Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mid Valley Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident receiving IV Vancomycin was given a scheduled dose before the ordered trough level was obtained, and the lab draw was not completed as scheduled. Another resident with HTN and prior CVA had multiple doses of Amlodipine, Carvedilol, and Losartan held by MAs even though the resident's BP and pulse were within the physician's ordered parameters; staff cited confusion from conflicting hold parameters in the chart.
A resident with ESRD, dialysis dependence, and hypotension had an incorrect Midodrine order that included a hold parameter for SBP less than 140. The LVN followed the order as written, entered a code 3, and did not send the medication to the dialysis clinic. The NP and DON stated the order should not have had parameters and that the medication was intended to be sent with the resident for use during dialysis if BP dropped.
Medication Administration Error Rate Exceeded 5 Percent: Surveyors found an 8.11% med error rate after an MA failed to give a resident’s ordered anti-hypertensive meds because she relied on a diastolic BP parameter that was not in the active orders. The resident had HTN and a history of stroke, and her orders required holding the meds only if SBP was below 100, with Carvedilol also held if pulse was below 60. The LVN, ADON, and DON stated the meds should not have been held based on the resident’s vital signs and that older hold parameters in pharmacy comments were confusing but not part of the order.
Expired and unlabeled food was found in a resident's personal refrigerator. The refrigerator contained sealed pudding cups past the expiration date and a half-eaten cupcake without an open or expiration date. The resident had Alzheimer’s disease, a BIMS of 5, and severe cognitive impairment. Staff reported they checked refrigerator temperatures, but one housekeeper said she did not check food dates and had not been told to do so, while the facility policy required outside food to be labeled and handled properly.
Inadequate Hand Hygiene During Medication Administration: A MA did not perform hand hygiene for at least 20 seconds before giving meds to one resident and did not perform hand hygiene for at least 20 seconds before and after giving meds to another resident. One resident had severe cognitive impairment, and the other was cognitively intact. The facility policy addressed infection prevention and control but did not specify hand washing procedures.
A resident with dementia and other medical conditions had an authorization form signed by the responsible party requesting a complete copy of the medical record. An LVN in medical records forwarded the request to the Health Information Management (HIM) Director, who assumed responsibility for compiling and emailing the full chart. The HIM Director later reported she believed she had sent the records via secure email but could not find any email or confirmation showing they were sent, while the LVN was unsure of the required time frame for fulfilling such requests. Facility policy required access to records within 24 hours of request and fulfillment of copy requests within two working days, but the resident’s responsible party did not receive the requested records as required.
A resident with CHF, chronic pulmonary edema, dementia, and other comorbidities had physician orders for continuous O2 at 2 L via nasal cannula and a care plan addressing oxygen therapy, but the plan did not include her repeated behavior of removing the nasal cannula and being non‑compliant with O2. Multiple staff, including CNAs, LVNs, and the RT, reported that the resident frequently or constantly removed her oxygen and required staff to repeatedly replace it and monitor her. The MDS nurse and DON acknowledged that this behavior was known to staff and should have been included on the care plan, but it was not, and facility policies on oxygen administration and care plans did not specifically address documenting such behaviors.
A resident with dementia, diabetes, and trauma-related pain had a PRN acetaminophen order and was documented in a nurse’s note as having received the medication for back pain after a fall, but the August MAR contained no corresponding nurse signature or entry showing it was administered. The LVN later stated she likely forgot to document the dose on the MAR despite prior training on MAR/TAR use, and the DON confirmed the medication should have been signed off and that the MAR did not show administration, while the facility’s medication administration policy lacked specific language on documenting administered medications in the MAR.
A resident with multiple medical conditions had a documented DNR status in her records, but the facility failed to obtain the required physician's signature on the Out-of-Hospital Do Not Resuscitate (OOH-DNR) form. Staff interviews confirmed that, despite the DNR status being noted electronically and a verbal order from the physician, the official OOH-DNR form was incomplete, lacking the physician's signature as mandated by facility policy.
A resident with multiple medical conditions, including diabetes and dehydration, was found with a peripheral IV lock covered by a transparent dressing that was not dated or initialed, contrary to facility policy and standard nursing practice. Nursing staff and the DON confirmed that the dressing should have been labeled to track placement and changes, but documentation was lacking and the responsible nurse could not recall recent IV administration training.
A normal saline flush was found left at the bedside of a cognitively impaired resident, rather than being stored in a locked compartment as required. Facility staff confirmed that medications should not be accessible at the bedside, and facility policy mandates secure storage of all drugs and biologicals.
A CNA was observed reusing wipes multiple times while providing perineal and catheter care to a male resident with a Foley catheter, and performed the care with the resident standing, causing discomfort. Staff interviews revealed inconsistencies in training and understanding of proper technique, and facility policies lacked clear guidance on the use of wipes versus washcloths.
A resident with a history of pruritus and behaviors of itching and scratching did not have these issues reflected in their care plan, despite staff awareness, medical documentation, and ongoing treatment. The care plan only included general skin risk statements and omitted specific interventions or objectives related to the resident's pruritus, contrary to facility policy and staff acknowledgment that such conditions should be documented.
A resident with multiple complex medical conditions did not have a physician-ordered weekly total body skin assessment documented as required. The Treatment Nurse, who was responsible for these assessments, was absent, and the DON, who assumed responsibility, failed to document the assessment in the medical record. Both staff members had been deemed competent in skin assessment and documentation, and facility policy required weekly documentation, but the required record was missing for the specified week.
