Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mustang Park Therapy And Living Center during CMS and state inspections, most recent first.
Delayed Call Light Response: A facility failed to ensure timely response to resident call lights for 5 of 5 confidential residents reviewed. Residents reported waiting more than 30 minutes, with one stating it could take up to an hour and another reporting staff were slow to respond and sometimes turned off the call light without helping. Resident Council minutes documented repeated complaints about poor call light response, while the LVN, DON, and ADM described expectations for immediate or prompt response.
Cold meal trays served to residents. Two residents stated the food was always cold or rarely lukewarm, and 10 other residents said they received cold food when eating in their rooms. Staff observed a non-insulated cart with trays on the hall, and residents said trays sat for five to ten minutes before being passed. An LPN reported prior cold food complaints, while the DON said he was unaware of any complaints.
The facility failed to ensure snacks were offered and served consistently and that the time between the evening meal and breakfast stayed within the required window. A resident with DM, moderate cognitive impairment, and severe protein-calorie malnutrition said she wanted bedtime snacks but had never been offered any, while other residents reported snacks were not provided consistently and were often left at the nurses’ station. Staff said snacks were available if requested or delivered to bedbound residents, but the posted meal times created a 14-hour and 45-minute span between dinner and breakfast, and there was no posting about snack availability.
Food storage and sanitation deficiencies were identified in the kitchen. Surveyors observed dented canned goods in dry storage, a cracked and poorly sealed sugar bin, and opened refrigerated foods that were not labeled or dated and were exposed to air. Handwashing sink issues were also noted, including a waste receptacle containing food and plastic wrap and another sink without a garbage receptacle; staff stated paper towels from the second sink were carried to the first sink’s trash.
Hand hygiene was not performed between resident encounters during medication administration, and it was also not performed during incontinence care when gloves were changed and care tasks continued. One CNA/MA said she had not been trained to clean her hands between residents, while another CNA said she knew hand hygiene was required but did not do it because of nerves. The DON stated staff were supposed to perform hand hygiene between residents, and the facility policy identified hand hygiene as the primary means to prevent the spread of healthcare-associated infections.
Failure to Provide Written Transfer/Discharge Notices and Ombudsman Notification: The facility did not give written transfer/discharge notices to three residents when they were sent to the ER, did not include the reasons for the move or appeal rights in writing, and did not send copies to the LTC Ombudsman. Records and interviews showed one resident with osteomyelitis and severe malnutrition, one with COPD and metabolic encephalopathy, and one with CHF, CKD, and acute confusion were transferred without the required written notice; each resident stated they had not received a letter.
A resident with dysphagia, severe cognitive impairment, and dependence for eating was fed pureed food while leaning back in a geri-chair instead of being positioned upright at 90 degrees as directed in the care plan. An LVN and a CNA both fed the resident while he was not properly positioned, and staff stated they knew he was supposed to sit upright but did not consistently do so during meals.
A resident with multiple medical conditions and a behavioral care plan reported waiting approximately 15 minutes for staff to respond to her call light, ultimately calling 911 for assistance. Staff interviews confirmed frequent call light use and behavioral challenges, but facility policy required responses within five minutes. The deficiency was based on the failure to provide timely assistance as outlined in the facility's policy.
A resident with multiple medical conditions submitted a grievance about an undercooked meal, but facility staff failed to provide an appropriate response or written resolution as required by policy. The resident did not receive an apology or follow-up, and the outcome of the grievance was not communicated, resulting in a failure to honor the resident's right to prompt grievance resolution.
Two staff members transferred a resident with severe cognitive impairment and multiple medical conditions from the floor to a wheelchair without using a gait belt, instead lifting her under the armpits. This action was contrary to facility policy and staff training, which required the use of a gait belt for all transfers to prevent injury.
A resident with multiple chronic conditions was served an undercooked baked potato and lukewarm soup, with observations and staff interviews confirming inconsistent food quality and temperature. A test tray also showed food items not at appropriate serving temperatures, indicating the facility did not consistently provide palatable and properly prepared meals.
A resident with significant mobility and fall risk was unable to reliably summon staff due to a malfunctioning call light system. Despite repeated complaints and staff awareness of the issue, the problem persisted for weeks, resulting in delayed responses to the resident's needs and the resident resorting to calling 911 for help. Facility policy requiring a functional call system and timely response was not met.
