Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission Ridge Rehab & Nursing Center during CMS and state inspections, most recent first.
An unlocked treatment cart was observed at the nurse's station with scissors and multiple creams, liquids, gels, and lotions inside, while residents walked by and no staff were nearby. The DON and RNs stated the cart should have been locked when not in use, and the facility's medication storage policy required medication carts and supplies to be locked or attended to by authorized staff.
Medication administration errors involved BP-altering meds for four residents. One resident with CHF, HTN, CKD, AFib, DM, and dementia had inconsistent documentation and administration of Lisinopril and Metoprolol against hold parameters. Another resident with dialysis-dependent renal failure, HTN, hypotension, and HF had Midodrine documented as given on multiple occasions when BP was above the hold threshold, with some doses also lacking BP documentation. Two other residents with HTN had Lisinopril and Metoprolol documented as administered despite readings outside ordered parameters.
Improper food handling and beard restraint use were observed during meal service. A staff member helping a resident with a biscuit touched the food bare handed and tried to open it without gloves, while a dietary staff member plated food with a beard restraint worn incorrectly and not covering the mustache. The resident had PTSD and muscle wasting and atrophy, and staff stated they were aware food should not be handled with bare hands and that beard guards are required.
Uncovered Catheter Bag While Resident Was in Bed: A resident with paraplegia and an indwelling catheter was observed lying in bed with the foley bag visible and no privacy cover in place, despite an order and care plan directing that the bag be kept in a privacy bag while in bed or in a wheelchair. The resident said the cover was usually used and preferred it be on, while an LVN, CNA, and DON all stated privacy covers should be used to protect resident privacy and dignity.
Failure to document a DNR order for a resident with an advance directive. A resident with CHF, CKD, AFib, DM2, and dementia had an OOH-DNR signed by his RP, but the facility's EMR still showed Full Code and the DNR was not uploaded until nearly 2 months later. The ADON stated she initiated the DNR but forgot to enter the order after it was signed, and the DON and MR described the process for scanning and ordering code status so staff would know whether to perform CPR if the resident coded.
A resident with a right chest dialysis catheter did not have an EBP order, and the care plan did not include EBP for the device. Staff observations found no EBP sign on the door and no PPE inside or outside the room. The ADON/infection preventionist and DON both stated the resident should have had EBP in place, and the facility policy identified indwelling medical devices as an indication for EBP.
A nurse used a personal cell phone to photograph a cognitively impaired resident with multiple serious medical conditions while preparing to send the resident to the ER, intending to show the ADON the extent of blood on the bed. The photo was taken and shared without the resident’s consent, and a family member later reported hearing that a picture had been taken and felt this compromised the resident’s rights. The ADON, DON, and Administrator each acknowledged that a photo of the resident had been taken and that this action interfered with the resident’s right to privacy, contrary to facility resident-rights and personnel policies that prohibit unauthorized photography and personal device use.
A CNA failed to provide the required two-person assist and adequate supervision while performing incontinent care for a resident with severe cognitive and physical impairments, leaving the resident unattended on her side in bed. This resulted in the resident falling from the bed and sustaining a rib fracture and contusions. The resident's care plan and facility policies required two-person assistance for all care activities due to her high fall risk and total dependence on staff.
A resident with significant care needs was left in a soiled state overnight, with dried feces and urine found on his body and surrounding area, despite care plan requirements for frequent checks and hygiene. Staff interviews revealed inconsistent adherence to care protocols, and unauthorized photographs of the resident in this condition were taken, violating privacy and dignity policies.
A resident with diabetes and hypoglycemia was found unresponsive due to the facility's failure to monitor and document blood sugar levels as per physician's orders. The resident's blood sugar dropped below normal, leading to a critical incident where the resident coded while in EMS care. The facility staff did not document the administration of emergency interventions or the resident's condition accurately and timely, placing the resident at risk of not receiving necessary care.
A long-term care facility failed to maintain an effective infection prevention and control program, leading to two incidents of potential cross-contamination. One resident's open wounds came into contact with a soiled brief during care, while another resident with a g-tube did not receive appropriate Enhanced Barrier Precautions during medication administration. Staff interviews revealed gaps in training and awareness of infection control protocols.