A resident with a history of renal failure and fractures experienced a fall, prompting neuro checks as per protocol. However, four nurses failed to accurately document these checks, with repeated vital signs entries showing the same readings and dates. Interviews revealed that the nurses noted vitals on paper but did not update the electronic records, leading to discrepancies. The DON confirmed the errors but noted no negative effects on the resident.
A facility failed to include oxygen treatment in a resident's care plan, despite the resident using oxygen daily. The resident, with a history of serious medical conditions, was observed using oxygen without a corresponding care plan. Staff interviews revealed that the MDS coordinator had not received a physician's order for the oxygen, leading to its omission from the care plan, contrary to facility policy.
The facility failed to ensure proper respiratory care for two residents, as both were receiving oxygen therapy without physician orders and lacked appropriate signage. One resident, a male with severe cognitive impairment, was using oxygen without a posted sign, while a female resident with a history of strokes and heart failure also lacked a physician's order for her oxygen therapy. Staff interviews revealed a lack of clarity in responsibilities for managing physician orders and posting oxygen signs, leading to these deficiencies.
The facility did not comply with food service safety standards by failing to label and date food items in the freezer. An open bag of French toast was found unlabeled and undated, exposing it to air. A staff member admitted to not knowing how long it had been there and acknowledged the importance of labeling to prevent contamination. The Dietary Manager confirmed that all staff are responsible for this task, as per facility policy.
A facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents. An LVN did not follow Enhanced Barrier Precautions (EBP) while administering medication via a G-tube to a resident, wearing only gloves instead of the required gown and gloves. Additionally, the facility did not inform visitors that another resident was on contact precautions due to an ESBL infection, and no precaution sign was posted on the resident's door. These lapses in protocol could lead to cross-contamination and infection spread.
A resident with severe cognitive impairment experienced neglect during a Foley catheter change when LVN D and LVN R failed to stop the procedure despite the resident's cries of pain. The resident, who had multiple medical conditions, was subjected to continued catheter insertion, leading to significant discomfort and eventual hospital transfer due to hematuria. The nursing staff did not adhere to protocols requiring cessation of the procedure when a resident expresses pain.
A resident with severe cognitive impairment experienced pain during a Foley catheter change, but the LVNs involved did not stop the procedure despite the resident's cries for help. The resident, who had a history of urinary tract infection, hematuria, and dementia, was hospitalized due to hematuria. The facility failed to implement its abuse prevention policies, leading to Immediate Jeopardy.
A resident with severe cognitive impairment and a history of wandering exited a facility undetected and was found in the parking lot near a busy street. Despite previous observations of the resident's exit-seeking behavior, the care plan did not address these behaviors until after the incident. The facility lacked adequate monitoring and did not report the incident to the state, as the resident was not considered missing.
A resident with a urinary catheter experienced pain and hematuria during a catheter change when LVNs failed to stop the procedure despite resistance and the resident's cries of distress. The resident, with a history of UTIs and dementia, was sent to the hospital for evaluation. The facility's failure to notify the doctor and address the resident's discomfort led to an Immediate Jeopardy situation.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised and was found in the parking lot. Despite being quickly redirected back inside without injury, the incident was not reported to the state within the required 24-hour timeframe. The facility's Administrator and DON did not report the incident, citing corporate guidelines, despite the facility's policy requiring such reporting.
A facility failed to update the care plan for a resident with dementia who exhibited wandering and exit-seeking behaviors. Despite these behaviors being documented in progress notes and discussed with the resident's responsible party, the care plan was not revised to include interventions until several months later. This oversight could have led to missed or delayed continuity of care.
A resident with multiple serious health conditions did not receive his prescribed heart failure medication, Entresto, due to its unavailability. The responsible nurse failed to notify the doctor or pharmacy, despite being aware of the protocol. The facility's Director of Nursing acknowledged the lapse in following the policy for timely medication administration.
Medication Administration Errors With IV Antibiotic and Antihypertensive Orders
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 2 of 5 residents reviewed for medication errors. One resident, who had acute respiratory failure with hypoxia, a tracheostomy, and ventilator-associated pneumonia, was ordered IV Vancomycin every 12 hours and also had a Vancomycin trough scheduled for 04/08/26. The resident received the 8:00 a.m. Vancomycin dose before the trough level was obtained, and the laboratory logbook showed the blood draw was not completed that morning. The ADON stated the lab was short staffed, the trough was not collected, and the nurse should not have administered the Vancomycin without the level being drawn. The second resident, who had hypertension, cerebral infarction, aphasia following cerebral infarction, dysphagia following cerebral infarction, and other sequelae of cerebral infarction, had orders for Amlodipine, Carvedilol, and Losartan Potassium with hold parameters based on systolic blood pressure and, for Carvedilol, pulse. Review of the MAR showed multiple missed opportunities when medication aides held these medications even though the resident's blood pressure and pulse were within the physician's ordered parameters. The missed administrations involved the morning dose of Amlodipine, the morning and evening doses of Carvedilol, and the morning, evening, and bedtime doses of Losartan Potassium across multiple dates in March and April 2026. Interviews showed that MA D held the medications because the resident's diastolic blood pressure was below 60 and because she saw conflicting hold parameters in the chart. LVN E stated the orders only required holding the medications if systolic blood pressure was below 100, and that MA D should not have held them. The ADON stated old hold parameters remained in the pharmacy comments area and were not removed when the physician updated the orders, which could make it appear there were two sets of hold parameters. The DON stated that if blood pressure medications were held when they should have been given, the resident's blood pressure could become too high and lead to stroke.
