically, an incident occurred in which a male resident with a history of impaired vision, right femur and tibia fractures, and osteoarthritis fell out of a shower chair while being transported back to his room. The incident resulted in a right distal shaft femur fracture, which was confirmed by hospital records. The resident required extensive assistance for mobility and had been receiving physical therapy following the injury. Despite the severity of the injury and the requirement to report such incidents to the State Agency, the facility did not submit a report regarding the fall and resulting fracture. The incident was documented internally, and the resident's family and medical provider were notified. However, the event was not reported to the State Agency as required by facility policy and state regulations. The omission was confirmed through interviews with facility staff, including the Abuse Coordinator, DON, and other nursing staff, who indicated that they either did not believe the incident met the criteria for reporting or were unaware of the reporting requirements. The facility's own Abuse Prohibition Policy mandates immediate reporting of all allegations and substantiated occurrences of abuse, neglect, or serious bodily injury to the state agency. In this case, the incident was not reported, and the failure to do so was attributed to the staff's interpretation of the event as non-suspicious and not indicative of neglect or abuse. The lack of timely reporting was further highlighted when a complaint was later filed by the resident, prompting an investigation.
Failure to Notify Responsible Party of Medication Discontinuation
Penalty
Summary
The facility failed to immediately notify a resident's responsible party (RP) when there was a significant change in treatment, specifically the discontinuation of the medication Ativan, as ordered by the physician. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 7, and diagnoses including anxiety disorder, major depressive disorder, and primary hypertension. Documentation review showed that Ativan was discontinued, but there was no record of the RP being notified of this change. The RP later confirmed in an interview that she was not informed about the discontinuation and would have wanted to know, especially as she lived out of state. Interviews with facility staff, including the ADON, DON, and ADM, confirmed that it was the facility's expectation and policy to notify the RP of such significant changes, but this did not occur. The ADON acknowledged the oversight, and both the DON and ADM reiterated that the RP would not have known about the medication change without being contacted. The facility's policy requires notification of the family or legal representative and physician when there is a significant change in the resident's status or a need to alter treatment, which was not followed in this instance.
Failure to Update Resident's Code Status in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes that met the resident's medical, nursing, and mental and psychosocial needs. The deficiency was identified when the facility did not update the resident's care plan to reflect a change in the resident's Advanced Directive from Do Not Resuscitate (DNR) to full code. This oversight resulted in the resident not receiving CPR when they expired at the facility. The resident, a male with diagnoses including heart failure, diabetes, and hypertension, had a BIMS score indicating intact cognition and was able to communicate his needs and wishes. Despite expressing a desire to change his code status to full code during a care plan meeting, this change was not documented in the care plan. Interviews with facility staff, including the Social Worker (SW), MDS Coordinator, and Director of Nursing (DON), revealed that the responsibility for updating the care plan was not clearly assigned, leading to the resident's wishes not being followed. The facility's policy required a comprehensive, person-centered care plan to be developed and implemented for each resident, but this was not adhered to in this case. The failure to update the care plan with the resident's code status change was attributed to a lack of communication and responsibility among the staff, as the previous MDS Coordinator, who was responsible for the update, was no longer at the facility. This deficiency was determined to be an Immediate Jeopardy situation, indicating a serious risk to resident safety.
Removal Plan
- A comprehensive review of all residents was conducted to verify code status and to ensure care plan status reflects resident current choices by DON, ADON, and Corporate Clinical Specialists.
- An Ad Hoc QAPI was held to include Medical Director, DON, Administrator and Corporate Clinical Specialist.
- A care plan training session was successfully conducted by Corporate Clinical Specialist with the interdisciplinary team, focusing on the detailed process of updating code status within the care plan, as well as providing clear instructions on how to effectively implement and modify any necessary changes.
- The above information will be included in new hire orientation, by the Administrator.
- The DON/designee will ensure advance directive care plans are updated immediately following a status change and will conduct audits of advance directive care plans to ensure accuracy in electronic medical records (E.M.R.) weekly. After, the DON/designee will follow the above process twice a month, then monthly thereafter.
- The facility QA Committee will meet weekly to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee.
