Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mitchell County Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to protect resident dignity and privacy when CNAs used personal cell phones while providing care, including showers and feeding. Seven residents said the behavior happened on every shift, made them feel ignored and embarrassed, and caused privacy concerns and delays between bites during meals. The DON and ADM stated staff should focus fully on residents and that cell phones were not allowed in resident care areas.
Failure to Invite Residents and Representatives to Care Plan Meetings The facility did not document advance notice or invitations for care plan/IDT meetings for multiple residents, including residents with dementia, cognitive impairment, mobility limitations, pain needs, wounds, therapy services, and complex medical diagnoses. Interviews showed residents and family members were not invited to meetings, and staff stated the IDT discussed care plans internally while the DON called families with updates instead of holding or documenting formal care plan conferences.
Grievance Procedure Not Made Available to Residents: The facility failed to provide 9 of 10 residents with accessible information on how to file a grievance or complaint. Residents stated they did not know about anonymous grievances, where to get a grievance form, who to submit it to, what happens after filing, or that they could receive a written decision. Observations showed the posted information did not include grievance instructions, while the ADM stated she was the grievance officer and that forms were available in the entryway hallway and at the nurses' station.
A kitchen survey found food items in the refrigerator and freezer stored in clear bags with no use-by dates, and a garbage can next to the prep table left uncovered while not in use. Staff and leadership stated that kitchen staff were responsible for dating and labeling food, the DM was responsible for monitoring it, and that the uncovered trash can should have had a lid. Facility policy required refrigerated and frozen foods to be covered, labeled, and dated, and refuse containers to be covered when not in use.
A resident meal service deficiency occurred when multiple residents reported cold, bland, and poorly textured food, and surveyors found that most sampled tray items were cold, with some mushy, sticky, or chunky. Kitchen and admin staff said they were responsible for monitoring food temp, texture, and flavor, but could not explain the poor quality; they also reported a malfunctioning steamtable and possible delays in serving. The facility policy required palatable, visually appealing meals served at appropriate temperatures.
Incomplete DNR Form: A resident with dementia, AKF, and DM2 had a DNR order documented on the face sheet, physician order summary, and care plan, but the OOH DNR form was incomplete because the physician did not print his name and the license number was missing. The BOM and ADM both confirmed the form was not valid if not filled out correctly and stated there was no system to monitor DNR accuracy.
Two residents received PRN Lorazepam orders without the required 14-day stop date, and the record did not show a documented diagnosed specific condition supporting PRN psychotropic use. One resident had dementia, moderate cognitive impairment, and hospice care with Lorazepam administered on multiple occasions, while the other had dementia with severe cognitive impairment and hospice care with a long-standing PRN Lorazepam order for anxiety and restlessness. The DON and ADM acknowledged PRN psychotropics required review for stop dates, and the facility policy stated PRN psychotropic use must be tied to a documented specific diagnosis and limited to 14 days.
Failure to Follow Standard Precautions During Perineal Care: Two CNAs were observed performing peri-care without proper hand hygiene and glove changes. One CNA cleaned a resident with dementia and incontinence, then placed a clean brief without changing gloves or cleaning hands. Another CNA removed gloves after peri-care, put on a new pair without hand hygiene, and then assisted a resident with standing and dressing. The ADON, who also served as the IP, acknowledged the issue and the facility policy required hand hygiene after glove removal and before moving from a contaminated to a clean body site.
The facility failed to maintain RN coverage for at least eight consecutive hours per day, seven days a week, on four specific days. Staff interviews revealed a lack of awareness and understanding of the RN coverage policy. The DON and ADON were responsible for ensuring coverage but were unaware of the uncovered days until later. The absence of RN coverage could potentially place residents at risk of inadequate care.