Incorrect Midodrine Order and Missed Dialysis Medication
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of Resident #6 when the facility failed to ensure the physician’s Midodrine order was correct. Resident #6 was a male with end stage renal disease, dependence on renal dialysis, and hypotension. His MDS reflected intact cognition with a BIMS score of 15. His care plan noted that he received dialysis on Mondays, Wednesdays, and Fridays and that medications were to be given as ordered by his physician. The physician’s order summary dated 04/09/26 reflected Midodrine HCI 5 mg, one tablet by mouth one time a day every Monday, Wednesday, and Friday for hypotension on dialysis days, with instructions to hold if systolic blood pressure was less than 140 and notify the nurse/MD. On 04/08/26, the MAR showed the Midodrine was not administered and a code 3 was entered for medication held because blood pressure was outside parameters. During interview, the NP stated the hold parameter was not correct and that the order should not have had any parameters; he said the medication should have been sent with the resident to the dialysis clinic regardless of blood pressure. The DON stated the resident’s Midodrine was intended to be sent to the dialysis clinic in case his blood pressure dropped, and that the dialysis clinic did not keep medications on hand. She also stated the order was not correct and should not have had parameters, but the LVN followed the order as written and did not send the medication with the resident. The dialysis RN confirmed the facility was to send a labeled Midodrine pill with the dialysis communication sheet, and the dialysis communication form for that treatment reflected asymptomatic hypotension during treatment with a request to send Midodrine with the patient.
Medication Administration Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure its medication error rate was not 5 percent or greater. Surveyors found an 8.11% medication error rate, based on 3 errors out of 37 opportunities, involving 1 of 5 residents observed during medication administration. The deficiency centered on a medication administration error for a resident with a history of hypertension, cerebral infarction, aphasia following cerebral infarction, dysphagia following cerebral infarction, and other sequelae of stroke. Her quarterly MDS reflected a BIMS score of 15, indicating she was cognitively intact. The resident’s care plan addressed heart disease and risk for complications including chest pain, shortness of breath, edema, and high blood pressure, with interventions to administer medications as ordered and monitor vital signs as indicated. Her physician’s orders included Amlodipine Besylate 10 mg daily, Carvedilol 12.5 mg twice daily, and Losartan Potassium 50 mg twice daily, each with hold parameters based on systolic blood pressure, and Carvedilol also based on pulse. During observation, the resident’s blood pressure was 122/53 and pulse was 64, but the MA did not administer the three anti-hypertensive medications. During interview, the MA stated she held the medications because the diastolic blood pressure was below 60, and she believed the resident was outside the parameters for administration. The LVN and ADON stated the active physician orders only required holding the medications if systolic blood pressure was below 100, with Carvedilol also held if pulse was below 60, and that the MA should not have held the medications. The ADON explained that older hold parameters remained in the pharmacy comments area and could appear confusing, but were not part of the administration order. The DON stated the medications were later given after the nurse contacted the nurse practitioner.
Expired and Unlabeled Food Found in Resident Refrigerator
Penalty
Summary
The facility failed to enact a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for Resident #43. During observation, Resident #43's personal refrigerator contained 3 small sealed cups of pudding with an expired date of 12/10/25 and a half-eaten carrot cupcake that did not have an open date or expiration date. The resident's refrigerator temperature log was posted next to the refrigerator and showed it had last been checked on 04/07/26 in the AM. Resident #43's record showed diagnoses including Alzheimer's Disease Unspecified, Essential Hypertension, Gastro-Esophageal Reflux Disease without Esophagitis, Hyperlipidemia, and Cognitive communication deficit. The quarterly MDS assessment showed a BIMS of 5, indicating severe cognitive impairment. In interview, Resident #43 stated he did not know when the food items were brought. Housekeeper A stated she checked the refrigerator temperature when cleaning the room but did not check food dates and had not been told to do so. The Housekeeping Supervisor stated housekeeping staff were responsible for checking residents' personal refrigerators and were told to check temperatures, expiration dates, and label open dates. The ADM stated housekeeping checked residents' personal refrigerators daily and that expiration dates should be checked. The facility's Outside Foods policy stated outside food should be labeled with the resident's name and date and that proper food handling should be used once outside food is brought into the facility.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility did not maintain hand hygiene practices during medication administration for two residents. Resident #14 was an [AGE] year-old male admitted with diagnoses including unspecified dementia, paroxysmal atrial fibrillation, type 2 diabetes mellitus, hyperlipidemia, essential hypertension, and cognitive communication deficit. His quarterly MDS reflected a BIMS score of 3, indicating severe cognitive impairment. During observation, MA D scrubbed her hands for 8 seconds before administering medication to Resident #14, rather than the at least 20 seconds reflected in CDC guidance. Resident #82 was an [AGE] year-old female admitted with diagnoses including fracture of the right patella, type 2 diabetes mellitus, hyperlipidemia, essential hypertension, and long term use of anticoagulants. Her admission MDS reflected a BIMS score of 15, indicating she was cognitively intact. During observation, MA D scrubbed her hands for 8 seconds before administering medication to Resident #82 and scrubbed her hands for 11 seconds after administering medication to Resident #82. In interview, MA D stated hands were washed for 30-35 seconds total and that she was counting scrub time, not total time. The ADON stated hand washing scrub time was supposed to be at least 20 seconds, and the DON stated infection control was in-serviced all the time. The facility policy reflected staff responsibilities for infection prevention and control, but did not specify hand washing procedures.
Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to timely access to personal and medical records. A male resident with unspecified dementia, moderate cognitive impairment (BIMS score of 09), type 2 diabetes mellitus, and acute pain due to trauma was admitted and later discharged from the facility. His care plan reflected impaired cognitive function related to dementia. After discharge, the resident’s responsible party (RP) completed and signed an authorization to disclose protected health information form requesting the resident’s medical records. On the date of the request, the Medical Records LVN received the RP’s request for the resident’s records and forwarded it to the Health Information Management (HIM) Director. The LVN reported that, because the family requested the entire chart, the HIM Director decided she would handle compiling and emailing the records directly to the RP. The LVN stated she typically provided records such as medication lists after clearance from the HIM Director, but in this case, the HIM Director took responsibility for sending the full chart. The LVN was unsure of the exact time frame required to send requested records and indicated she would need to review facility policy, though she believed records were usually sent timely. The HIM Director stated she had completed gathering the requested records and believed she had sent them via secure email, which normally generated a confirmation receipt. However, upon reviewing her email, she found no record of sending the resident’s requested records and no confirmation receipts. She acknowledged having multiple record requests at that time and could not locate any evidence that the records for this resident had been sent. The facility’s policy stated that residents have the right to access all records pertaining to their care within 24 hours of an oral request followed by a signed written request, and that requests to purchase copies of records would be granted within two working days. Despite this policy, the requested records were not provided to the resident’s RP as required.
Failure to Care Plan Resident’s Repeated Removal of Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who required continuous oxygen therapy received care consistent with professional standards of practice and a comprehensive, person-centered care plan. The resident was an older female with diagnoses including unspecified dementia without behavioral disturbance, type 2 diabetes mellitus, combined systolic and diastolic congestive heart failure, chronic pulmonary edema, and paroxysmal atrial fibrillation. A 5‑day MDS showed she was cognitively intact with a BIMS score of 14. Physician orders directed continuous oxygen at 2 L via nasal cannula, and the care plan included a focus on oxygen therapy related to CHF with an intervention to administer oxygen per MD orders. Despite this, the care plan contained no language addressing the resident’s behavior of removing her nasal cannula or non‑compliance with oxygen therapy. Multiple staff interviews confirmed that the resident frequently removed her oxygen. An LVN stated the resident would occasionally remove her oxygen and that nurses and the respiratory therapist would replace it when notified by CNAs or during rounds. A CNA reported that the resident removed her oxygen and that staff repeatedly put it back on, only for the resident to remove it again. Another LVN described the resident as constantly removing her oxygen and needing frequent correction. The respiratory therapist reported that the resident was always taking off her oxygen and that staff were constantly checking to ensure it was on, with this behavior being communicated in report. The MDS nurse acknowledged that staff had reported the resident sometimes removed her oxygen and needed reminders, and he stated that this behavior should have been on the care plan but was not, explaining that he relied on behavior reports, particularly after the resident’s readmission, to update care plans. The DON also stated that the resident had continuous oxygen orders and had previously been known to constantly remove her oxygen, and that staff were aware and had to monitor her. Both the MDS nurse and the DON stated that the behavior of removing oxygen should have been on the care plan, but it was not included, and facility policies on oxygen administration and care plans did not contain specific language about documenting such behaviors on the care plan.
Failure to Accurately Document PRN Pain Medication on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident who had dementia with moderate cognitive impairment, type 2 diabetes mellitus, and acute pain due to trauma. The resident’s care plan identified a risk for discomfort or pain related to immobility, with an intervention to administer pain medication as recommended by the physician. A physician’s order was in place for PRN acetaminophen 650 mg by mouth every 6 hours as needed for pain, not to exceed 3000 mg in 24 hours. Nursing documentation on the same day indicated that the resident complained of back pain after a fall and was provided PRN acetaminophen. However, review of the resident’s August medication administration record (MAR) showed that the PRN acetaminophen order was entered with a start time but had no nurse signature or indication that the medication was administered, despite the nurse’s progress note stating it had been given. During interview, the LVN acknowledged that if she administered the medication, she was responsible for documenting it on the MAR and stated she probably forgot to click it as administered. She confirmed she had been trained on medication administration documentation and understood that failure to document could affect subsequent nurses’ knowledge of prior doses. The DON confirmed that the medication should have been signed off on the MAR, that LVN A was responsible for the documentation, and that the MAR did not reflect administration. Review of the facility’s medication administration policy showed no specific language regarding documentation of administered medications in the MAR.
Failure to Obtain Physician Signature on OOH-DNR Form
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, an elderly female with diagnoses including Type 1 Diabetes Mellitus, muscle wasting and atrophy, and dehydration, was admitted with a documented DNR status on her electronic face sheet, care plan, and physician orders. However, review of the OOH-DNR form revealed it was undated and missing the attending physician's signature in the designated sections, which is necessary to make the document official and legally binding. Interviews with facility staff, including the ADON, Social Services, and DON, confirmed that while the DNR status was discussed and documented in the electronic record, the OOH-DNR form was not fully executed as required. The Social Services staff member, responsible for completing the form, acknowledged that the physician's signature is essential for the document's validity. The DON stated that a verbal order from the physician was obtained and used to update the code status, but the OOH-DNR form itself remained incomplete without the physician's signature. Facility policy requires the physician's signature on the OOH-DNR form to implement advance directives, which was not followed in this instance.