A facility failed to complete a PASRR evaluation for a resident with paranoid schizophrenia, resulting in a deficiency. The resident was admitted with diagnoses including diabetes, schizophrenia, and dementia, but the PASRR Level 1 screening incorrectly indicated no mental illness. The MDS nurse misunderstood the primary diagnosis requirements, leading to the oversight. This failure could have prevented the resident from receiving necessary specialized services.
A facility failed to update a resident's comprehensive care plan after significant changes in medical condition, including a diet change to NPO, insertion of a g-tube, and initiation of enteral feeding. The resident, with severe cognitive impairment and complex medical history, did not have his care plan revised after a fall and hospitalization. Interviews with the DON and ADON revealed a lack of awareness of the care plan deficiencies, despite the facility's policies emphasizing the importance of comprehensive care planning.
A wound care cart was found unlocked and unattended, exposing wound care supplies and medications. An LVN acknowledged the importance of locking the cart to prevent unauthorized access and potential harm. The DON confirmed the cart should always be locked for safety, and the facility ADM noted the absence of a specific policy on locking carts.
A resident with multiple health issues was found unresponsive on the bathroom floor, went into cardiac arrest, and died. The facility failed to report the incident to the state agency as required, despite the resident's unexpected death and unwitnessed fall. The administration and nursing staff did not consider the incident reportable, and no investigation was conducted.
A resident with diabetes and hypoglycemia was found unresponsive, but the facility failed to document critical medical interventions and observations. Blood sugar checks and Glucagon administration were not recorded, and postmortem assessments contained inaccuracies. Interviews revealed inconsistencies in the documentation process, highlighting a deficiency in maintaining complete and accurate clinical records.
A resident with severe cognitive impairment eloped from a facility due to inadequate supervision and security measures. The resident was unaccounted for 36 minutes and found 100 feet from the entrance after traveling 500 feet from the 200 hall exit door. An unknown employee used a master code to unlock the door, disabling the alarm. Staff interviews revealed a lack of awareness and implementation of elopement policies, and the master code was widely known, contributing to the security breach.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in addressing their needs. One resident lacked required floor mats to prevent falls, while others had care plans that were not updated to reflect eligibility for offsite activities. Additionally, injuries sustained by two residents were not documented in their care plans, highlighting a lack of adherence to the facility's care planning policy.
A facility failed to provide a written notice of transfer or discharge to a resident, their representative, and the LTC Ombudsman. The resident was transferred without proper notification, and interviews with staff revealed inconsistencies in the discharge process. The facility's policy required a 30-day notice for non-emergent discharges, which was not followed, indicating a systemic issue in discharge procedures.
The facility failed to update care plans for two residents to reflect actual falls, leading to potential risks of incorrect care. One resident's care plan did not include falls resulting in hospitalization, while another's did not reflect a fall causing a hip fracture. Staff interviews revealed a lack of timely updates, despite the facility's policy requiring care plans to be revised based on changing needs.
The facility failed to secure the 300 hall shower room, with the door found unlocked or propped open during inspections. Staff, including SNA C and the DON, confirmed the lock was broken, with the issue persisting for weeks. The MS had reported the need for a replacement lock, but it was on back order, and no work order was documented. Despite in-service training on keeping shower doors locked, the problem continued, posing a risk to residents, staff, and visitors.
Unlocked Treatment Cart at Nurse's Station
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 1 of 1 treatment carts observed for medication and treatment storage. During an observation on 05/14/2026 at 9:04 AM, an unlocked treatment cart was found parked at the nurse's station with no nurses or other staff nearby. The cart contained scissors, multiple creams, multiple liquids, multiple gels, and multiple lotions, and the lock was popped out so all drawers could be opened and accessed. Residents were observed walking and passing by the unlocked cart at the nurse's station. During interviews, the DON stated the facility did not currently have a treatment nurse and that floor nurses performed their own treatments; she also stated there were only two floor nurses working that day and the cart should have been locked when not in use so residents could not access anything that could harm them. RN-A stated she had not used the treatment cart that day and that it was supposed to be kept locked when not in use because a resident could access scissors and treatments that could possibly harm them. RN-B stated she had not used the cart yet that day and believed it had been left unlocked by a nightshift nurse; she also stated the cart was supposed to remain locked when not in use. Record review of the facility's Medication Storage Policy stated medications and biologicals are to be stored safely, securely, and properly, and that medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.
