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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Millbrook Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Resident Council meetings were held in an open Activities Room adjacent to a hall with resident rooms, without doors separating the area for privacy. The Activities Director acknowledged discussions could be overheard by staff, residents, or others on the hall, and 10 residents stated the space did not allow them to discuss facility concerns privately. The Administrator stated the facility had no policy on Resident Council meetings.
Care plans for six residents did not reflect their Full Code or DNR preferences, and one resident’s care plan did not include any advance directive information. Records showed active code status orders for each resident, but the care plans only noted general advance directive education or omitted the directive entirely. The MDS Coordinator, Social Worker, and DON were unaware the care plans lacked the required code status details, despite facility policy stating advance directives should be communicated to the care plan team and included in the resident plan of care.
Food Storage and Labeling Failures in Kitchen: Surveyors found expired, undated, and unlabeled items in the dry pantry, along with multiple unsealed foods exposed to air in the pantry, refrigerator, and freezer. Dented cans were mixed with other canned goods, and some frozen items showed signs of spoilage or contamination. The DM and dietary staff stated they were responsible for labeling, dating, sealing, and removing expired or dented items, but the observed items had been overlooked during routine checks.
A facility failed to maintain its infection prevention and control program when CNAs provided incontinent care and transfers to two residents without following PPE and hand hygiene expectations. One CNA cared for a resident with a G-tube without a gown and reused gloves after bowel care, while another CNA and a second CNA assisted a resident with a G-tube and malnutrition without gowns; one CNA also used the same gloves after cleaning urine-soiled skin to apply a clean brief, dress the resident, and transfer the resident. Interviews showed inconsistent understanding among CNAs, an LVN, and the infection preventionist about gown use, glove changes, and hand hygiene.
Dining Room Lighting and Cleanliness Deficiencies: Surveyors observed dusty ceiling fans and a dusty chandelier above dining tables, along with multiple nonworking and flashing light bulbs that left the Dining Room dim. Ten residents said they ate meals there and preferred clean fixtures and properly working lighting. The Housekeeping Supervisor said her dept was not responsible for the fixtures, while the Maintenance Director said he was aware of the lighting issues, was responsible for cleaning the dust, and was unsure when the fans and chandelier were last cleaned.
Failure to report an alleged abuse incident: A resident with cerebral palsy and epilepsy stated that a CNA pushed her out of bed during incontinent care, causing a fall, forehead bleeding, pain, and a left-hand injury requiring a soft cast. An LVN only reported that the CNA was "a little too rough," and the Administrator initially treated the event as a fall and did not report it to the state agency. The facility policy required immediate reporting of abuse allegations to the Administrator.
Missed Quarterly MDS Assessment for a Resident with Dementia and COPD. The facility did not complete a required quarterly MDS for a resident with dementia, anxiety, COPD, chronic bronchitis, and DM2. The MDS Coordinator said the assessment was overdue, had been opened but not completed, and that she was responsible for opening it and notifying the IDT.
Failure to provide adequate supervision during incontinent care: A resident with cerebral palsy, epilepsy, and moderate cognitive impairment fell out of bed while a CNA was providing care alone. The resident reported a laceration and broken finger, the DON stated the resident was not far enough up in bed and the CNA should have asked for assistance, and an LVN assessed the laceration and sent the resident to the ER.
A resident with a G-tube was observed receiving incontinent care while the feeding pump was running, and a CNA paused the pump and then turned it back on after care was completed. The CNA stated she routinely paused pumps for residents with G-tubes and had not been educated on G-tube care, while the RN and DON stated CNAs were not allowed to operate feeding pumps and were supposed to notify the charge nurse instead. The facility policy addressed G-tube care but did not specify who managed the pump.
A resident with legal blindness and intact cognition was fed by a Medical Records Staff member who stood over the bed rather than sitting at eye level, contrary to facility policy and staff training. The resident, typically independent with eating, was not provided with appropriate meal set-up and cues, resulting in a lack of dignified meal service.
A resident with severe cognitive impairment and multiple chronic conditions did not receive pain assessments at the start of each shift as required by their care plan. Documentation showed inconsistent pain level checks, and staff interviews confirmed that the care plan's directives were not consistently followed.
A resident's discontinued Lorazepam remained on a medication cart after the order was stopped, despite facility policy requiring immediate removal and destruction of such medications. Staff interviews revealed confusion about the process, with an LVN acknowledging the risk and the ADON stating that discontinued drugs were kept on the cart and counted until the DON, who had sole access to the narcotic closet, returned.
Three residents with chronic respiratory conditions did not have their oxygen tubing and humidifier bottles dated or changed as required, and in one case, oxygen tubing was found on the floor and not stored properly. Nursing staff and the DON confirmed that equipment should be changed weekly, dated, and stored in plastic bags, but these practices were not consistently followed, resulting in lapses in infection control.
A resident with multiple complex medical conditions was discharged without a completed discharge summary, omitting essential information such as diagnoses, treatment course, lab results, and medication reconciliation. The Social Service Designee confirmed the summary was not completed, contrary to facility policy requiring comprehensive discharge planning.
