Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Memorial City Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Resident’s cellphone was taken to stop 911 calls. An LVN removed the resident’s phone and kept it at the nurse’s station after the resident repeatedly called 911 and complained of pain. The resident was cognitively intact, had lupus, epilepsy, anxiety, and significant ADL dependence. The roommate reported the resident was crying, using the call light, and calling for help when the phone was taken, and the resident later said she felt anxious, horrible, and mistreated.
A resident with lupus and chronic pain repeatedly pressed her call light, cried out in pain, called 911 twice, and pulled the fire alarm while asking to go to the hospital. The record showed required pain checks were not documented on consecutive days, and staff interviews indicated the resident’s distress was treated as behavior rather than as pain needing prompt assessment and response.
Failure to Offer COVID-19 Vaccine to Residents: The facility did not offer the COVID-19 vaccine to residents because staff believed repeated refusals meant it no longer needed to be offered. The ICPN, DON, MD, and administrator each stated they were unaware residents should still be offered the vaccine and allowed to accept or refuse it. The facility policy required residents and staff to be offered the vaccine, screened for contraindications, and educated before it was offered.
A resident with severe cognitive impairment, muscle weakness, a CVA history, and dependence for multiple ADLs was observed lying in bed with his call light placed on the head of the bed and out of reach. He stated he could not reach it and that it was out of reach most of the time. CNA and RN staff were unaware how it was placed there, and the DON stated call lights were to always be within reach.
Incomplete Transfer and Discharge Notice: A resident with severe cognitive impairment, fractures, pain, and discharge-planning difficulties received a discharge notice for nonpayment that listed an out-of-state address but did not identify a confirmed safe discharge location. The notice also omitted the Ombudsman's name and email address, and staff interviews showed the facility had not verified the discharge destination or provided the notice to the Ombudsman's office.
A resident with dementia, cognitive impairment, and multiple pain-related diagnoses was transferred to the hospital after a cough and family request, but the facility did not properly update and retransmit the MDS discharge information when the anticipated return did not result in readmission. The MDS Nurse said the discharge MDS was completed, but the care plan remained open because the discharge was not manually changed from anticipated return to returned not anticipated, and the quarterly/annual MDS later showed as overdue.
Expired Insulin Pens Kept in Medication Cart: Two residents with orders for insulin glargine had opened insulin pens kept in the med cart beyond the 28-day limit. An RN stated she should have checked the opening dates before each administration and discarded the pens after 28 days, while the DON said nurses were expected to check insulin pen dates before each administration.
Three residents who were dependent on staff for bathing and personal hygiene did not receive scheduled showers or bed baths as required by their care plans, with no documentation of refusals in the EMR or progress notes. Residents reported not being offered baths, and staff interviews confirmed complaints about missed care. The facility's policy required documentation of care and refusals, but this was not consistently followed.
A resident with severe cognitive and mobility deficits was found in bed without access to a call light, which had been placed on the floor and reportedly removed by staff due to frequent use. Staff interviews confirmed the expectation that call lights remain within reach, but there was no specific facility policy in place.
The facility failed to maintain a safe and clean environment for residents, with issues such as damaged and unclean walls, a loose headboard, and improperly stored personal care items. Staff interviews revealed a lack of communication and follow-up on maintenance and housekeeping issues, impacting residents' well-being and infection control.
The facility failed to provide appropriate respiratory care and equipment storage for several residents, leading to deficiencies. A resident received oxygen at a higher rate than prescribed, and multiple residents had respiratory equipment improperly stored, increasing infection risk. Staff did not consistently follow procedures for storing and labeling equipment, and the facility's policy lacked specific requirements, contributing to the oversight.
A facility failed to maintain proper infection control during tracheostomy care for a resident with severe cognitive impairment and multiple medical conditions. RN A and LVN B did not dispose of used materials in a biohazard bag, instead placing them in a clear trash bag and a linen container. Both staff members acknowledged the correct procedure but did not follow it, potentially leading to infection control issues.
The facility failed to maintain an effective pest control program, leading to the presence of pests in resident rooms. A live roach was found on a resident's bed during medication administration, and a spider was observed on the wall near another resident's bed. Staff reported these incidents, but pest control records showed no recent concerns, despite some ant activity and flies being noted. The facility's housekeeping policy requires a clean environment, but the presence of pests indicates a lapse in this standard.
A shower room was found with soiled towels, used personal care containers, gloves, hair, and dirty floors with stains and debris. Staff interviews revealed unclear procedures and inconsistent communication regarding cleaning responsibilities between CNAs, nursing, and housekeeping. Facility policies required a clean and sanitary environment, but these were not followed, resulting in an unclean and uncomfortable shower room for residents.
A resident with multiple chronic conditions received ongoing anticoagulant medication monitoring for aspirin administration without an active physician order for anticoagulant therapy. Documentation and interviews revealed confusion regarding the purpose of aspirin and a lack of clear, accurate medical records, resulting in monitoring that was not supported by current physician orders.
A resident with Alzheimer's disease who required assistance with mobility developed an unstageable pressure ulcer to the buttocks due to the facility's failure to implement and document required pressure ulcer prevention measures, such as frequent turning and repositioning. Staff interviews and record reviews confirmed that care plan interventions were not consistently followed, and there was no system in place to ensure compliance with pressure injury prevention protocols.
A resident with severe cognitive impairment and high fall risk experienced multiple falls without updates to their care plan. The facility failed to ensure the resident's bed was in the lowest position and did not implement new interventions after falls, leading to injuries. Staff interviews revealed confusion about care plan responsibilities after the MDS nurse quit, contributing to the deficiency.
