Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mesa Hills Post Acute during CMS and state inspections, most recent first.
A resident with schizophrenia, bipolar disorder, severe intellectual disabilities, and severely impaired cognition had an order to monitor Haloperidol and Invega outcomes each shift using I, S, or W. An LPN entered 0 instead of the ordered alphabetic code on multiple shifts, and the ADON and DON confirmed the entries were incorrect and did not match the prescriber order.
A resident with severe cognitive impairment, cerebral palsy, psoriasis, seborrheic dermatitis, and diabetes developed scratches and dried blood on the face and arm after staff observed no marks earlier in the shift. An LVN assessed the resident, cleaned the wounds, and assumed the resident scratched herself, but did not notify the MD or resident representative; a second LVN also did not make notifications after receiving report. The DON later learned of the incident during the morning meeting.
Failure to Maintain Clean Fingernails and Personal Hygiene: A resident with severe cognitive impairment, CP, psoriasis, seborrheic dermatitis, hypertrophic nails, and DM was assessed as needing substantial/maximal assistance with personal hygiene. During observation, the resident had visible debris under multiple fingernails and uneven nail edges on both hands. The Activity Director said she did not trim the nails because that task was done by nursing staff for residents with DM, and the DON said residents with diagnoses such as DM were handled by nursing staff.
Failure to Follow Droplet Precautions During Room Assignment: A newly admitted resident was placed in the same room as another resident who was under droplet precautions for MRSA. The ADON/IP, Admissions Coordinator, and DON all acknowledged the room assignment should not have occurred, and the facility policy required transmission-based precautions to be followed, including masking, hand hygiene, and limiting resident movement.
Incomplete antipsychotic consent forms were found for multiple residents receiving psychotropic meds. The forms for Seroquel, Risperdal, Risperidone, and Olanzapine were missing required signatures and/or dates from the prescriber, resident, or resident representative, while the residents were receiving the medications and had diagnoses including dementia, bipolar disorder, schizophrenia, depression, anxiety, and PTSD.
Unnecessary antipsychotic use for residents with dementia. The facility administered antipsychotic medications to multiple residents with dementia and severe cognitive impairment, including olanzapine, risperidone, and quetiapine, for broad indications such as psychosis, affective mood disorder, and mood disorder. Records showed routine administration despite diagnoses of Alzheimer’s disease or dementia, and staff stated they relied on provider diagnoses and did not question the indication unless behaviors or family concerns arose.
PASRR screening and referral errors occurred when Form 1012s were completed incorrectly for residents with mood disorders and when new PASRR Level II assessments were not initiated after new psychiatric diagnoses such as psychosis and schizoaffective disorder. Records showed residents with bipolar disorder, depression, PTSD, major depressive disorder, OCD, dementia, and psychotic disorders, while the MDS nurse acknowledged the discrepancies and stated new PASRR screenings should have been submitted.
A resident with a trach, gastrostomy, and severe cognitive impairment was observed receiving care without proper infection control: an RN did not disinfect the BP cuff between uses and did not wear a gown during gastric tube medication administration despite EBP orders. In addition, the medication room contained an expired COVID test, expired IV supplies, an enteral administration set without protective wrapping, and soiled equipment including a stained camera system and a stained enteral feeding pump.
A resident admitted with schizophrenia, dementia, anxiety disorder, and paranoid schizophrenia had an inaccurate PASRR PL1 that listed dementia as the primary diagnosis and was negative for MI, ID, and DD. The Form 1012 also reflected dementia as not primary, Section C was not completed by the physician, and the MDS nurse acknowledged the error and stated she had not received PASRR training.
Incomplete and inaccurate care plans: The facility failed to ensure that two residents had comprehensive, person-centered care plans that matched their assessed needs. One resident’s care plan addressed chronic renal failure but did not include hemodialysis, even though the MDS showed dialysis was in place, and another resident’s care plan was not completed beyond limited items such as activities, discharge preferences, a fall, and code status. Staff, including the CS/MDS nurse, MDS nurse, and DON, acknowledged the missed dialysis care planning and the incomplete care plan.
A facility failed to keep two residents’ care plans current. One resident’s plan still listed a mechanical soft diet and weight loss-related interventions even though the resident was on a regular-texture diet with thin liquids and had weight gain. Another resident’s plan did not reflect that she ate with her fingers and refused assistance with eating, even though staff observed those behaviors and confirmed she needed help with meals.
Failure to Follow Ordered G-Tube Flushes During Medication Administration: A resident with a G-tube, severe cognitive impairment, and dependence on tube feeding had a physician order for 30 mL water flushes before and after medication administration every shift. During observation, an RN administered meds via the tube without flushing before or after, and later stated he forgot to do so. The DON confirmed the ordered flushes were required and that the facility policy called for meds to be given as prescribed.
Significant medication errors occurred when an LPN administered BP-lowering meds outside ordered parameters and failed to give Midodrine when indicated for a resident with severe cognitive impairment, HTN, ESRD on dialysis, quadriplegia, and aphonia. The resident’s orders specified hold parameters for Diltiazem and Metoprolol and PRN Midodrine for hypotension, but staff documented administration despite low BP and also failed to administer Midodrine when BP was within range. The DON stated Metoprolol should have been held and Midodrine should have been given when the resident was hypotensive.
An opened container of food thickener in the 100 hall med room was found without an open date on the container. The DON said the facility was not using it anymore, and staff gave conflicting statements about who was responsible for checking supplies and OTC meds in med rooms. The facility policy stated nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Inaccurate MAR and Dialysis Documentation: The facility failed to keep resident records accurate when contact precautions remained on the MAR after they were discontinued and nurses continued signing for them, and when pre-dialysis EMR forms for another resident contained incorrect and untimely vital signs, including a blood pressure entry on the wrong arm. Staff interviews confirmed the EMR and dialysis documentation were not entered accurately or at the time of care.
Two male residents with mental/behavioral health diagnoses and documented issues with aggression and poor impulse control became involved in a verbal altercation in a hallway and bedroom area. One resident, known by staff to have a short fuse, a history of verbal aggression, racist comments, and prior physical aggression toward another resident, obtained a reaching aid from his wheelchair and swung it at the other resident, who blocked the blow with his forearm and sustained a small bruise. Staff interviews confirmed that the aggressor’s behaviors were known before the incident and that the event constituted physical abuse, despite existing care plan interventions intended to de-escalate agitation and protect the rights and safety of others.
Two residents with moderate cognitive impairment and behavioral and dementia-related care plans were involved in a morning altercation at a coffee stand in which one resident verbally abused and physically struck the other, as witnessed and described by multiple staff including a CNA, MA, and LVN. Later that day, the same resident sustained a 1 cm skin tear to the shin while being taken to his room by the DON, after which he repeatedly alleged that a “doctor” had pushed or rammed him into the bed frame, an account that varied over time but was reported by staff, the DON, and the ADM as an allegation of abuse. Although the facility’s abuse policy required prompt reporting and thorough investigation of all abuse allegations, the DON and ADM did not report either the resident-to-resident physical contact or the allegation that the DON caused the injury to state authorities, and the ADM acknowledged he had no documentation of a comprehensive investigation beyond nursing progress notes and his undocumented interviews.
Two residents with moderate cognitive impairment were involved in an incident where one became verbally and physically aggressive toward the other at a coffee stand, with staff observing swatting and at least one hit to the arm before separating them. Later the same day, the aggressive resident sustained a small skin tear on his leg while being taken to his room and alleged that a doctor, understood by staff to be the DON, had rammed his leg into the bed frame, though his account varied and some staff believed he kicked the bed himself. In both situations, multiple staff, including an LVN, CNA, MA, DON, ADON, and the Administrator/abuse coordinator, were aware of the resident‑to‑resident physical contact and the allegation that a staff member caused an injury, but the Administrator did not report either allegation to the State Survey Agency within the required two‑hour timeframe, contrary to the facility’s abuse reporting policy.
Two residents with dementia and behavioral issues were involved in an altercation at a coffee stand where one resident verbally abused and physically struck another despite staff attempts to intervene, and later that day the aggressive resident sustained a 1 cm skin tear to his shin while being taken to his room and repeatedly alleged that a doctor/DON had banged his leg against the bed. Although the ADM, acting as abuse coordinator, stated he investigated both the resident-to-resident incident and the allegation against the DON, he relied largely on nursing notes, had no written staff statements or other documentation of a thorough investigation, concluded there had been no physical contact in the altercation despite staff accounts of pushing and hitting, and did not further investigate or report the allegation that the DON caused the injury, contrary to the facility’s abuse policy requiring investigation and reporting of all abuse allegations.