A nurse left a resident's medication blister cards, displaying the resident's name and medication details, unattended on a medication cart in a hallway while responding to another resident. The medication cards were accessible to others during this time, exposing protected health information and violating facility policy and HIPAA regulations. Staff interviews confirmed that this action breached confidentiality requirements.
A resident with complex medical needs did not receive five scheduled medications within the required administration window, instead receiving them significantly late. Nursing staff were unclear on procedures for late medication administration, and there was a lack of recent training on this issue. The DON and Administrator confirmed that medications should be given within the prescribed timeframe and that staff should report delays, but this protocol was not followed.
A nurse left a resident's medication blister cards unattended on top of a medication cart in the hallway while responding to another resident, resulting in multiple medications and the resident's identifying information being accessible to others. Staff interviews and facility policy confirmed that medications are required to be locked in the cart at all times when not being administered.
The facility failed to provide appropriate call light devices for three residents with limited hand use, resulting in their inability to call for assistance. A resident with a stroke and another with contracted hands were given button-type call lights they could not use, while a third resident's call light was out of reach. Staff acknowledged the issues but did not ensure suitable alternatives were provided, contrary to facility policy.
The facility failed to store food in accordance with professional standards, as observed in their kitchen. Unlabeled, undated, and uncovered food items were found in the refrigerator, including cups of liquids and slices of cake. The Dietary Manager and staff confirmed that such practices could lead to foodborne illnesses, violating the facility's policy and FDA Food Code requirements.
The facility failed to maintain proper infection control as staff did not perform adequate hand hygiene during incontinent care for three residents. CNAs did not change gloves or sanitize hands between handling soiled and clean items, increasing the risk of infection spread. The facility's policy aligns with CDC guidelines, but these practices were not followed, indicating a deficiency in infection control measures.
A resident with major depressive disorder and anxiety disorder was left exposed during incontinent care when a CNA opened the privacy curtain while the door was open, compromising the resident's dignity. The facility's policy requires maintaining privacy by keeping doors closed and curtains drawn, which was not followed.
The facility failed to ensure accurate assessments for two residents, as the MDS Nurse did not complete the BIMS for their quarterly MDS assessments. The nurse signed off on the assessments without verifying the completion of the BIMS, relying on the system's automatic process. The Social Worker, new to the facility, was still learning the process and may have overlooked some assessments, highlighting the importance of BIMS in detecting changes in residents' conditions.
A facility failed to maintain a resident's personal hygiene by not ensuring his fingernails were trimmed, despite his inability to perform activities of daily living independently. The resident, who required maximum assistance due to conditions like hemiplegia and diabetes, had long, chipped nails with buildup, posing infection risks. Staff interviews revealed a lack of awareness and responsibility for nail care, contrary to the facility's policy requiring necessary services for grooming and hygiene.
A resident's room was found with a soiled brief on the floor, emitting a urine odor, indicating a failure to maintain a clean and homelike environment. Despite multiple staff checks, the brief was not promptly removed, posing infection control risks. The resident, dependent on staff for all ADLs, had multiple medical conditions. Staff interviews revealed acknowledgment of the issue, with the responsibility for removal attributed to nursing staff.
A medication aide in a LTC facility failed to follow infection control protocols by picking up dropped medications without gloves and administering them to a resident. Interviews confirmed that the proper procedures were not followed, despite recent in-service training on infection control.
Resident Council Meetings Held Without Private Space
Penalty
Summary
The facility failed to provide a private meeting space for residents' monthly Resident Council Meetings for 10 of 10 confidential residents reviewed for Resident Council. The monthly meetings were held in the Activities Room at the end of the 200 Hall, which the Activities Director stated had been used for Resident Council since her employment at the facility. During interview, the Activities Director stated the meeting area did not have doors separating it from the 200 Hall and acknowledged there was a risk that discussions could be overheard by staff, residents, or others on the hall. Observation of the Activities Room showed it was an open area adjacent to the 200 Hall, which contained 15 resident rooms. The room shared common walls with two occupied resident rooms and had one interior/exterior side door leading to the facility's designated smoking area. During the observation, several residents and staff were seen entering and exiting through that side door. A partition barrier with a gray curtain on wheels was present, and the Activities Director stated it was placed between the 200 Hall and the Activities Room during Resident Council Meetings, with a sign stating Resident Council Meeting in Progress. In a confidential group meeting, 10 residents who regularly attended Resident Council stated the Activities Room did not provide privacy for them to discuss facility operations, staff, and care concerns. They stated the area was connected to the 200 Hall, had one side door to the smoking area and parking lot, and that staff had disrupted some prior meetings. The residents stated they preferred a location with doors to ensure privacy and prevent others from overhearing their discussions. The Administrator stated the facility did not have a policy on Resident Council and Resident Council Meetings, and the facility's Notice of Resident Rights and Responsibilities did not include information related to Resident Council and Resident Council Meetings.