Failure to Update Code Status Leads to Resident's Death
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident had requested a change in his code status from DNR (do not resuscitate) to Full Code, but the facility did not update his records to reflect this change. As a result, when the resident experienced a medical emergency and became non-responsive, CPR was not administered, and he subsequently expired. The resident was a male with diagnoses including heart failure, diabetes, and hypertension. He had a BIMS score indicating intact cognition and was able to communicate his needs and wishes. Despite his request to change his code status to Full Code during a care plan meeting, the facility's records and the nurse's station binder still reflected a DNR status. This discrepancy led to the failure to provide life-saving measures when the resident fell back in his bed and became non-responsive while talking to EMS. Interviews with facility staff revealed that the responsibility for updating the resident's code status was not fulfilled. The MDS Coordinator, who was responsible for making the change, did not update the records, and the nursing staff followed the outdated DNR status in the electronic medical records. This oversight resulted in the resident's wishes not being honored, and no CPR was performed, contributing to the resident's death.
Removal Plan
- A comprehensive review of all residents was conducted by DON, ADON, and Corporate Clinical Specialists to verify code status, medical orders, care plan, and DNR documentation.
- Care plans were checked to ensure alignment with advance directive documentation by DON, ADON, and Corporate Clinical Specialists.
- Advance directive binders at the nurses' station were cross-checked, with necessary adjustments made to DNR documentation by DON, ADON, and Corporate Clinical Specialists. DON/Designee will keep binders updated on an ongoing basis. All staff were in-serviced on binders kept at the nursing station.
- An Ad Hoc QAPI was held to include Medical Director, DON, Administrator, and Corporate Clinical Specialist.
- Inservice DON and ADON was completed by Corporate Clinical Specialist on the following: How to document, identify and update code status on residents. CCS/DON/Nursing Administration will in-service licensed staff on the following: How to document, identify and update code status on residents. Competency was validated by verbal quizzes. Any staff that were not in-serviced will not be able to work the floor until training and competency is validated by DON/Designee.
- Inservice was provided to all staff on how to identify code status by nursing admin. Competency validated by verbal quizzes.
- The above information will be included in new hire orientation by Administrator.
- The Administrator/designee will conduct audits of advance directive documentation to ensure accuracy in electronic medical records (E.M.R.) weekly. After 4 weeks, the Adm/Designee will follow the above process twice a month for 8 weeks, then monthly thereafter.
- DON/designee will perform quarterly mock code drills for 1 year to ensure staff can effectively identify code status and respond correctly to emergencies.
- The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee.
Expired Med Tech License Leads to Deficiency
Penalty
Summary
The facility failed to ensure that professional staff were licensed, certified, or registered in accordance with applicable state laws, specifically concerning medication administration for four residents. Med Tech M administered medications to these residents while her Med Tech license was expired. This lapse in licensure compliance occurred over a period of eight days, during which Med Tech M was unaware of her expired status and continued to provide medications to residents. The residents involved had various medical conditions, including heart failure, diabetes, hypertension, chronic respiratory failure, COPD, and depression. Despite the expired license, there were no recorded medication errors during the period Med Tech M administered medications. However, the facility's failure to ensure that Med Tech M's license was current could have placed residents at risk for inadequate care and services. Interviews with facility staff revealed that the responsibility for tracking license renewals was not clearly managed. The HRR admitted to not tracking licenses prior to the incident, and the ADM confirmed that Med Tech M was removed from medication administration duties once the expired license was discovered. The facility's policy required a system for license verification and tracking, which was not effectively implemented, leading to this deficiency.
Failure to Report Incident of Unhonored Advanced Directive
Penalty
Summary
The facility failed to report an incident involving a resident whose Advanced Directive was not followed, resulting in the resident not receiving CPR and subsequently expiring. The incident was not reported to the State Survey Agency as required by regulations. The resident, a male with diagnoses including heart failure, diabetes, and hypertension, was admitted to the facility and had a BIMS score indicating intact cognition. On the day of the incident, the resident experienced chest pain and shortness of breath, and despite being placed on oxygen and receiving aspirin, he became non-responsive and was pronounced dead shortly after EMS arrived. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the ADM was responsible for reporting the incident but failed to do so. The facility's policy required such incidents to be reported within 24 hours, but this was not adhered to. The ADM acknowledged the expectation to report the incident and admitted that the state reportable was not sent, which could lead to further neglect of residents. The facility's failure to report the incident as required by state law and facility policy constitutes a deficiency in ensuring the safety and well-being of its residents.
