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 Medina Valley Health & Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to ensure MDS assessments accurately reflected resident status for multiple residents. One resident’s quarterly MDS omitted anticonvulsant use despite Depakote being administered and documented in the MAR and care plan, another resident’s annual MDS omitted diuretic use despite Furosemide being ordered and given, and two residents’ MDS assessments failed to show hospice services even though hospice admission was documented in the chart and care plan. Staff interviews confirmed the assessments should match the MAR and resident record.
A resident on EBP with a wound and Foley catheter received incontinent care from two CNAs who wore gloves only, not gowns, and one CNA touched a clean brief with dirty gloves after cleaning stool. In a separate event, an LVN administered insulin to another resident without cleaning the insulin pen’s rubber stopper and without sanitizing her hands between glove changes. The DON stated gowns were required for the resident on EBP and that hand hygiene and cleaning the insulin pen stopper were expected.
A resident with multiple pressure injuries, including a stage 4 sacral ulcer treated with NPWT, did not receive complete wound care during an observed dressing change. The LPN cleansed only portions of the wound bed, allowed wound vac tubing to contact the floor and remain there during care, and disinfected only the outside of scissors without cleaning the blades. The DON stated staff were expected to cleanse the entire wound bed and clean the entire pair of scissors, including the blades, and the facility policy required wound cleansing per MD order and filling the entire wound base and sides.
RN coverage was not provided for at least 8 consecutive hours a day, 7 days a week. Review of RN timecards showed no RN hours on two dates, while the facility census documented 90 residents on each of those dates. The DON and Administrator both stated RN presence was important for oversight, monitoring LVNs, and providing direction if an issue occurred, and the facility policy required RN services for at least 8 consecutive hours a day, 7 days a week.
A resident’s medical record did not include documentation of an altercation with another resident. The resident later reported that the other resident hit her with a walker during an argument, while an RN said he separated the residents and notified the DON but did not document the event. An LVN said she assumed the RN had documented it, and the Administrator stated staff were expected to document aggressive incidents and related assessments in the progress notes.
Laundry Dryers Had Excess Lint Buildup: The facility failed to keep 2 dryers in a safe operating condition when about 2-3 inches of lint were observed on top of the lint screens. The Housekeeping Supervisor said the Maintenance Director usually cleaned the upper part of the lint screen daily, but he had been out ill for a few days and the Assistant Maintenance Director had other duties. The facility policy stated that essential equipment, including laundry equipment, must be maintained in safe operating condition.
Late Quarterly MDS Assessment: A resident with CAD, bladder dysfunction, and anxiety had a quarterly MDS overdue beyond the required completion window. The MDS Coordinator said the assessment was overlooked and that the tracker used to identify due assessments does not always find everyone who is due; she also stated the MDS reviews the resident’s care over the prior 90 days so staff have current information on care needs.
The facility failed to maintain food safety and sanitation standards in the kitchen. Sanitizing buckets were placed near uncovered food, expired flour was not discarded, and the ice machine contained an unknown black substance. The dishwasher sanitation log was incomplete, and test strips were expired. Staff interviews revealed a lack of adherence to proper procedures, contributing to these deficiencies.
A resident with a history of UTIs and ESBL resistance developed dysuria and hallucinations, but the facility failed to notify the provider of these changes. The LVN did not document informing the NP, and the NP was unaware of the symptoms. The facility's policy requires notifying the physician of significant changes, which was not followed.
A facility failed to accurately reflect a resident's hearing impairment and use of an amplifier in the MDS assessment. The resident, with moderate cognitive impairment, reported a non-functional amplifier due to a damaged wire, yet the MDS indicated minimal hearing difficulty and no device use. The care plan included ensuring functional adaptive equipment, but the oversight was confirmed by the LVN/MDS Coordinator.
A facility failed to conduct a PASRR Level II assessment for a resident with a diagnosis of Major Depressive Disorder (MDD), despite the presence of mental illness indicators and the administration of psychotropic medications. The oversight was attributed to the resident's status as a VA beneficiary, leading to the assumption that services would be provided through the VA. The administrator acknowledged the omission and recognized the need for PASRR assessments for all residents with mental illness.
A facility failed to identify a resident's mental illness on the PASRR assessment, despite the resident having diagnoses of PTSD and MDD. The resident's medical records indicated severe cognitive impairment and mood indicators, yet three PASRR Level I assessments incorrectly recorded no evidence of mental illness. The Administrator acknowledged the error, attributing it to the resident being a VA beneficiary, and stated that a follow-up PASRR Level II assessment should have been conducted.
The facility failed to update care plans for two residents, one with hearing impairment and another with a history of UTIs. The care plans did not reflect the residents' current needs, such as the use of a hearing aid and monitoring for UTI symptoms, despite residents' reports and staff awareness. This deficiency could lead to inadequate care and services.