Care plans omitted advance directive code status
Penalty
Summary
The facility failed to develop person-centered, comprehensive care plans with measurable objectives and timeframes for six reviewed residents, and failed to revise those care plans to clearly address each resident’s Full Code or DNR status. The report states that the care plans for Resident #12, Resident #9, Resident #43, Resident #4, Resident #59, and Resident #8 did not include the special directions for their advance directives, even though each resident had an active code status order in the record. Resident #8’s care plan also did not include any advance directives at all on the printed care plan reviewed by surveyors. Record review showed that Resident #12 had diagnoses including encephalopathy, dementia, schizoaffective disorder, multiple sclerosis, and acute kidney failure, with severe cognitive impairment on MDS and a DNR advance directive supported by an active DNR order. Resident #43, Resident #4, and Resident #59 each had diagnoses including dementia, COPD, diabetes, anoxic brain damage, epilepsy, quadriplegia, and chronic kidney disease-related anemia, with moderate cognitive impairment on MDS and active Full Code orders. Resident #9 had diagnoses including diabetes, stroke, and chronic kidney disease, with moderate cognitive impairment and an active Full Code order. Resident #8 had diagnoses including postprocedural hypothyroidism, schizoaffective disorder, and Type 2 diabetes, intact cognition on MDS, and an active Full Code order. During interviews, the MDS Coordinator stated she was unaware that the care plans for the six residents did not address their Full Code or DNR status and confirmed that all six residents’ advance directives in the EHR reflected their requested code status. She also stated that Resident #8’s advance directive should have been included on the care plan upon admission. The Social Worker and DON both stated they were unaware that the six residents’ care plans did not include the special directions, and the DON stated nursing staff were not responsible for entering the advance directive information on care plans. The facility’s policies stated that advance directives should be communicated to the care plan team and that the interdisciplinary team shall develop and revise comprehensive care plans, but the reviewed care plans did not reflect the residents’ code status preferences as documented in the record.
Food Storage and Labeling Failures in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen. During the initial kitchen tour, surveyors observed multiple items in the dry pantry that were expired, undated, or not labeled with a complete expiration date. These included nutritional drink mix, powdered cane sugar, pancake mix, diced sweet red peppers, therapeutic nutrition drinks, thickened dairy beverage, glucose control drinks, cake mix, elbow macaroni, yellow cake mix, hamburger pickles, and sweet and sour sauce. Several items in the dry pantry were also found unsealed and exposed to air, including tortillas, baking soda, macaroni, potato chips, refried pinto beans, grain and wild rice, corn meal, elbow macaroni, and sugar. Surveyors also observed dented cans in the dry pantry, including dented cans of tuna, cranberry sauce, cream of mushroom soup, mushroom pieces and stems, and black beans. In the refrigerator area, custard in bowls was found unsealed and exposed to air. In the freezer area, multiple items were found unsealed and exposed to air, including turkey, hamburger, shredded cheese, lunch meat slices, gravy, bacon, corndogs, pancakes, beef patties, taquitos, and burritos. One frozen turkey package contained meat that was white in appearance with green spots, and one metal pan labeled hamburger contained a pool of liquified blood. One container labeled margarine was empty, had black particles at the bottom, and was filled with water. The Dietary Manager stated she had been employed for 3 weeks and said the items found by the surveyor were overlooked by mistake by kitchen staff during weekly checks. She stated that all kitchen staff were responsible for ensuring items were labeled with the item name, storage date, and use-by date, that items were sealed and closed, and that expired items were thrown away immediately. She also stated dented cans were to be removed from the shelf and placed in a designated area in her office. Dietary Aide I and Dietary Aide J stated that staff were responsible for labeling, dating, checking expiration dates, sealing items, and removing dented cans, and both acknowledged that expired, unsealed, or dented food could cause illness if consumed. The facility policies reviewed stated that food products should be protected from contamination, old stock rotated and used first, leftovers dated and labeled, and food storage areas maintained in a clean, safe, and sanitary manner.
Infection Control Failures During Incontinent Care and Transfers
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 6 residents reviewed for infection control. During observation, CNA C provided incontinent care to a resident with a G-tube and cognitive communication deficit, completed hand hygiene and double gloved, but did not put on a gown despite the posting on the door indicating staff were required to wear a gown and gloves. CNA C cleaned the resident after a moderate bowel movement, then applied a clean brief without changing gloves or performing hand hygiene, and then positioned the resident and turned on the feeding pump. CNA C later stated she had not been informed to use a gown while caring for residents with a G-tube and said she had been taught not to clean her hands in between care, only before and after care. For another resident with malnutrition, dysphagia, heart failure, anorexia, and a G-tube, CNA E and CNA F were observed assisting with transfer and incontinent care while gloved but without gowns. CNA F did not perform hand hygiene after cleaning the resident who was soiled with urine and used the same gloves to apply a clean brief, assist the resident to get dressed, and transfer the resident from bed to chair. CNA F stated she was supposed to change gloves and complete hand hygiene after cleaning the resident, but forgot, and said she was not aware she was supposed to wear a gown and gloves because she had been told the resident was not on any precaution. Interviews showed inconsistent understanding of the facility's infection control expectations. CNA E stated she had been in-serviced that if there was a posting on the door staff were to mask and gown up, but she did not see the posting until after caring for the resident. LVN G stated she was not aware of residents who were to be on enhanced barrier precautions and said staff were required to gown only for residents in isolation, not those with a G-tube. LVN H, the infection preventionist, stated staff were expected to wear gowns and gloves for residents on enhanced barrier precautions, but also stated staff were not required to perform hand hygiene after changing gloves during incontinent care until after changing gloves up to three times, and said she was not aware what the infection control policy indicated regarding hand hygiene. The DON stated staff were to complete hand hygiene every time they changed gloves and after cleaning the resident before applying a clean brief or touching belongings.