The facility was found to have deficiencies in food storage and hygiene practices, including expired and dented canned foods, improper hand hygiene by kitchen staff, and unlabeled food items. A dishwasher was observed wrapping silverware without washing hands or wearing gloves, despite being trained to do so. The kitchen manager admitted to not being aware of expired foods, and the dietary manager emphasized the importance of proper hygiene to prevent health risks to residents.
The facility failed to develop comprehensive care plans for six residents, lacking measurable objectives and timeframes for addressing medical, nursing, mental, and psychosocial needs. Care plans were not updated or individualized for issues like vision, communication, and urinary incontinence. Staff interviews revealed a lack of awareness and training in care plan creation and updates.
The facility failed to ensure resident privacy during wound care for two residents, leading to potential exposure. An RN did not fully close privacy curtains or window blinds during care, despite being trained to do so. The facility's administration was unaware of these lapses, although their policy emphasized maintaining resident dignity and privacy.
A resident with severe cognitive impairment received Trazadone for depressive episodes without informed consent, as required by the facility's policy on psychotropic medications. Staff interviews revealed a lack of awareness and a clear system for obtaining medication consents, leading to the administration of the medication without the necessary consent from the resident or their representative.
A facility failed to honor a resident's DNR order due to inconsistent documentation across the EMR, care plan, and physical chart. Despite having a valid DNR, the resident was listed as full code in the EMR, risking unwanted CPR. Staff interviews revealed reliance on incorrect records, and the facility's policy on advance directives was not followed, leading to a violation of the resident's rights.
The facility failed to ensure the medication cart for hall 100 was free of expired medications, as observed with a bottle of Acetaminophen 500 mg/Diphenhydramine HCl 25 mg past its expiration date. RN B confirmed the oversight, and both the DON and ADM were unaware of the expired medication, despite it being the nursing staff's responsibility to remove such items. The facility's policy requires nursing staff to maintain medication storage and contact the pharmacy for expired items.
The facility failed to properly store medications on the Hall 100 medication cart, where two loose pills were found. RN B, responsible for checking the cart, was unaware of how the pills became loose. The DON and ADM were also unaware of the issue, despite facility policies requiring medications to be stored in their original packaging and kept orderly. This lapse in adherence to the policy was observed during a survey.
A long-term care facility failed to maintain an effective infection control program, as evidenced by two incidents involving staff and residents. An RN did not sanitize her hands between glove changes during wound care for a resident with a pressure ulcer, while a CNA did not wear a gown during catheter care for a resident on Enhanced Barrier Precautions. Both staff members acknowledged their lapses, and the facility's policy requires gowns and gloves during high-contact care activities to prevent infection.
The facility failed to provide education and document pneumococcal and influenza immunization status for two residents, both with severely impaired cognition. Staff interviews revealed a lack of awareness and accountability in the immunization process, with the ADON responsible for monitoring. The facility's policy required offering the influenza vaccine annually, but this was not followed, leading to the deficiency.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and privacy when staff used personal cell phones while providing care, including assisting with showers and feeding residents. Seven confidential residents reported that CNAs were on their cell phones during care on every shift, which made them feel ignored, not a priority, embarrassed, and concerned that staff could make mistakes because they were distracted. The residents also stated that their privacy was violated and that they did not know the names of the CNAs involved. The same residents reported that staff also used cell phones while feeding residents during meals, causing significant wait times between bites. During interviews, the DON and ADM stated residents should receive privacy and full staff attention during care, that cell phone use was not allowed in resident care areas, and that staff were trained on resident rights, dignity, privacy, and cell phone use during orientation and in-services. The facility policy titled Resident Rights stated employees shall treat all residents with kindness, respect, and dignity and protect privacy and confidentiality.