A resident with moderate cognitive impairment and physical limitations did not receive necessary assistance with ADLs, including oral hygiene and grooming, as outlined in his care plan. On a survey date, staff failed to brush his teeth or wash his face, and his nails were not clipped despite his diabetic condition. Observations showed the resident appeared unkempt, and interviews revealed staff were unaware of specific care needs, leading to inadequate hygiene care.
Two residents received inadequate care, risking urinary tract infections. A resident with a history of UTIs was left with fecal residue after perineal care, while another with a urinary catheter had the bag improperly positioned above bladder level, causing backflow. CNAs involved acknowledged their mistakes, which contradicted facility policies on cleanliness and catheter positioning.
The facility failed to maintain accurate records for controlled drugs, leading to discrepancies in documentation for two residents. A resident with severe cognitive impairment had a discrepancy in Clonazepam doses between the MAR and the controlled medication log. Another resident with moderate cognitive impairment had a similar issue with Tylenol #3. The facility's policy requires matching documentation, but this was not adhered to, as observed during a review of the medication cart and logs.
A facility failed to label an insulin pen with the opened date for a resident with Type 2 Diabetes Mellitus, risking the administration of expired medication. The resident had multiple health conditions, and the oversight was noted during a medication pass observation. The facility's policy required labeling with the opened date, which was not followed.
The facility failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in documentation and care. One resident's complaints of dysuria were not documented timely, and another resident's wound care order was not entered in active orders promptly. The facility's documentation policy requires accurate and timely records, but these deficiencies indicate a failure to adhere to these standards.
A facility failed to coordinate hospice care and maintain necessary documentation for a resident with a terminal prognosis. The required Physician Certification of Terminal Illness and Hospice Election form were missing from the records, and staff interviews revealed a lack of understanding and communication regarding the documentation needed for hospice services.
A facility failed to maintain proper infection control when two CNAs did not perform hand hygiene between glove changes while providing incontinent care to a resident with a history of ESBL resistance and UTIs. Despite being on enhanced barrier precautions, the CNAs were unsure about the necessity of hand hygiene between glove changes, contrary to the facility's policy. The DON confirmed the requirement for hand hygiene to prevent infections.
A dishwashing sink in the facility was leaking and repaired with an unknown sealant, raising concerns about food safety. The sink could not hold water for more than five minutes, and staff were unsure if the sealant used was food safe, potentially affecting the cleanliness of dishes used for residents' food.
The facility failed to properly dispose of garbage and refuse, as liquid was leaking from Dumpster #1, staining the driveway. The DS acknowledged the issue, and the MS reported power washing the area weekly while awaiting new dumpsters. The facility's policy requires containers to be durable, cleanable, and free from leaks, which was not adhered to.
The facility failed to report allegations of abuse and neglect involving two residents within required timeframes. One resident alleged rough treatment and inappropriate behavior by a CNA, while another was improperly transferred, resulting in transient pain. Both incidents were not reported to the state agency, despite facility policies requiring prompt reporting.
A resident requiring two-person assistance for mechanical lift transfers was transferred by a CNA alone, resulting in the resident hitting his head. The resident, with Parkinson's and dementia, needed substantial assistance, as outlined in his care plan. Despite being trained, the CNA acted independently, violating facility policy and risking the resident's safety.
A resident with a urinary catheter was not provided appropriate care to prevent infections due to a failure in using sterile technique during catheter flushing. The resident, diagnosed with obstructive and reflux uropathy, required catheter irrigation with sterile water. However, an LVN used a non-sterile syringe, potentially exposing the resident to infection. The facility's policy and nursing leadership emphasized the need for sterile procedures, which were not followed in this instance.
A medication cart was found unlocked and unattended in a public area, with six residents nearby, violating the facility's policy and state and federal laws. The DON confirmed the importance of keeping carts locked to prevent unauthorized access, as some residents were mobile and could potentially access the medications.
A resident with severe cognitive impairment and multiple health issues fell from a Geri chair, resulting in a head injury. The facility delayed reporting the incident to the State Agency, believing the injury was not major due to the resident's stable condition. This delay violated the facility's policy requiring immediate reporting of such incidents.