Failure to Label IV Dressing According to Facility Policy
Penalty
Summary
A deficiency occurred when a resident with a history of Type 1 Diabetes Mellitus, muscle wasting, atrophy, and dehydration was found to have a peripheral intravenous (IV) lock covered with a transparent dressing that was not dated or initialed. The resident's care plan required frequent monitoring of the IV site for signs of infection or infiltration, and the facility's policy specified that the dressing should be labeled appropriately. During observation, the dressing on the resident's right hand lacked both a date and initials, and interviews with nursing staff and the DON confirmed that the nurse who inserted the IV was responsible for labeling the dressing. The staff acknowledged the importance of labeling to track when the IV was placed or last changed. Record review and staff interviews revealed that the facility's policy and standard nursing practice require IV dressings to be dated and initialed to ensure timely changes and proper monitoring. The DON and nursing staff were unable to determine who had placed the IV due to missing documentation, and the nurse assigned to the resident could not recall recent training on IV administration. The failure to label the IV dressing was directly observed and confirmed by staff, and the facility's own policy outlined the requirement for proper labeling of IV dressings.
Improper Storage of Medication at Bedside
Penalty
Summary
A deficiency occurred when a normal saline flush, classified as a drug/biological, was found stored at the bedside of a resident rather than in a locked compartment as required. The resident, a female with diagnoses including type 1 diabetes mellitus, muscle wasting, atrophy, and dehydration, was severely cognitively impaired according to her BIMS score. Her care plan included monitoring for complications related to intravenous therapy. During an observation, the normal saline flush was seen on the resident's television stand, and the resident stated that a nurse had left it there. Interviews with facility staff, including an LVN and the DON, confirmed that medications or saline flushes should not be left at the bedside, as this could allow access by residents or visitors and risk contamination or adverse reactions. Review of facility policy also indicated that medication storage should be secure and locked when not in use. The failure to store the normal saline flush in a locked compartment constituted noncompliance with professional standards and facility policy.
Improper Perineal and Catheter Care Technique Observed
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate perineal and catheter care to a male resident with an indwelling Foley catheter. The resident, who had a history of hematuria, benign prostatic hyperplasia, urinary retention, and urinary tract infection, was observed during care where the CNA reused wipes multiple times when cleaning the urethral opening of the penis. The CNA also provided incontinence care with the resident standing, despite the resident expressing discomfort and fatigue during the process. The resident's catheter tubing was observed to be hanging due to gravity during the care. Interviews revealed inconsistencies in staff training and understanding of proper catheter care techniques. The CNA involved stated she had been trained to use a new wipe for each swipe but did not recall reusing wipes during the observed care, acknowledging that reusing wipes could lead to contamination and infection. The Director of Nursing (DON) and another CNA responsible for training provided conflicting information regarding the correct procedure, with the trainer emphasizing the importance of using one wipe per swipe and performing care with the resident lying down for better access and visibility. A review of facility policies and training materials showed that while the facility conducted regular training and competency checks, the written policy did not clearly define the clean technique or specify the use of wipes versus washcloths. The Texas nurse aide curriculum referenced by the facility also lacked specific guidance on the use of wipes. The observed deficient practice of reusing wipes and providing care with the resident standing was not aligned with the training described by the staff and could contribute to infection risk.
Failure to Include Pruritus and Itching Behaviors in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed all identified needs for a resident, specifically omitting the resident's pruritus (itchy skin) and associated behaviors of itching and scratching from the care plan. The resident, a male with multiple diagnoses including type 2 diabetes mellitus, bladder cancer, acute respiratory failure, dysphagia, and nontraumatic intracranial hemorrhage, was cognitively intact and had expressed concerns about itching during a care plan meeting. Documentation showed that medical staff were aware of the pruritus, a dermatology referral was made, and topical treatments were used, which improved the resident's symptoms. Despite these interventions and ongoing awareness among nursing staff, the resident's care plan did not include any specific mention of pruritus or the behaviors of itching and scratching. Both the Treatment Nurse and the MDS nurse acknowledged during interviews that these conditions and behaviors should have been included in the care plan. The care plan only contained general statements about skin assessment and risk for skin breakdown, without addressing the specific issue of pruritus or the resident's behaviors. The staff could not provide a clear reason for this omission, even though they recognized the importance of accurately reflecting all current conditions and behaviors in the care plan. Facility policy required that care plans be reflective of identified problems or risks, include measurable outcome objectives, and appropriate interventions. The DON, MDS nurse, and Treatment Nurse all confirmed that skin conditions and related behaviors should be documented in the care plan if present. However, the care plan for this resident was not updated to include pruritus or the associated behaviors, despite ongoing documentation and staff awareness of the issue. This failure was identified through record review and staff interviews.
Failure to Document Weekly Physician-Ordered Skin Assessment
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident by not documenting a physician-ordered weekly total body skin assessment. The resident, a cognitively intact male with multiple diagnoses including type 2 diabetes mellitus, bladder cancer, acute respiratory failure, dysphagia, and nontraumatic intracranial hemorrhage, had an active order for weekly skin assessments every Monday. Record review showed that the last documented skin assessment was completed on 02/19/25, with no documentation for the following week as required by the physician's order. Interviews with the Treatment Nurse revealed that she was responsible for completing weekly skin assessments but was not working from 02/13/25 to 03/03/25. During her absence, the DON was expected to delegate or complete the assessments. The Treatment Nurse was unable to identify who, if anyone, completed the assessment for the week of 02/26/25 and confirmed that the last documented assessment was on 02/19/25. She acknowledged the importance of following physician orders and documenting assessments but was unsure of the facility's policy and had not received specific training on documentation procedures. The DON confirmed responsibility for completing the skin assessments during the Treatment Nurse's absence and stated that she completed the assessment on 02/26/25 but did not document it in the resident's record, attributing the omission to oversight. The DON also confirmed the importance of documentation and stated that the facility policy required weekly skin assessments to be documented in the medical record. Review of competency checklists indicated that both the DON and Treatment Nurse had been checked off as competent in skin assessment and documentation. Facility policy also specified that weekly skin assessments should be documented by a licensed nurse.