Failure to Administer Hospital-Ordered Medications on Admission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the accurate acquiring, receiving, dispensing, and administering of medications. A resident was discharged from the hospital with orders for Levofloxacin and Metronidazole to treat infections. However, these medications were not documented as ordered upon the resident's admission to the facility, resulting in a delay in administration. The resident did not receive the first dose of Levofloxacin until nine days after admission and the first dose of Metronidazole eight days after admission. Interviews with facility staff revealed that the admitting nurse, LVN J, did not recall entering the antibiotic orders upon the resident's admission. LVN K later discovered the omission and initiated the orders after consulting with the nurse practitioner (NP). The NP confirmed that the resident did not receive the antibiotics as ordered upon admission and noted that the hospital physician was attempting to determine the most effective antibiotic for the resident's lung lesions. The NP could not ascertain if the delay in receiving antibiotics had any adverse effects on the resident. The facility's Director of Nursing (DON) and Administrator (ADM) both stated that it was expected for all hospital discharge orders to be entered into the system at the time of admission. The facility's policy on medication reconciliation for new admissions and readmissions was not followed, leading to the deficiency. The report highlights the failure to ensure that the resident received the necessary medications promptly, which could have impacted the resident's recovery and well-being.
Failure to Document Flu Vaccinations Leads to Double Dosing
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure that each resident was offered influenza and pneumococcal immunizations as required. Specifically, the facility did not document the administration of flu vaccines for two residents, leading to them receiving double vaccinations. This oversight was identified during a review of records and interviews with staff and residents. Resident #3, a female with moderate cognitive impairment and multiple diagnoses including hypertension and diabetes, received a flu shot on two consecutive days in November 2024. The facility's records did not reflect any prior documentation of the flu shot being administered before these dates. Similarly, Resident #4, a female with intact cognitive function and diagnoses including heart failure and COPD, also received a flu shot twice, with no prior documentation of the first administration. Interviews with the residents indicated they did not recall receiving two shots, and no adverse reactions were reported. Interviews with facility staff, including the RN who administered the vaccines and the current DON, revealed that the flu shots given during a clinic in October 2024 were documented on paper but not uploaded to the facility's electronic system, PCC. This lack of documentation led to the double administration of the flu vaccines. The ADM confirmed that the previous DON, who assisted with the clinic, was no longer employed at the facility, and attempts to contact the previous MDS Coordinator and DON were unsuccessful.
Failure to Implement Admissions Policy for Personal Property Inventory
Penalty
Summary
The facility failed to implement an admissions policy that did not require residents to waive potential facility liability for the loss of personal property. This deficiency was identified for three residents who did not have completed inventory sheets for their personal belongings upon admission. The absence of these inventory sheets could place residents at risk of not having their personal property replaced in the event of damage or loss. The facility's undated admission packet indicated that residents or their representatives should complete and sign an inventory form listing personal belongings at the time of admission, but this was not done for the residents reviewed. Interviews and record reviews revealed that Resident #1, Resident #2, and Resident #3 did not have completed inventory sheets in their electronic medical records. Resident #1 had filed a grievance about missing personal items, which the facility reimbursed. Resident #3 alleged that his belongings were missing, but the facility's social worker stated that he was confused and did not arrive with the items he claimed were missing. The social worker and an LVN both acknowledged the importance of completing inventory sheets to track residents' belongings, but noted that this practice was not being followed. The facility did not provide a policy on admissions or inventory sheets when requested.