Failure to Invite Residents and Representatives to Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents had the right to participate in the development and implementation of their person-centered plans of care for 13 of 13 residents reviewed for comprehensive care plans. Record review and interviews showed that the facility did not document invitations for care plan meetings for Resident #1, Resident #2, Resident #20, or 10 additional confidential residents, and there was no documentation that these residents or their representatives were provided prior notice to participate in care plan meetings. Resident #1 was a female admitted with diagnoses including fracture of the right femur, anemia, pneumonia, hypertension, acute diastolic congestive heart failure, macular corneal dystrophy, history of cerebral infarction, and history of falling. Her admission MDS showed minimal hearing difficulty, impaired vision with corrective lenses, BIMS 11/15, limited to moderate ADL assistance needs, use of a walker and wheelchair, pain requiring PRN medication, a mechanically altered diet, wound care needs, and therapy services. Her care plan addressed triggered concerns from the admission MDS, and her overall goal was discharge to the community, but the record did not show any IDT or care plan meeting documentation between admission and the survey review period. During interview, Resident #1 stated she did not think she had participated in a care plan meeting, and a family member stated the facility communicated with him individually rather than through a care plan/IDT meeting. Resident #2 was a male with diagnoses including dementia, altered mental status, chronic hepatitis C, hyperlipidemia, depressive disorder, PTSD, polyneuropathy, osteoporosis, urethral fistula, and traumatic brain injury. His quarterly MDS showed impaired vision with corrective lenses, BIMS 5/15, wheelchair use, extensive ADL assistance, frequent bladder incontinence, an ostomy for bowel, falls, mechanically altered diet, skin tears and moisture associated skin damage, and use of antidepressant and antibiotic medications. His care plan addressed triggered concerns, but the record did not show any IDT or care plan meeting documentation during the review period. A family member stated he had not been invited to or attended any care plan/IDT meeting regarding Resident #2's care. Resident #20 had diagnoses including dementia, acute kidney failure, acquired absence of specified parts of the digestive tract, cholecystitis, atrial fibrillation, arthritis, type 2 diabetes mellitus, insomnia, depressive disorder, hypertension, and GERD. Her quarterly MDS showed impaired vision with corrective lenses, BIMS 6/15, wheelchair use, extensive ADL assistance, incontinence of bladder and bowel, medically complex conditions, scheduled pain medication, a mechanically altered diet, moisture associated skin damage, insulin injections, and antidepressant use. Her care plan addressed triggered concerns, but there was no documentation of an IDT or care plan meeting during the review period, and her family member stated she had never been invited to a care plan/IDT meeting. Interviews with staff showed the MDS Coordinator stated they did not send letters or have care plan meetings, and that the IDT team met to discuss the plan of care while the DON called families with updates. The DON stated the facility got the IDT team together, reviewed residents' care plans, and then called family members or responsible parties to discuss quarterly and annual assessments, but did not send letters to invite residents or family members to care plan meetings. The DON also stated that during COVID-19 the meetings were done by phone and never started back, and that she documented notifications on paper because the EMR did not have a place for notes. The Administrator stated she had been told the MDS nurse did not do care plan meetings and that the DON notified families with updates, and she acknowledged the importance of notifying residents and families and giving them a chance to talk to the IDT about questions or concerns. The facility policy stated residents have the right to participate in care planning, receive advance notice of care planning conferences, and have an explanation documented if participation is not practicable.
Grievance Procedure Not Made Available to Residents
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to residents for 9 of 10 confidential residents reviewed. During interviews and record review, those residents stated they did not know they could file a grievance anonymously, that the grievance procedure had never been discussed in Resident Council, and that they had not observed a posting of the grievance procedure in prominent locations. They also stated they did not know where to obtain a grievance form, who to give it to, what happened after a grievance was filed, or that they had the right to receive a written decision once the grievance was resolved. Observations of prominent postings on 04/28/2026 at 3:00 PM showed the facility did not include instructions regarding the grievance procedure with any of the prominent postings. During interview on 04/28/2026 at 3:35 PM, the ADM stated she was the grievance officer, that grievance forms were available on a shelf in the entryway hallway and at the nurses' station, and that the Activities Director completed grievance forms during monthly Resident Council meetings when concerns were voiced. The ADM also stated staff completed grievance forms for some complaints discussed face to face, that grievances were assigned to the appropriate department for resolution, and that completed forms were kept in a notebook for 3 plus years. Record review showed the grievance policy stated a copy of the grievance/complaint procedure should be posted on the resident bulletin board, and the policy last updated in April 2017 stated the ADM assigned grievance investigation to the grievance officer and that the resident or person filing the grievance would be informed of the findings.