Inaccurate Documentation of Neuro Checks Post-Fall
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically in the documentation of neuro checks following a fall. The resident, a female with a history of end-stage renal failure, muscle weakness, and fractures, experienced a fall from her bed while reaching for snacks. Although the resident was found alert and oriented with no visible injuries, neuro checks were initiated as per facility protocol. The neuro checks, which were supposed to be conducted at specific intervals, were not accurately documented by four nurses. The records showed repeated vital signs entries with the same readings and dates, indicating that new vital signs were not recorded as required. Interviews with the involved nurses revealed that they had conducted the checks and noted the vitals on paper but failed to transfer the updated information to the electronic medical record. This resulted in the documentation showing incorrect and outdated vital signs. The Director of Nursing (DON) confirmed the discrepancies in the neuro check documentation and acknowledged that the nursing staff did not follow the protocol of recording new vital signs at each interval. Despite the documentation errors, the DON noted that there were no negative effects on the resident, as she had not sustained any injuries from the fall. The facility's policy on professional standards of care emphasizes the importance of accurate documentation, which was not adhered to in this case.
Failure to Include Oxygen Treatment in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included the omission of oxygen treatment in the care plan. This deficiency was identified during a review of the resident's records, which showed no physician's order for oxygen, despite the resident using oxygen via nasal cannula daily. The resident, a male with a history of pneumonia, encephalopathy, transient ischemic attack, cerebral infarction, chronic kidney disease stage 3, and major depressive disorder, was observed using oxygen without a corresponding care plan. Interviews with facility staff revealed that the MDS coordinator was responsible for care planning and had not received a physician's order for the oxygen, leading to its exclusion from the care plan. The Director of Nursing acknowledged that the absence of a care plan for oxygen could result in staff not being aware of the resident's needs, potentially leading to inadequate oxygen support. The facility's policy requires that care plans include measurable objectives and interventions for identified needs, which was not adhered to in this case.
Deficiencies in Oxygen Therapy Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen therapy management. Resident #187, a male with severe cognitive impairment and multiple health conditions, was observed using oxygen via a nasal cannula without a physician's order or an oxygen sign posted on his door. Interviews with staff revealed that the responsibility for posting oxygen signs and ensuring physician orders were in place was not adequately managed, as the nurse assumed the order was already in place. Similarly, Resident #78, a female with severe cognitive impairment and a history of strokes and heart failure, was also receiving oxygen therapy without a physician's order. Observations confirmed the use of oxygen via nasal cannula, but the necessary physician's order was missing from her records. Staff interviews indicated a lack of clarity on who was responsible for entering physician orders into the electronic record, leading to the oversight. The facility's policies on oxygen administration require a physician's order for oxygen therapy, but these were not followed for the two residents. The absence of physician orders and proper signage for oxygen use could lead to potential risks, as noted by the staff, but the report does not detail any specific consequences that occurred as a result of these deficiencies.
Failure to Label and Date Food Items in Freezer
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not ensure that all food items in the freezer were labeled and dated, which is a requirement according to their policy. An open bag containing five slices of French toast was found in the freezer without any labeling or dating, exposing it to air. During an interview, a staff member admitted to not knowing how long the French toast had been in the freezer and acknowledged the importance of labeling and dating food items to prevent contamination and ensure quality. The staff member also mentioned that they could not recall the last time they received training on this procedure. The Dietary Manager confirmed that all dietary employees are aware of the requirement to label and date food items in storage areas, as per the facility's policy, which aligns with state, federal, and US Food Codes and HACCP guidelines.
Infection Control Lapses in PPE Use and Visitor Notification
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) did not adhere to Enhanced Barrier Precautions (EBP) while administering medication via a G-tube to a resident. Despite the presence of an EBP sign and available personal protective equipment (PPE) outside the resident's room, the LVN only wore gloves and not a gown, as required. The LVN admitted to forgetting to wear the gown due to nervousness, acknowledging that the resident was on EBP due to having a G-tube, which necessitates gown and glove use to prevent infection spread. In the second incident, the facility failed to inform visitors that another resident was on contact precautions due to an infection with ESBL in the urine. There was no contact precaution sign posted on the resident's door, and a visitor reported not being informed about the contagious nature of the infection, nor using PPE during visits. The LVN confirmed the resident's contact precaution status and acknowledged the importance of informing visitors and placing signs to prevent infection spread. The Director of Nursing (DON) confirmed that visitors should have been informed and required to wear PPE, and that signs should have been posted to alert staff and visitors. The facility's policy on infection prevention and control, which includes the use of EBP and contact precautions, was not followed in these instances. The policy outlines the necessity of using PPE during high-contact activities and ensuring that signs are posted to inform and protect staff and visitors. These lapses in protocol could lead to cross-contamination and the spread of infections among residents and visitors.