Dining Room Lighting and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain the Dining Room in a safe, sanitary, orderly, and comfortable condition. During observations on three separate days, surveyors found four ceiling fans above dining tables to be dusty, one chandelier above two dining room tables to be dusty, one chandelier light bulb not working properly, five of 20 light bulbs in the Dining Room not working, and two light bulbs flashing on and off continuously. The Dining Room lighting was described by residents in a confidential group meeting as very dim. Ten residents participated in the confidential group meeting and stated that they ate their meals in the Dining Room. They reported that they had not noticed the dust on the chandelier and ceiling fans, but they preferred that all light fixtures in the Dining Room work properly and that the fixtures and fans be clean. The residents also stated that the dim lighting was a concern because they wanted to avoid further damage to their vision. During interviews, the Housekeeping Supervisor stated that she had not noticed the dust on the chandelier or ceiling fans and had not observed the lighting problems during her visits to the Dining Room. She stated that her department was not responsible for cleaning or maintaining the lights and fans, and identified the Maintenance Director as responsible for those tasks. The Maintenance Director stated that he was aware of the lighting issues, had ordered replacement fixtures, and was responsible for cleaning the dust on the light fixtures and ceiling fans. He also stated that he was not sure when the ceiling fans and chandelier were last cleaned and that the facility did not have Maintenance Request Logs, using the TELS system instead. A record review showed an email receipt for purchased light fixtures and the facility policy stated that common living areas should be individualized and that furniture and fixtures in common areas should enhance residents' abilities to maintain independence.
Failure to Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported immediately to the Administrator and to HHSC after a resident stated that a CNA was "a little too rough" during incontinent care. Resident #56 reported that CNA K pushed her out of bed on 04/11/2026, causing her to fall face down while wearing glasses, with blood on her forehead, pain throughout her body, and injury to her left hand that later required a soft cast. The resident also stated she felt safe only when other staff provided care instead of CNA K. The record shows the facility completed a change of condition, notified the medical director, obtained new orders, sent the resident to the emergency room for further evaluation, notified the guardian, interviewed staff, and completed in-services. However, LVN A stated that after the resident later told her CNA K was rough, she reported only that the CNA was "a little too rough or something to that affect" to LVN J. The Administrator stated she was not told that the resident had been pushed and initially believed the event was a fall out of bed that did not warrant a report to HHSC. During interviews, the DON stated the resident had cerebral palsy and epilepsy and that the resident changed her story about the event. The DON also stated that if the floor nurse had been informed a resident was pushed, a report to HHSC had to be completed. The Administrator later stated she would report the incident after receiving new information and said she had not thought it was reportable at the time because of the resident's statements. The facility policy required staff with knowledge of an actual or potential violation to report it immediately to the supervisor or Administrator, and required all allegations of abuse, neglect, misappropriation of resident property, or exploitation to be reported immediately to the Administrator.
Missed Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a Quarterly MDS Assessment for one resident, Resident #43, within the required 90-day timeframe. Record review showed the resident was admitted with diagnoses including dementia, anxiety, COPD, chronic bronchitis, and type 2 diabetes. The resident’s most recent Quarterly MDS Assessment was dated 12/19/25 and reflected a BIMS score of 12, indicating moderate cognitive impairment. During interview, the MDS Coordinator stated she had recently become the MDS Coordinator in December 2025 and was unaware that Resident #43’s Quarterly MDS Assessment had not been updated. She stated Quarterly MDS Assessments should be completed for every resident every 90 days and acknowledged that the assessment for Resident #43 should have been completed but was not. She also stated a Quarterly MDS Assessment had been opened on 04/17/26 but was not completed, and that it was her responsibility to open the assessment and inform the IDT it was open. The report also noted that the MDS Coordinator stated proper care with special instructions would not be followed for each resident's needs if the assessment was not completed.