Inaccurate MDS Assessments for Medication Use and Hospice Status
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for 4 of 6 residents reviewed. For Resident #4, the quarterly MDS did not document anticonvulsant use even though the resident had diagnoses including dementia, diabetes, anxiety, insomnia, stroke, hyperlipidemia, hypertension, and heart disease, and the order summary and MAR showed Depakote 500 mg twice daily was being administered during the look-back period. The resident’s care plan also identified anticonvulsant use for mood stabilization. For Resident #41, the annual MDS did not document diuretic use even though the resident had diagnoses including dementia, seizures, hyperlipidemia, hypertension, heart disease, diabetes, and cerebral infarction. The order summary and MAR showed Furosemide 40 mg daily was being given during the look-back period, and the care plan documented that the resident was on diuretic therapy. Interviews with the MDS Coordinator, DON, and Administrator reflected that the MDS should accurately reflect what was occurring with the resident and what was documented in the chart and MAR. For Resident #3, the Significant Change MDS indicated hospice care was not received even though the care plan identified a terminal prognosis and included choosing a hospice provider, and a facility notification showed the resident was admitted to hospice. For Resident #42, the quarterly MDS did not show hospice services even though the order summary documented hospice admission for combined systolic heart failure and the MDS Coordinator stated the resident was admitted on hospice and it should have been included. The facility policy stated resident assessments are to be accurate and reflective of the resident’s status at the time of assessment.
Infection Control Failures During Incontinent Care and Insulin Administration
Penalty
Summary
The facility failed to maintain its infection prevention and control program during care for a resident who was admitted with sepsis due to methicillin susceptible Staphylococcus aureus, neuromuscular dysfunction of the bladder, and a sacral pressure ulcer. The resident’s admission assessment showed severely impaired cognition for daily decision making, dependence on staff for turning and personal hygiene, and a care plan that placed the resident on enhanced barrier precautions because of a wound and an indwelling Foley catheter. The care plan required gowns and gloves for high-contact care activities, including changing briefs, toileting, hygiene, device care, and wound care. During observation of incontinent care, two CNAs provided care to the resident while wearing gloves only and did not wear the required PPE gown. One CNA cleansed the resident’s peri area and buttocks, cleaned stool from the resident, and then used the same dirty gloves to pick up and place a clean brief on the resident. The CNA acknowledged she had made a mistake by touching the clean brief with dirty gloves. Both CNAs stated they needed gowns because the resident had wounds and a catheter, and one CNA stated she needed to change her gloves to prevent infection. The facility also failed during insulin administration to another resident with type 2 diabetes who received sliding-scale insulin and had moderately impaired cognition. An LVN checked the resident’s blood glucose, returned to the medication cart, removed her gloves, put on another pair without sanitizing her hands, and then placed a needle cap on the insulin pen without cleaning the rubber stopper first. She then primed and administered the insulin. The LVN stated she should have cleaned the insulin pen’s rubber stopper and sanitized her hands between glove changes, and the DON stated staff were expected to sanitize or wash their hands between glove changes and clean the insulin pen stopper to prevent infection.
Incomplete wound care and improper handling of NPWT supplies
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for a resident with multiple pressure injuries, including three stage 3 pressure ulcers and one stage 4 pressure ulcer. The resident was admitted with diagnoses that included sepsis due to methicillin susceptible Staphylococcus aureus, neuromuscular dysfunction of the bladder, and a sacral pressure ulcer. The resident’s MDS assessment showed severely impaired cognition for daily decision making and dependence on staff for turning and personal hygiene. The care plan addressed the resident’s multiple pressure injuries and included wound vac use for the sacral wound, with interventions to administer treatments as ordered, monitor wound healing weekly, measure the wound, assess the wound perimeter and bed, and report changes to the MD. The physician order for the sacral stage 4 pressure ulcer directed daily wound care on Mon, Wed, and Fri with cleansing and drying of the affected area and application of green foam NPWT dressing at -125 mmHg continuous suction. During observation of wound care, the LVN removed the existing foam dressing and tubing, discarded them, and cleansed portions of the wound bed, but areas of the wound bed were not cleansed before the new dressing was applied. The LVN also removed tubing from a bag and replaced the canister on the wound vacuum unit; during this process, the tubing dropped and contacted the floor and remained there while wound care continued. The LVN used scissors to cut wound care supplies and wiped only the exterior surfaces with a disinfectant wipe, without opening the scissors to clean the inner blades or cutting surfaces. After the dressing was applied, the tubing that had been on the floor was picked up and connected to the resident’s wound vacuum device. The LVN stated she did not know the tubing had been on the floor and acknowledged that if it had been on the floor it would be considered dirty. The DON stated staff were expected to cleanse the entire wound bed and clean the entire pair of scissors, including the blades, while the facility policy required wound cleansing according to physician order and filling the entire wound base and sides, tunnels, and undermined areas.