Medication administration errors with blood pressure medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors involving blood pressure-altering medications for four residents. The report states that Resident #2, who had congestive heart failure, hypertensive heart disease with heart failure and chronic kidney disease, atrial fibrillation, diabetes, and dementia, had orders for Lisinopril and Metoprolol Succinate with hold parameters based on blood pressure and heart rate. On 02/04/26, the MAR showed Lisinopril was held because the blood pressure was documented as outside parameters, while Metoprolol was documented as administered with a blood pressure of 111/73. On 02/25/26, both medications were documented with a blood pressure of 105/78 and both were documented as not administered due to vitals outside parameters. Resident #5, who had acute kidney failure with dialysis dependence, diabetes, hypertension, hypotension, and heart failure, had an order for Midodrine 10 mg three times daily with instructions to hold if SBP was greater than 120. The February 2026 MAR and blood pressure summary showed 22 opportunities in which Midodrine was documented as administered when the recorded blood pressure was outside the ordered parameters, including multiple readings above the hold threshold. The record also showed some occasions where the medication was not administered and no blood pressure was documented in the blood pressure summary at the scheduled time. Resident #8 had essential hypertension and an order for Lisinopril 20 mg with instructions to hold if SBP was less than 110 or DBP was less than 60 and notify the MD. The MAR showed Lisinopril was administered on 02/08/26 with a blood pressure of 100/60. Resident #16 had essential hypertension and an order for Metoprolol Tartrate 25 mg with instructions to hold if SBP was less than 110, DBP was less than 60, or HR was less than 60. The MAR showed Metoprolol Tartrate was administered on 02/17/26 with a heart rate of 56. During interviews, nursing staff stated that blood pressure medications should be given or held according to ordered parameters and that the documentation appeared to be in error in some instances.
Improper Food Handling and Beard Restraint Use During Meal Service
Penalty
Summary
Food was not distributed and served in accordance with professional standards for food service safety. During lunch service in the dining room, a staff member helping serve residents touched Resident #4’s biscuit with bare hands, pushed it back onto the plate, and then attempted to open the biscuit for the resident without wearing gloves. Resident #4 had asked for help because she could not open it herself. The report also noted that the food was plated and handed to staff for distribution by DA H, whose beard restraint was worn improperly and did not cover the mustache, only the beard. Resident #4 was a 63-year-old female with diagnoses including PTSD and muscle wasting and atrophy, not elsewhere classified. In interviews, the staff member stated she was trying to help the resident with the biscuit and did not remember touching the food without gloves, and said it had been a while since training on serving residents and cross contamination. DA H stated he was not aware his beard restraint was worn incorrectly and said it may have moved while working or not been put on correctly initially. The dietary manager stated kitchen staff are required to wear protective clothing, beard guards, and hair nets while working in the kitchen, and that staff helping serve residents are not to touch food with bare hands.
Uncovered Catheter Bag While Resident Was in Bed
Penalty
Summary
The facility failed to ensure the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for one resident who was reviewed for resident rights. The resident was a [AGE]-year-old female with paraplegia, an intact BIMS score of 15, and an indwelling catheter included in her care plan. The care plan directed catheter care at least every shift and at each incontinent episode, and the active order required the foley bag to be kept in a privacy bag while in bed or in a wheelchair every shift. During an observation, the resident was lying in bed with the room door closed, and her catheter bag was visible with no privacy cover over it. Later the same day, the resident was observed in her wheelchair in a common area with a privacy cover over the catheter bag. The resident stated the bag was usually covered and that she preferred the privacy cover be used. An LVN stated residents with catheter bags should always have a privacy cover unless the resident requested otherwise, and a CNA stated she noticed the uncovered bag around 10:00 AM and then placed a new privacy cover over it after receiving one from the LVN. The DON stated privacy covers should always be used for catheter bags unless the resident requested not to use one, and that it was important to use privacy bags to protect residents' privacy and dignity.