A resident with severe cognitive impairment and on anticoagulant therapy experienced multiple falls due to inadequate supervision and failure to update the care plan with necessary interventions. Despite being a known fall risk, the resident's care plan was not revised after falls, and staff were unaware of the necessary interventions. Observations revealed environmental hazards, such as the absence of a fall mat and an unreachable call light, contributing to the resident's risk of harm.
A resident's bathroom in the facility was found to be in an unsanitary and unsafe condition, with a leaking toilet base and a strong odor of urine. Despite the resident's report of the issue persisting for months, staff interviews revealed a lack of timely action to address the problem. The resident's care plan emphasized the need for a safe environment due to fall risks, yet the bathroom's condition was neglected, posing a potential hazard.
The facility failed to maintain an effective pest control program, with numerous gnats observed in resident rooms and a live roach at the nurses' station in the 300 hall area. Residents expressed discomfort due to the persistent presence of gnats, and a roach was found near unsealed snacks. Staff interviews revealed a lack of a specific pest control policy, despite claims of proactive management.
The facility failed to respond to call lights in a timely manner, affecting four residents with various medical conditions. One resident was found in an unclean room with feces on the floor, while another experienced delays in call light responses, taking over 30 minutes. Two other residents reported dissatisfaction with nursing services due to delayed responses, with one stating the night shift did not respond at all. These issues were supported by grievances filed by other residents, indicating a systemic problem within the facility.
The facility failed to respond to call lights in a timely manner, affecting several residents with various medical conditions. One resident was found in an unclean environment due to unaddressed call lights, while others reported waiting over 30 minutes to an hour for assistance. Despite attempts by the DON to address the issue, persistent complaints and grievances indicate ongoing neglect in providing prompt care.
The facility failed to maintain an effective pest control program, resulting in a persistent roach infestation in residents' rooms, nursing stations, and common areas. Despite multiple treatments from February to July 2024, roach activity continued, with staff and residents reporting sightings. The maintenance supervisor admitted to being unaware of the pest control policy, and the DON acknowledged the ongoing issue. The facility's pest control efforts were inconsistent, failing to adhere to the policy requiring monthly servicing and prompt response to pest issues.
A resident with a history of cerebral infarction and dementia experienced respiratory distress, but the LTC facility failed to provide timely care. Despite being unresponsive and having low oxygen saturation, immediate interventions were not initiated. The NP's attempts to provide care were hindered by a malfunctioning suction machine, and emergency services were delayed. The resident was later declared brain dead and expired after support was removed.
Resident’s cellphone was taken to stop 911 calls
Penalty
Summary
The facility failed to ensure a resident remained free from abuse when an LVN removed the resident’s cellphone and kept it at the nurse’s station as a way to stop the resident from calling 911. The resident was cognitively intact with a BIMS score of 15 and had diagnoses including lupus, epilepsy, anxiety disorder, obesity, pain in unspecified joints, stiffness, muscle wasting and atrophy, cognitive communication deficit, and need for assistance with personal care. The resident was dependent for multiple ADLs, including toileting, bathing, dressing, footwear, and personal hygiene, and was always incontinent of bowel and bladder. The record showed that the resident had called 911 multiple times during the night and had also attempted to pull the fire alarm. The LVN stated that after the resident passed her a cellphone and 911 was on the line, she told the operator the resident was fine and hung up. She later stated that, as an intervention to prevent further 911 calls, she and a CNA got the resident out of bed and she took the resident’s cellphone to the nurse’s station. She acknowledged she did this to prevent the resident from making additional 911 calls and said she thought she was doing the right thing. The resident’s roommate stated the resident had been crying, pressing the call light, and calling the front desk from her cellphone for help, and that the LVN took the phone from the resident while 911 was still on the line. The resident later stated that when staff took her phone to prevent her from calling 911 and would not address her pain, she felt anxious, horrible, and mistreated. The MD stated she would not expect staff to take a resident’s phone as an intervention to avoid 911 calls, and the DON stated taking a resident’s cellphone could be considered abuse and could hinder the resident’s ability to call 911.
Failure to Address Resident Pain and Requests for Help
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with lupus, epilepsy, anxiety, obesity, joint pain, stiffness, muscle wasting and atrophy, and cognitive communication deficit. The resident’s care plan identified her as at risk for pain and discomfort related to lupus, and she had standing and newly added pain-related orders, including scheduled acetaminophen-codeine and gabapentin, along with an order for a lumbar spine x-ray after she reported pain. On 03/04/2026, the resident repeatedly sought help during the early morning hours. The report states she pressed her call light, cried out in pain, called 911 twice, and pulled the fire alarm while requesting to go to the hospital. A roommate stated the resident woke up crying in pain around 4:00 a.m., called the facility front desk from her cellphone, and called 911 again after staff responded. The roommate also stated the resident continued yelling for assistance until about 5:00 a.m., when staff got her out of bed and into a wheelchair, and later returned her to bed after the fire alarm was activated. The resident’s record showed pain monitoring was required every shift using a 0-10 scale, but no pain levels were recorded on 03/03/2026 or 03/04/2026. The record also showed that after the resident reported pain, a nurse completed a pain evaluation and medication was administered, and later that day the MD documented severe, sharp pain that was worse than usual and ordered additional pain treatment and imaging. Staff interviews reflected that the resident’s calls to 911 were treated as behavior rather than as pain-related distress, and one nurse stated she told 911 the resident was fine and removed the resident’s cellphone. The report states the facility failed to monitor and address the resident’s pain during the period when she was repeatedly seeking help and requesting hospital transfer.