A resident with type 2 DM, major depressive disorder, and dementia had an MDS showing moderate cognitive impairment and a need for supervision or touching assistance with multiple ADLs, including toileting, bathing, lower body dressing, footwear, transfers, and ambulation. However, the resident’s care plan addressed only impaired cognitive function and did not include the diagnoses of DM or major depressive disorder, nor the documented ADL assistance needs. The MDS nurse and DON both acknowledged that these conditions and ADL dependencies should have been care planned, and the omission was attributed to the MDS nurse being backed up with care plans, despite facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes.
Staff failed to follow infection prevention practices when a CNA simultaneously fed two residents requiring substantial/maximal assistance with eating, using the same hand without performing hand hygiene between them. Both residents had cognitive impairment and functional deficits related to dementia, confusion, and coordination problems, and their care plans indicated they needed setup for eating. An LVN was assigned to oversee the meal and monitor safety and infection control but did not observe the CNA’s actions due to addressing another resident issue. The DON later confirmed that facility expectations required feeding one resident at a time with hand hygiene performed between residents.
The facility did not coordinate assessments with the PASRR program for two residents with mental health and intellectual disability diagnoses, failing to incorporate PASRR recommendations into care plans and to submit required service request forms to the state within the mandated timeframe. Staff interviews revealed gaps in knowledge and process, resulting in the residents not receiving specialized services as identified by the IDT.
The facility did not update or individualize care plans for three residents following significant changes in condition, new treatments, or behaviors. One resident's care plan was not revised after a hospitalization for pneumonia, another's did not address new IV antibiotics for a positive sputum culture, and a third's did not include tobacco use despite evidence of smoking. Staff interviews confirmed that care plans were not consistently updated as required by facility policy.
Surveyors identified failures in food storage and preparation, including unlabeled and undated meat in the freezer, raw chicken thawing in a vegetable-only sink without running water, and employee medication and a soft drink cup stored in a food refrigerator. Staff and administration confirmed these actions were not in line with facility policies or food safety standards.
A resident with severe cognitive impairment and multiple risk factors experienced several falls, which were documented in the care plan and incident log but were not accurately coded in the MDS assessment. Facility staff confirmed the assessment did not reflect the resident's actual fall history, resulting in an inaccurate MDS that did not align with documented care needs.
A resident with dementia, diabetes, and mobility issues was observed to have long, thick, discolored toenails that were not trimmed due to repeated refusals and combative behavior. Despite care plans and podiatrist involvement, staff did not document further attempts or alternative strategies to address the resident's foot care needs, and leadership acknowledged the issue without implementing additional interventions.
A resident with moderate cognitive impairment and multiple medical conditions was found with cigarettes at his bedside, despite facility policy requiring smoking items to be securely stored by staff. Staff interviews confirmed that cigarettes should not be kept in resident rooms, but the resident was able to bring them in and keep them without staff knowledge.
A nurse failed to wear a gown, as required by Enhanced Barrier Precautions, while administering medication via a gastrostomy tube to a resident with hemiplegia and severe cognitive impairment. Although the care plan and facility policy specified the use of gowns and gloves for residents with indwelling devices, only gloves were used during the observed care. Staff interviews confirmed knowledge of the EBP requirements and the availability of PPE.
A resident with multiple medical conditions had an Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form that was not signed by a physician as required. Although the resident's care plan and orders reflected DNR status, the form was uploaded into the electronic record without the necessary physician signature. Staff interviews revealed confusion and inconsistent practices regarding verification and documentation of DNR status, resulting in the DNR not being legally valid until after the issue was identified by surveyors.
A resident with severe cognitive impairment and a history of wandering eloped from the facility after a CNA turned off a door alarm without notifying nursing staff or verifying the cause. The resident's absence was not discovered until after a shift change, and the individual was later found by police several miles away and returned safely. The deficiency resulted from failure to follow established elopement protocols.
Several residents with cognitive impairments were found living in rooms that were not thoroughly cleaned or properly maintained, with issues such as broken fixtures, damaged walls, missing privacy blinds, and food debris present. Staff and housekeeping did not consistently address these problems, and maintenance records showed no work orders for needed repairs, despite facility policy requiring a safe and comfortable environment.
A resident with severe cognitive impairment and a feeding tube received care from CNAs who, without proper training or authorization, paused and restarted the feeding pump during incontinent care. Facility policy and job descriptions did not permit CNAs to handle feeding pumps, and interviews confirmed that only licensed nurses were authorized to do so.
Staff discovered drug paraphernalia in a resident's room after detecting a strong smoke odor. The incident was reported internally and to the police, but not to the State Survey Agency as required by federal regulations. Facility leadership did not consider the event reportable due to the absence of a negative outcome or direct link to abuse or neglect, despite policy requiring timely reporting of such allegations.
A resident with diabetes, anxiety disorder, and nicotine dependence was found smoking outside with cigarettes and a lighter, despite a care plan requiring smoking supplies to be stored at the nurses' station. Staff interviews confirmed that smoking items should not be kept by residents without independent privileges, and the facility policy required direct supervision. The incident revealed a lapse in supervision and adherence to safety protocols.
A resident with multiple health conditions experienced significant weight loss after staff failed to implement dietitian-recommended nutritional interventions, despite physician agreement and ongoing documentation of adequate meal intake. The LVN did not enter the new orders into the electronic record, resulting in the resident not receiving the prescribed multivitamin and fortified cereal.
Incorrect Psychotropic Medication Outcome Documentation
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints not required to treat the resident’s medical symptoms when it did not ensure correct documentation of ordered psychotropic medication outcomes. The resident had diagnoses including schizophrenia, bipolar disorder, severe intellectual disabilities, and ataxia, and a quarterly MDS reflected a BIMS score of 05, indicating severely impacted cognition. The care plan identified that the resident used psychotropic medications for behavior management and directed staff to monitor for side effects and effectiveness every shift. The resident’s physician ordered Haloperidol and Invega outcome codes of I = Improved, S = Same, and W = Worsened every shift, active 07/15/2026. The July 2026 MAR showed that the 7:00 a.m. to 7:00 p.m. shift was documented with a code of 0 on July 20, 21, 24, 25, and 26, 2026. During interview, the LVN who charted the entries stated he had entered 0 in error and said he had been confused because the resident also had an order to monitor side effects that required a numerical code. The ADON and DON reviewed the record and confirmed that the order required alphabetical codes, not a numerical code, and that the entries were incorrect. They stated that the resident’s behaviors would not be monitored correctly and that staff would not know whether the medications were working. The facility’s policies stated that medications are to be administered in accordance with prescriber orders and that medications administered must be documented in the medical record.
Failure to Notify MD and Resident Representative of Change in Condition
Penalty
Summary
The facility failed to immediately inform the resident, consult the resident’s physician, and notify the resident representative when there was a significant change in the resident’s physical status for one resident reviewed. The deficiency involved a resident with severe intellectual disabilities, cerebral palsy, seborrheic dermatitis, psoriasis, enlarged hypertrophic nails, and type 2 diabetes mellitus, whose BIMS score was 00, indicating severe cognitive impairment. Her care plan identified a potential for skin impairment related to psoriasis and seborrheic dermatitis and directed staff to report abnormalities, failure to heal, and signs or symptoms of infection to the MD. According to staff interviews, a CNA observed the resident without marks or scratches earlier in the evening, then later saw scant smeared blood on the bed sheet covering the resident’s face and scratches on the resident’s face and arm, along with dried blood under her fingernails. The CNA immediately notified an LVN. The LVN assessed the resident, noted small amounts of dried smeared blood on the face and on the bed sheet covering the chin, assumed the resident had scratched herself because she was being seen by a dermatologist for a skin condition, cleaned the wounds, and did not notify the physician or the resident representative. The LVN stated he got busy with other residents and did not make those notifications. A second LVN later received report that the resident had scratched herself during the evening shift, assumed the first LVN had already reported and documented the incident, and also did not notify anyone. The DON later stated he was informed during the morning meeting, checked the resident, informed the MD and resident representative, and began the investigative process. The facility policy titled Change in Condition stated the licensed nurse is responsible for notifying the physician or practitioner as required, notifying the resident representative when appropriate, and documenting all findings and actions.