Failure to Provide Adequate Supervision During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident was protected from accident hazards and provided adequate supervision during incontinent care. Resident #56, who had diagnoses of cerebral palsy and epilepsy and an MDS BIMS score of 12 indicating moderate cognitive impairment, was observed in bed during the initial tour not positioned in a low bed as indicated in the care plan. The resident reported that on 04/11/26 a CNA came in alone to provide incontinent care and that she fell out of bed during the care. The resident stated she believed the CNA intentionally pushed her out of the bed, resulting in a laceration and broken finger. The DON stated the resident told the CNA she did not grab the turn bar and kept turning until she rolled off the bed, and that if the CNA realized the resident was not far enough up in bed, the CNA should have asked for assistance. LVN I stated the resident fell out of bed during incontinent care, assessed the laceration, and sent the resident to the emergency room because of the laceration and pain. The facility incident report listed the resident in the fall incident column with a fall on 04/11/26 at 3:42 p.m.
Improper CNA Management of Feeding Pump During G-Tube Care
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received appropriate treatment and services to prevent complications of enteral feeding. Resident #65 was a [AGE] year-old male admitted with diagnoses including hypertension, muscle weakness, muscle wasting, lack of coordination, gastrostomy status, and cognitive communication deficit. His quarterly MDS indicated he was always incontinent of bowel and bladder and required maximum assistance with toileting. His care plan, revised 02/16/26, identified tube feeding as part of his care and included monitoring and reporting complications such as aspiration, fever, shortness of breath, tube dislodgement, infection at the tube site, tube malfunction, abdominal pain, distension, constipation, diarrhea, nausea/vomiting, and dehydration. During observation on 04/20/2026 at 5:25 AM, CNA C was providing care to Resident #65 while the feeding pump was running. CNA C paused the feeding pump before providing incontinent care and turned it back on when care was completed. In interview, CNA C stated she normally paused the pump when caring for residents with G-tubes, did not inform the charge nurse, and had not been educated on care for residents with G-tubes. RN D stated CNAs were not supposed to pause or turn off the feeding pump and were to notify the charge nurse, who would manage the pump. The DON also stated CNAs were not allowed to operate feeding pumps and that CNA C had not been educated on G-tube care. The facility policy on gastrostomy tube care and management addressed proper care and maintenance of gastrostomy tubes but did not specify who was to manage the feeding pump.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to protect and promote the right to a dignified existence for one resident during a lunch meal service. Specifically, a Medical Records Staff member stood beside the resident's bed and leaned over him to feed him, rather than sitting at eye level as required by facility policy and standard practice. The resident, who was legally blind but had intact cognition and was typically independent with eating, was observed being fed two spoonfuls of Jello and two spoonfuls of chicken noodle soup while the staff member stood over him. The resident also took sips of water and a shake supplement but refused to eat more food from his plate. Interviews with staff, including the Medical Records Staff, LVN, CNAs, and the DON, confirmed that the expected practice is for staff to sit at eye level with residents when assisting with meals, and to provide set-up and cues rather than direct feeding unless necessary. The resident's care plan indicated that assistance should be provided as needed, with a focus on maintaining the resident's level of function and dignity. Facility policy and the admission packet both emphasized the importance of treating residents with respect and dignity, which was not followed in this instance.
Failure to Implement and Document Pain Assessments per Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including dementia, cognitive communication deficit, type 2 diabetes, hypertension, heart failure, muscle weakness, peripheral vascular disease, and a history of falls. The resident's care plan, initiated in early September, specified that pain assessments should be conducted and documented every shift due to the presence of acute/chronic pain related to peripheral vascular disease. However, record review showed that pain assessments were not consistently performed or documented at the start of each shift as required by the care plan. Interviews with facility staff, including the DON Trainee and the Administrator, confirmed that the care plan's directives were not followed, and that nursing staff were responsible for completing and documenting pain assessments. Documentation reviewed indicated irregular pain level checks, with several shifts lacking any recorded assessment. The facility's own care planning policy requires the interdisciplinary team to develop and implement a comprehensive care plan, with all interventions communicated and carried out as specified, but this was not adhered to in the case of the resident in question.
Failure to Remove Discontinued Medication from Medication Cart
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring that discontinued medication was promptly removed from a medication cart. Specifically, Lorazepam (Ativan) prescribed to a resident was discontinued on 09/19/25, as documented in the resident's electronic order summary and Medication Administration Record. Despite this, the medication remained on Medication Cart #1 as observed on 09/25/25. During interviews, an LVN acknowledged the medication should have been removed and recognized the risk of discontinued medication remaining accessible. The DON Trainee was unfamiliar with the facility's policy but stated that discontinued drugs should be removed and destroyed quickly. The ADON explained that discontinued medications were typically given to the DON, who was on leave, and that nurses continued to count the medication until the DON returned, as only the DON had access to the narcotic closet. The facility's policy required that outdated or discontinued medications be immediately removed from stock and disposed of according to established procedures. However, the continued presence of discontinued Lorazepam on the medication cart indicated a failure to follow this policy. The ADON stated that there was no risk as the medication was still being counted, but this contradicted the facility's written procedures and the understanding of other staff members. The Administrator Trainee was also unaware of the specific risks or policies regarding discontinued medications.