Failure to Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure each resident was offered the COVID-19 vaccine unless the immunization was medically contraindicated or the resident had already been immunized. During interviews, the ICPN stated the facility did not offer COVID vaccines to residents because residents and their representatives always declined the vaccination, so the facility stopped offering it. She stated she was unaware the facility should have continued to offer the vaccine and allow residents to accept or refuse it, and she did not recall when the facility stopped offering it. The DON, MD, and administrator each stated they were unaware the facility should have offered the COVID vaccine to residents and allow them to accept or refuse it, and each did not recall when the facility stopped offering the vaccine. Record review of the facility’s Infection Control Policy dated 05/13/2023 showed residents and staff were to be offered the COVID-19 vaccine when supplies were available, screened for prior immunization and contraindications, and given education about the vaccine before it was offered. CDC ACIP recommendations dated October 2024 stated adults aged 65 years and older should receive 2 doses of the 2024-2025 COVID-19 vaccine, and CDC COVID recommendations dated 11/19/2025 stated the vaccine helps protect against severe illness, hospitalization, and death and is especially important for persons ages 65 and older.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure Resident #38’s call light was within reach while he was lying in bed. Resident #38 was a male admitted to the facility with diagnoses including cerebral infarction, muscle weakness, and a history of falling. His admission MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and he was dependent on staff for personal hygiene, toileting hygiene, showering, upper body dressing, and lower body dressing. He was also always incontinent of bladder and bowel and used a wheelchair for mobility. His care plan identified an ADL self-care performance deficit related to cerebral infarction and noted he was at risk for falls related to cerebral infarction and muscle weakness. A progress note stated the resident’s bed was to be in the lowest position and the call light within reach. However, during observation, the resident was found lying in bed with the call light placed on the head of the bed and out of reach. The resident stated he could not reach it and said it was out of his reach most of the time. CNA Q stated he was unaware how the call light was placed out of reach and said he checked call light placement every morning and whenever he went to residents’ rooms. RN Q stated she was unaware why the call light was not within reach and said she checked call lights when providing care. The DON stated residents’ call lights were to always be within reach and that staff were expected to round every 2 hours and ensure call lights were within reach.
Incomplete Transfer and Discharge Notice
Penalty
Summary
The facility failed to ensure that the written notice of transfer or discharge for a resident contained all federally required elements. The notice for the resident, who had severe cognitive impairment with a BIMS score of 00 and a history of fractures, radial nerve injury, chronic pain, and difficulty with discharge planning, did not include a safe discharge location. The notice also did not contain the Ombudsman's name and email address. The resident had been admitted after a fall with multiple fractures and had ongoing issues with pain, mobility limitations, and refusal of some assessments and services. Progress notes reflected repeated discharge planning discussions, concerns about nonpayment, and the resident's refusal to provide financial information or cooperate with placement planning. The facility issued a 30-day discharge notice for nonpayment and listed an out-of-state address as the discharge location, but later interviews showed the facility had not contacted anyone at that address and could not confirm that it was a safe discharge location. During interviews, facility staff stated the resident had not provided enough information to identify a safe discharge plan and that the discharge notice lacked the Ombudsman information. The Ombudsman also stated the facility had not provided her office with a copy of the discharge notice. The facility's policy required the notice to include the specific reason for discharge, effective date, discharge location, appeal rights, appeal assistance information, and the Ombudsman's contact information, but the notice reviewed by surveyors did not contain all of those required elements.
MDS Discharge Assessment Not Properly Updated After Hospital Transfer
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete MDS data to the CMS system for one closed record, CR #154. CR #154 was admitted with diagnoses including right shoulder pain, unspecified fall, pain in unspecified joint, muscle wasting and atrophy of multiple sites, cognitive communication deficit, need for assistance with personal care, and dementia with no behavioral, psychotic, mood, or anxiety disturbance. A comprehensive MDS reflected a BIMS score of 08, indicating moderate impaired cognition. The discharge MDS reflected an unplanned discharge with anticipated return due to a short-term hospital transfer. CR #154 developed a cough on 01/20/2026, and the change-of-condition form documented that family wanted the resident sent to the hospital. The NP was notified and orders were given for a stat CXR, guaifenesin, and DuoNeb PRN. Progress notes show the family requested hospital transfer related to the cough, the DON was informed, and CR #154 was transported by EMS to the hospital on 01/23/2026. Additional notes reflected ongoing discussion with family about Medicare coverage and financial responsibility, and the facility admission, transfer, discharge log showed the resident discharged on 01/23/2026. On review of the record on 04/23/2026, CR #154's quarterly/annual MDS was 77 days overdue. During interview, the MDS Nurse stated she was responsible for transmitting MDS discharges and said the discharge MDS had been completed on 01/23/2026, but the care plan was not closed because the resident did not return within 30 days and the system did not generate the expected notification. RRN A stated that when a resident discharges with anticipated return and does not readmit, the facility must manually complete a discharge deletion so the care plan closes and no further MDS tasks trigger, and he stated the discharge was not manually changed from anticipated return to returned not anticipated. The facility policy stated that a significant correction assessment must be completed no later than the 14th calendar day after determination that a significant error occurred and that a Part A PPS discharge assessment must be completed within 14 days after the end date of the most recent Medicare stay.