RN Coverage Not Provided 7 Days a Week
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Review of RN timecards from 8/1/2025 through 2/24/2026 showed no RN hours for Monday 9/1/2025 and Friday 12/26/2025. The facility census on each of those dates documented 90 residents in the building. During interview, the DON stated it was important to have sufficient RN staff to monitor the LVNs and to be present if there was an issue in the building. The Administrator stated it was important to have sufficient RN staff to provide oversight and direction if something should happen, and stated her expectation was that there be an RN in the facility for 8 consecutive hours a day, 7 days a week. The facility policy titled Nursing Services and Sufficient Staff stated it is the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, and that, except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
Incomplete documentation of resident altercation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting an incident involving Resident #71 and Resident #83 in the electronic medical record. Resident #71 was an older female with diagnoses including dementia, major depressive disorder, and generalized anxiety disorder. Her quarterly MDS showed a BIMS score of 13, and her care plan noted she was resistant to care, sometimes refused medications, urine testing, showers, and nail care, and needed consistent approaches and clear explanations during care. Record review showed no nursing progress notes documenting any incident between 2/21/26 and 2/22/26, even though later behavioral health documentation reflected that Resident #71 told the nurse practitioner she had a "blow up" over the weekend and admitted calling a staff member a racial epithet. Resident #83’s progress note documented a verbal outburst in a public area and that staff redirected the resident, with the nurse practitioner notified and medication orders discussed with the responsible party. During interview, Resident #71 stated that Resident #83 hit her with a walker during an argument about another male resident, and that RN B separated them and took her away from the area. RN B stated he was not present for the initial altercation but later separated the residents, took Resident #71 to her hallway, and notified the DON. He said he instructed LVN C to document the incident and notify the family, but LVN C stated RN B did not ask her to document the incident or notify the family or physician, and she assumed RN B had documented it because he was the staff member present. The Administrator stated staff were expected to complete skin assessments, notify the physician and resident representative, and document incidents involving aggressive behaviors or altercations, and also stated staff should have documented the incident in the progress notes so later allegations could be explained when reviewing the medical record.
Laundry Dryers Had Excess Lint Buildup
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one laundry room reviewed for physical environment because the 2 dryers had built up lint on top of the lint screens. During an observation of the laundry room and interview on 02/27/26 at 1:57 pm, the dryers were found to have about 2-3 inches of lint on top of the lint screens, and the bottom part of the lint screens appeared to have been swept off with only a small amount of lint staying in the bottom of the dryer. The Housekeeping Supervisor stated that the Maintenance Director usually cleaned the upper part of the lint screen at least once a day because there were wires that might cause issues, but the Maintenance Director had been out ill for a few days and the Assistant Maintenance Director had other duties. She stated she did not know if other arrangements were going to be made for cleaning the dryers while the Maintenance Director was out. The facility's Physical Environment: Electrical Equipment policy dated 2025 stated that the facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition and that essential equipment, including laundry equipment, shall be cleaned, repaired or replaced as soon as practicable.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete Resident #42’s quarterly MDS assessment by the required due date. Resident #42 was a [AGE]-year-old female admitted on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, neuromuscular dysfunction of bladder, and anxiety disorder. Her last quarterly MDS assessment was dated 11/6/25, and the MDS assessment list dated 2/26/26 showed the next quarterly ARD was due 2/6/26 and complete by 2/20/26, but it remained overdue. During interview, the MDS Coordinator stated she could not say why the quarterly MDS had not been completed and said she tried to run a tracker to identify due assessments, but it does not always find everyone who is due. She stated the MDS was overlooked and explained that the assessment reviews the resident’s care over the last 90 days so staff have access to current information on residents’ care needs. The record also showed Resident #42’s memory was intact for daily decision making, and the facility policy stated that assessments should be accurate and completed by qualified staff.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. Sanitizing buckets were improperly placed next to uncovered food items, specifically a tray of onions. Additionally, expired flour was found in the kitchen, with discard dates that had already passed. The ice machine was noted to have an unknown black substance inside, and the machine's cleaning log indicated it had not been cleaned recently. Furthermore, the dishwasher sanitation log was incomplete for several days, and the test strips used to check sanitizer levels were expired. Interviews with staff revealed a lack of awareness and adherence to proper procedures. A dishwasher aide admitted to being new and acknowledged that the sanitation log should be completed twice daily. The dietary supervisor (DS) confirmed that expired flour should be discarded and that maintenance was responsible for cleaning the ice machine. The maintenance supervisor (MS) was unaware of the black substance in the ice machine and confirmed it should not be present. The facility's policies on ice machine maintenance and food safety date marking were not followed, contributing to the deficiencies observed.