A resident with Alzheimer's disease and moderate cognitive impairment was found in bed with the call light on the floor and out of reach. The resident was unable to access the call light and requested help from the surveyor. Staff interviews and facility policy confirmed that call lights should always be within reach to allow residents to request assistance.
A CNA failed to perform hand hygiene after touching a potentially contaminated curtain and before donning clean gloves to provide incontinence care for a resident with vascular dementia and incontinence. This lapse was inconsistent with facility policy and standard precautions, as confirmed by interviews with the DON and an LVN.
Six residents with varying levels of cognitive and physical impairment were found to have nurse call lights out of reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed the expectation that call lights be within reach, but observations showed this was not consistently done.
Four dependent residents did not receive their scheduled showers, and there was no documentation to confirm that bathing assistance was provided. Interviews revealed that residents received showers less frequently than scheduled, often only after complaints, due to CNA shortages and turnover. Both the DON and ADON were unable to produce records of shower provision, citing changes in ownership and documentation systems.
Four residents requiring respiratory care did not have their respiratory equipment, such as nasal cannulas and a trach hose, properly stored when not in use. Instead, the equipment was found unbagged and on the floor, contrary to care plans and physician orders. Facility staff confirmed that this practice did not meet expected standards for infection prevention and equipment management.
A resident with severe cognitive impairment and a suprapubic catheter was observed with an uncovered catheter bag visible from the room entrance, in violation of facility policy and dignity standards. Both an LVN and the DON acknowledged that the catheter bag should have been covered to protect the resident's dignity.
A resident with cognitive impairment and aphasia exited the facility undetected and walked several miles to an emergency department, after staff failed to promptly notice and report the absence. The resident was not previously identified as an elopement risk, and the door used did not alarm, resulting in a lack of adequate supervision and failure to prevent the accident.
A resident with multiple medical conditions experienced ongoing issues with ill-fitting dentures, resulting in pain and difficulty eating. Although the resident reported the problem to the ADON and requested to see an outside dentist, there was no timely follow-up, documentation, or communication with the Social Worker or DON. The lack of action and coordination among staff led to the resident's dental needs not being addressed as required by facility policy.
The facility failed to submit PBJ staffing data to CMS for Q2 2024 due to a change in ownership and lack of access to previous records. The new management could not retrieve necessary data from the bankrupt previous owners, leading to a deficiency in reporting. The facility also lacked a specific policy for PBJ data submission.
The facility failed to provide palatable and attractive meals, as observed by state surveyors and reported by residents. Meals were often tasteless, cold, and improperly prepared, with issues such as bland mashed potatoes and overly vinegary green beans. Despite following recipes, the Dietary Manager was unaware of resident complaints, indicating a gap between policy and practice.
A resident with a suprapubic catheter was found with unsecured tubing, contrary to facility policy requiring a stabilization device every shift. The resident, who had severely impaired cognition and a history of UTIs, was at risk of trauma and infection. The oversight occurred after a shower, as confirmed by the DON and LVN involved.
A resident with a suprapubic catheter did not receive care in accordance with Enhanced Barrier Precautions, as CNAs failed to wear gowns during high-contact care activities. Despite signage and PPE availability, the CNAs believed the precautions were no longer necessary. The resident had multiple medical conditions and required specific precautions due to his indwelling catheter, but staff miscommunication led to a lapse in infection control protocols.
A resident with severely impaired cognition was left exposed during incontinent care due to a missing privacy curtain, which was not replaced after a room cleaning. Staff failed to prevent unauthorized entry during care, violating resident privacy and dignity. The facility's policies on privacy were not followed, leading to a risk of embarrassment for the resident.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Cook F did not log food temperatures for a dinner service, and several opened food items were not labeled with a received or opened date. These actions could place residents at risk for foodborne illness.
The facility failed to clean a resident's bathroom for three consecutive days, despite the resident's severe obesity, cellulitis, type 2 diabetes, and major depressive disorder. This neglect increased the resident's depression and risk of infection, as confirmed by multiple observations and staff interviews.