Failure to Maintain Clean Fingernails and Personal Hygiene
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received the necessary assistance to maintain good nutrition, grooming, and personal and oral hygiene. The resident was a female with severe intellectual disabilities, cerebral palsy, seborrheic dermatitis, psoriasis, enlarged hypertrophic nails, and type 2 diabetes mellitus. Her MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and her care plan documented that she required substantial/maximal assistance with personal hygiene. During observation, the resident was seen eating dinner in her room with brownish and whitish/yellowish substances under several fingernails on her left hand, blackish/brownish substances under one fingernail, yellowish substance under multiple fingernails, and uneven edges on all fingernails on both hands. The Activity Director stated she did not trim the resident's nails because that task was done by nursing staff for residents with diabetes. The DON stated manicures were part of activities, but residents with diagnoses such as diabetes were done by nursing staff, and that the resident was calm and allowed nurses to trim her fingernails but became easily startled when she felt the clippers on her nails.
Failure to Follow Droplet Precautions During Room Assignment
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when it did not follow isolation protocols for a newly admitted resident who was placed in the same room as another resident under droplet precautions. Resident #2 was admitted on 6/24/26 with diagnoses including Alzheimer's disease, chronic kidney disease stage 3, osteoarthritis, and peripheral vascular disease. His records showed a Nursing Home Discharge MDS dated 6/29/2026 with the BIMS score left blank, a care plan dated 6/25/26 noting substantial to maximal assistance was needed for bathing, bed mobility, and personal hygiene, and physician orders dated 7/2/26 for skilled services with no isolation precautions ordered. Resident #3 was admitted on 6/19/26 and had diagnoses including pneumonia due to staphylococcus, a personal history of other infections and parasitic diseases, and persistent vegetative state. His comprehensive MDS dated 6/25/26 also had the BIMS score left blank, and Section GG showed he was dependent on staff for ADLs. His order summary dated 7/2/26 indicated he was transferred to the hospital for evaluation and treatment as ordered by the physician. The facility’s policy stated that transmission-based precautions, including droplet precautions, require staff and visitors to wear a surgical mask when entering the room, perform hand hygiene before and after contact, limit resident movement outside the room unless medically necessary, and place a mask on the resident during transport when tolerated. During interviews, the ADON/IP stated Resident #2 was admitted to room [ROOM NUMBER]-A and should not have been roomed with Resident #3 because Resident #3 was under droplet precautions for MRSA. She said if a resident was under contact or droplet precautions, another resident should not have been placed in the same room, and she could not explain why Resident #2 was admitted to the same room as Resident #3. The Admissions Coordinator said the team agreed to admit Resident #2 with Resident #3, but she was not aware Resident #3 was under droplet precautions and said the precaution was missed on her roster. The DON stated he did not know why Resident #2 was placed in the same room with Resident #3 and said residents under transmission-based precautions were roomed alone unless both residents had the same infection.
Incomplete Antipsychotic Consent Forms
Penalty
Summary
The facility failed to ensure that residents were fully informed and that consent forms for antipsychotic medications were correctly completed for six residents reviewed. The deficiency involved HHSC Form 3713 for antipsychotic or neuroleptic medication treatment, where required signatures and dates were missing for the practitioner, resident, or resident representative on multiple forms. The report states that these incomplete forms were present while the residents were receiving antipsychotic medications such as Seroquel, Risperdal, Risperidone, Olanzapine, and Quetiapine. Resident #4 had diagnoses including bipolar disorder, depression, generalized anxiety disorder, PTSD, diabetes, acute kidney failure, and heart failure, and had a BIMS score of 15 indicating intact cognition. The resident had an active order for Seroquel 100 mg at bedtime for bipolar disorder. The consent form for antipsychotic treatment listed Seroquel as the proposed therapy, but the practitioner’s signature and date were missing, and the resident’s signature was not dated. Resident #56 had dementia, Alzheimer’s disease, major depressive disorder, anxiety disorder, and a BIMS score of 2 indicating severe cognitive impairment. The resident received Risperdal 0.5 mg daily for affective mood disorder, but the consent form had no signature or date from the person prescribing the medication or designee. Resident #73 had dementia with behavioral disturbance, bipolar disorder, psychosis, mood disorder, and schizoaffective disorder, with a BIMS score of 00 and dependence for multiple activities. Olanzapine was ordered and administered from April through June 2026, but the consent form was not signed or dated by the physician. Resident #82 had dementia, major depressive disorder, persistent mood disorder, and severe cognitive impairment, and received Risperdal 0.25 mg at bedtime; the consent form lacked dates next to the prescriber’s signature and the resident representative’s signature. Resident #104 had Alzheimer’s disease and anxiety disorder with a BIMS score of 03, and received Seroquel 25 mg daily; the consent form was not signed or dated by the physician. Resident #109 had bipolar disorder and schizophrenia with a BIMS score of 11 and received Risperidone 1 mg twice daily; the consent form was not signed or dated by the physician and was not dated by the resident.
Unnecessary antipsychotic use for residents with dementia
Penalty
Summary
The facility failed to ensure that five residents were free from chemical restraints not required to treat their medical symptoms. For Resident #9, the record showed a diagnosis of unspecified dementia with severe cognitive impairment, along with anxiety, depression, and psychosis, yet she received Zyprexa 5 mg twice daily for unspecified psychosis. The chart also reflected that the medication was administered routinely during the review period. For Resident #56, the record showed diagnoses of unspecified dementia, Alzheimer’s disease, depression, anxiety, and recurrent severe major depressive disorder with psychotic symptoms, with a BIMS score indicating severe cognitive impairment. Despite this, the resident received Risperdal 0.5 mg daily for affective mood disorder, and the medication was administered throughout the review period. The resident’s care plan identified antipsychotic use and listed black box warning concerns, but the order remained in place with the stated indication. For Resident #73, the record showed dementia with behavioral disturbance, bipolar disorder, psychosis, mood disorder, and schizoaffective disorder, with severe cognitive impairment and dependence for multiple activities of daily living. The resident received olanzapine 2.5 mg at bedtime for mood disorder due to known physiological condition with mixed features, and the medication was administered across April, May, and June. For Resident #82, the record showed unspecified dementia with severe cognitive impairment and mood-related diagnoses, yet she received Risperdal 0.25 mg at bedtime for affective mood disorders. For Resident #104, the record showed Alzheimer’s disease, anxiety, depression, and severe cognitive impairment, yet she received Seroquel 25 mg daily for affective mood disorder, with administration documented across April, May, and June.
PASRR Screening and Referral Errors
Penalty
Summary
The facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program to the maximum extent practicable for four residents reviewed. Two residents had Form 1012s completed incorrectly after admission, and two residents developed new mental health diagnoses that were not referred for a new PASRR Level II assessment. The deficiency involved residents with diagnoses including bipolar disorder, depression, PTSD, schizoaffective disorder, psychosis, anxiety, and dementia. For one resident, the record showed a PASRR Level I screening was negative, but the Form 1012 was marked "yes" for mood disorder while also indicating that no new Level I screening was needed. The resident’s record reflected diagnoses of bipolar disorder, depression, generalized anxiety disorder, and PTSD, and the MDS showed intact cognition with active mental health diagnoses. A second resident had a similar issue: the PASRR Level I screening was negative, but the Form 1012 was marked "yes" for mood disorder and again indicated that no new Level I screening was needed. That resident’s record reflected diagnoses of major depressive disorder, bipolar disorder, obsessive-compulsive disorder, unspecified dementia, and other dementia-related psychotic and mood disturbances. Two other residents had later psychiatric diagnoses that were not referred for PASRR Level II assessment. One resident’s record reflected diagnoses of dementia, major depressive disorder, anxiety disorder, and unspecified psychosis, and a psychiatric subsequent assessment documented unspecified psychosis. Another resident’s record reflected dementia, hallucinations, and other schizoaffective disorders, with a psychiatric note documenting schizoaffective disorder, bipolar type. The MDS nurse stated the Form 1012s were incorrect, that new PASRR screenings should have been submitted for the residents with new diagnoses, and that she had not received training on PASRR services from the facility. The DON stated that if residents were not screened appropriately, they could potentially miss out on services.