Failure to Notify Provider of Resident's Change in Condition
Penalty
Summary
The facility failed to consult with a resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. This deficiency was identified for a resident who developed dysuria and visual hallucinations, but the facility did not notify the resident's provider of these changes. The resident, who had a history of urinary tract infections and was on enhanced barrier precautions due to ESBL resistance, reported these symptoms to an LVN, but there was no documentation of the provider being informed. The resident's progress notes did not reflect any mention of dysuria or hallucinations in the days leading up to the report. A late entry note by the LVN indicated that the resident had reported burning during urination but did not express other symptoms. The LVN stated that the facility used McGeers criteria to determine if symptoms needed to be reported and treated, and since the resident only had one symptom, it was not reported to the NP. The NP confirmed that they were not informed of the dysuria or hallucinations and had not ordered treatment for these symptoms. Interviews with the DON revealed that nursing staff are expected to report changes in status to the provider and document these reports. However, the DON noted that dysuria alone was not considered a symptom of a UTI and that the resident had not reported mental symptoms. The facility's policy on Notifications of Changes requires prompt consultation with the resident's physician for significant changes in condition, but this was not adhered to in this case.
Inaccurate MDS Assessment for Hearing Impairment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding their hearing impairment and the use of an amplifier as a hearing aid. The resident, who was admitted with diagnoses including unspecified sequelae of cerebral infarction and major depressive disorder, was noted to have moderate cognitive impairment with a BIMS score of 11. However, the MDS assessment dated 10/1/24 inaccurately indicated that the resident had minimal difficulty hearing and did not use a hearing device. This discrepancy was identified during a review of the resident's records and through interviews with staff and the resident. Further investigation revealed that the resident had informed staff that the amplifier provided to him was no longer functional due to a damaged wire, and he was awaiting a replacement. Despite this, the resident's care plan, revised on 10/8/24, included an intervention to ensure that adaptive equipment needed by the resident was provided and functional. An interview with the LVN/MDS Coordinator confirmed the oversight in the MDS assessment, acknowledging that it did not reflect the resident's need for a hearing device. The facility was unable to provide a policy for resident assessment when requested by the surveyors.
Failure to Conduct PASRR Level II Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all residents with mental illness, specifically those identified through the PASRR Level I screening, received a PASRR Level II Evaluation and Assessment. This deficiency was identified for one resident who was reviewed for PASRR services. The resident in question, who had a diagnosis of Major Depressive Disorder (MDD), was not identified as having a mental illness on the PASRR screening conducted in March 2023, which should have triggered a Level II assessment. This oversight could potentially place residents at risk of not receiving necessary specialized services. The resident, who was admitted to the facility with multiple diagnoses including MDD, was found to have moderate cognitive impairment and mood indicators such as depression and anxiety. Despite these indicators and the administration of psychotropic medications, no follow-up PASRR Level I or II assessment was conducted after the diagnosis of MDD. The facility's administrator acknowledged the omission, attributing it to the resident being a VA beneficiary, which led to the assumption that services would be provided through the VA. However, the administrator recognized that PASRR assessments should be conducted for all residents with mental illness, regardless of their VA status, to ensure no one is overlooked.
Failure to Identify Mental Illness in PASRR Assessment
Penalty
Summary
The facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for a resident with mental health diagnoses. The resident, who was admitted with diagnoses including PTSD and Major Depressive Disorder (MDD), was not recognized as having a mental illness on the Level I PASRR screening. This oversight occurred despite the resident's medical records indicating severe cognitive impairment and mood indicators such as depression and PTSD. The resident's care plan included the use of an antidepressant and monitoring for changes in behavior, mood, and cognition. The facility conducted three PASRR Level I assessments, all of which incorrectly recorded that there was no evidence of mental illness. The Administrator acknowledged the error, stating that the resident should have had a positive PASRR Level I outcome and a follow-up PASRR Level II assessment. The Administrator mentioned that the oversight was due to the resident being a VA beneficiary, who must receive services through the VA. The facility's policy requires all applicants to be screened for serious mental disorders or intellectual disabilities in accordance with the State's Medicaid rules, which was not adhered to in this case.
Deficiencies in Care Plan Updates for Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for two residents. For one resident, the care plan did not reflect that he was hearing impaired and used an amplifier as a hearing aid. Despite the resident's moderate cognitive impairment and his communication about the damaged amplifier, the care plan was not updated to address his hearing needs. Interviews with staff confirmed that the care plan did not include this critical information, which is essential for staff to understand and meet the resident's needs. Another resident's care plan was not updated to reflect her history of urinary tract infections (UTIs) and did not include interventions for staff to monitor for UTI symptoms. Despite the resident's intact memory and her reports of UTI symptoms to staff, the care plan lacked specific instructions for monitoring and addressing these symptoms. Interviews with staff revealed a reliance on the resident's ability to report symptoms and a lack of specific care plan interventions tailored to her history of UTIs. The facility's failure to update and revise care plans as needed could result in residents not receiving the necessary care and services. The lack of updated care plans for these residents highlights a deficiency in the facility's processes for ensuring that care plans accurately reflect residents' current needs and conditions.