Expired Insulin Pens Kept in Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when it did not ensure that opened insulin glargine pens were dated and discarded within 28 days of opening for Resident #30 and Resident #41. Resident #30 had an active order dated 04/09/2026 for insulin glargine 100 units/ml multiple-dose pen, 20 units SQ daily for diabetes. Resident #41 had an active order dated 03/11/2026 for insulin glargine 100 units/ml multiple-dose pen, 30 units SQ daily for diabetes. During an observation of Hall 100's medication cart on 04/24/2026 at 12:08 p.m., staff were found to have opened and dated two insulin glargine 100 units/ml multiple-dose pens for Resident #30 and Resident #41 and kept them in the medication cart beyond 28 days from the opening date. Both pens had been opened and dated on 03/23/2026. RN Q stated she should have checked the opening dates before each administration and discarded the pens after 28 days of opening, and said she was unaware the pens were expired. The DON stated she expected nurses to check insulin pen opening dates before each administration and discard them after 28 days, and that she spot checked insulin pens for expiration dates weekly.
Failure to Provide Scheduled Bathing and Hygiene Services to Dependent 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 grooming and personal hygiene. Specifically, three residents who required substantial or total assistance with bathing did not receive scheduled showers or bed baths on multiple occasions, as documented in their care plans and electronic medical records (EMR). The missed care was not attributed to resident refusals, as there was no documentation of refusals in the progress notes or EMR for these residents, and interviews with the residents confirmed they had not refused care. One resident, a female with a history of pelvic fracture, anemia, and left upper limb nerve lesion, was bedbound and required maximal assistance for bathing. She was frequently incontinent and her care plan specified scheduled bathing three times per week. However, records showed she received only one bath and one documented refusal over a month, missing numerous scheduled baths. She reported to surveyors that staff did not offer her baths and were rude when she requested them. Another resident, a male with heart failure, COPD, quadriplegia, and other chronic conditions, was dependent on staff for all bathing and was always incontinent. His records showed no data for bathing tasks and only two refusals documented in progress notes, despite missing all scheduled baths during the review period. He also reported not receiving scheduled showers and that staff told him they were too busy. A third resident, a female with multiple sclerosis, osteoarthritis, and an indwelling catheter, was dependent on staff for all personal hygiene and had a stage 4 pressure ulcer. Her records indicated only one bed bath documented in the EMR and no refusals, despite missing all other scheduled baths. She stated she received maybe two baths a week and could not recall her last bath. Staff interviews revealed inconsistent knowledge of which residents refused care, and several staff members acknowledged receiving complaints from residents about not getting showers or baths. The facility's policy required documentation of care and refusals in the EMR, but this was not consistently done for the affected residents.
Failure to Ensure Resident Access to Call Light in Bed
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical diagnoses, including vascular dementia, Alzheimer's disease, and mobility deficits, did not have access to a functioning call light while in bed. Observation revealed the call light was on the floor, out of the resident's reach, and the resident reported that staff had removed it from her room because she used it too frequently. The resident's care plan specifically required that the call light be within reach due to her risk for falls and need for staff assistance with activities of daily living. Interviews with staff confirmed that all personnel were responsible for ensuring call lights were accessible to residents, and that call lights should not be left on the floor. The nurse on duty acknowledged the importance of call light accessibility, especially for residents with confusion and mobility issues. The Director of Nursing stated that monthly in-services were conducted on call light procedures, but also confirmed that the facility did not have a specific written call light policy.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as observed during a survey. In the rooms of three residents, there were issues with damaged and unclean walls. One resident's room had missing paint, another had a hole in the wall with a TV plug hanging out and dirty walls, and a third had chipped paint along the baseboard. Additionally, a resident's headboard was loose and moving, and there were brown stains and a hole with exposed wiring on the walls. These conditions were not reported or addressed in a timely manner, as evidenced by interviews with staff who were unaware of the issues. The facility also failed to properly label and store personal care items for a resident, which is necessary for infection control. A wash basin was found on a nightstand and another in the bathroom, both unlabeled and not bagged. The CNA responsible for the resident acknowledged the importance of labeling and bagging personal care items to prevent cross-contamination but did not ensure it was done. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Housekeeping Supervisor, and Maintenance Director revealed a lack of communication and follow-up on maintenance and housekeeping issues. The DON stated that staff were supposed to report environmental issues to maintenance, but the Maintenance Director was unaware of the problems in the resident's room. The Housekeeping Supervisor noted that rooms should be cleaned daily, but the walls in one resident's room were not cleaned as required. The ADON and CNA also expressed concerns about the impact of these deficiencies on residents' well-being and infection risk.
Inadequate Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, leading to deficiencies in the care provided. Resident #14 was observed receiving oxygen at 8L/min, contrary to the physician's order of 6L/min. This discrepancy was noticed by LVN A, who confirmed the correct order with LVN B and adjusted the oxygen level accordingly. Despite the adjustment, the initial oversight placed the resident at risk of receiving inappropriate oxygen levels. Multiple residents, including Residents #21, #11, #17, #43, and #86, were found to have respiratory equipment improperly stored, increasing the risk of respiratory infections. Resident #21's nebulizer machine was found on the floor, and the tubing was not stored properly. Similarly, Resident #11's nebulizer tubing and mask were not dated or stored in a plastic bag, and Resident #17's oxygen tubing was left on the floor. Resident #43 and Resident #86 also had oxygen tubing on the floor, which was not stored in a clean and sanitary location. The facility's failure to adhere to professional standards of practice and the residents' care plans resulted in inadequate respiratory care. The observations and interviews revealed that the staff did not consistently follow procedures for storing and labeling respiratory equipment, which is crucial for infection control. The DON acknowledged the importance of proper storage and labeling but noted that the facility's policy did not specify these requirements, contributing to the oversight.