Food Storage and Sanitation Lapses in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During a kitchen tour, a garbage can next to the food prepping table was observed uncovered and not in use. In the walk-in refrigerator, hamburger buns and lettuce were found in separate clear plastic bags with no use-by date. In the walk-in freezer, chicken breast patties, mixed vegetables, and grilled chicken meat burgers were found in separate clear plastic bags with no use-by date. During interviews, kitchen staff and leadership stated that staff were responsible for labeling and dating food items, and that the DM was responsible for monitoring labeling and dating. One staff member stated she may have been rushing and forgot to put the dates and labels on the food items. The same staff member stated the garbage can next to the food prepping table should have been covered at all times unless in use. The RD, ADM, and DM each stated that undated or unlabeled food items and an uncovered garbage can could cause food contamination or food poisoning, and that the garbage can should have had a lid when not in use. Record review of the facility's Food Receiving and Storage policy stated that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated with a use-by date, and refrigerated foods are to be monitored so they are used by their use-by date, frozen, or discarded. Record review of the Sanitation policy stated that garbage and refuse containers are to be properly contained with lids or otherwise covered. The observed food storage and sanitation conditions did not match those policy requirements.
Meals Served Cold and Poorly Prepared
Penalty
Summary
The facility failed to provide food and drink that were palatable, attractive, and served at a safe and appetizing temperature. During the initial tour, four residents voiced concerns about the food. One resident said the food was greasy, had no seasoning or taste, and was cold and never hot. Another resident stated the food had no texture, no variety, was not hot, and that the vegetables were overcooked. A third resident said the food was of poor quality and that he ate sandwiches instead, and a fourth resident reported that meals were cold, there was no variety, and the chicken was dry. On observation, a sample tray was requested to include all food forms served, including the alternate plate. When the tray was delivered to the survey room, surveyors found that five of nine sampled foods were cold. One sampled item was mushy, one was sticky, and one pureed item was chunky. The sampled foods included regular, mechanical, and pureed items, and the findings showed problems with temperature, texture, flavor, and appearance across the meal forms served. During interviews, kitchen and administrative staff stated they were responsible for monitoring temperature, texture, and flavor, but could not explain why the meals were not palatable. Staff reported that the middle steamtable was not working properly or had been out of service for about a month, and that meals may not have been served quickly enough after being placed on the serving line. The dietary policy in the record stated that meals should be palatable, visually appealing, and served at appropriate temperatures, with standardized recipes, attractive plating, and texture-modified foods maintaining moisture and flavor.
Incomplete DNR Form
Penalty
Summary
The facility failed to ensure that Resident #20’s right to formulate an advance directive was honored because the resident’s Out-of-Hospital Do Not Resuscitate form was incomplete. Resident #20 was a female admitted to the facility with diagnoses including dementia, acute kidney failure, and type 2 diabetes. Her face sheet listed DNR under advance directives, and the physician order summary and care plan also reflected a DNR order. Record review of the DNR form showed the physician did not print his name after signing, and the physician license number was missing. During interviews, the BOM and ADM both stated the DNR was not valid if it was not filled out correctly and verified the missing information on Resident #20’s form. They stated there was no system for monitoring DNRs for accuracy and identified human error as the reason the form was incomplete.