Medication Room Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and that only authorized personnel had access to the keys for the medication room. On the date of the survey, the medication room was observed to be unlocked and unsupervised, with residents passing by in their wheelchairs. This situation was confirmed during an interview with the Assistant Director of Nursing (ADON), who acknowledged that the room was usually locked when not in use and that authorized staff, such as nurses and medication aides, had access to it. Further observations and interviews revealed that the ADON herself left the medication room unlocked when she exited, and both RN A and LVN B confirmed that the medication room should be locked at all times to prevent unauthorized access. The facility's medication labeling and storage policy, revised in February 2023, mandates that compartments containing medications and biologicals must be locked when not in use. The failure to adhere to this policy could lead to medications going missing or being ingested by residents, posing a risk to their health and safety.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, which was identified during a survey. The resident, a male with Alzheimer's disease, polyarthritis, and dementia, was admitted to the facility and had a severely impaired cognition with a BIMS score of 3. Despite the requirement for a comprehensive care plan to be completed within 21 days of admission, only a baseline care plan was documented, and no comprehensive care plan was developed. This oversight was confirmed through interviews with facility staff, including an LVN and the DON, who acknowledged the absence of a comprehensive care plan. The deficiency was attributed to the vacancy of the MDS Nurse position, which was responsible for completing care plans. The DON and ADM both stated that the expectation was for all residents to have a baseline care plan completed within 48 hours and a comprehensive care plan within 21 days. The lack of a comprehensive care plan left staff without guidance on how to provide necessary care for the resident, including ambulation, eating, walking, and ADLs. The facility's policy required the baseline care plan to be used until a comprehensive assessment and interdisciplinary person-centered care plan were developed, which did not occur in this case.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, making them inaccessible to unauthorized staff, visitors, and residents. This deficiency was observed when Med Cart #1 was found unsupervised and unlocked in the hallway near the nurses' station. The cart contained prescription and over-the-counter medications, ointments, glucometer supplies, insulin pens, and insulin syringes. The medication aide (MA) responsible for the cart was not within eyesight, and another staff member had to shout for the MA to return and lock the cart. This incident occurred in a busy area with numerous staff and residents present. Interviews with the MA, LVN, DON, and ADM revealed a consensus that the medication cart should have been locked whenever the staff member was not directly in front of it. The MA acknowledged the lapse in protocol, despite having recently attended an in-service on med-cart safety. The LVN, DON, and ADM all identified significant risks associated with the unlocked cart, including the potential for residents to access medications they are not prescribed, leading to allergic reactions or overdose. The expectation from all interviewed staff was clear: medication carts must be locked when unattended to prevent unauthorized access and ensure resident safety.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, which is a deficiency in their care planning process. The resident, a male with Alzheimer's disease, polyarthritis, and dementia, was admitted to the facility and had a severely impaired cognition with a BIMS score of 3. Despite the requirement for a comprehensive care plan to be completed within 21 days of admission, only a baseline care plan was completed, and no comprehensive care plan was developed. This oversight was identified during a record review and interviews with facility staff. Interviews with the LVN, DON, and ADM revealed that the MDS Nurse, who was responsible for completing care plans, had vacated the position two weeks prior, leading to the lapse in care plan development. The staff acknowledged that without a comprehensive care plan, there was no guidance for providing necessary care to the resident, including ambulation, eating, walking, and ADLs. The facility's policy required a baseline care plan to be used until a comprehensive assessment and care plan were developed, but this was not adhered to, resulting in a lack of direction for the resident's care.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. The care plan was not completed upon the resident's admission and was not updated to reflect changes in the resident's care needs, such as falls, medications, cognition, and other health concerns. This oversight placed the resident at risk of not having their individualized needs met in a timely manner, potentially affecting their physical and psychosocial well-being. The resident, an elderly male, was admitted with multiple diagnoses, including recurrent major depressive disorder, age-related cognitive decline, difficulty walking, joint pain, insomnia, urinary tract infection, and essential hypertension. Despite these conditions, the care plan only addressed the resident's risk of wandering due to confusion and wandering behavior. The comprehensive MDS assessment indicated severe cognitive impairment and frequent feelings of depression, yet these were not adequately addressed in the care plan. Interviews with facility staff revealed that the MDS Nurse, responsible for completing and updating care plans, was not fulfilling these duties due to a lack of understanding of the Point Click Care system and unclear job responsibilities. The Director of Nursing admitted to not ensuring that care plans were completed as needed, assuming the MDS Nurse was capable due to prior experience. This lack of oversight and communication contributed to the deficiency in providing a comprehensive care plan for the resident.