Failure to Document DNR Order for a Resident with Advance Directive
Penalty
Summary
The facility failed to coordinate obtaining and documenting a physician's order for an existing advance directive for Resident #2, whose record showed an Out-Of-Hospital Do-Not-Resuscitate (OOH-DNR) order signed by his RP. Resident #2 was a [AGE]-year-old male with diagnoses including acute on chronic congestive heart failure, hypertensive heart disease with heart failure and chronic kidney disease, obstructive sleep apnea, paroxysmal atrial fibrillation, type 2 diabetes mellitus, and unspecified dementia. His admission MDS reflected a BIMS score of 11, indicating moderate cognitive impairment. Record review showed the resident's care plan and physician order summary still reflected Full Code status, including an active verbal order for Full Code. The OOH-DNR form reflected the RP signed it, and the facility's Request for Do No Resuscitate form indicated the RP requested DNR status and that the physician was notified, with the form also documenting that the physician had ordered a DNR for the resident. However, the DNR was not uploaded into PCC until almost 2 months later, and the physician order was not entered when the form was signed. During interviews, the ADON stated she initiated the resident's DNR but forgot to put the order in after it was signed, and said the order should have been entered and the care plan updated the same day the doctor signed the DNR. The MR and DON described the facility process for scanning DNR paperwork into the EMR and entering the code status order, and both stated it was important that advance directives be in the EMR so staff knew whether to perform CPR if the resident coded. The report stated that if Resident #2 had coded before the DNR was entered, staff would have done CPR, which was against his and/or his RP's wishes.
Failure to Implement Enhanced Barrier Precautions for Resident With Dialysis Catheter
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not maintain Enhanced Barrier Precautions for Resident #5, who had a right chest dialysis catheter. Resident #5 was an [AGE]-year-old female with acute kidney failure with dependence on renal dialysis, type 2 diabetes mellitus, hypertension, hypotension, and heart failure. Her quarterly MDS reflected a BIMS score of 5, indicating severe cognitive impairment. Her physician order summary included orders to assess the dialysis device located in the right chest and to monitor the dialysis catheter for infection, pain, and bleeding every shift, but there was no order for EBP. Resident #5’s care plan addressed her need for hemodialysis for renal failure, but it did not include EBP related to the right chest dialysis catheter. Observations of her room on multiple occasions showed no EBP sign on the door and no PPE inside or outside the room. During interviews, the ADON/infection preventionist and the DON both stated that Resident #5 should have had EBP in place, and the DON identified dialysis catheters as devices for which EBP was used. The facility’s EBP policy stated that EBP are indicated for residents with wounds and/or indwelling medical devices and that postings outside the room and Point Click Care are used to communicate when EBP is required.
Unauthorized Photograph Violates Resident Privacy Rights
Penalty
Summary
The deficiency involves a failure to protect a resident’s right to privacy and confidentiality when a staff member took a photograph of the resident without permission. The resident was last admitted with diagnoses including metabolic encephalopathy, cirrhosis of the liver, chronic hepatic failure, nutritional anemia, and thrombocytopenia. An MDS assessment showed a BIMS score of 07, indicating severe cognitive impairment, and records documented that the resident used a walker for mobility, required partial to moderate assistance with dressing, and needed setup or supervision for eating and personal hygiene. The care plan noted impaired cognitive function and interventions to provide a homelike environment. According to an Employee Coaching form, a nurse (LVN A) used her personal cell phone to take a photo of the resident while preparing to send the resident to the emergency room, stating the purpose was to show the ADON the amount of blood on the resident’s bed. LVN A acknowledged in interview that she took the picture and shared it with the ADON, that she deleted the photo afterward, and that she realized it was against resident rights because the resident was unable to give permission at the time. A family member reported hearing that a photo had been taken and felt this compromised the resident’s rights, although the family could not produce or verify the photograph. The ADON confirmed that a picture of the resident had been sent to her and that it was deleted immediately, and stated that the resident’s rights were compromised. The DON, who had recently started working at the facility, reported being informed that a picture of the resident had been taken by LVN A and that this represented a failure to properly protect the resident’s rights. The Administrator also stated he was made aware that a picture may have been taken by a nurse and that this interfered with the resident’s rights. Facility policies on resident rights specified that residents have a right to personal privacy and secure, confidential personal and medical records, and the personnel handbook prohibited use of personal communication devices during work hours and the use of any image-recording device without express permission of the facility and each person whose image is recorded.