PRN Lorazepam Orders Lacked Required Limits and Documentation
Penalty
Summary
The facility failed to ensure that two residents did not receive PRN psychotropic medication without a documented diagnosed specific condition in the clinical record and failed to ensure PRN orders for Lorazepam were limited to 14 days. Resident #21 had a history of unspecified dementia without behavioral disturbance, type 1 diabetes with nephropathy, cerebral infarction, and hospice care. Her quarterly MDS showed moderate cognitive impairment with a BIMS score of 8, and the active diagnoses section did not list anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, or PTSD. Her care plan included PRN Lorazepam for restlessness and anxiousness, and physician orders dated 9/19/2025 included Lorazepam Intensol oral concentrate every 4 hours as needed for mild to moderate anxiety or agitation. Resident #21’s MAR showed Lorazepam was administered in March and April 2026, but the order did not have a stop date and extended beyond 14 days. Resident #40 had shortness of breath, delirium due to known physiological conditions, dementia with mood disturbance, and hospice care. Her quarterly MDS showed severe cognitive impairment with a BIMS score of 6, and the active diagnoses section did not list anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, or PTSD. Her care plan included PRN Lorazepam for psychotropic medication use, and physician orders dated 10/01/2024 included multiple PRN Lorazepam concentrate doses every 2 hours as needed for anxiety and restlessness. Resident #40’s MAR for February, March, and April 2026 did not show any administered Lorazepam doses, but the PRN order also lacked a stop date and remained beyond 14 days. During interviews, the DON stated PRN psychotropic medication should not go past 14 days except, in her belief, for hospice residents, and the ADM stated the DON was responsible for ensuring PRN psychotropics were reviewed for stop dates. The facility policy stated PRN psychotropic medications are not to be prescribed or administered unless necessary to treat a diagnosed specific condition documented in the clinical record, and PRN orders are limited to 14 days.
Failure to Follow Standard Precautions During Perineal Care
Penalty
Summary
The facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection during perineal care for 2 residents. During observation of care for one resident with dementia, severe cognitive impairment, and total incontinence of bladder and bowel, a CNA cleaned the resident’s buttocks after a bowel movement, removed a glove from only one hand, applied a glove to that hand only without hand hygiene, and then placed a clean brief under the resident without changing gloves or performing hand hygiene. During observation of care for another resident admitted with a right femur fracture and moderate cognitive impairment, a CNA performed peri-care while the resident was on the toilet, then removed gloves and put on a new pair without using hand sanitizer or washing hands before assisting the resident to stand and pulling up the brief and pants. The CNA stated she should have used hand sanitizer before putting on the new gloves and said she had been checked off on peri-care about a week earlier. The ADON, who also served as the Infection Preventionist, stated she already knew there was a problem because some CNAs had reported what they had done and she told them it was not right. She described her expectations for peri-care and reviewed the facility’s check-off sheet. The facility policy on Standard Precautions stated that hand hygiene is performed after removing gloves and that gloves are changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, on four specific days. This deficiency was identified during a review of nursing services for the period from January 17, 2025, to February 18, 2025. The absence of RN coverage on January 25, 26, and February 8, 9, 2025, was confirmed through interviews and record reviews. The facility's policy requires RN coverage to provide continuous daily care, oversee shifts, and assist licensed vocational nurses (LVNs) with decision-making in critical situations. Interviews with staff revealed a lack of awareness and understanding of the RN coverage policy. RN B and RN C mentioned their roles in providing guidance to LVNs and pronouncing death, but there was no indication of their presence on the uncovered days. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were responsible for ensuring RN coverage, but both were unaware of the uncovered days until the issue was brought to their attention. The ADON admitted to not making additional efforts to cover the shifts when a volunteer RN called in, and the DON was unavailable to cover the shifts herself. The facility's policy mandates that a registered nurse provides services for at least eight consecutive hours every 24 hours, seven days a week. However, the system in place to monitor RN coverage relied heavily on the ADON and DON, who failed to ensure compliance with this requirement. The Administrator (ADM) also relied on the DON for monitoring RN coverage and was unaware of the uncovered days until reviewing the time sheets. The lack of RN coverage on the specified days could potentially place residents at risk of not receiving adequate care.