Failure to Maintain and Date Oxygen Equipment for Multiple Residents
Penalty
Summary
The facility failed to ensure that residents receiving oxygen therapy were provided with adequate respiratory care, specifically regarding the maintenance and infection control of oxygen tubing and humidifier bottles. Observations revealed that for three residents, oxygen tubing and prefilled humidifier water bottles were not dated as required, and in one case, the oxygen tubing was found on the floor. Additionally, one resident's oxygen tubing was not stored in a plastic bag or drawer as per facility policy. These lapses were identified through direct observation, interviews with staff, and review of resident records. The residents involved had significant medical histories, including chronic respiratory conditions such as COPD, asthma, and chronic respiratory failure, as well as other comorbidities like renal insufficiency, diabetes, and anemia. Their care plans and physician orders specified the use of oxygen therapy and outlined the need for regular changing and dating of oxygen equipment. Despite these documented requirements, the facility did not consistently follow through with the necessary infection control practices, as evidenced by undated equipment and improper storage. Interviews with nursing staff and the DON confirmed that the expectation was for oxygen tubing and humidifier bottles to be changed weekly, dated, and stored appropriately to prevent contamination. Staff acknowledged the importance of these practices and stated they had received in-service training on infection control and oxygen equipment care. However, the observed deficiencies indicated a failure to adhere to both facility policy and physician orders, potentially compromising infection control for residents receiving oxygen therapy.
Failure to Complete Required Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged to another care setting. Specifically, the discharge summary was missing key elements such as a recapitulation of the resident's stay, including diagnoses, course of treatment, pertinent laboratory results, a final summary of the resident's status, and a reconciliation of all pre-discharge medications with post-discharge medications. The resident's record only included a final progress note indicating the resident was discharged in stable condition with her daughter, had her medications and belongings, and that the room was empty, but did not provide the required detailed clinical information or individualized care instructions. The resident involved had a history of cerebrovascular disease, type 2 diabetes mellitus, adjustment disorder with anxiety, morbid obesity, hemiplegia, cerebral infarction, and muscle wasting. She had moderately impaired cognitive function, used a wheelchair, and required assistance with activities of daily living. During interviews, the Social Service Designee (SSD) confirmed that the discharge summary was not completed and was unable to provide a reason for the omission. Review of facility policy indicated that the SSD and/or Case Manager, with input from the Interdisciplinary Team, are responsible for ensuring a comprehensive discharge planning process, which was not followed in this instance.
Unattended Medication Cards Lead to Breach of Resident Confidentiality
Penalty
Summary
A deficiency occurred when a nurse (LVN A) left a resident's medication blister cards, which displayed the resident's name and medication information, unattended on top of a medication cart in the hallway. This incident was observed when LVN A was administering medications to a resident and was interrupted by another resident calling for assistance. LVN A left the medication cards on the cart and entered another resident's room, leaving the cart and the medication cards unattended for about one minute. The unattended medication cards contained identifiable information, including the resident's name, date of birth, and details of prescribed medications. The medication cart was located in a public area of the hallway, in front of the resident's doorway, and was accessible to other residents, visitors, and staff during the time it was left unattended. Multiple staff interviews confirmed that leaving medication cards unsecured on the cart is against facility policy and is considered a breach of confidentiality, as the information on the cards is protected health information under HIPAA regulations. The resident whose information was exposed had complex medical needs, including cognitive and physical impairments, and required multiple medications for various conditions such as anxiety, depression, hypertension, and muscle weakness. The facility's policies require that all medications and related records be secured and locked in the medication cart when not in use, and staff are trained to never leave such information unattended. The incident was confirmed through observation, record review, and staff interviews, all of which indicated that the nurse failed to follow established protocols for maintaining the confidentiality and security of resident medical records.
Failure to Administer Scheduled Medications Within Prescribed Timeframe
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the timely administration of physician-ordered medications for one resident. Specifically, the resident did not receive five of his routine, doctor-ordered medications during the scheduled 7:00 am to 9:00 am window, and instead received them at approximately 10:35 am. This was confirmed through observation, interviews, and record review, which showed that the medications were not administered within the facility's established timeframe of one hour before or after the scheduled time. The resident involved was a male with multiple complex medical conditions, including atrial fibrillation, hypertension, renal insufficiency, diabetes, aphasia, hemiplegia, malnutrition, anxiety, and a history of stroke. He was dependent on staff for all activities of daily living, used a wheelchair, and had a G-tube for medication administration. His care plan and physician orders required several medications to be administered at 8:00 am, including medications for anxiety, depression, hypertension, muscle wasting, and gastrointestinal issues. Interviews with nursing staff revealed a lack of clarity and training regarding the procedures to follow when medications are administered outside the prescribed timeframe. Staff members were unsure of the exact steps to take if medications were given late and had not received recent training on this issue. The Director of Nursing and the Administrator both acknowledged that medications should be given within the specified window and that staff should notify supervisors if unable to do so, but there was no evidence that this protocol was followed in this instance.