Infection Control Lapses in Resident Care and Medication Storage
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident and one medication storage room. Resident #23 was admitted with diagnoses including nontraumatic intracerebral hemorrhage in the cerebellum, essential hypertension, tracheostomy, gastrostomy, and persistent vegetative state. The quarterly MDS reflected a BIMS score of 6, indicating severe cognitive impairment, and also showed that the resident received most calories and fluids by tube feeding. The resident’s order summary included enhanced barrier precautions during high-contact care activities because of the gastric tube and foley catheter. During an observation, RN C did not wipe down the blood pressure cuff between resident use before checking Resident #23’s blood pressure. During the same observation, RN C did not wear a gown while administering medications through the resident’s gastric tube. RN C stated he forgot to disinfect the cuff and forgot to put on a gown. He also stated that disinfecting equipment between resident use was important because of cross contamination, and that wearing a gown during care for residents with indwelling devices was important to avoid spreading infection. An inspection of the 100 hall medication room found multiple infection control and storage issues. An expired at-home COVID test was stored in a cabinet with oral medications, inhalation medications, and IV fluids. Expired IV supplies were found on the counter and in a cabinet, including IV extension sets and IV catheters. An enteral feeding pump administration set was stored without a protective wrapper in a drawer labeled for enteral administration kits. A baby monitor type camera, screen, and power cord with brownish stains were stored in a soiled bag in a cabinet labeled ostomy supplies. A separate enteral feeding pump with tan-colored stains was stored on a cart in the medication room. The DON, ADON, LVN B, and the CS/MDS nurse each described responsibilities for cleaning, storing, and checking supplies, and the DON stated the soiled equipment and expired items should not have been stored there.
PASARR Screening Not Completed Accurately for Resident With Schizophrenia
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one newly admitted resident. The resident was admitted on 03/07/2025 with diagnoses that included schizophrenia as the primary diagnosis, dementia without behavioral disturbance, anxiety disorder, and paranoid schizophrenia. The facility’s PL1 dated 03/07/2025 was marked negative for MI, ID, and DD and listed dementia as the primary diagnosis, despite the resident’s documented schizophrenia diagnosis. There were no other PL1 screenings for the resident. The resident’s Form 1012 dated 03/07/2025 stated that the individual did not have a dementia diagnosis or had dementia that was not primary, and Section C was not completed by the physician. The MDS nurse signed the Form 1012 and later stated the PL1 contained an error and that a new PL1 and 1012 would be needed to correct it. The MDS nurse also stated she had not received training on PASRRs. The DON stated that if a resident was not screened properly for PASRRs, residents could be missing services.
Incomplete and inaccurate care plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents that reflected their assessed needs and included measurable objectives and timeframes. For one resident, the comprehensive care plan addressed chronic renal failure and related interventions, but it was not updated to reflect that the resident was on hemodialysis. The resident’s admission MDS showed a BIMS score of 13 and indicated he was cognitively intact, and Section O identified hemodialysis on admission and while a resident. The care plan in the record focused on chronic renal failure, with interventions such as assisting with ADLs, dietary consultation, medication administration, and monitoring for signs and symptoms of acute failure, but dialysis was not included. For the second resident, the comprehensive care plan was not completed. The resident’s record showed multiple diagnoses, including malignant neoplasm of the pancreas, non-Hodgkin lymphoma, hypertension, anemia, thrombocytopenic purpura, adrenocortical insufficiency, and an implantable cardiac defibrillator. The PPS MDS reflected a BIMS score of 12, indicating moderate cognitive impairment. The care plan that was reviewed only addressed preferences in activities, discharge/transfer preferences, a witnessed fall, and code status, and the record also showed that a comprehensive care plan had been reviewed and closed due to discharge. Staff interviews showed that care plan responsibility was shared among nursing and MDS staff, but the dialysis status for the first resident was missed and the second resident’s care plan was not completed. The CS/MDS nurse stated the dialysis should have been care planned and that the resident’s dialysis was still not on the care plan. The MDS nurse stated she was responsible for keeping care plans up to date, said she must have missed the dialysis order, and acknowledged that she had not completed the care plan for the second resident. The DON stated the MDS nurses were responsible for care plans, that he did not review care plans except for acute incidents, and that he could not explain why the first resident’s dialysis was not care planned for two months or why the second resident’s care plan might not have been reviewed after readmission.
Care Plans Not Updated for Diet Changes, Weight Gain, and Eating Assistance Needs
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for two residents. One resident had a care plan that still reflected a mechanical soft diet and weight loss-related interventions even though the current order was for limited concentrated sweets, no added salt, regular texture, and thin liquids, and the resident had documented weight gain. Another resident had a care plan that identified a 1-person assist for eating, but it did not reflect that the resident ate with her fingers and refused assistance with eating. For the first resident, the record showed diagnoses including autism disorder, type 2 diabetes mellitus, adult failure to thrive, dysphagia, generalized muscle weakness, unspecified protein-calorie malnutrition, and reduced mobility. The MDS reflected moderate cognitive impairment, weight gain, and a therapeutic diet. The care plan continued to list nutritional risk related to malnutrition and weight loss, along with limited concentrated sweets, no added salt, mechanical soft texture, and thin liquids, even though the order summary showed regular texture and thin liquids and the nutritional risk assessment documented weight gain and recommendations related to excessive energy intake. For the second resident, the record showed diagnoses including Alzheimer’s disease and anxiety disorder, with severe cognitive impairment on the quarterly MDS and substantial/maximal assistance needed for eating. During observations, the resident was seen eating lunch with her fingers, emptying food onto the table and scooping it with her fingers, and later alternating between using a spoon and her fingers, including eating pudding with her fingers only. Staff interviews confirmed that the resident was supposed to be assisted with eating but often refused help, and multiple staff stated that eating with fingers and refusal of assistance should have been care planned. The care plan, however, did not reflect those behaviors or preferences.
Failure to Follow Ordered G-Tube Flushes During Medication Administration
Penalty
Summary
The facility failed to ensure that a resident who received enteral feeding was provided the ordered treatment and services to prevent complications of enteral feeding. Resident #23 was a [AGE]-year-old male admitted with diagnoses including nontraumatic intracerebral hemorrhage in the cerebellum, essential hypertension, tracheostomy, gastrostomy, and persistent vegetative state. His quarterly MDS reflected a BIMS score of 6, indicating severe cognitive impairment, and showed that he received 51% or more of his calories and 501 cc/day or more of his fluid intake by tube feeding. His care plan identified a potential fluid deficit and noted that he was dependent with tube feeding and water flushes. The order summary reflected a physician order to flush the gastric tube with 30 mL of water before and after medication administration every shift. During an observation, RN C administered medications through the gastric tube without flushing it before or after the medication pass. In interview, RN C stated he forgot to flush the tube before starting and after completing medication administration. The DON stated that when a specific order existed for flushing before and after medication administration, the ordered amount of water was to be used, and that failure to flush could cause the tube to clog and prevent the resident from receiving prescribed nutrition or medications. The facility’s policies stated medications were to be administered as prescribed and that enteral nutrition orders could include flushing the tube before and after medications were administered.
Significant Medication Errors With Blood Pressure Medications
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors involving blood pressure medications. Resident #76 was a severely cognitively impaired female admitted with metabolic encephalopathy, essential hypertension, end stage renal disease with dialysis dependence, quadriplegia, and aphonia. Her physician orders included Diltiazem 90 mg via PEG tube three times daily with instructions not to administer if BP was below 100/60 and HR below 60, Metoprolol Tartrate 25 mg via PEG tube three times daily with instructions to hold if BP was below 100/60 and/or HR was below 60, and Midodrine 10 mg via PEG tube every 6 hours as needed for hypotension with instructions to hold if SBP was above 110. On 06/09/26 at 9:00 pm, LVN A documented the resident’s BP as 98/50 and administered both Diltiazem and Metoprolol despite the documented values being outside the ordered parameters. On 06/14/26 at 3:00 pm, LVN B documented BP 93/58 and pulse readings of 117 for Diltiazem and 76 for Metoprolol, administered both medications outside of parameters, and did not administer Midodrine even though the resident’s BP was within the ordered parameters for that medication. On 06/14/26 at 9:00 pm, LVN A documented BP 101/59, did not administer Diltiazem or Metoprolol, and did not administer Midodrine even though the resident’s BP was within the parameters for administration. During interview, LVN B stated she had spoken with the NP and was told to give Diltiazem if the pulse was over 100, so she administered it on 06/14/26; she also stated she did not think to give Midodrine. The DON stated Diltiazem should have been clarified because it was only to control heart rate, Metoprolol should have been held on both dates because it affected both BP and heart rate, and Midodrine should have been given when the resident was hypotensive. The DON also stated the last medication administration in-service was in March and the pharmacist observed two medication passes monthly.