Failure to Provide Adequate ADL Assistance for Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident with moderate cognitive impairment and physical limitations due to a cerebral infarction and major depressive disorder. The resident was dependent on staff for personal hygiene, including oral care and grooming, as outlined in his care plan. However, on one of the survey dates, the nursing staff did not brush the resident's teeth or wash his face, and his nails had not been clipped for an undetermined period, despite his diabetic condition requiring special attention to nail care. Observations and interviews revealed that the resident appeared unkempt, with long nails and uncombed hair, and expressed dissatisfaction with the lack of hygiene care. The resident stated that staff only washed his face when he had appointments and did not regularly brush his teeth, which was important to him. A CNA admitted to not having time to assist the resident with his hygiene needs on the survey date due to other responsibilities, such as showering other residents. The CNA also indicated that she would mark hygiene tasks as not applicable if she did not provide assistance during her shift. Further interviews with facility staff, including an LVN and the DON, highlighted a lack of awareness and communication regarding the resident's specific care needs, such as nail care for diabetics. The LVN was unaware that only nurses should cut the nails of diabetic residents, and the DON confirmed that nail care could be provided as needed, not just on scheduled days. The DON also noted that the resident's care refusals should be documented, but the resident denied refusing care. The facility's policy emphasized the importance of maintaining residents' abilities in ADLs, but the observed deficiencies indicated a failure to adhere to this policy.
Inadequate Incontinent and Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for two residents, leading to potential risks of urinary tract infections. Resident #15, a female with a history of cerebral infarction and urinary tract infections, was observed receiving inadequate incontinent care. During an observation, CNA L left visible fecal residue on the resident's gluteal cleft after performing perineal care, which could contribute to infection. The CNA admitted to not ensuring the resident was thoroughly cleaned, acknowledging the importance of wiping until no feces remained. Resident #191, a female with a urinary catheter due to neuromuscular dysfunction of the bladder, was also subject to improper care. During an observation, CNAs J and K were seen raising the resident's catheter bag above the bladder level, causing urine to flow back toward the bladder. This action contradicts the facility's policy, which mandates keeping the catheter bag below the bladder to prevent backflow and potential infections. Both CNAs acknowledged the mistake and the risk of infection associated with their actions. The facility's policies on perineal and catheter care emphasize the importance of cleanliness and proper positioning to prevent infections. However, the observed actions of the CNAs did not align with these policies, as they failed to ensure thorough cleaning and correct catheter bag positioning. The Director of Nursing confirmed the expectations for staff to prevent backflow and ensure residents are free from visible feces to avoid skin breakdown and infections.
Discrepancies in Controlled Drug Documentation
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of controlled drugs, leading to discrepancies in medication documentation for two residents. For Resident #24, who has severe cognitive impairment and multiple diagnoses including anxiety disorder and major depressive disorder, the administered dose of Clonazepam was logged on the electronic Medication Administration Record (MAR) but not on the controlled medication reconciliation log. The blister pack showed 34 doses left, while the log showed 35 doses. Similarly, for Resident #41, who has moderate cognitive impairment and is on a scheduled pain medication regimen, the administered dose of Tylenol #3 was recorded on the MAR but not on the controlled medication reconciliation log. The blister pack showed 22 pills left, while the log showed 24 pills. The facility's policy on Controlled Substance Administration and Accountability requires that all controlled substances be recorded on a designated usage form, with documentation matching the MAR and controlled drug record. However, observations and interviews revealed that this policy was not followed, as discrepancies were found between the MAR and the controlled medication log. Med Aide B acknowledged that medication errors could occur if controlled medications were not documented immediately after administration, potentially affecting residents' pain and anxiety management.
Failure to Label Insulin Pen with Opened Date
Penalty
Summary
The facility failed to ensure that all medications were labeled in accordance with currently accepted professional principles, specifically for one resident who was reviewed for medication labeling and storage. The deficiency was identified during an observation of a medication pass, where it was noted that the opened date was not documented on the insulin pen used by a resident. This oversight could potentially lead to the resident receiving expired medication, as insulin pens expire 28 days after being opened if stored at room temperature. The resident involved had multiple diagnoses, including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Anxiety Disorder, Dementia, Hypertension, Hyperlipidemia, and Major Depressive Disorder. The resident's care plan indicated the need for diabetes medications as ordered by a doctor. During the observation, a registered nurse acknowledged the risk of administering expired medication due to the lack of an opened date on the insulin pen. The facility's policy required that all medications and biologicals be labeled with the date they were opened, but this was not adhered to in this instance.