Neglect During Foley Catheter Change
Penalty
Summary
The facility failed to protect a resident from neglect during a Foley catheter change, which resulted in the resident experiencing significant discomfort and pain. The resident, a male with severe cognitive impairment and multiple medical conditions including urinary tract infection and benign prostatic hyperplasia, was subjected to a catheter change by LVN D and LVN R. Despite the resident's cries of pain and requests to stop, the nurses continued the procedure, which is against the protocol that requires stopping if a resident expresses discomfort. During the procedure, the resident cried out and expressed significant distress, yet the nurses did not cease the procedure immediately. LVN D and LVN R failed to recognize and appropriately respond to the resident's pain, which was evident in a video recording of the incident. The resident's cries for help were ignored, and the catheter change was completed despite the resident's clear indications of pain and discomfort. The incident was further compounded by the lack of immediate and appropriate response from the nursing staff, as they did not stop the procedure or provide any pain relief measures. The situation escalated to the point where the resident was transferred to the hospital due to hematuria, which was noted after the catheter change. This neglectful action placed the resident at risk of further harm and highlighted a significant deficiency in the facility's care practices.
Failure to Implement Abuse Prevention Policies During Catheter Change
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of a male resident with severe cognitive impairment. The resident, who had a history of urinary tract infection, hematuria, benign prostatic hyperplasia, dementia, and heart failure, experienced pain during a Foley catheter change. Despite the resident's cries of pain and requests to stop, the licensed vocational nurses (LVNs) involved did not cease the procedure, which resulted in the resident being hospitalized due to hematuria. The incident occurred when LVN D and LVN R were changing the resident's Foley catheter. The resident expressed discomfort and pain, yet the nurses continued with the procedure. LVN D initially attempted to advance the catheter but encountered resistance. Despite this, the procedure continued, and the resident was not medicated for pain before or after the catheter change. The resident's cries for help were ignored, and the situation was not reported to the facility's administrator as required by the facility's abuse policy. The failure to adhere to the facility's Abuse Neglect Exploitation (ANE) policy and the lack of appropriate response to the resident's pain and distress led to the identification of Immediate Jeopardy. The facility's staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), were aware of the situation but did not take immediate corrective action. The resident was eventually sent to the hospital after continued bleeding was observed in the catheter bag, highlighting the severity of the oversight and the potential risk to other residents.
Removal Plan
- The resident identified as #2 was reassessed and Resident #2's plan of care reviewed to validate that appropriate intervention is in place related to foley insertion and care.
- Regional Nurse / Director of Nursing provided in-service training to LVN D, LVN R, and RN ADON regarding Abuse Neglect and Exploitation Prevention, Reporting and Protecting, and Procedure for insertion of indwelling foley catheter.
- Monitoring, assessing for signs/symptoms of pain prior to procedure, during procedure and responding to any complaints of pain; including stopping the procedure, providing non-pharmacological and pharmacological interventions to relieve discomfort.
- If resistance is noted upon insertion of the indwelling foley catheter, the nurse should cease the procedure, ensure the resident is safe and comfortable, and notify the PCP for further instructions.
- Nursing should continue to monitor the resident status and communicate abnormal findings to the PCP.
- Director of Nursing / Assistant Director of Nursing / Designee conducted an audit to identify all residents with indwelling foley catheters to identify any resident having signs/symptoms of pain associated with the catheter and/or signs/symptoms of hematuria.
- Director of Nursing / Assistant Director of Nursing / Designee interviewed residents with indwelling foley catheters to identify any concerns of pain during the procedure of changing of catheter.
- The Regional Nurse / DNS educated the licensed nurses regarding Abuse Neglect and Exploitation Prevention, Reporting and Protecting, and Procedure for insertion of indwelling foley catheter.
- Director of Nursing / Assistant Director of Nursing and Clinical Leadership will conduct training for all newly hired nurses, PRN nurses and agency nurses prior to the nurses working.
- Director of Nursing / Assistant Director of Nursing will require nurses to perform return demonstration of the procedure for the insertion of the foley catheter to establish competency.
- The Administrator and Director of Nurses conducted an Ad Hoc QAPI review of this situation and the immediate corrective action plan with the facility's Medical Director.
- Director of Nursing / Assistant Director of Nursing / Designee will conduct audits/rounds to inspect residents with indwelling foley catheters to identify signs/symptoms of hematuria and observe nurses during the procedure of placing/changing an indwelling catheter to evaluate competency.
- Director of Nursing / Assistant Director of Nursing / Designee will review the nursing 24hr report, and progress notes to identify issues with placing/changing the indwelling foley catheter and ensure appropriate follow-up interventions are in place.
- All findings will be reported to the QAPI committee and the committee will determine compliance or additional training and oversight is required.
Resident Elopes Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment for a resident with severe cognitive impairment and a history of wandering and exit-seeking behavior. The resident, who had been admitted for rehabilitation services, was able to exit the facility undetected and was found in the parking lot, close to a busy two-way street. Despite previous observations and documentation of the resident's wandering tendencies, the care plan did not adequately address these behaviors prior to the incident. Interviews with staff revealed that the resident had been observed attempting to exit the facility on multiple occasions, yet the care plan to manage these behaviors was not implemented until after the incident. The resident's exit-seeking behavior had been discussed in care plan meetings, but the necessary interventions were not put in place in a timely manner. The facility lacked wander guards, and although emergency exits were alarmed, the front doors through which the resident exited were not adequately monitored. The incident was not reported to the state, as the facility's administration believed it did not meet the criteria for reporting. The facility's Director of Nursing and Administrator acknowledged the resident's wandering behavior but did not activate a code yellow, as the resident was not considered missing. The lack of immediate and effective response to the resident's exit-seeking behavior highlights a significant oversight in the facility's supervision and safety protocols.