Unattended Medications Left on Medication Cart
Penalty
Summary
A deficiency occurred when a nurse left a resident's medication blister cards unattended on top of a medication cart in the hallway, while she entered another resident's room with the door closed. The unattended medications included Buspirone, Pantoprazole, Gabapentin, Escitalopram, Dantrolene, and Metoprolol, all clearly labeled with the resident's identifying information. The medication cart was left in front of the resident's doorway and was unattended for about one minute, during which time the medications were accessible to anyone passing by. The resident involved was a male with multiple complex medical conditions, including atrial fibrillation, hypertension, renal insufficiency, diabetes, aphasia, CVA/TIA, hemiplegia, malnutrition, anxiety, and dysphagia. He was dependent on staff for activities of daily living and received several scheduled medications via G-tube. The nurse stated she had just administered the resident's medications when she heard another resident calling for help and left the medication cards on the cart while she attended to the other resident's needs. Interviews with other nursing staff and facility leadership confirmed that medications are required to be locked in the medication cart at all times when not being administered, and that leaving medications unattended is against facility policy. Staff acknowledged that leaving medications out could result in unauthorized access to medications and resident information. Facility policies and staff statements consistently indicated that only licensed nurses and certified medication aides are permitted access to medication carts, and that all drugs and biologicals must be stored in locked compartments when not in use.
Inadequate Call Light Accessibility for Residents
Penalty
Summary
The facility failed to provide appropriate call light devices for three residents, leading to deficiencies in accommodating their needs and preferences. Resident #16, who had limited use of her hands due to a stroke, was provided with a button-type call light that she could not use. Despite her inability to press the button, staff did not ensure she had a suitable alternative, such as a pad-type call light, which was previously available to her. This oversight resulted in Resident #16 being unable to call for assistance when needed, as evidenced by her being found wet and unable to use the call light to alert staff. Similarly, Resident #61, who had contracted hands and severe cognitive impairment, was also given a button-type call light that she could not use. Observations showed that her hands were clenched in fists, making it impossible for her to press the button. Staff acknowledged that she was unable to use the call light and stated they checked on her frequently, but there was no evidence of an assessment to provide her with a more suitable device, such as a pad-type call light, which she had used in a previous room. Resident #27's call light was found on the floor, out of her reach, while she was in bed. Although staff later placed the call light within reach, the initial oversight meant that she could not call for assistance if needed. The facility's policy required that call lights be within reach, but this was not consistently followed. Interviews with staff, including the DON and ADON, revealed a lack of awareness and follow-through in ensuring that residents had access to appropriate call light devices, highlighting a systemic issue in accommodating residents' needs effectively.
Improper Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen. During an inspection, the facility's refrigerator was found to contain unlabeled, undated, and uncovered food and beverage items, including 18 cups of dark liquid, 11 cups of white liquid, and 36 slices of yellow cake. These items were not stored according to the facility's policy, which requires leftovers to be dated, labeled, covered, cooled, and stored in the refrigerator within half an hour. The Dietary Manager acknowledged the importance of labeling and dating food items to prevent contamination and ensure residents receive the correct food and beverages. Interviews with the Dietary Manager, a staff member, and the Dietitian confirmed that improper food storage practices, such as failing to label, date, and cover food items, could lead to foodborne illnesses. The facility's policy, revised in 2007, emphasizes preventing food contamination to avoid foodborne illnesses. The Food and Drug Administration Food Code also requires food storage containers to be identified with the common name of the food and for refrigerated, ready-to-eat food to be clearly marked with the date by which it should be consumed or discarded. The facility's failure to comply with these standards could place residents at risk for foodborne illness.
Inadequate Hand Hygiene Practices During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene during incontinent care for three residents. CNA A did not change gloves or sanitize hands between handling soiled and clean items while providing care to two residents, one of whom had a large bowel movement during the process. This oversight was acknowledged by CNA A, who admitted to understanding the risk of infection spread due to improper glove use. Another incident involved CNA E, who failed to perform hand hygiene after providing incontinent care to a resident before accessing the clean linen cart. This lapse was attributed to a focus on completing assigned tasks, as stated by CNA E during an interview. The Director of Nursing confirmed the expectation for staff to perform hand hygiene before and after care, and when changing gloves, to prevent infection spread. The facility's hand hygiene policy, which aligns with CDC guidelines, emphasizes the importance of hand hygiene in preventing infection transmission. Despite this policy, the observed failures in hand hygiene practices during incontinent care for the three residents indicate a significant deficiency in the facility's infection control measures.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident during the provision of incontinent care. The resident, a female with a history of major depressive disorder and anxiety disorder, was observed in her room with the door open while receiving care. Although the privacy curtain was initially closed, it was opened by the CNA while disposing of trash, leaving the resident's coccyx exposed to passers-by in the hallway. This incident occurred despite the resident's care plan indicating the need for staff assistance with incontinent care and the facility's policy requiring privacy during such care. Interviews with the CNA and the Director of Nursing revealed that the CNA did not close the door due to being focused on completing her tasks, acknowledging that this oversight compromised the resident's dignity. The Director of Nursing confirmed that the facility's expectation was to maintain resident privacy by keeping doors closed and curtains drawn during care. The facility's policy on Resident Rights - Dignity and Respect, dated 10/2015, mandates that residents be examined and treated in a manner that maintains the privacy of their bodies, which was not adhered to in this instance.