Undated Food Thickener Stored in Medication Room
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food additives in accordance with professional standards for food service safety in 1 of 2 medication storage rooms reviewed, the 100 hall medication room. During inspection of the room, surveyors found 1 of 2 containers of food thickener stored on a shelf in a cabinet labeled enteral and milks that had been opened but was not dated with the date it was opened. In interviews, the DON stated he was not sure how long the food thickener had been in the cabinet and said the facility did not even use it anymore because only dietary was trained and allowed to thicken foods and drinks. The LVN stated the CS/MDS nurse was responsible for ensuring that supplies and OTC medications in the medication rooms were up to date, while the CS/MDS nurse stated she did not go into the medication supply rooms. The ADON stated nurses, ADONs, and pharmacy were responsible for ensuring medications and supplies in the medication storage rooms were not expired, and said medication room checks were done weekly by nurses, every two weeks by ADONs, sporadically by the DON, and once a month by the pharmacist. The facility policy stated nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Inaccurate MAR and Dialysis Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for two residents. For one resident, the chart showed contact precautions were discontinued by verbal order, but the order remained in the electronic MAR and nurses continued to sign off on contact precautions after the discontinuation date. The resident’s record included diagnoses of tracheostomy status, severe sepsis without septic shock, pneumonia, and persistent vegetative state, and the quarterly MDS reflected that the BIMS could not be completed. For the second resident, the facility’s electronic pre-dialysis forms contained inaccurate vital sign documentation. The resident was admitted with diagnoses including metabolic encephalopathy, essential hypertension, end stage renal disease, dependence on renal dialysis, quadriplegia, and aphonia, and the admission MDS reflected severely impaired cognitive skills for daily decision making. The pre-dialysis forms documented blood pressure, temperature, pulse, respirations, and oxygen saturation values that were not the most recent readings at the time of the entries, including some values documented hours after the assessment time and one blood pressure entry recorded on the left arm. Staff interviews confirmed the documentation problems. An LVN stated he had been signing the MAR for contact precautions even though the order had been discontinued and remained in the EMR. The RN stated he received a verbal order to discontinue contact precautions but did not remove the order from the EMR. For the dialysis documentation, an LVN stated the electronic pre-dialysis form automatically populated with prior vital signs and that she was not sure why the correct values were not entered, while another LVN stated she documented the blood pressure on the resident’s left arm by accident. The DON stated the expectation was accurate and timely documentation, and the facility policy required documentation to be objective, complete, accurate, and completed at the time of treatment or immediately after.
Failure to Prevent Resident-on-Resident Physical Abuse Involving Known Aggressive Behavior
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. Resident #1, a male with a history of other mental and behavioral disorders and a BIMS score of 12 indicating moderate cognitive impairment, had documented care plan focuses for physical aggression related to anger and poor impulse control, as well as behavior problems including verbal outbursts toward staff and other residents. Interventions in his care plan included intervening before agitation escalated, guiding him away from sources of distress, engaging calmly in conversation, walking away and re-approaching later if he became aggressive, and intervening as necessary to protect the rights and safety of others by diverting attention and removing him from situations as needed. Despite these identified behaviors and planned interventions, Resident #1 remained in situations where he could and did become physically aggressive toward another resident. Resident #2, a male with bipolar disorder and a BIMS score of 15 indicating intact cognition, had a care plan focus for verbal aggression related to ineffective coping skills, poor impulse control, anxiety, and bipolar disorder. His care plan included similar interventions to those of Resident #1, such as intervening before agitation escalated, guiding him away from distress, engaging calmly in conversation, and walking away and re-approaching later if he became aggressive. Prior to the incident, records indicated that neither resident had displayed documented physical or verbal behaviors toward others on their MDS assessments, although multiple staff interviews described Resident #1 as having a short fuse, being verbally aggressive, making racist comments, and having been physically aggressive with another resident by shaking that resident’s wheelchair. On the night of the incident, nursing notes documented that Resident #1 and Resident #2 were initially talking in a normal tone in the hallway before going into Resident #1’s room. Resident #2 then exited the room, and loud voices were heard from both residents in the hallway. Resident #2 went to the patio, and staff noted he was very upset. Resident #1 obtained a long grabber/reaching aid and wheeled himself to a hallway area while being loud and angry toward Resident #2. When Resident #2 heard him and came into the hallway, both residents yelled profanities at each other. According to LVN B, Resident #1 claimed Resident #2 had shaken his chair, then Resident #1 grabbed the reaching aid from the back of his wheelchair and swung it at Resident #2, who blocked the blow with his left forearm. A subsequent skin assessment revealed a minor bruise less than an inch in diameter on the posterior left forearm of Resident #2. Resident #2 reported that Resident #1 had previously threatened to hit him with the reaching aid and that this was the first time he followed through. Multiple staff, including the DON, ADON, LVN B, and the Administrator, characterized the event as physical abuse and acknowledged that every resident has the right to be free from abuse, including abuse by other residents. Staff interviews further established that Resident #1’s aggressive and verbally abusive behaviors were known prior to this incident. The ADON stated Resident #1 had a short fuse, made racist comments to staff, and had been physically aggressive with another resident by shaking that resident’s wheelchair. The DON similarly reported witnessing Resident #1 grab and shake another resident’s wheelchair and described him as having a short fuse, though improved compared to when he first arrived. LVN A described Resident #1 as edgy, impatient, verbally aggressive toward staff and residents, and having threatened to get her fired, and stated it did not surprise her when she learned he had hit another resident. Despite these known behaviors and the facility’s written policy stating that residents have the right to be free from abuse, neglect, exploitation, and misappropriation of property, including abuse by other residents, Resident #1 was able to use his reaching aid to strike Resident #2, resulting in a bruise and constituting physical abuse.
Failure to Report and Thoroughly Investigate Resident-to-Resident Altercation and Alleged Staff Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse policy by not reporting and not thoroughly investigating two separate abuse-related incidents involving two residents on 04/03/26. Resident #1, a male with multiple diagnoses including type 2 diabetes, osteoporosis, hepatic encephalopathy, alcoholic cirrhosis, major depressive disorder, adult failure to thrive, and a history of mental and behavioral disorders, had a BIMS score of 12 indicating moderate cognitive impairment. His care plan, revised shortly before the incident, identified him as physically aggressive related to anger and poor impulse control, with interventions such as early redirection, calm engagement, and staff walking away and re-approaching later. Resident #2, a male with type 2 diabetes, major depressive disorder, and unspecified dementia, had a BIMS score of 8, also indicating moderate cognitive impairment, and was care planned for impaired cognitive function/dementia. On the morning of 04/03/26, staff documented and later described an altercation between Resident #1 and Resident #2 at a portable coffee stand. A progress note by LVN A at 8:38 AM recorded that Resident #1 began verbally and physically getting aggressive when Resident #2 asked for coffee, yelling derogatory words and then getting up and swatting at Resident #2. LVN A and other staff attempted to redirect Resident #1, but he refused and continued yelling. In interviews, CNA B and MA D stated they saw Resident #1 become aggressive, with CNA B reporting that Resident #1 was able to “sort of push” Resident #2 in the chest and LVN A stating that Resident #1 was able to hit Resident #2 on the arm despite her standing between them. Staff reported that the administrator (ADM) was notified and spoke with the residents. However, the DON and ADM later stated they believed there had been no physical contact between the residents, and the ADM acknowledged that, although he said he interviewed staff, he had no documentation of those interviews or any other records to show a thorough investigation beyond the nursing progress note. Later that same day around lunchtime, a second incident occurred involving Resident #1 and the DON. A progress note at 12:15 PM documented that the DON redirected Resident #1 to his room, during which Resident #1 was still yelling, and that once inside the room Resident #1 started throwing kicks and hit the bed frame with his left shin, resulting in a 1 cm skin tear. In interviews, CNA B and MA D stated that Resident #1 later alleged that a “doctor” had rolled him in a chair and banged his leg on the bed, and both indicated that LVN A and the ADM were aware of this allegation. LVN A confirmed that Resident #1 said a doctor had pushed him into the bed and hurt his leg, and that she did not know if he meant the DON, while the DON stated that he only wheeled Resident #1 into the room, that Resident #1 turned his wheelchair on his own, kicked his leg, and then blamed the DON. The ADON stated Resident #1 said the DON had taken him to his room and that he hit his leg, which she interpreted as Resident #1 hitting his leg himself. The ADM stated that Resident #1 gave conflicting accounts, at one point saying the DON rammed him into the bed frame and at another saying he might have kicked the bed himself, and that Resident #1 later called the police and told them somebody had pushed him into the bed frame. The ADM acknowledged that he did not further investigate beyond speaking with Resident #1 and the DON, did not obtain or retain staff statements, and did not report either the resident-to-resident physical contact or the allegation that the DON caused the skin tear to the State Survey Agency, despite the facility’s abuse policy requiring allegations of abuse to be reported and investigated within required timeframes. Resident #2 later told surveyors he was doing well, had no problems, and did not recall the incident or know who Resident #1 was, and he was observed without distress or injury. Resident #1, when interviewed by surveyors, stated that a doctor had brought him to his room and banged his leg into the metal bed frame, causing a bleeding cut that nurses treated, and that he had called the police because he wanted that doctor arrested. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy stated that residents have the right to be free from abuse and that the facility must protect residents from abuse by anyone, develop and implement policies to prevent and identify abuse, and investigate and report any allegations within required federal timeframes. Despite this policy, the DON confirmed that neither the incident between Resident #1 and Resident #2 nor the allegation that the DON caused Resident #1’s leg injury were reported to the State Survey Agency, and the ADM conceded that he had no documentation to demonstrate a thorough investigation of these allegations.