Failure to Provide Appropriate Catheter Care Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a urinary catheter, leading to an Immediate Jeopardy situation. During a Foley catheter change for a male resident with a history of urinary tract infections, hematuria, benign prostatic hyperplasia, dementia, and heart failure, the licensed vocational nurses (LVNs) involved did not stop the procedure when resistance was felt. Despite the resident's cries of pain and requests to stop, the LVNs continued with the catheter change without notifying the doctor or taking appropriate action to address the resident's discomfort. The resident, who had severely impaired cognition and was bedbound, experienced hematuria and pain following the catheter change. The LVNs involved in the procedure failed to recognize and respond to the resident's distress, as evidenced by a video recording where the resident was heard yelling and pleading for the procedure to stop. The LVNs did not acknowledge the resident's pain or discomfort during interviews, despite the video evidence showing otherwise. The facility's failure to stop the procedure and notify the physician when resistance was encountered during the catheter change resulted in the resident being sent to the hospital for further evaluation. The Immediate Jeopardy was identified due to the potential for more than minimal harm to residents receiving Foley catheter changes, as the facility did not ensure that staff were adequately trained to handle such situations appropriately.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an incident involving a resident who exited the facility unsupervised, which was a violation of the requirement to report alleged neglect to the State Survey Agency within 24 hours. The incident occurred when a resident with severe cognitive impairment and a history of wandering behavior exited the facility through the front door and was found in the parking lot. Despite the resident being quickly redirected back into the facility without injury, the incident was not reported to the state as required. The resident involved was an elderly female with diagnoses including dementia, muscle weakness, and malnutrition. Her quarterly MDS indicated a severely impaired cognitive status with wandering behavior occurring frequently. The care plan had identified her as exit-seeking and at risk for elopement, with interventions in place such as 1:1 supervision and distraction techniques. However, on the day of the incident, the resident managed to leave the facility, reaching the far end of the parking lot near a busy street before being escorted back inside. Interviews with staff revealed that the resident was not immediately noticed missing until seen by CNAs through a window. The facility's Director of Nursing (DON) and Administrator both acknowledged the incident but did not report it, believing it was unnecessary since the resident was found quickly and did not leave the premises. The facility's policy required reporting of such incidents, but the Administrator cited corporate guidelines as the reason for not reporting. The lack of timely reporting could increase the risk of unreported allegations of neglect, potentially affecting all residents.
Failure to Update Care Plan for Resident with Wandering Behaviors
Penalty
Summary
The facility failed to ensure that the care plan for a resident with dementia, muscle weakness, and malnutrition was reviewed and revised by the interdisciplinary team after each assessment. The resident, who was severely cognitively impaired, exhibited wandering and exit-seeking behaviors that were not addressed in the care plan until March 27, 2024, despite these behaviors being observed and documented in progress notes as early as January 2024. The care plan was not updated to include interventions for these behaviors until several months after they were first noted. Interviews with staff revealed that the resident's wandering and exit-seeking behaviors were known to the staff, and attempts were made to redirect the resident when she was found trying to exit the facility. The social worker and other staff members had communicated with the resident's responsible party about these behaviors and the potential need for a memory care unit. However, the care plan was not updated in a timely manner to reflect these discussions and the resident's needs. The facility's policies required that care plans be updated and reviewed at least quarterly and with significant changes in conditions. Despite this, the resident's care plan did not include her wandering and exit-seeking behaviors until March 2024, which was a significant oversight given the documented instances of these behaviors. The facility's failure to update the care plan in a timely manner could have resulted in missed or delayed continuity of care for the resident.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically by not ensuring the availability of the physician-ordered medication Entresto for heart failure. The resident, a male with multiple serious health conditions including hypertension, chronic kidney disease, and heart disease, was admitted to the facility and had an order for Entresto to be administered twice daily. However, the medication was not available on the day it was needed, and the resident did not receive his prescribed dose on that day. The report details that the medication was not in the facility's Pyxis system, and the pharmacy used by the facility would not have been able to deliver the medication until the following evening. Despite being informed of the unavailability of the medication, the responsible nurse did not notify the doctor or the pharmacy to seek an alternative solution. The nurse and the Certified Medication Aide (CMA) both acknowledged that they were aware of the protocol to notify the doctor and pharmacy when medications were not available, but this protocol was not followed. Interviews with the Director of Nursing (DON) and other staff revealed that there was a lack of documentation and verification regarding the availability of Entresto upon the resident's admission. The DON admitted that the facility's policy required timely acquisition and administration of medications, and that the failure to notify the doctor about the unavailability of Entresto could negatively impact the resident. Despite training provided to staff on the importance of making such notifications, the necessary steps were not taken in this instance, leading to the deficiency noted in the report.
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What surveyors actually found near you
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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.
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Nursing homes near Mercedes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Veranda Rehabilitation And Healthcare | 2 mi | ★★★★★ | 6 | 0 |
| Windsor Nursing And Rehabilitation Center Of Wesla | 6 mi | ★★★★★ | 5 | 1 |
| Valley Grande Manor | 6.6 mi | ★★★★★ | 12 | 0 |
| Weslaco Nursing And Rehabilitation Center | 7 mi | ★★★★★ | 4 | 0 |
| Harlingen Nursing And Rehabilitation Center | 12 mi | ★★★★★ | 11 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.