A facility failed to maintain an infection control program when an LVN did not wear a gown while providing care to a resident on contact isolation precautions for a multidrug-resistant organism. Despite being in-serviced on proper PPE use, the LVN entered the room with only a mask and gloves, risking the spread of infection.
A resident with severe cognitive impairment and existing pressure ulcers experienced a significant deterioration in health due to a new pressure ulcer on the sacrum. The facility failed to notify the wound physician in a timely manner, resulting in the wound developing into a Stage 4 pressure ulcer. Staff did not follow proper notification procedures, and there was a lack of documentation and follow-up, leading to delayed wound care and management.
A resident with severe cognitive impairment and existing pressure injuries did not receive consistent weekly skin assessments, leading to the development of an unstageable pressure ulcer on the sacrum. Despite physician orders for treatment and a WMD consultation, the facility delayed consulting the WMD for 12 days, during which the wound worsened. Inadequate documentation and communication among staff contributed to the deficiency.
Delayed Call Light Response
Penalty
Summary
The facility failed to ensure residents received reasonable accommodation of their needs and preferences when call lights were not answered in a timely manner for 5 of 5 confidential residents reviewed. During confidential interviews, all 5 residents reported call light response times greater than 30 minutes. One resident stated it could take up to an hour for the call bell to be answered, and another resident stated staff were slow to respond and that she had waited up to an hour before someone came, though she could not give a date. One resident said she had not reported the issue to anyone and had simply assumed staff would get to her when they could. Record review of Resident Council Meeting Minutes showed repeated complaints about call light response, including complaints that staff would come into the room and turn the call light off without assisting with the resident’s needs. During interviews, an LVN stated she had not received any call light response time complaints and said the facility expectation was to answer immediately, noting staff had been in-serviced in March on call light response time. The DON stated call lights should never stay on longer than five minutes and that staff should either assist the resident or get someone who could, while the ADM stated call lights should be answered as soon as possible. Facility in-service records and the undated policy on answering call lights both stated the importance of timely responses to residents’ requests and needs.
Cold meal trays served to residents
Penalty
Summary
The facility failed to ensure that food was palatable, attractive, and served at a safe and appetizing temperature for 10 confidential residents and two reviewed residents, including a female resident with ESRD and schizophrenia and another female resident with stroke, diabetes, and non-Alzheimer's dementia. The resident with a BIMS score of 10 stated the food was not good and was always cold, with only rare occasions of it being lukewarm, and said she did not think reporting it would help. The resident with a BIMS score of 15 stated the food was always cold and never hot and said she had reported it to the residents council. Observation of a food cart on the hall showed a non-insulated cart with 10 trays being passed by two staff members. Ten confidential residents interviewed stated they received cold food when eating in their rooms, and residents stated the carts had sat on the hall for five to ten minutes before trays were passed. A CNA stated she had received cold food complaints and would rewarm trays in the microwave, and an LVN stated she had received cold food complaints and had reported them to the previous DON and entered grievances five months earlier. Resident council minutes noted the new meal cart was not insulated and caused food to cool faster. The grievance log for January through March 2026 contained no complaints of cold food, and the DON stated he was not aware of any cold food complaints.
Inconsistent Snack Service and Excessive Time Between Evening Meal and Breakfast
Penalty
Summary
The facility failed to ensure meals and snacks were served in accordance with residents’ needs, preferences, and requests, including ensuring there were no more than 14 hours between a substantial evening meal and breakfast the following day unless a nourishing bedtime snack was served. Surveyors found that the evening meal was posted for 5:00 PM and breakfast for 7:45 AM, creating a span of 14 hours and 45 minutes, and there was no posting advising residents about snack availability or snack times. The facility policy stated that snacks were to be offered and served daily in accordance with residents’ needs, preferences, and requests, and that all diabetic residents were to receive a bedtime snack. Resident #40 was a female resident with diagnoses including metabolic encephalopathy, COPD, type 2 diabetes, severe protein-calorie malnutrition, and spinal stenosis. Her MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and she required substantial to maximal assistance with care. During interview, she stated she would like bedtime snacks because she was diabetic and needed them, but she had never been offered any snacks and had not asked for one. In confidential interviews, 10 residents said snacks were not provided consistently, and residents reported snacks were kept at the nurses’ station and were only available to those who could ambulate there. Staff interviews confirmed that snacks were placed at the nurses’ station, bedbound residents were supposed to be taken snacks by aides, and residents could receive snacks if they asked.