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility was found to have several deficiencies in its dietary services, specifically in the storage, preparation, and serving of food. During an inspection, it was observed that the facility had expired and dented canned foods in its storage pantry, including sweetened condensed milk, evaporated milk, and green chili peppers. Additionally, several food items such as Ritz crackers, Fritos chips, and ranch dressing were past their expiration dates. There was also an unlabeled baggie of what appeared to be coffee grounds without a proper date label. These issues indicate a failure to adhere to proper food storage and labeling practices, which are essential to prevent food contamination and foodborne illnesses. The inspection also revealed improper hand hygiene practices by kitchen staff. A dishwasher was observed wrapping silverware without washing her hands or wearing gloves, despite being trained to do so. This occurred on multiple occasions, and the dishwasher acknowledged her failure to follow proper procedures, which could lead to the spread of germs and infections. The kitchen manager confirmed that staff had been trained on handwashing and glove use, but acknowledged the oversight in monitoring and enforcing these practices. Interviews with the kitchen manager, dietary manager, and administrator highlighted a lack of adherence to established policies and procedures regarding food safety and hygiene. The kitchen manager admitted to not being aware of the expired foods and stated that it was his responsibility to ensure expired items were removed. The dietary manager emphasized the importance of disposing of expired foods and maintaining proper hygiene to prevent health risks to residents. The administrator expressed an expectation for staff to follow policies, but noted the absence of a specific policy related to expired canned goods. These deficiencies in food handling and hygiene practices could potentially compromise the health and safety of the residents.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for six residents, which included measurable objectives and timeframes to address their medical, nursing, mental, and psychosocial needs. The care plans were not updated or individualized to address specific issues such as vision, communication, urinary incontinence, and psychosocial well-being. This deficiency was identified through observations, interviews, and record reviews, revealing that the care plans lacked necessary interventions and goals. For Resident #10, the care plan did not include interventions for visual function or communication, despite the resident having severely impaired cognition and requiring specific communication strategies. Similarly, Resident #24's care plan was missing interventions for vision and communication, even though the resident had severe cognitive impairment and specific communication challenges. Resident #27's care plan lacked interventions for visual function and urinary incontinence, despite the resident's moderate cognitive impairment and need for assistance with these issues. Resident #34's care plan did not address visual function, although the resident had impaired vision and required glasses. Resident #36's care plan also lacked interventions for visual function, despite the resident's need for glasses during certain activities. Lastly, Resident #39's care plan was missing interventions for visual function, communication, urinary incontinence, and psychosocial well-being, even though the resident had severe cognitive impairment and multiple related challenges. Interviews with staff revealed a lack of awareness and training regarding the creation and updating of care plans, contributing to the deficiency.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect, dignity, and care in a manner that promoted their quality of life. Specifically, the facility did not protect and promote the rights of two residents, Resident #35 and Resident #41, by failing to provide privacy during wound care procedures. This deficiency was observed during wound care sessions where RN C did not fully pull the privacy curtain or close the window blinds, exposing the residents to potential bodily exposure to the hallway and facility exterior. Resident #35, a male with diagnoses including adult failure to thrive, anxiety, dementia, and a stage 2 pressure ulcer, was observed during a wound care session where RN C did not ensure privacy by failing to close the curtain and window blinds. This oversight occurred despite RN C's acknowledgment of the importance of privacy during personal care and her training to provide such privacy. The resident's bed was positioned near the window, and there was a roommate present, increasing the risk of exposure. Similarly, Resident #41, a female with age-related cognitive decline, chronic kidney disease, and a stage 2 pressure ulcer, experienced a similar lack of privacy during wound care. RN C admitted to concentrating on the wound care steps and forgetting to close the curtain and blinds. The facility's administration was unaware of these privacy lapses, although the facility's policy emphasized the importance of maintaining resident dignity and privacy during personal care. The ADM confirmed that the expectation was for staff to always provide privacy by closing doors, curtains, and blinds during care.