Failure to Provide Required Supervision and Two-Person Assist During Incontinent Care Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and did not use the required two-person assist while providing incontinent care to a resident with severe cognitive and physical impairments. The resident, who had diagnoses including dementia with agitation, heart disease, multiple fractures, muscle weakness, abnormal gait, contractures, and was dependent on staff for all activities of daily living (ADLs), required two-person assistance for transfers, bed mobility, and incontinent care as documented in her care plan and MDS. Despite these requirements, the CNA left the resident unattended on her side in bed to retrieve gloves, resulting in the resident falling from the bed. The incident was unwitnessed, but statements from staff and review of the resident's care plan confirmed that the resident was a high fall risk and required two-person assistance for all care activities. The CNA admitted to leaving the resident on her side and not having all supplies ready before starting care, contrary to her training and the resident's care plan. The resident was found on the floor with injuries including a rib fracture and contusions to her face and back. The resident was non-ambulatory, unable to self-propel, and had a history of falls and high fall risk scores since admission. Interviews with staff indicated that the requirement for two-person assistance, especially for residents on air mattresses or with mechanical lifts, was known or should have been known, and that leaving a dependent resident unattended during care was considered neglect. The facility's policies on fall prevention, abuse/neglect, and safe resident handling emphasized the need for proper supervision and adherence to care plans, which were not followed in this incident. The failure to provide adequate supervision and assistance directly led to the resident's fall and subsequent injuries.
Failure to Provide Adequate Incontinent Care and Violation of Resident Privacy
Penalty
Summary
A male resident with multiple diagnoses, including heart failure, malnutrition, fecal urgency, and muscle weakness, was found to have not received adequate incontinent care as required by his care plan. The care plan specified that the resident, who was always incontinent of bladder and bowel and at risk for skin breakdown, should be checked every two hours, have peri care after each incontinence episode, and have barrier cream applied. Despite these interventions being documented, the resident was found by a family member to be sitting in a recliner with dried, caked-on feces and dried urine on his legs and the floor around him, indicating he had been soiled and wet all night. The family member, a retired nurse, described the situation as negligent and cruel, and noted that while some CNAs performed the required checks, others did not. Staff and resident signatures were required on changing sheets, and a sign in the resident's room reminded staff of the two-hour checks. Interviews with staff revealed inconsistent adherence to the two-hour check protocol. The DON confirmed that all staff were responsible for these checks and that nurses were to ensure compliance. However, several staff members, including CNAs and nurses, either denied knowledge of the incident or stated that the resident was found in a severely soiled state, with some describing the situation as neglectful. One CNA, who was assigned to the resident's hall, was reported by colleagues to frequently neglect her duties, spend time on her phone, and avoid resident care. This CNA admitted to checking on the resident last at 4:00 am but failed to chart the care provided. The incident was not documented in the resident's progress notes for the date in question. Additionally, staff took unauthorized photographs of the resident in the soiled condition, which violated facility policy regarding resident privacy and dignity. The facility's policies explicitly prohibit taking or distributing photographs of residents in compromising situations without consent, as this constitutes mental abuse and a violation of resident rights. Multiple staff members acknowledged seeing the photos, but it was unclear who took them. The facility's policies also define neglect as the failure to provide necessary care to avoid physical harm or emotional distress, and the events described met this definition according to staff interviews and policy review.
Failure to Document and Monitor Blood Sugar Levels
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to a critical incident. The resident, a male with multiple diagnoses including diabetes mellitus and hypoglycemia, was found unresponsive on the bathroom floor. The facility staff did not complete blood sugar checks as per the physician's orders, resulting in the resident's blood sugar dropping below normal levels. This led to the resident becoming unresponsive and subsequently coding while in the care of EMS at the facility. The documentation by the facility staff was inadequate and untimely. LVN G and LVN D failed to document the resident's blood sugar results on the morning of the incident and after the resident was found unresponsive, respectively. Additionally, there was no documentation of the administration of the Glucagon Emergency Injection Kit by LVN D or RN E, which was given when the resident was found unresponsive. Furthermore, LVN D did not accurately and timely document the progress notes, postmortem assessment, or the discharge summary in the resident's electronic health record (EHR) after the resident's death. The facility's lack of proper documentation and adherence to professional standards of practice placed the resident at risk of not receiving the necessary care and services to maintain his highest practicable physical, mental, and psychosocial well-being. The facility's failure to document critical information, such as blood sugar levels and emergency interventions, raises concerns about the accuracy and reliability of the care provided. The incident was not investigated by the facility, and there was no indication that the death was reported as required by regulations.