Deficiencies in Documentation and Care for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in documentation and care. For one resident, the facility did not timely document complaints of dysuria on two occasions. The resident, who had a history of urinary tract infections and was on enhanced barrier precautions, reported burning during urination to an LVN, but the complaint was not documented until ten days later as a late entry. The resident continued to experience symptoms without follow-up from staff, and the LVN admitted that if something is not documented, it is considered not to have occurred. Another resident, who was at risk for pressure injuries, had a wound care order that was not documented in the active orders until two days after it was ordered. The resident developed a skin issue to her gluteal fold area, and although wound care was provided, it was not documented in the treatment administration record for several days. The DON stated that the order was PRN and did not require daily documentation, but the audit report showed discrepancies in the order entry date. The facility's policy on documentation requires accurate, complete, and timely records, but the deficiencies observed indicate a failure to adhere to these standards. The lack of timely documentation and follow-up on residents' symptoms and care orders could lead to misinformation about the professional care provided, affecting the quality of care for residents.
Failure to Coordinate Hospice Care and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified during a review of records and interviews, which revealed that the facility did not have the necessary hospice documentation, including the Physician Certification of Terminal Illness and Hospice Election form, for a resident with a terminal prognosis related to malignant neoplasm of the breast. The resident was receiving hospice services, but the facility's records were incomplete, lacking critical documents that are essential for ensuring quality end-of-life care. Interviews with facility staff and hospice representatives highlighted a lack of communication and understanding regarding the required documentation. The Social Worker (SW) responsible for ensuring the presence of hospice documents was unaware of the necessary forms and relied on incorrect information from the hospice company. The Director of Nursing (DON) confirmed that the hospice binder should have included the missing forms upon the resident's admission to hospice. The facility's policy mandates coordination with hospice representatives to ensure comprehensive care, but this was not adequately executed, leading to the identified deficiency.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinent care to a resident. The resident, a female with a history of cerebral infarction, ESBL resistance, and recurrent UTIs, was on enhanced barrier precautions due to her medical history. During the care, the CNAs did not perform hand hygiene between glove changes, despite handling potentially infectious materials. This was observed multiple times as they changed gloves without sanitizing their hands, which is against the facility's hand hygiene policy. The CNAs admitted to being unsure about the necessity of hand hygiene between glove changes, although they acknowledged its importance in preventing infections. The facility's policy clearly states that hand hygiene should be performed before donning and after removing gloves, indicating a lapse in adherence to established protocols. The Director of Nursing confirmed that hand hygiene is required between each glove change to prevent infections, highlighting a gap in staff training or compliance with infection control practices.
Dishwashing Sink Leak and Unsafe Repair
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically a multi-compartment dishwashing sink. During an observation, it was noted that the middle compartment of the dishwashing sink, used for rinsing dishes, was leaking water onto the floor and could not hold water for more than five minutes. A soft, yellowish substance was observed along the inside bottom of the sink, which was used to repair the leak. However, the staff, including the Dietary Supervisor (DS) and Maintenance Supervisor (MS), were unsure if the sealant used was food safe. This uncertainty raised concerns about the potential for dishes not being rinsed correctly, which could lead to foodborne illness for residents consuming food washed in potentially contaminated water.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed with two dumpsters, Dumpster #1 and Dumpster #2. Liquid was leaking from the bottom corner of Dumpster #1, creating large brown and reddish stains on the driveway. During an interview, the DS acknowledged not having noticed the stains before but confirmed the leakage from Dumpster #1. The MS reported that he had been power washing the stained driveway weekly and was awaiting the delivery of new dumpsters, which could take more than a month. The facility's policy on the disposal of garbage and refuse, dated 2024, requires that garbage and refuse containers be durable, cleanable, free from cracks or leaks, and covered when not in use. Additionally, refuse containers and dumpsters kept outside should have tightly fitting lids, doors, or covers, and the surrounding area should be kept clean to minimize debris accumulation and insect or rodent attraction. The facility's failure to adhere to these policies resulted in the observed deficiencies.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect involving two residents within the required timeframes. In the first case, a Licensed Vocational Nurse (LVN) and the Administrator were informed of an allegation of physical and sexual abuse involving a resident who claimed that a Certified Nursing Assistant (CNA) was rough and made her uncomfortable by hugging and kissing her. Despite the resident's severe cognitive impairment and the distress expressed, the allegation was not reported to the state agency as required. In the second case, a CNA and the Administrator were aware of an incident where a resident was transferred using a mechanical lift by a single CNA, contrary to the care plan that required assistance from two staff members. This improper transfer resulted in the resident experiencing transient pain after hitting his head on the headboard. The incident was documented, and the resident was assessed with no immediate injuries observed, but the allegation of neglect was not reported to the state agency. Both incidents involved the same CNA, who was eventually terminated for not following facility policies and procedures. The facility's failure to report these allegations of abuse and neglect to the appropriate authorities within the mandated timeframes could place residents at risk. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention emphasizes the importance of identifying, investigating, and reporting such incidents promptly, which was not adhered to in these cases.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who required two-person staff assistance with mechanical lift transfers. A Certified Nursing Assistant (CNA) transferred the resident by herself using a mechanical lift, which resulted in the resident experiencing transient head pain. The resident was assessed as needing more than one staff member for all transfers due to conditions including Parkinson's disease with dyskinesia and dementia, which affected his cognitive and physical abilities. The incident occurred when the CNA attempted to transfer the resident without assistance, leading to the resident hitting his head on the headboard. The resident's care plan clearly indicated the need for a mechanical lift with two staff members for transfers, and the facility's policy required two staff members for such procedures. Despite this, the CNA proceeded alone, citing a lack of available backup, which was against the facility's established protocols. The facility's records showed that the CNA had been previously educated and in-serviced on the transfer policy, yet she failed to adhere to it. The incident was reported to the Director of Nursing (DON) and the Administrator, who confirmed that the CNA was aware of the policy but chose to act independently. The resident was assessed following the incident, and no injuries were observed, but the failure to follow protocol posed a risk to the resident's safety.