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident in advance of the risks and benefits of proposed care and treatment, specifically regarding the administration of the antipsychotic medication Trazadone for depressive episodes. The deficiency was identified for one resident who was receiving psychoactive medications without informed consent, placing them at risk of receiving treatments without their or their representative's informed consent. The resident in question had a severely impaired cognition, as indicated by a BIMS score of 06, and was unable to communicate effectively due to aphasia and other cognitive deficits. The facility's policy requires that psychotropic medications, such as antipsychotics and anti-anxiety medications, be prescribed, monitored, and reviewed with the involvement of residents, families, and/or representatives. However, the facility did not obtain a signed consent for the administration of Trazadone to the resident, despite the medication being administered from February 1 to February 17, 2025. Interviews with facility staff, including the MDS Coordinator, DON, ADM, and ADON, revealed a lack of awareness of any missing medication consents and an absence of a clear system to ensure that consents were obtained before administering psychotropic medications. The facility's policy on psychotropic medication use emphasizes the importance of obtaining consent to ensure that residents and their representatives are informed about the medication, its potential side effects, and the right to decline treatment. Despite this, the staff interviews indicated that the responsibility for obtaining consent was not clearly defined, and there was no consistent monitoring system in place to ensure compliance with the policy. The deficiency highlights a gap in the facility's processes for managing medication consents, particularly for residents with cognitive impairments who are unable to advocate for themselves.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to ensure that a resident's advance directive and code status were accurately documented and communicated across all relevant platforms. Resident #27, who was admitted with diagnoses including Parkinson's disease and moderate cognitive impairment, had a completed Do Not Resuscitate (DNR) order that was not reflected in the electronic medical record (EMR). Despite having a valid DNR order, the resident's EMR incorrectly listed him as full code, indicating that CPR should be performed in the event of cardiac arrest. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), the Minimum Data Set (MDS) Coordinator, and the Director of Nursing (DON), revealed inconsistencies in the facility's documentation and communication of code status. Staff members relied on the EMR and a list at the nurse's station to determine a resident's code status, but the list was not observed at the nurse's station, and the EMR for Resident #27 was incorrect. The DON and Assistant Director of Nursing (ADON) acknowledged the importance of consistent and accurate information but were unaware of the discrepancies in Resident #27's records. The facility's policy on advance directives requires that such documents be maintained in a readily accessible location and that the resident's wishes be communicated to direct care staff. However, the failure to update Resident #27's EMR and ensure consistency across the care plan and physical chart resulted in a significant risk of administering unwanted CPR, violating the resident's rights. Interviews with the resident's family member confirmed the desire for the DNR to remain in place, highlighting the facility's oversight in honoring the resident's end-of-life wishes.
Expired Medication Found on Hall 100 Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that the medication cart for hall 100 was free of expired medications. During an observation, a bottle of over-the-counter medication labeled Acetaminophen 500 mg/Diphenhydramine HCl 25 mg was found on the cart with an expiration date of 11/2024, which had already passed. RN B, who was present during the observation, confirmed the expiration and stated that expired medications should not be on the cart. RN B, who had been employed at the facility for only a few months, was unsure of the frequency of audits conducted by nursing administration to check for expired medications. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that neither was aware of the expired medication on the cart. Both stated that it was the responsibility of the nursing staff to ensure expired medications were removed. The facility's policy on medication labeling and storage indicated that nursing staff are responsible for maintaining medication storage areas and contacting the dispensing pharmacy for instructions on handling expired medications. The presence of expired medication on the cart could lead to residents not receiving the full therapeutic effect of their prescribed medications.