Food Storage and Handwashing Sink Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen reviewed for food safety. During observation, handwashing sink #1 had garbage receptacles containing items other than disposable paper towels, including food and plastic wrap, and handwashing sink #2 did not have a garbage receptacle. The Dietary Manager stated that staff using sink #2 disposed of used paper towels by walking them to the garbage receptacle at sink #1. In the dry storage room, surveyors observed multiple canned food items with dents on the top seal or side of the cans, including butterscotch pudding, black eyed peas, mild cheddar cheese sauce, marinara sauce, diced tomatoes and green chilies, and beef raviolo in tomato and meat sauce. A large white bin containing sugar was also observed with a cracked plastic lid that had been taped, but the tape was peeling and the bin was not fully sealed, leaving the contents exposed to air. The Dietary Manager stated that staff stocking food were responsible for checking cans for dents, that dented cans were removed from use and placed in her office, and that any can with a dent would not be used regardless of size. In the walk-in refrigerator, surveyors observed opened food items without required dates, including kosher dill spears, mayonnaise, and sweet and sour sauce, as well as a gallon zipper bag of sliced cheese that was exposed to air. During interview, staff stated that all kitchen staff were responsible for stocking deliveries, that dates written on cans reflected the date items were received, and that residents could become sick if served food left open or food from dented cans. The facility’s Food Receiving and Storage policy required dry foods to be handled and stored to maintain packaging integrity, and refrigerated foods to be covered, labeled, and dated.
Hand Hygiene Not Performed Between Resident Care Tasks
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when staff did not perform hand hygiene between resident encounters and during incontinence care. During medication administration, CNA/MA D gave medications to one resident, returned to the medication cart without performing hand hygiene, then prepared and administered medications to a second resident without performing hand hygiene between the two residents. CNA/MA D later stated she did not know she was supposed to perform hand hygiene between residents and said she had never been trained to do so, although she acknowledged it was important to prevent the spread of infection. During incontinence care for another resident, CNA E donned gloves, removed the brief, cleaned the resident’s penis and scrotum, cleaned the buttocks, laid down a clean brief, and applied barrier cream, changing gloves during the task but not performing hand hygiene between steps. CNA E stated she was supposed to perform hand hygiene when she changed gloves and said she had been trained to do so, but did not do it during this care because of nerves. The resident had diagnoses including end-stage renal disease, diabetes, and schizophrenia, and had moderately impaired cognition. The DON stated staff were supposed to perform hand hygiene between residents and that staff were trained to do so. The facility’s hand-washing in-service stated all nurses and CNAs are to wash hands before and after every encounter with residents, and the facility policy identified hand hygiene as the primary means to prevent the spread of healthcare-associated infections.
Failure to Provide Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of transfers to the emergency room, the reasons for the move, and the right to appeal, and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 3 of 6 residents reviewed for discharge planning. The report identified Resident #5, Resident #40, and Resident #45 as the affected residents. The deficiency was based on interviews and record reviews showing that written transfer or discharge notices were not provided when these residents were sent to the emergency room. Resident #5 was a female resident with diagnoses including osteomyelitis of the lower leg, type 2 diabetes, atherosclerosis of native arteries of extremities with gangrene, severe protein-calorie malnutrition, and hallux rigidus. Her MDS reflected a BIMS score of 12/15 and she required maximum to dependent assistance with care. A progress note documented that she was sent to the ER due to avascular necrosis. The record contained no evidence that she received a written transfer or discharge notice or that the LTC Ombudsman was notified. During interview, Resident #5 stated she had never received a written letter when she was sent to the ER and said she would have liked to receive one for her records. Resident #40 was a female resident with diagnoses including metabolic encephalopathy, COPD, type 2 diabetes, severe protein-calorie malnutrition, and spinal stenosis. Her MDS reflected a BIMS score of 10/15 and she required substantial to maximal assistance with care. A progress note documented that she was sent to the ER because her oxygen was 85%, she was lethargic, could not keep her eyes open, and had a temperature of 104.5. There was no evidence that she received a written transfer or discharge notice or that the LTC Ombudsman was notified. Resident #40 stated during interview that she had never received a written letter when she was sent to the ER. Resident #45 was a cognitively intact female resident with diagnoses including systolic CHF, type 2 diabetes mellitus without complications, obstructive and reflux uropathy, CKD, and presence of urogenital implants. Her MDS reflected a BIMS score of 15/15, and she was mostly independent except for set-up or clean-up assistance with tub/shower transfers. A progress note documented that she was sent to the ER due to shaking, inability to verbalize beyond her name, pain, disorientation, and inability to recognize staff or her roommate. There was no evidence that she received a written transfer or discharge notice or that the LTC Ombudsman was notified. Resident #45 stated she had never received a written letter and would have liked one with more details about why she was sent to the ER.