Improper Disposal of Biohazard Materials During Tracheostomy Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper disposal of biohazard materials during tracheostomy care for a resident. During an observation, RN A and LVN B completed tracheostomy suctioning for a resident but failed to dispose of used materials, including gauze, gloves, and a tracheostomy inner tube with bodily fluids, in a biohazard bag. Instead, these materials were placed in a clear trash bag and then in a container used for linen, which is not the correct procedure for handling biohazardous waste. The resident involved was a male with severe cognitive impairment and multiple medical conditions, including anoxic brain damage, tracheostomy status, and pneumonia. Interviews with LVN B and RN A revealed that they were aware of the proper procedure for disposing of biohazard materials but did not follow it. LVN B acknowledged that the failure to use a biohazard bag could lead to infection control issues, while RN A admitted that the materials should have been double-bagged and placed in a biohazard bag before being taken to the soiled utility room. The facility's Equipment Protocol policy requires potentially contaminated items to be placed in an impervious clear plastic bag labeled as contaminated and processed accordingly.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in resident rooms. During a medication pass, a live roach was observed crawling on the side of a resident's bed, and a Licensed Vocational Nurse (LVN) had to brush it away with a face towel while administering medication through a gastric tube. In another instance, a spider was found on the wall near a resident's bed, and a Certified Nursing Assistant (CNA) had to remove it using a towel. The CNA mentioned that pest sightings are reported in the facility's computer system and noted that pests tend to appear when it rains. Interviews with the Director of Nursing (DON) and the Maintenance Director revealed that they were aware of the pest issues, but no recent concerns had been reported by pest control. The Maintenance Director mentioned that work orders, including those for pest control, are checked daily, and ambassadors are responsible for reporting environmental issues. A review of the facility's pest control records showed visits by pest control on three occasions, with no sightings of roaches or spiders, but some ant activity and flies were noted. The facility's housekeeping policy emphasizes maintaining a clean and orderly environment, yet the presence of pests indicates a lapse in this standard.
Failure to Maintain Clean and Safe Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in one of the two shower rooms on Hall 400. During an observation, the shower room was found with large soiled towels on the floor, used empty containers of personal care items on wood shelving, gloves on the floor, and a ball of white hair. The floor was dirty with brown and black stains, and there was debris behind the shelving. These conditions were directly observed by a CNA, who acknowledged the uncleanliness and began cleaning the room during the survey. Interviews with staff revealed confusion and inconsistency regarding responsibility and procedures for cleaning the shower room. The CNA stated that CNAs were not supposed to leave items behind and that both nursing staff and housekeeping were responsible for cleanliness. However, the communication process for requesting cleaning was unclear, with references to a missing communication book and possible computer-based communication that could not be demonstrated. Housekeeping staff confirmed that the shower room should be cleaned at least daily and as needed, but acknowledged that the room had not been cleaned the previous day. The Environmental Service Department also stated that cleaning between uses was important for infection control, but the room had not yet been cleaned on the day of observation. Review of facility policies indicated requirements for maintaining a safe, sanitary, and comfortable environment, with specific mention of infection prevention and control, general housekeeping, and resident rights to clean conditions. Despite these policies, the observed state of the shower room and staff interviews demonstrated a failure to adhere to established procedures, resulting in an unclean and uncomfortable environment for residents using the shower room.
Failure to Maintain Accurate Physician Orders for Anticoagulant Monitoring
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not having a current physician order for anticoagulant medication, despite ongoing monitoring for anticoagulant effects. Record review showed that the resident, an elderly female with multiple diagnoses including muscle wasting, COPD, dementia, hypertension, chronic pain, and polyosteoarthritis, had orders for anticoagulant monitoring tied to aspirin administration. However, there was no active physician order for an anticoagulant medication at the time the monitoring was being performed. Documentation indicated that the resident received anticoagulant monitoring every twelve hours for aspirin, with changes in dosage and discontinuation dates, but without a corresponding active order for anticoagulant therapy. Interviews with the DON revealed confusion regarding the purpose of aspirin therapy and the rationale for continued monitoring, as well as a lack of clarity in documentation. The facility's medication administration policy requires medications to be administered as ordered by the physician and in accordance with professional standards, which was not followed in this case.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
A resident with Alzheimer's disease, who required assistance with activities of daily living and was at risk for pressure ulcers, developed an unstageable pressure ulcer to the bilateral buttock while under the facility's care. The resident's care plan included interventions such as frequent turning and repositioning, as well as weekly skin checks, but there was no documentation that these interventions were consistently implemented. Skin assessments completed prior to the incident did not indicate any skin breakdown, and there was no documentation of turning and repositioning in the clinical record. Staff interviews revealed that the resident had not been getting out of bed for several days prior to hospital transfer, and CNAs were unable to confirm how often the resident was turned or repositioned. The wound care nurse and other staff acknowledged that the wound was acquired at the facility and could have been prevented with proper repositioning. The Director of Nursing (DON) admitted there was no system in place to monitor whether the resident was being turned as required by facility policy, and that this failure placed residents at risk for skin breakdown and pressure injuries. Upon discovery of the wound, the resident was found to have an open area with dark discoloration and drainage, and was subsequently transferred to the hospital, where the wound was assessed as unstageable. The family and hospital staff confirmed the presence of the wound and the resident's critical condition upon admission. The facility's failure to implement and document pressure ulcer prevention interventions, as outlined in the care plan and facility policy, directly contributed to the development of the unstageable pressure ulcer.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not ensure that the resident's bed was in the lowest position as per the care plan while the resident was in bed. Additionally, the facility did not update the resident's care plan with new interventions after the resident experienced three falls, which placed the resident and other fall-risk residents at risk of serious harm and injury. The resident involved was a male with Fragile X syndrome, muscle weakness, unspecified falls, lack of coordination, and cognitive communication deficit. He had a BIMS score of 0, indicating severe cognitive impairment, and required total assistance for sit-to-stand and bed transfers. Despite being at high risk for falls, as indicated by multiple fall risk evaluations, the facility did not update the resident's care plan with new interventions following his falls, which included injuries such as a hematoma and skin tears. Interviews with facility staff revealed a lack of communication and responsibility regarding updating the resident's care plan. The MDS nurse responsible for the resident's care plan had recently quit, and there was confusion among staff about who should update the care plan. Despite discussions in morning meetings about the resident's falls, the care plan was not updated, and staff were not informed of new interventions. This lack of action and communication contributed to the deficiency identified by surveyors.