Improper Medication Storage on Hall 100 Cart
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals in the medication cart for Hall 100, as observed during a survey. Two loose pills were found in the drawer of the medication cart, identified as Furosemide 40 mg and Cyclobenzaprine 10 mg. RN B, who was responsible for checking the cart for proper medication storage, was unaware of how the pills became loose and acknowledged that it was her duty to ensure medications were stored correctly. She had received training on proper medication storage but was not informed about the frequency of such training at the facility. The Director of Nursing (DON) and the Administrator (ADM) were also unaware of the loose pills on the medication cart. Both stated that it was the responsibility of the nursing staff and administration to ensure proper medication storage. The facility's policy on medication labeling and storage emphasized the importance of storing medications in their original packaging and maintaining a clean and orderly storage area. The policy also required that each resident's medications be stored separately to prevent mixing. Despite these guidelines, the presence of loose pills on the cart indicated a lapse in adherence to the facility's medication storage policy.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving staff and residents. RN C did not perform hand hygiene between glove changes during wound care for a resident with a stage 2 pressure ulcer. This resident, a male with diagnoses including adult failure to thrive, anxiety, dementia, and hypertension, was admitted with a pressure ulcer that required daily cleansing and dressing. During the wound care procedure, RN C changed gloves without sanitizing her hands, which she later acknowledged as a lapse in protocol. Another incident involved CNA E, who did not wear a gown while providing catheter care to a resident on Enhanced Barrier Precautions (EBP). This resident, a female with Parkinson's Disease, dementia, hypertension, anxiety, and an overactive bladder, required daily catheter care. Despite a sign indicating the need for gown and gloves, CNA E only wore gloves during the procedure. She later admitted to the oversight, recognizing the importance of wearing a gown to prevent infection. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were unaware of these lapses in protocol. Both acknowledged the importance of proper hand hygiene and EBP adherence, emphasizing that staff should be trained and follow these protocols consistently. The facility's policy on EBPs, revised in March 2024, outlines the necessity of using gowns and gloves during high-contact care activities to prevent the transmission of multi-drug resistant organisms.
Failure to Document and Offer Immunizations
Penalty
Summary
The facility failed to provide education regarding pneumococcal immunization and did not document evidence of receiving, refusal, or education regarding pneumococcal immunization for two residents. Additionally, the facility did not document the influenza immunization status for these residents, placing them at risk for infections and decreased quality of life. The residents involved were a female with dementia and a male with depressive episodes, dysphasia, cognitive communication deficit, reduced mobility, and aphasia, both of whom had severely impaired cognition. Interviews with facility staff, including the MDS Coordinator, DON, ADM, and ADON, revealed a lack of awareness and accountability regarding the immunization process. The MDS Coordinator and DON were unaware of any residents missing immunizations, while the ADM and ADON acknowledged the responsibility of offering immunizations but could not provide reasons for the oversight. The ADON, responsible for monitoring immunizations, stated that a list was made and given to nurses to offer and administer the immunizations, but this process failed for the two residents in question. The facility's policy required offering the influenza vaccine annually to all residents and employees without medical contraindications, with documentation of refusal placed in the resident's medical record. However, the policy was not followed, as evidenced by the lack of documentation and offering of the influenza vaccine to the two residents. The failure to adhere to the policy and ensure proper documentation and offering of immunizations led to the deficiency identified in the report.
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What surveyors actually found near you
We read the 12 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Colorado City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Snyder | 21.1 mi | ★★★★★ | 12 | 0 |
| Sterling Hills Rehabilitation And Healthcare Cente | 29.4 mi | ★★★★★ | 5 | 0 |
| Sweetwater Healthcare Center | 29.7 mi | ★★★★★ | 7 | 0 |
| Lamun-lusk-sanchez Texas State Veterans Home | 34.6 mi | ★★★★★ | 0 | 0 |
| Parkview Nursing And Rehabilitation Center | 37.2 mi | ★★★★★ | 0 | 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.