Inadequate Infection Control Practices in LTC Facility
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 case, a resident with multiple diagnoses, including dementia and diabetes, had open wounds on the sacrum and buttocks area. During a wound care observation, it was noted that the resident's wounds came into contact with a soiled brief multiple times. The Licensed Vocational Nurse (LVN) responsible for the care admitted to being nervous and unaware of the contact, acknowledging that such exposure could lead to cross-contamination and infection. The Director of Nursing (DON) confirmed that the resident's wounds should not have been exposed to soiled surfaces, as this could increase the risk of infection and delay healing. In the second incident, another resident with a gastrostomy tube and multiple complex medical conditions was not provided with appropriate Enhanced Barrier Precautions (EBP) during medication administration. The LVN administering the medication did not wear the required gown or face shield, despite the resident being on EBP due to their susceptibility to infection. The LVN was unaware of the need for additional protective equipment, and there was no signage indicating the resident's EBP status. The DON stated that EBP was necessary for residents with g-tubes and other invasive devices to prevent cross-contamination and infection. Interviews with staff revealed gaps in training and awareness regarding infection control practices. The LVN involved in the second incident had recently been rehired and had not received adequate training on g-tube medication administration. Additionally, housekeeping staff were unfamiliar with EBP protocols, indicating a broader issue with staff education and competency checks. The facility's infection prevention and control policy emphasized the importance of preventing infection through comprehensive measures, but these were not effectively implemented in the observed cases.
Failure to Complete PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a PASRR evaluation was completed for a newly admitted resident, identified as Resident #5, prior to or after admission. The resident was admitted with diagnoses including diabetes, paranoid schizophrenia, and vascular dementia. Despite having a diagnosis of paranoid schizophrenia and being on antipsychotic and antidepressant medications, the PASRR Level 1 screening incorrectly indicated no evidence of mental illness. This oversight could have resulted in the resident not receiving necessary specialized therapy and equipment services. Interviews with the MDS nurse revealed a misunderstanding regarding the primary diagnosis, believing that dementia as a primary diagnosis negated the need for a PASRR evaluation for mental illness. The nurse admitted that the 1012 form was never sent, and the resident's diagnoses were misaligned. The facility's policy requires timely and accurate submission of NFSS forms, but this was not adhered to in this case, leading to the deficiency.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for a resident. The resident's care plan was not updated following significant changes in his medical condition, including a change in diet from mechanical to nothing by mouth, the insertion of a new g-tube, and the initiation of enteral feeding. Additionally, the care plan was not revised after the resident experienced a fall that resulted in hospitalization. The resident, who had severe cognitive impairment and required maximal assistance for all functional abilities, had a complex medical history including conditions such as Giardiasis, Methicillin Resistant Staphylococcus, gastro-esophageal reflux disease, chronic respiratory failure, malnutrition, unspecified dementia, stroke, aphasia, and dysphagia. Despite these complexities, the care plan did not reflect the necessary updates to address his current medical needs and interventions, such as the removal of the Red Glass Program after the resident began receiving enteral feeding. Interviews with the DON and ADON revealed a lack of awareness regarding the failure to update the care plans. They acknowledged that the care plans were integral to resident care and should reflect all aspects of the resident's condition to measure if interventions were meeting the goals set by the interdisciplinary team. The facility's policies emphasized the importance of developing and implementing a comprehensive person-centered care plan, yet these were not adhered to in the case of the resident.
Unlocked Wound Care Cart Poses Risk
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, specifically concerning a wound care cart. During observations, the wound care cart was found unlocked and unattended, allowing access to multiple wound care supplies and medications. An interview with an LVN revealed that the cart should be locked at all times to prevent unauthorized access and potential tampering or ingestion of medications. The LVN could not recall the last in-service training on locking carts. The DON confirmed that the cart should not have been left unlocked and emphasized the importance of keeping it locked for safety. The facility administrator stated there was no specific policy on keeping medication or wound care carts locked when not in use.