Failure to Use Sterile Technique in Catheter Care
Penalty
Summary
The facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, the facility did not use a sterile technique when flushing the resident's urinary catheter. The resident, a male admitted for long-term care with a BIMS score of 15 indicating no cognitive impairment, had a diagnosis of obstructive and reflux uropathy and retention of urine. The physician's orders required the resident's indwelling urinary catheter to be flushed with 100cc of sterile water twice daily to prevent blockage. On one occasion, LVN A used a non-sterile piston syringe instead of a sterile syringe to flush the resident's catheter, which could place the resident at risk for infection. This was confirmed during an interview with LVN A, who acknowledged the error and reported it to the physician and the resident. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both confirmed that the expectation was to use a sterile technique for catheter irrigation, and the use of a non-sterile syringe did not meet this standard. The facility's catheter irrigation policy also required the procedure to be performed by a licensed nurse under physician orders.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by state and federal laws. During an observation and interview, a state investigator and an RN found Medication cart #1 unlocked and unattended in a public area with six residents present. RN A acknowledged that the cart should not have been unlocked and emphasized the importance of keeping medication carts locked to prevent unauthorized access by residents and visitors. The Director of Nursing (DON) confirmed that the facility's policy required medication carts to be locked when unattended. The DON highlighted the risk of negative outcomes if residents accessed the medications, especially since some residents were mobile and could potentially open the drawers. The responsibility for ensuring the carts were locked fell on the charge nurse, and the RN supervisor, ADON, and DON were expected to check the carts during rounds. The facility's policy on medication storage reiterated the need for all drugs and biologicals to be stored in locked compartments.
Failure to Timely Report Resident Fall with Major Injury
Penalty
Summary
The facility failed to report an allegation of resident neglect involving an unwitnessed fall with a major injury for a resident within the required timeframe of 2 hours. The resident, who was severely cognitively impaired and dependent on assistance for daily activities, was found on the floor after sliding from a Geri chair. Despite the resident indicating he hit his head, the incident was not reported to the State Agency until nearly two months later. The resident had a history of cerebral infarction, traumatic hemorrhage, dementia, and muscle weakness, which contributed to their vulnerability. After the fall, the resident was transferred to a hospital where a CT scan revealed a parenchymal hemorrhagic contusion. Despite the injury, the resident showed no changes in mental or physical functions, which led the facility's administrator to initially believe the injury was not major and did not require immediate reporting. Interviews with facility staff revealed that the resident preferred to be near the nursing station and participate in activities, as being alone in bed caused anxiety. The facility's policy required immediate reporting of such incidents, but the administrator delayed reporting based on the doctor's assessment and the resident's stable condition. This delay in reporting could potentially increase the risk of neglect for all residents due to unreported allegations.
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 779 citations issued within 25 miles in the last 12 months — including the 16 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 Castroville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westover Hills Rehabilitation And Healthcare | 8.6 mi | ★★★★★ | 6 | 0 |
| Legend Oaks Healthcare And Rehabilitation - West S | 8.6 mi | ★★★★★ | 11 | 0 |
| The Mission At Blue Skies Of Texas East | 8.8 mi | ★★★★★ | 0 | 0 |
| Lakeside Nursing And Rehabilitation Center | 9.2 mi | ★★★★★ | 0 | 0 |
| Las Colinas Of Westover | 9.4 mi | ★★★★★ | 18 | 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.