Failure to Timely Report Resident Aggression and Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report alleged abuse and resident‑to‑resident aggression to the State Survey Agency within the required two‑hour timeframe. One male resident with multiple diagnoses including type 2 diabetes, osteoporosis, hepatic encephalopathy, alcoholic cirrhosis, major depressive disorder, adult failure to thrive, and a history of mental and behavioral disorders had a BIMS score indicating moderate cognitive impairment. His care plan identified physical aggression related to anger and poor impulse control, and a behavior problem related to major depressive disorder with verbal outbursts toward staff and other residents. Despite these identified behaviors and interventions, an incident occurred in which this resident became verbally and physically aggressive toward another male resident with dementia and moderate cognitive impairment while both were at a portable coffee stand. Progress notes and staff interviews reflected that the aggressive resident began yelling derogatory words at the other resident when he asked for coffee, and then began swatting at him. Staff, including an LVN, a CNA, and a medication aide, intervened and attempted to redirect and separate the residents. The LVN reported that the aggressive resident was able to hit the other resident on the arm even though she positioned herself between them, and staff then moved the residents away from each other. The second resident was documented as having no acute distress or abnormalities after the incident and did not recall the event during a later interview. The DON and Administrator were notified of the altercation, but the DON stated he believed there had been no physical contact, and the Administrator stated staff did not tell him that any physical contact had occurred. The incident, which involved an allegation and observation of resident‑to‑resident physical aggression, was not reported to the State Survey Agency. A second unreported allegation involved the same aggressive resident and the DON later that day. According to progress notes and interviews, the DON wheeled the resident to his room around lunchtime. Once in the room, the resident turned his wheelchair, yelled about his leg, and was found to have a 1 cm skin tear on his left shin with minimal bleeding and well‑approximated edges. The resident alleged that a “doctor” had pushed or rammed him into the bed frame, and multiple staff, including a CNA and a medication aide, understood that he was referring to the DON when he said “doctor.” The DON, ADON, LVN, and Administrator were all aware that the resident was alleging that the DON had caused the injury, although the DON and ADON believed the resident had kicked the bed frame himself and noted that the resident’s statements changed back and forth. The Administrator acknowledged that the resident again alleged that somebody had hurt him when speaking with police later that day and stated that, under the facility’s policy requiring allegations of abuse to be reported within two hours, he should have reported the allegation to the State Survey Agency. Despite this, neither the resident‑to‑resident physical aggression nor the allegation that the DON caused the resident’s leg injury was reported to the State Survey Agency as required by the facility’s abuse, neglect, exploitation, and misappropriation prevention policy and federal reporting timeframes. The facility’s written policy stated that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that the facility would protect residents from abuse or mistreatment by anyone, including other residents and staff. The policy further required the facility to investigate and report any allegations within timeframes required by federal requirements. In these two incidents, staff and leadership were aware of an observed physical altercation between residents and an allegation by a resident that a staff member (identified by the resident as a doctor and understood by staff to be the DON) caused a skin tear to his leg. Nonetheless, the Administrator, acting as abuse coordinator, decided not to report either allegation to the State Survey Agency within the mandated two‑hour window, resulting in the cited deficiency for failure to ensure all alleged violations involving abuse, neglect, or mistreatment were reported immediately as required.
Failure to Thoroughly Investigate Abuse Allegations Involving Resident-to-Resident Altercation and Injury
Penalty
Summary
The deficiency involves the facility’s failure to have evidence that all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for two residents. One incident occurred when a resident with moderate cognitive impairment and a history of physical aggression and behavioral problems became verbally and physically aggressive toward another cognitively impaired resident while both were at a portable coffee stand. According to a progress note by an LVN, the aggressive resident began yelling derogatory words, the other resident defended himself, and the aggressive resident got up and started swatting at him. Staff attempted to redirect the aggressive resident, but he refused and continued yelling. Interviews with CNA and medication aide staff indicated that the aggressive resident was able to push the other resident in the chest and hit his arm before staff separated them and moved them away from each other. The DON and ADM were notified, but the DON later stated he believed there had been no physical contact, and the ADM stated staff had not told him that any contact occurred. The second incident involved an allegation that the DON (whom the resident referred to as a doctor) caused a 1 cm skin tear on the aggressive resident’s left shin while taking him to his room later that same day. A progress note documented that the resident, while being redirected to his room by the DON, began throwing kicks and hit the bed frame with his left shin, resulting in a small, well-approximated skin tear. However, multiple staff interviews revealed that the resident repeatedly alleged that a doctor had rolled him in a chair and banged his leg on the bed, and that he wanted that doctor arrested for abuse. The medication aide and LVN both reported that the resident was telling staff that a doctor had hurt his leg, and the ADON recalled the resident saying the DON had taken him to his room and that he hit his leg, though she interpreted this as the resident having hit his leg himself. The DON stated he only wheeled the resident into the room and that the resident turned his own wheelchair, kicked his leg, and then complained of pain, while blaming the DON for pushing him into the bed. The ADM, identified as the abuse coordinator, stated he investigated both incidents but could not produce documentation of a thorough investigation beyond the nursing progress notes. For the resident‑to‑resident altercation, he said he interviewed staff and concluded there was no physical contact, despite staff interviews to surveyors describing pushing and hitting. He acknowledged that the progress notes did not show his investigation process and that he had no records of staff statements. For the allegation that the DON caused the skin tear, the ADM stated he spoke with the resident, who alternated between saying the DON rammed him into the bed and saying he might have kicked the bed frame himself. The ADM also spoke with police after the resident called them, but he did not further investigate by interviewing other staff who were nearby and did not report the allegation to the State Survey Agency. The facility’s abuse policy required investigation and reporting of any allegations of abuse within required timeframes, but the ADM admitted he could have done a better job investigating and had nothing else to show a thorough investigation of these abuse allegations.
Failure to Develop Comprehensive Person-Centered Care Plan for Resident with Diabetes, Depression, and ADL Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple documented diagnoses and ADL needs. Record review showed that the resident, an older male admitted with type 2 diabetes, major depressive disorder, and unspecified dementia, had an MDS indicating moderate cognitive impairment (BIMS score of 8) and documented needs for supervision or touching assistance with several ADLs, including toileting hygiene, bathing, lower body dressing, footwear, transfers, and ambulation over various distances. Despite these identified conditions and functional limitations, the resident’s care plan, initiated earlier in the admission, only addressed impaired cognitive function/dementia and did not include the diagnoses of diabetes or major depressive disorder, nor did it reflect the resident’s ADL assistance needs. During interviews, the MDS nurse confirmed that the resident’s diabetes, major depressive disorder, and ADL dependence should have been included in the care plan and acknowledged that these elements were missing because she was backed up with care plans and trying to catch up. The DON also confirmed that the resident’s diagnoses and ADLs should have been care planned, even though the resident was more independent, and stated that care plans were developed and updated by the MDS nurse. Observation and interview with the resident showed he was doing well at the time, able to ambulate and communicate needs without distress, and reported that staff treated him respectfully and provided what he needed. The facility’s own policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs, but this was not followed for this resident.