Failure to Report Resident's Unwitnessed Fall and Death
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency when a resident was found unresponsive on his bathroom floor, went into cardiac arrest, and subsequently died at the facility. The resident, a male with multiple diagnoses including idiopathic peripheral autonomic neuropathy, diabetes mellitus, and hypertension, was found by a charge nurse and a CNA. Despite being unresponsive, the resident was breathing when discovered. Emergency Medical Services (EMS) were called, and while preparing to transfer the resident, he coded, and CPR was initiated. The resident was pronounced dead by an RN after EMS followed their protocols. The facility's administration and nursing staff did not report the incident to the state as required. The Administrator and Director of Nursing (DON) both acknowledged that the death was unexpected, as the resident was not on hospice care. However, they did not consider the incident reportable, as they did not view the death as suspicious. The DON admitted that there was no investigation conducted by the facility regarding the death, and the Administrator concurred with the decision not to report the incident. The facility's policy requires that all allegations of abuse, neglect, exploitation, mistreatment, or injuries of unknown source be reported to the facility administrator and subsequently to the Health and Human Services Commission (HHSC) if they meet certain criteria. Despite this policy, the facility did not report the resident's death, which involved an unwitnessed fall and unresponsiveness, to the state agency within the required timeframe. This failure to report could place residents at risk for not having allegations of abuse or neglect reported, potentially leading to injury or a decrease in physical, mental, and/or psychosocial wellbeing.
Deficiency in Documentation of Resident Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, leading to a deficiency in documentation. The resident, who had a history of diabetes mellitus, hypoglycemia, and other medical conditions, was found unresponsive on the bathroom floor. Despite the critical nature of the situation, several key medical interventions and observations were not documented by the nursing staff. Specifically, the blood sugar results were not recorded by the LVNs on the morning and evening of the incident, and the administration of Glucagon by the RN was also omitted from the records. The resident's medical records were incomplete, with missing documentation of blood sugar checks and the administration of emergency medication. The facility's MAR and other records lacked entries for the resident's blood sugar levels and the use of Glucagon, which were crucial given the resident's condition of hypoglycemia. Additionally, the postmortem assessment and discharge summary contained inaccuracies and omissions, such as incorrect times and missing details about the resident's condition and treatment prior to EMS arrival. Interviews with facility staff revealed a lack of clarity and consistency in the documentation process. The DON acknowledged the importance of timely and accurate documentation, noting that the absence of such records could lead to questions about the care provided. The facility's documentation policy emphasizes the need for comprehensive and timely entries, yet the staff failed to adhere to these standards, resulting in a deficiency that could impact the quality of care and treatment for residents.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, specifically in the case of a resident who was unaccounted for approximately 36 minutes and eloped from the facility. The resident, who had a severe cognitive impairment with a BIMS score of 4, was found 100 feet from the front entrance after traveling approximately 500 feet from the 200 hall exit door. The resident's care plan had identified her as at risk for wandering and elopement, with interventions in place to address these risks, but these were not effectively implemented. The incident occurred when an unknown employee used a master code to unlock the 200 hall exit door, which disabled the alarm and allowed the resident to exit the facility unnoticed. Interviews with staff revealed a lack of awareness and implementation of the facility's elopement prevention and response policies. Many staff members were unaware of the correct procedures to follow during an elopement, and there was confusion about the use and knowledge of the master code, which had not been changed since 2019. The facility's failure to ensure all staff were trained and aware of the elopement policies placed residents at risk for injury and accidents. The maintenance supervisor confirmed that the master code was removed from all doors after the incident, but prior to that, the code was widely known and used by various staff members, contributing to the security breach that allowed the resident to elope.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to deficiencies in addressing their physical, mental, and psychosocial needs. For one resident, the care plan required floor mats to be placed at the bedside to prevent falls, but these were not in place during the surveyor's observation. Interviews with staff, including the MDS Coordinator, DON, RN, and CNA, confirmed the absence of the floor mats and highlighted a lack of recent in-service training on following care plans. Several residents were eligible to attend special offsite activities for senior adults, but their care plans were not updated to reflect this eligibility. The facility lacked a policy for residents signing out when leaving for these activities, relying solely on sign-out logs that were not consistently used. Interviews with the ADM and MDS nurse revealed that specific orders for attending these activities were missing from the residents' physician orders, and care plans were not updated to include falls or other significant events. Two residents had injuries that were not reflected in their care plans. One resident had bruising and swelling to her finger, with conflicting reports about the cause of the injury, and another resident had a large bruise on her upper arm, possibly related to pulling out a midline. The facility's care planning policy required ongoing discussions with residents and representatives to update care plans based on changing needs, but this was not consistently followed, as evidenced by the lack of updates for these injuries.