Inaccurate Resident Assessments Due to Incomplete BIMS
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the residents' status for two residents reviewed for accuracy of assessments. The MDS Nurse did not complete the Brief Interview for Mental Status (BIMS) for the quarterly MDS assessments of two residents, despite signing off on the assessments as completed. This oversight was due to the absence of interview information during the lookback period, and the MDS Nurse relied on the system's automatic completion process without verifying the actual completion of the BIMS. For one resident, the MDS assessment indicated that the BIMS should be conducted, but it was not completed, and the section was marked with a dash. The MDS Nurse admitted to entering dashes because the interview information was unavailable during the lookback period and acknowledged that the facility's Social Worker, who typically completed the BIMS, was new and still learning the process. The resident's electronic medical record showed a BIMS score indicating severe cognitive impairment, but the MDS Nurse believed there was no risk due to regular BIMS assessments. For the second resident, the MDS assessment also indicated that the BIMS should be conducted, but it was not completed, and the section was marked with a dash. The MDS Nurse followed the same process as with the first resident, entering dashes based on instructions from the CMS RAI Manual. The resident's last BIMS assessment showed a score indicating cognitive intactness, but the MDS Nurse did not notice the absence of a recent BIMS. The Social Worker, who started working at the facility shortly before the assessments, stated that she was still learning the process and may have overlooked some assessments, emphasizing the importance of BIMS in detecting changes in residents' conditions.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary assistance to maintain personal hygiene, specifically in keeping his fingernails trimmed. The resident, a cognitively intact male with a history of coronary artery disease, stroke, diabetes, and hemiplegia, required maximum assistance for bathing and personal hygiene. Observations revealed that his fingernails were very long, chipped, and had a thick buildup beneath one nail, posing a risk of infection or injury. Interviews with staff, including the Charge Nurse, RN, Activity Director, and CNA, indicated a lack of awareness and responsibility regarding the maintenance of the resident's fingernails. The facility's policy stated that residents unable to carry out activities of daily living should receive necessary services to maintain good grooming and hygiene. However, the staff assumed that nail care was performed on shower days by CNAs, and there was a lack of communication and coordination among staff members. The Activity Director, who conducted daily rounds, did not notice the condition of the resident's nails until it was pointed out, and the DON was unaware of the Activity Director's involvement in nail care. This oversight in providing adequate personal hygiene care for the resident highlights a deficiency in the facility's adherence to its policy and procedures.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the presence of a soiled brief on the floor of the resident's room. The resident, a male with multiple medical conditions including nontraumatic intracerebral hemorrhage, hydrocephalus, asthma, aphasia, and gastrostomy, was dependent on staff for all activities of daily living (ADLs). During an observation, a soiled brief was found on the floor between the wheels of the resident's bed and his tube feeding pole, emitting an odor of urine in the room. Interviews with various staff members, including CNAs, LVN, and the DON, revealed that the soiled brief was not removed promptly, despite the room being checked multiple times. CNA A admitted to seeing the soiled brief after providing care but did not remove it immediately. The Charge Nurse, LVN C, and the DON acknowledged that leaving a soiled brief on the floor was unacceptable and posed risks such as infection control issues and upsetting residents and their families. Housekeeping staff and the Housekeeping Supervisor stated that resident rooms were cleaned daily, and any additional cleaning needs should be communicated by the staff. However, the responsibility for removing soiled briefs was attributed to the nursing staff. The facility's policy emphasized providing a clean and homelike environment, which was not adhered to in this instance, leading to the deficiency.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by an incident involving a medication aide (MA) and a resident. During the preparation of medications for a resident, the MA accidentally knocked the medication cup, causing the medications to fall onto the medication cart. The MA then picked up the medications without wearing gloves and administered them to the resident. This action was contrary to infection control protocols, which require the use of gloves and the discarding of any medications that fall onto potentially contaminated surfaces. Interviews with the MA, Assistant Director of Nursing (ADON), and Operations Manager confirmed that the MA was aware of the proper procedures but failed to follow them. The MA admitted that the medication cart was considered dirty and that gloves should have been used to prevent cross-contamination. The ADON and Operations Manager reiterated that the medications should have been discarded and gloves should have been worn. The facility's policy on hand hygiene, revised in July 2014, emphasizes the importance of hand washing to prevent the transmission of infections.
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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 Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Gardens | 0.8 mi | ★★★★★ | 11 | 0 |
| Avir At Lancaster | 1.7 mi | ★★★★★ | 18 | 1 |
| Lancaster Nursing & Rehabilitation | 2 mi | ★★★★★ | 11 | 0 |
| Desoto Nursing & Rehabilitation Center | 3.4 mi | ★★★★★ | 15 | 1 |
| Five Points Nursing And Rehabilitation | 3.8 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.