Removal Plan
- Resident #1 was reassessed by Director of Nursing head to toe for injury and pain. The MD was notified of the findings with no new orders received.
- Resident #1 was reassessed by the Director of Nursing and/ or designee related to use of Plavix and potential side effects, as well as falls, fall risk and fall interventions with no concerns noted. The MD was notified with no new orders were received.
- The IDT reviewed Resident #1's plan of care related falls, injuries, pain and use medication Plavix. The plan of care was updated to reflect interventions regarding falls, injuries, pain and pharmacy consult medication as indicated and the RP was notified.
- The Director of Nursing and/ or designee reassessed residents who sustained falls head to toe for pain and injury with no new concerns.
- The Director of Nursing and/ or designee reviewed the status of resident injuries sustained from falls with no concerns for appropriate treatment, care plan interventions and resolutions.
- The Director of Nursing and/ or designee reviewed the fall risk assessments for current residents for timely completion where indicated fall risk was reassessed and updated.
- The IDT reviewed the falls care plans for residents identified to be at high risk for falls and/ or residents with physician orders for an anticoagulant for appropriate interventions and implementation. There were updates completed as indicated.
- The Director of Nursing and/ or designee reviewed the progress notes to ensure resident falls and/ or changes in condition related to falls were identified and addressed. There were no concerns noted.
- The Director of Nursing and/or designee educated staff on updated care plans. Care Plans and/or interventions will be updated by the nursing staff at the time of occurrence. Care Plan policy was reviewed and there were no updates. The Kardex and tasks will be updated to ensure DCS are aware of interventions placed in the care plans. Nursing staff were reeducated on reviewing the Kardex and task for updated interventions.
- The Director of Nursing and/ or designee reviewed the care plans for current residents who sustained falls for implementation of interventions to address the fall. Where applicable the care plans were modified for individualization.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on fall prevention and the Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls.
- The Regional Clinical Specialist reeducated the Director of Nursing on the Incident and Accident Policy.
- The Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. Resident changes in condition to include new and/ or repeat falls, changes in cognition and/ or gait and ADL status.
- The Director of Nursing and/ or designee began reeducation for the IDT (Administrator, Licensed Nurses, Social Work, Care Management Nurses, Activities Director, Director of Rehab, Dietary Manager) on the policy for comprehensive care plans. Re-education included timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions.
- The Director of Nursing and/ or designee began reeducation with 100% of Licensed Nurses on the Incident and Accident policy to include: Accident and Incident report completion and documentation requirements e.g. immediate actions/ interventions to prevent a fall and supervise residents. Resident fall risk and fall risk reassessment, fall interventions and timeliness, resident supervision related to falls, as well as risk for injury from falls related to use of anticoagulant medication. Resident monitoring and PN documentation post fall (minimum of 72 hours). Changes in condition, to include notifications, interventions, documentation, monitoring and follow-up. Completion of resident skin evaluations, wound assessment forms, pain assessments, treatment orders, monitoring and care plans.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, DON and/or designee prior to the start of their next scheduled shift.
- The Director of Nursing/ designee will review the 24-hour report for any changes in condition related to new falls or risk for falls. Ensure the physician is notified timely and that actions are taken timely to address the change in condition, actual fall and/ or fall risk.
- An Ad Hoc QAPI was conducted attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 656- Develop/Implement Comprehensive Care Plan.
- The Director of Nursing will monitor the following daily for 30 days, then three times weekly for two months. Changes in condition, to include resident falls. DON will ensure falls are promptly addressed by reviewing the 24-hour report and residents clinical records during the Morning Clinical Meeting Accident and Incidents for completion, immediate interventions and care planning, completion of assessments and notifications. Resident falls and anticoagulant medication are care planned for new falls and new orders for anticoagulants. Skin evals, wounds assessments forms and orders for injuries resulting from Incidents and Accidents.
Inadequate Supervision and Care Plan Updates for Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions for a resident who was a known fall risk and was prescribed an anticoagulant. This deficiency resulted in multiple falls, including incidents on 7/21/2024, 9/14/2024, and 9/15/2024, which led to injuries and hospitalization. The resident, who had severe cognitive impairment and required total assistance for mobility, was not adequately monitored, and his care plan was not updated following these falls. The resident's care plan, which should have included specific interventions to prevent falls, was not revised after the incidents. Despite being identified as high risk for falls, the care plan lacked updated interventions to address the resident's behavior of leaning forward in his wheelchair and pulling up on handrails. Interviews with facility staff revealed a lack of communication and responsibility regarding the updating of care plans, with staff unaware of the resident's recent falls and the necessary interventions. Observations showed that the resident's environment was not adequately adjusted to prevent falls, such as the absence of a fall mat by the bed and the call light being out of reach. The facility's failure to update the care plan and implement effective fall prevention measures placed the resident at risk of serious harm, as evidenced by the repeated falls and injuries.
Removal Plan
- Resident #1 was reassessed by Director of Nursing head to toe for injury and pain. The MD was notified of findings with no new orders received.