Failure to Communicate with Resident During Care
Penalty
Summary
The facility failed to treat a resident with respect and dignity during a mechanical lift transfer and incontinent care. Two CNAs did not identify themselves or explain the procedure to the resident, who exhibited nonverbal signs of fear and pain, such as widened eyes, an open mouth, and facial grimacing. The resident, who had unspecified dementia and was dependent on a hoyer lift for transfers, was not engaged by the CNAs during the procedure. Instead, the CNAs conversed with each other about personal matters, neglecting to communicate with the resident. The resident's family member expressed frustration over the staff's lack of communication, noting that the resident understood when spoken to despite her inability to communicate verbally. The facility's Director of Nursing (DON) stated that staff are expected to communicate professionally with residents, focusing solely on their care. An in-service conducted by the DON prior to the incident emphasized the importance of acknowledging, introducing, and explaining procedures to residents. However, during the observed incident, the CNAs failed to adhere to these guidelines, resulting in the resident's distress.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain good hygiene, nutrition, grooming, and personal and oral hygiene. Specifically, the facility did not provide showers to three residents in compliance with their shower schedules. This deficiency was observed in three out of five residents reviewed for ADLs, potentially placing them at risk of a decline in hygiene and other related issues. Resident #2, a cognitively intact male with intellectual disabilities and mobility issues, was supposed to receive showers on Mondays, Wednesdays, and Fridays. However, records showed he only received one shower over a month-long period. During an interview, he expressed feeling neglected and having to wash up using the sink in his room. Similarly, Resident #3, a female with moderate cognitive impairment and physical disabilities, was also supposed to receive showers three times a week but only received four showers in a month. She reported feeling unclean and unable to remember her last shower. Resident #4, a cognitively intact male with physical disabilities, also did not receive showers as scheduled, receiving only three showers in a month. He expressed frustration and a sense of neglect due to the lack of assistance with his care. Interviews with staff revealed that shower aides were responsible for giving showers, but if they were absent, other aides were supposed to step in. However, there was a lack of communication and accountability, leading to missed showers. The Director of Nursing acknowledged the issue and the potential negative outcomes of not receiving regular showers.
Failure to Apply Hand Contracture Cushion
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, specifically by not applying a hand contracture cushion as prescribed. The resident, an elderly female with unspecified dementia, generalized muscle weakness, and osteoarthritis, was observed without the necessary hand cushion during a transfer. The cushion was intended to prevent further contraction and skin irritation or wounds on her contracted left hand. The resident's care plan and physician's orders included the use of a hand contracture cushion to be applied every Monday, Wednesday, and Friday, but this was not adhered to. During interviews, it was revealed that the responsibility for ensuring the cushion was in place fell to the nursing staff. A nurse admitted to removing the cushion for wound care and forgetting to replace it. The Director of Nursing confirmed the importance of following physician orders to prevent further contraction or skin issues. The facility's policy on physician orders did not address the importance of adherence, contributing to the oversight.