Failure to Perform Hand Hygiene While Feeding Multiple Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program when a CNA did not perform hand hygiene while feeding two residents during the same meal service. During a lunch observation on 3/10/2026, CNA A sat between Resident #1 and Resident #2 and used the same right hand to alternately feed both residents without performing hand hygiene between residents. CNA A later acknowledged that residents should be assisted one at a time and that feeding two residents simultaneously without hand hygiene created a possibility of cross contamination. The facility’s own staff education practices included monthly in-services on infection control and weekly reminders on hand hygiene. Resident #1 was an older male with Alzheimer’s disease, dysphagia, and lack of coordination, admitted on 8/06/2025. His MDS assessment showed he required substantial/maximal assistance with eating, and his care plan indicated an ADL self-care performance deficit related to dementia and impaired balance, with an intervention stating he required setup to eat. Resident #2, admitted on 12/10/2024, had diagnoses including cerebral ischemia, muscle weakness, and lack of coordination, and also required substantial/maximal assistance with eating per his MDS, with a care plan noting an ADL self-care performance deficit related to confusion and dementia and an intervention that he required setup to eat. During the meal, LVN B was assigned to oversee lunch, ensure correct diets, and monitor resident safety, but did not notice the CNA’s feeding practice because she was de-escalating another resident situation. The DON stated that CNAs were expected to feed one resident at a time and perform hand hygiene between residents, and that a nurse was assigned to the dining room to monitor infection control practices, but these expectations were not followed during the observed incident.
Failure to Coordinate PASRR Assessments and Submit Service Requests
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for two residents who were identified as PASRR positive. Specifically, the facility did not incorporate the recommendations from the PASRR Level II determination and evaluation report into the residents' care planning. The service request forms were not sent to the state PASRR unit within 30 days of the Interdisciplinary Team (IDT) meeting, which was necessary for the residents to receive the specialized services identified during the meeting. Both residents required total care and assistance with all activities of daily living (ADLs) and had diagnoses including bipolar disorder, anxiety disorder, and severe intellectual disabilities. Interviews with facility staff revealed a lack of understanding and familiarity with PASRR requirements and processes. The MDS nurse, who was responsible for submitting PASRR specialized services, was not employed at the time of the residents' admissions and confirmed that the required submissions had not been made. The ADON and DON both acknowledged limited knowledge of PASRR procedures and the importance of timely reporting. As a result, the residents were not receiving the specialized services recommended by the PASRR process, and the facility's own policy regarding PASRR was not followed.
Failure to Update and Individualize Resident Care Plans
Penalty
Summary
The facility failed to develop and update comprehensive, person-centered care plans with measurable objectives and timeframes for three residents, as required by policy and regulation. For one resident with end stage renal disease and metabolic encephalopathy, the care plan was not revised after a hospitalization for pneumonia, despite a significant change in condition and new interventions such as nebulizer treatments and oxygen therapy. Documentation showed that the care plan's target dates and interventions were not updated to reflect the resident's most recent hospitalization and treatment needs. Another resident with chronic obstructive pulmonary disease and a tracheostomy received intravenous antibiotics for a positive sputum culture, but the care plan did not identify or address this new treatment. Interviews with staff confirmed that the care plan should have been updated when the antibiotic order was received, and that failure to do so could affect the ability of nurses to provide appropriate care. A third resident with diabetes, hypertension, and moderate cognitive impairment was found to possess cigarettes in his room, but his care plan did not address tobacco use. Staff interviews revealed that although the resident was not identified as a smoker on admission, he did smoke while at the facility, and this should have been included in his care plan. The facility's policy required care plans to be updated upon significant changes in condition, new treatments, or upon readmission from the hospital, but these requirements were not met for the residents involved.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and sanitation within the facility's kitchen. Raw chicken was found thawing in a two-compartment sink labeled for vegetables only, without running water, and raw ground beef was placed on the counter next to this sink. Additionally, three clear bags containing meat in the walk-in freezer were not labeled or dated. Inside the reach-in refrigerator, a small box labeled as an employee's medication and a large soft drink cup were found stored alongside food items. These practices were not in accordance with professional standards and the facility's own policies, which require all foods to be covered, labeled, and dated, and prohibit the storage of personal items and medications in food storage areas. Interviews with staff and administration confirmed that the observed practices were not compliant with facility policies or food safety standards. The Dietary Director acknowledged that the meat should have been labeled and dated, and that the medication and soft drink cup should not have been stored in the refrigerator. The staff member whose medication was found in the refrigerator admitted to storing it there without informing management, despite knowing it was not allowed. The administrator confirmed that staff had been in-serviced on these policies and that alternative storage options for personal items and medications were available, such as employee lockers and a lounge refrigerator.
Failure to Accurately Code Falls in Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their status, specifically regarding falls. Record review showed that the resident, who had Alzheimer's disease, muscle weakness, lack of coordination, and hemiplegia/hemiparesis, experienced multiple falls as documented in the care plan and incident log. Despite these documented falls, the resident's most recent quarterly MDS assessment did not indicate any falls since admission or the prior assessment. Interviews with facility staff, including the ADON, DON, and MDS coordinator, confirmed that the MDS assessment was inaccurately coded and did not capture the resident's falls. The staff acknowledged that the MDS should have been updated to reflect the falls, and that the failure to do so could result in the MDS not triggering appropriate interventions for fall risk. The MDS nurse responsible for the inaccurate assessment was no longer employed at the facility. Facility policy and CMS RAI Manual guidelines require that MDS assessments consistently reflect information from progress notes, care plans, and resident observations. In this case, the MDS assessment did not align with the documented incidents and care plan interventions, resulting in an inaccurate representation of the resident's fall history.
Failure to Provide Adequate Foot Care Due to Unaddressed Care Refusal
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with multiple medical conditions, including dementia, diabetes mellitus, muscle weakness, and difficulty walking. The resident's toenails were observed to be long, thick, discolored, and curving toward another toe, with staff and podiatrist documentation confirming the inability to trim the nails due to the resident's combative and resistive behaviors. Despite care plan interventions to refer to a podiatrist and monitor foot care needs, there were no documented further attempts to address the toenail issue after an initial refusal, and the resident's condition persisted over several months. Staff interviews revealed that the resident was known to be combative and would not allow staff to provide personal care, including nail trimming, often requiring multiple staff members for basic hygiene tasks. The CNA and LVN both acknowledged the resident's refusal and the risk posed by the untrimmed nails, but also indicated that alternative approaches or interventions, such as medication to facilitate care, had not been attempted. The podiatrist confirmed multiple unsuccessful attempts to provide care, and the responsible family member was aware of the ongoing issue and the need for podiatric intervention. Facility leadership, including the DON and Administrator, were aware of the resident's right to refuse care but had not implemented additional strategies to address the ongoing refusal or to mitigate the risk associated with the resident's foot condition. The facility's policy required staff to attempt to identify underlying causes of care refusal and to try different approaches, but there was no evidence that such measures were consistently or effectively implemented in this case.
Failure to Prevent Resident Access to Cigarettes in Violation of Smoking Policy
Penalty
Summary
The facility failed to ensure a resident received adequate supervision to prevent accidents and did not maintain an environment free from accident hazards. A male resident with moderate cognitive impairment, as indicated by a BIMS score of 11, and diagnoses including Type 2 Diabetes Mellitus, hypertension, alcohol abuse, and gait abnormalities, was found with a box of cigarettes at his bedside. Facility policy prohibits residents without independent smoking privileges from keeping smoking items in their rooms, requiring such items to be stored securely by staff. Despite this, the resident was able to obtain and keep cigarettes in his room without staff knowledge. Multiple staff interviews confirmed that cigarettes are supposed to be kept locked at the nurses' station or in medication carts, and that residents are not allowed to have them in their rooms. The resident admitted to bringing the cigarettes in his jacket and not informing staff. Staff members, including a CNA and an LVN, reported not seeing the cigarettes during their rounds earlier that day. The DON and Administrator both acknowledged the policy and were unsure how the resident was able to keep cigarettes in his room, noting that the resident may have brought them in after being out on pass.
Failure to Follow Enhanced Barrier Precautions During G-Tube Care
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow Enhanced Barrier Precautions (EBP) during the administration of medication via a gastrostomy tube for a resident with hemiplegia and gastrostomy status. The resident was severely cognitively impaired, totally dependent on staff for nutrition, and required EBP during high-contact care activities due to the presence of an indwelling medical device. The resident's care plan specified the need for EBP, including the use of gowns and gloves during high-contact activities such as device care. During an observed medication administration, the LVN performed hand hygiene and donned gloves but did not wear a gown as required by the resident's care plan and facility policy. Interviews with the LVN, other nursing staff, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) confirmed that staff were aware of the EBP requirements for residents with indwelling devices, and that personal protective equipment (PPE) was available on the linen carts. The LVN acknowledged the oversight and the importance of following EBP to prevent the spread of infection. Facility policy required the use of gowns and gloves for residents with devices such as feeding tubes, but this protocol was not followed during the observed event.