- Resident #1 was reassessed by the Director of Nursing and/ or designee related to use of Plavix and potential side effects, as well as falls, fall risk and fall interventions with no concerns noted. The MD was notified with no new orders received.
- The IDT reviewed Resident #1's plan of care related falls, injuries, pain and use medication Plavix. The plan of care was updated to reflect interventions regarding falls, injuries, pain and pharmacy consult medication as indicated and the RP was notified.
- The Director of Nursing and/ or designee reassessed residents who sustained falls head to toe for pain and injury with no new concerns.
- The Director of Nursing and/ or designee reviewed the status of resident injuries sustained from falls with no concerns in the last 30 days for appropriate treatment, care plan interventions and resolutions.
- The Director of Nursing and/ or designee reviewed the fall risk assessments for current residents for timely completion where indicated fall risk was reassessed and updated.
- The IDT reviewed the falls care plans for resident identified to be at high risk for falls and/ or residents with physician orders for an anticoagulant for appropriate interventions and implementation. There were updates completed as indicated.
- The Director of Nursing and/ or designee reviewed the progress notes for the last 30 days to ensure resident falls and/ or changes in condition related to falls were identified and addressed. There were no concerns noted.
- The Director of Nursing and/or designee educated staff on updated care plans. Care Plans and/or interventions will be updated by the nursing staff at the time of occurrence. Care Plan policy was reviewed and there were no updates. The Kardex and tasks will be updated to ensure DCS are aware of interventions placed in the care plans. Nursing staff were reeducated on reviewing the Kardex and task for updated interventions.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk.
- The Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on fall prevention and the Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls.
- The Regional Clinical Specialist reeducated the Director of Nursing on the Incident and Accident Policy.
- The Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. Resident changes in condition to include new and/ or repeat falls, changes in cognition and/ or gait and ADL status.
- The Director of Nursing and/ or designee began reeducation for the IDT (Administrator, Licensed Nurses, Social Work, Care Management Nurses, Activities Director, Director of Rehab, Dietary Manager) on resident care plans, timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions.
- The Director of Nursing and/ or designee began reeducation with 100% of Licensed Nurses on the Incident and Accident policy to include: Accident and Incident report completion and documentation requirements e.g. immediate actions/ interventions to prevent a fall and supervise residents. Resident fall risk and fall risk reassessment, fall interventions and timeliness, resident supervision related to falls, as well as risk for injury from falls related to use of anticoagulant medication. Resident monitoring and PN documentation post fall (minimum of 72 hours). Changes in condition, to include notifications, interventions, documentation, monitoring and follow-up. Completion of resident skin evaluations, wound assessment forms, pain assessments, treatment orders, monitoring and care plans.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, DON and/or designee prior to the start of their next scheduled shift.
- The Director of Nursing/ designee will review the 24-hour report for any changes in condition related to new falls or risk for falls. Ensure the physician is notified timely and that actions are taken timely to address the change in condition, actual fall and/ or fall risk.
- An Ad Hoc QAPI was conducted attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 689-Accidents/ Supervision.
- The Director of Nursing will monitor the following daily for 30 days, then three times weekly for two months. Changes in condition, to include resident falls. DON will ensure falls are promptly addressed by reviewing the 24-hour report and residents clinical records during the Morning Clinical Meeting. Accident and Incidents for completion, immediate interventions and care planning, completion of assessments and notifications. Resident falls and anticoagulant medication are care planned for new falls and new orders for anticoagulants. Skin evals, wounds assessments forms and orders for injuries resulting from Incidents and Accidents.
Failure to Maintain a Safe and Clean Environment for a Resident
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the condition of the resident's bathroom. The resident's toilet base was stained and dirty, and the toilet was in disrepair, with a liquid substance leaking from its base. The bathroom emitted a strong odor of urine, and the resident reported that the issue had persisted for months despite informing staff. The resident's care plan highlighted the need for a safe environment due to his risk of falls, yet the unsanitary and unsafe bathroom conditions were not addressed. Interviews with facility staff revealed a lack of awareness and action regarding the resident's bathroom condition. The Activity Director noted the toilet's dirtiness and submitted a maintenance request but did not observe the water on the floor. The DON acknowledged the missing ring around the toilet base, which contributed to the leak, and recognized the potential hazard for the resident, who occasionally stood up from his wheelchair. The Maintenance Director admitted to not having inspected the resident's room before and identified issues with the toilet's caulking and wax ring, which had deteriorated over time, leading to the unsanitary conditions.