Failure to Ensure Resident Privacy and Consent for Monitoring
Penalty
Summary
The facility failed to uphold the resident rights of a resident, specifically regarding privacy and consent for electronic monitoring. The resident, who had intact cognition and was dependent on staff for all activities of daily living, was placed in a room with another resident who had electronic monitoring equipment installed. The monitoring equipment included audio capabilities, and the resident did not consent to this monitoring. The resident became aware of the audio feature after a private conversation was overheard and reported by the roommate's family, leading to feelings of distress and a lack of privacy. Additionally, the facility did not obtain the necessary consent from the resident before searching her personal property. The resident reported an incident where a registered nurse searched her drawer without permission, looking for vape pens to store in the medication room. This unauthorized search further contributed to the resident's sense of violated privacy and lack of control over her personal space. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator (ADM), revealed a lack of proper documentation and consent procedures for electronic monitoring. The staff acknowledged the importance of obtaining consent and maintaining privacy but failed to implement these practices effectively. The facility's policies on resident rights and personal property were not adhered to, resulting in a deficiency in respecting and supporting the resident's rights to privacy and dignity.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and only accessible to authorized personnel. Observations revealed that medication carts on the 500 and 100 halls were not properly secured, with medications left unattended on top of the carts. Additionally, a medication cup containing three types of unidentified cream was found unattended on a linen cart in the 500 hall. These lapses in security were noted during a period when multiple staff and residents passed by the unsecured medications. Further deficiencies were observed in the storage of medications at residents' bedsides. A medication cup with three types of cream was found on the over-the-bed table of a resident with moderately impaired cognition and multiple health conditions, including cancer and heart failure. The facility's policy did not allow for medications to be stored at the bedside unless in their original containers, and there was no physician order permitting bedside storage for this resident. Another resident, also with moderately impaired cognition and various health issues, had eye drops left on her nightstand, which she did not self-administer. The facility's policy required medications to be stored in the medication room or carts, not at the bedside. Interviews with facility staff, including the Corp RN, LVN, ADON, DON, and ADM, confirmed that the facility's policies were not followed. Staff acknowledged that medications should be locked and secured, and that leaving them unattended could lead to misuse or adverse reactions. The facility's policies on medication storage and administration did not adequately address the issue of bedside storage, contributing to the observed deficiencies.
Failure to Provide Adequate Bathing Services
Penalty
Summary
The facility failed to ensure that a resident, who was unable to carry out activities of daily living independently, received the necessary services to maintain good grooming and personal hygiene. The resident, a male with multiple diagnoses including legal blindness, hypertension, and congestive heart failure, was observed to have received inadequate showering services. Despite the facility's policy requiring regular bathing, the resident reported having only three showers since admission, with some instances of only having his back and legs wiped down, which was not considered a full bath or shower by the facility's standards. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed discrepancies in the understanding and implementation of the facility's bathing policy. The ADON and DON both acknowledged that wiping a resident's back and legs does not constitute a bath or shower. The facility's policy, revised in March 2018, mandates that residents unable to perform ADLs independently should receive appropriate care to maintain personal hygiene. However, the resident's care plan did not address showering, and the facility's records showed inconsistencies in documenting the resident's bathing schedule.
Linen Cart Safety Violation
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards in two of its resident hallways, Hall 1 and secured Hall 6. During observations, it was noted that the linen carts in these areas contained items that posed potential risks to residents, including a non-aerosol MedLine odor eliminator spray, MedLine Remedy Antifungal Ointment, Coloplast Hydrophilic Wound Dressing, MedLine Remedy Cleansing Foam, MedLine Soothe and Cool Barrier ointment, and opened packages of disposable razors. These items were not supposed to be on the linen carts, which should only contain linens, briefs, and gloves. The presence of these items was identified as a potential hazard, as residents could access them, leading to possible accidents or injuries. Interviews with facility staff, including a CNA, RN, ADON, and DON, revealed that there was a lack of adherence to the facility's expectations regarding the contents of the linen carts. The CNA and RN acknowledged that the carts should only contain specific items and identified the potential harm of having unauthorized items on the carts. The ADON and DON confirmed that razors and external use creams should not be on the carts and emphasized that it is the responsibility of CNAs, charge nurses, and administrative staff to ensure compliance. The facility lacked a specific Linen Cart policy, and the existing Sharps Disposal Policy did not address the storage and safety of personal use razors, contributing to the oversight.
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 45 citations issued within 25 miles in the last 12 months — including the 1 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 Lampasas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lampasas Nursing And Rehabilitation Center | 0.5 mi | ★★★★★ | 10 | 1 |
| Caraday Of Lampasas | 0.9 mi | ★★★★★ | 6 | 0 |
| Copperas Cove Nursing & Rehabilitation | 16.8 mi | ★★★★★ | 12 | 0 |
| Hill Country Heights | 17.5 mi | ★★★★★ | 7 | 0 |
| Avir At Burnet | 21.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.