Failure to Provide Written Notice of Transfer or Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident, their representative, and the Office of the State Long-Term Care Ombudsman. This deficiency was identified during a review of Resident #8, who was transferred to an assisted living facility with a memory care unit. The resident's representative reported that they were not given any notice or explanation for the transfer and were told to find another facility or take the resident home by the end of the day, with the transfer occurring the next day. The facility's failure to provide written notice in a language or manner understood by the resident and their representative was a significant oversight. Interviews with facility staff, including CNAs, the ADON, and the Administrator, revealed inconsistencies and a lack of clarity regarding the discharge process and the provision of written notices. The ADON recalled medication issues and disagreements with the previous DON, while the Administrator admitted to not providing a written discharge notice. The Director of Medical Records confirmed that written notices were not consistently provided, and the system for triggering such notices was flawed. The facility's policy required a 30-day notice for non-emergent discharges, which was not adhered to in this case. The record review showed that Resident #8 had a history of wandering and elopement risk, which contributed to the decision to transfer. However, the discharge summary lacked a written notice, and the facility's documentation system failed to initiate the necessary notifications. The facility's discharge and transfer policy, revised in April 2024, mandates written notice for non-emergent transfers, which was not followed, highlighting a systemic issue in the facility's discharge procedures.
Failure to Update Care Plans for Falls
Penalty
Summary
The facility failed to revise and update the care plans for two residents, R#4 and R#7, to reflect actual falls that occurred. For R#4, the care plan did not include unwitnessed falls with injury that happened on 09/18/23 and 09/24/23, despite the resident being hospitalized for altered mental status due to a urinary tract infection. The care plan had not been updated since 06/23/24, even though the resident was identified as a high fall risk in multiple assessments. Similarly, R#7's care plan was not updated to include a fall with injury on 04/18/24, which resulted in a right hip fracture and subsequent hospitalization. The care plan had not been revised since 06/23/24, and the resident was also identified as a high fall risk in several assessments. Interviews with staff, including the CNA, RN, ADON, and MDS nurse, revealed a lack of timely updates to care plans, which are crucial for staff to provide appropriate care. The facility's failure to update the care plans in a timely manner could lead to residents receiving incorrect care, potentially causing health complications or injuries. The care plans are essential for communication among staff, ensuring that all are aware of the residents' current conditions and needs. Despite the facility's policy requiring care plans to be reviewed and revised based on changing needs, this was not adhered to in the cases of R#4 and R#7.
Failure to Secure Shower Room in 300 Hall
Penalty
Summary
The facility failed to maintain a safe and secure environment in the 300 hall shower room, as observed during multiple inspections. On two separate occasions, the shower room door was found either unlocked or propped open, posing a potential risk for falls and injuries to residents, staff, and visitors. Staff members, including SNA C and the DON, confirmed that the shower room door lock was malfunctioning, with SNA C noting that the issue had persisted for about a week, although she was unsure if it had been reported. The DON discovered the problem during the inspection and was unaware of the issue prior to that moment. Further investigation revealed that the Maintenance Supervisor (MS) had been aware of the broken lock for approximately six weeks and had communicated the need for a replacement to the administration. However, the lock was on back order, and no work order was documented in the maintenance log. Despite attempts to fix the lock, it remained non-functional. Interviews with staff, including RN E and CNA D, indicated that there was an expectation for shower doors to be locked for safety and privacy, and in-service training had been conducted on this protocol. However, the issue persisted, and the new CNA was not responsible for the oversight, as confirmed by the DON.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 10 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Refugio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockport Nursing And Rehabilitation Center | 21.5 mi | ★★★★★ | 4 | 0 |
| Gulf Pointe Plaza | 23.2 mi | ★★★★★ | 6 | 0 |
| La Bahia Nursing And Rehabilitation | 26.5 mi | ★★★★★ | 8 | 0 |
| Avir At Beeville | 28.2 mi | ★★★★★ | 5 | 0 |
| Avir At Portland | 29 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.