Failure to Ensure Proper Completion of DNR Documentation
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form was properly completed, specifically lacking the required physician's signature. The resident in question had a documented history of metabolic encephalopathy, unspecified dementia, muscle weakness, and bipolar disorder, and was admitted with a code status of DNR. The resident's care plan and physician orders reflected a DNR status, and the OOH-DNR form was signed by the resident's spouse but not by the attending physician, as required by both facility policy and state law. Interviews with facility staff revealed a breakdown in the process for obtaining and verifying the necessary physician signature on the DNR form. The social services staff provided the form to the resident or family and obtained their signatures, then forwarded the form to medical records for physician signature. However, the form was uploaded into the electronic medical record system without the physician's signature, and staff did not recall why this incomplete form was uploaded. The medical records staff confirmed that the physician's signature was only obtained after the surveyor's inquiry, despite the form being received the previous year. Further interviews with nursing and administrative staff indicated confusion and inconsistency regarding when a resident's DNR status should be updated in the electronic record system. Some staff believed that a DNR status in the system indicated a completed and valid DNR, while others acknowledged that without the physician's signature, the DNR was not legally valid. The facility's policy and state requirements both specify that the physician's signature is necessary for the DNR to be honored, but this step was not completed in a timely manner for the resident in question.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment and multiple diagnoses, including dementia, schizophrenia, Alzheimer's disease, psychosis, muscle weakness, malnutrition, and lack of coordination. The resident, who was independently ambulatory and admitted to a secured unit due to a history of wandering and elopement attempts, was able to leave the facility undetected. On the day of the incident, the resident approached a CNA, who was subsequently distracted by other duties. An alarm sounded from the back door, which the CNA turned off without verifying the cause or notifying a nurse, as required by facility protocol. The resident's absence was not discovered until after a shift change, at which point staff initiated a search and notified the appropriate personnel. The resident was later found by police several miles away from the facility and returned safely. Interviews and record reviews confirmed that the CNA did not follow the elopement protocol, specifically by disabling the alarm and failing to alert nursing staff. The facility's elopement policy required monitoring of residents at risk for elopement and immediate action if an alarm was triggered, but these procedures were not followed, resulting in the resident's unsupervised exit from the secured unit.
Removal Plan
- Resident was placed on 15-minute visual checks by nurse
- Wander guard
- Code changed to the Secure Unit Doors
- Added a camera with motion detection on the back door
- Added a fence to the back of the facility for an extra layer of security
- Staff were trained in elopement/supervision procedures
- The care plan was updated to include a wander guard and medications were reviewed
Failure to Maintain Safe, Clean, and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four residents in the memory unit, as evidenced by multiple observations and interviews. Resident rooms were found to be inadequately cleaned and maintained, with specific issues such as missing or broken fixtures, unpainted and damaged walls, holes in doors, and the presence of food particles and soiled items on the floor. For example, one resident's room had a cracked sink, missing hot water knob, unpainted areas with holes, and brown sticky substances on the floor. Another resident's room contained broken ceiling tiles, soiled toilet paper on the floor, broken blinds, and food debris on various surfaces. Staff interviews revealed that the residents in question had significant cognitive impairments, including dementia, encephalopathy, and schizoaffective disorders, and some exhibited behaviors such as destroying furniture and throwing items on the floor. Despite these known behaviors, staff and housekeeping did not consistently ensure that rooms were cleaned as needed. Housekeeping staff reported only cleaning the memory unit once per day, typically at the end of their shift, and stated that the workload was too great for one person. Staff also indicated that they had notified supervisors about the need for repairs and cleaning, but maintenance and housekeeping supervisors claimed they were unaware of the specific issues. Facility records showed no work orders for repairs or replacement of blinds, fixtures, or wall repairs in the memory unit during the relevant period. The facility's own policy required that rooms be maintained in a safe, functional, and comfortable condition, with all staff responsible for reporting and addressing maintenance and cleanliness issues. However, these policies were not followed, resulting in residents living in rooms that were not thoroughly cleaned or properly maintained.
Untrained CNAs Adjusted Feeding Pump Against Policy
Penalty
Summary
The facility failed to ensure that residents receiving enteral nutrition via feeding tubes were provided with appropriate care and that only trained and authorized staff handled feeding pumps. In one instance, a certified nurse aide (CNA) who was not properly trained and not permitted by facility policy adjusted a resident's feeding pump while providing incontinent care. The resident in question was a female with severe cognitive impairment, total dependence for toileting and personal hygiene, and a history of dysphagia requiring tube feeding. During care, the resident's head was lowered and the feeding machine was placed on hold, after which the CNA restarted the feeding pump without a nurse present. Interviews with CNAs and nursing staff revealed that CNAs were not supposed to pause, stop, or restart feeding pumps, as this was outside their scope of practice and not included in their job description. Both CNAs involved admitted to not being properly trained on feeding pumps, and the Director of Nursing confirmed that only licensed nurses were authorized to handle feeding machines. The facility's policy and job descriptions did not support CNAs performing these tasks, and there was no documentation of training for CNAs on feeding pump operation.
Failure to Timely Report Alleged Abuse and Drug Paraphernalia Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source, were reported to the State Survey Agency within the required time frames. Specifically, staff detected a strong smoke odor from a resident's room and, upon searching, found drug paraphernalia. The LVN who discovered the paraphernalia reported the incident to the ADON, who then notified the Administrator and the police. However, the incident was not reported to the State Survey Agency as required by federal regulations. Interviews with the DON and Administrator revealed that they did not consider the incident reportable because there was no negative outcome and it was not viewed as related to abuse or neglect. The facility's policy requires investigation and reporting of any allegations within federally required time frames, but this was not followed in this case. The resident involved had moderate cognitive impairment and multiple medical conditions, including cerebral infarction and chronic obstructive pulmonary disease.
Failure to Secure Smoking Supplies and Supervise Resident Smoking
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received adequate supervision and that smoking supplies were properly stored, as required by the resident's care plan and facility policy. The resident, an adult male with diagnoses including type 2 diabetes, anxiety disorder, and nicotine dependence, was care planned to have his smoking supplies stored at the nurses' station. Despite this, the resident was observed outside in the parking lot smoking with a box of cigarettes and a lighter in his possession. The resident stated he forgot to return the cigarettes to the CNA the previous night and kept them with him. Interviews with staff revealed that the CNA was responsible for retrieving and returning smoking supplies to the nurses' station during supervised smoking times, and that residents were not supposed to keep smoking items due to fire risk. The DON and Administrator both confirmed that the resident was expected to return smoking supplies after use, and that failure to do so could result in a fire hazard. Facility policy specified that residents without independent smoking privileges may not keep smoking items except under direct supervision.
Failure to Prevent Significant Weight Loss and Implement Dietitian Recommendations
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, resulting in significant weight loss over a three-month period. The resident, a male with a history of bipolar disorder, stroke with dysphagia, diabetes, and malnutrition, was identified as being at risk for nutritional deficit. Despite care plan interventions such as double portions, supplements, and monitoring for signs of malnutrition, the resident experienced an 8.4% weight loss, dropping from 119 pounds to 109 pounds. The facility's computerized records showed no other weights documented during this period, and the resident's nutritional intake was consistently recorded as 76%-100% for all meals reviewed. The dietitian recommended additional interventions, including a multivitamin with minerals and fortified cereal, after noting the significant weight loss. The physician agreed with these recommendations. However, the LVN responsible for implementing the new orders failed to enter them into the electronic medication record system, resulting in the resident not receiving the recommended nutritional support. The LVN acknowledged forgetting to input the orders and was unaware of how the omission occurred. Interviews with facility staff, including the dietitian, LVN, FNP, and DON, confirmed that the resident continued to lose weight despite being on supplements and that the recommended interventions were not carried out due to the missed order entry. The DON stated that weights should be monitored weekly and interventions implemented when weights decline, but this process was not effectively followed for this resident.
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 105 citations issued within 25 miles in the last 12 months — including the 4 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 Brownsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ebony Lake Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 12 | 0 |
| Alta Vista Rehabilitation And Healthcare | 1.4 mi | ★★★★★ | 15 | 0 |
| Fox Hollow Post Acute | 1.7 mi | ★★★★★ | 15 | 3 |
| Brownsville Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 7 | 0 |
| Las Alturas Nursing & Transitional Care Brownsvill | 2.7 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mesa Hills Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.