Pest Control Deficiency in Resident Rooms and Nurses' Station
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous gnats and a live roach in the 300 hall area. Observations and interviews revealed that gnats were present in the rooms of four residents, causing discomfort and frustration. One resident expressed that the gnats were particularly bothersome as he spent most of his time in his room. Another resident mentioned that despite pest control spraying, the gnats persisted, making him uncomfortable in his living space. Additionally, a live roach was observed at the nurses' station, emerging from a pest control book, with snacks nearby that were not fully sealed. Interviews with facility staff, including the Maintenance Director and the Director of Nursing (DON), indicated that pests such as gnats and roaches were not acceptable in resident areas. The Maintenance Director acknowledged that roaches could access snacks left at the nurses' station, and the DON stated that staff should document pest sightings in the pest control binder. The facility administrator mentioned that the facility did not have a specific pest control policy but relied on the pest control company's program specifications. Despite claims of proactive pest management, the presence of pests in resident rooms and the nurses' station was noted, with pest control services reportedly conducted weekly.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity by not responding to call lights in a timely manner, affecting four residents. Resident #1, a female with hypertension, atrial fibrillation, and type 2 diabetes, was found in an unclean room with feces on the floor and a full commode. Her representative reported that the resident's call light was not answered, leading to an accident when she attempted to use the commode by herself. Resident #2, a male with rhabdomyolysis, acute kidney failure, and hypothyroidism, also experienced delays in call light responses, with reports indicating it took over 30 minutes for staff to respond. Resident #3, a male with type 2 diabetes, hypertension, and poly-osteoarthritis, expressed dissatisfaction with the nursing service due to the delayed response to call lights, which often went unanswered for over 30 minutes. Resident #4, a male with epilepsy, Todd's paralysis, hypertension, and schizoaffective disorder, reported that the response time for call lights was about an hour, with no response from the night shift. These delays in responding to call lights were corroborated by grievances filed by other residents, indicating a systemic issue within the facility. The facility's policy on resident rights emphasizes the importance of dignity and respect, which was not upheld in these instances. Interviews with staff and residents revealed ongoing issues with call light response times, despite in-service training and attempts by the DON to address the problem. The facility's failure to respond promptly to call lights compromised the residents' quality of life and their ability to exercise their rights to self-determination and communication.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to treat residents with respect and dignity by not responding to call lights in a timely manner, affecting four residents. Resident #1, a female with hypertension, atrial fibrillation, and type 2 diabetes, was found in an unclean environment with feces on the floor and a full commode. Her representative reported that the call light was not answered, leading to an accident when the resident attempted to use the commode by herself. Resident #2, a male with rhabdomyolysis, acute kidney failure, and hypothyroidism, also experienced delayed responses to call lights, with reports indicating it took over 30 minutes for staff to respond. Resident #3, a male with type 2 diabetes, hypertension, and poly-osteoarthritis, expressed dissatisfaction with the nursing service due to the delayed response to call lights, which often went unanswered for over 30 minutes. Resident #4, a male with epilepsy, Todd's paralysis, hypertension, and schizoaffective disorder, reported that the response time for call lights was about an hour, with no response from the night shift. These delays in responding to call lights were corroborated by grievances filed by other residents, indicating a pattern of neglect in addressing residents' needs promptly. Interviews with staff and residents revealed ongoing issues with call light response times, with some residents waiting over an hour for assistance. The Director of Nursing acknowledged the problem and had attempted to address it by in-servicing staff and conducting unannounced visits. However, the persistent complaints and grievances suggest that the measures taken were insufficient to resolve the issue, leading to a failure in providing a safe, clean, and dignified environment for the residents.
Persistent Roach Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent infestation of roaches in various areas, including residents' rooms, nursing stations, medication carts, hallways, and the reception area. The pest control records indicate multiple treatments were conducted from February to July 2024, targeting different areas of the facility. Despite these efforts, roach activity continued to be reported in several locations, including the dining room, activities room, and reception desk. The pest control policy required monthly servicing and prompt response to pest issues, but the facility did not adhere to this policy consistently. Interviews with staff and residents revealed ongoing concerns about the roach infestation. A resident reported seeing a roach climbing the walls, and staff members, including an LVN and the DON, acknowledged the presence of roaches throughout the facility. The maintenance supervisor, responsible for coordinating pest control services, admitted to being unaware of the facility's pest control policy and confirmed the infestation had been an issue for over a year. He also noted that the pest control schedule was disrupted by a hurricane, leading to delays in treatment. The facility's pest control policy, dated April 1, 2017, required monthly servicing and a rapid response to pest issues. However, the facility's pest control efforts were inconsistent, with gaps in treatment and inadequate follow-up on reported sightings. The ongoing infestation posed a risk to the cleanliness and safety of the facility, affecting residents, staff, and visitors. Despite multiple treatments and reports of roach activity, the facility failed to effectively address the infestation, leading to continued pest presence in critical areas.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to provide immediate and appropriate respiratory care to a resident experiencing respiratory distress. The resident, who had a history of cerebral infarction, vascular dementia, and paraplegia, was observed by an LVN to be gurgling with emesis and unresponsive. Despite notifying the NP, no immediate monitoring or interventions were initiated. When the NP assessed the resident, her oxygen saturation had dropped to 60%, and she was unresponsive. Emergency services were called, but the resident was later declared brain dead and expired after artificial support was removed. The resident's care plan indicated she required extensive assistance with activities of daily living due to her cognitive and physical impairments. On the day of the incident, the resident had eaten breakfast and taken her medications as usual. However, she experienced a sudden change in condition, including vomiting and coughing, which was not promptly addressed by the facility staff. The NP attempted to provide care, including applying a non-rebreather mask and ordering oral suctioning, but the suction machine was reportedly malfunctioning, and the resident's condition continued to deteriorate. Interviews with facility staff revealed a lack of knowledge and preparedness in handling the emergency. The LVN who first responded to the resident's distress did not initiate appropriate interventions, and there was confusion about the availability and functionality of the oral suctioning equipment. The NP documented that the suction machine was malfunctioning, and there was a delay in calling emergency services. The facility's failure to provide timely and effective care placed the resident at risk of harm and ultimately contributed to her death.
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 762 citations issued within 25 miles in the last 12 months — including the 70 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 Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Arden Wood | 1.2 mi | ★★★★★ | 18 | 0 |
| Spring Branch Transitional Care Center | 1.8 mi | — | 0 | 0 |
| The Vosswood Nursing Center | 2.7 mi | ★★★★★ | 0 | 0 |
| The Buckingham | 3.6 mi | ★★★★★ | 8 | 0 |
| Treemont Health Care Center | 3.7 mi | ★★★★★ | 1 | 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.