Failure to Maintain Upright Position During Feeding
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #37 that included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #37 was a male admitted to the facility with diagnoses including heart failure, end-stage renal disease, Alzheimer’s disease, seizure disorder, malnutrition, respiratory failure, and dysphagia. His annual MDS reflected severe impairment in cognitive skills for daily decision-making, dependence on staff for eating, and use of a mechanically altered diet. His order summary reflected pureed texture and nectar consistency liquids, and the care plan identified risk for nutritional complications related to dysphagia with an intervention that the resident be in a chair at 90 degrees for all food and fluid intake. Observation and interview showed the resident was not consistently positioned upright while being fed. During one meal, he was being fed pureed food while seated in a geri-chair that was leaning back and not at a 90-degree angle; the LVN stated he was supposed to sit upright and adjusted the chair. During another meal, a CNA fed him while he was leaning back in the geri-chair and stated she could not sit him up because he would slide out of the chair; the DON then sat the chair up. Staff interviews reflected that the resident was supposed to be at a 90-degree angle to eat, and the DON stated staff had received in-service training regarding how to feed him. The facility policy on positioning the resident reflected maintaining natural spinal curves, stabilizing the pelvis, keeping the chest up and forward, and the head erect.
Failure to Ensure Timely Response to Call Light for Resident with Behavioral Care Plan
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodations for her needs, specifically regarding timely response to her call light. The resident, a cognitively intact female with diagnoses including cerebral edema, chronic respiratory failure with hypoxia, diabetes, and acute kidney failure, required partial to moderate assistance with toileting hygiene and was dependent for toilet transfers. On the date in question, the resident reported that she pressed her call light multiple times and waited approximately 15 minutes without a response, leading her to call 911 for assistance. Police responded to her call and spoke with both the resident and facility staff. Interviews with staff revealed that the resident was known for frequent use of the call light and for changing her mind about care needs shortly after declining assistance. Staff described repeated entries into her room to address her requests, and noted that she was care-planned for behaviors such as making false allegations and requesting continuous staff presence. On the day of the incident, staff recounted that the resident refused care from one CNA, requested another, and then refused that CNA as well, before eventually allowing the original CNA to return. During this time, the police arrived in response to her 911 call. Facility records and staff interviews indicated that the resident had a history of making allegations about delayed or refused care, and her care plan included interventions for these behaviors. The facility's policy required call lights to be answered within five minutes, but the resident reported a significantly longer wait time. Staff and administration acknowledged the resident's behavioral patterns and the ongoing investigation into her grievance, but the deficiency centered on the failure to ensure timely response to her call light as required by facility policy.
Failure to Promptly Resolve and Communicate Resident Grievance
Penalty
Summary
The facility failed to ensure that a resident's right to voice grievances was honored and that prompt efforts were made to resolve those grievances. Specifically, a cognitively intact male resident with a history of anxiety, depression, diabetes, morbid obesity, and multiple sclerosis submitted a grievance regarding an undercooked baked potato served at dinner. The resident reported that after submitting the grievance form to the Assistant Director of Nursing (ADM), the Dietary Manager (DM) approached him but did not apologize or take responsibility for the issue. Instead, the DM asked if the resident had requested the dietary staff to reheat the potato and suggested that he should notify staff immediately if such issues occur again. The resident felt that his concerns were not properly addressed and that there was no direct follow-up regarding the status of his grievance. Further review revealed that the facility's grievance policy required prompt resolution and a written response to the resident, including details of the investigation and outcome. However, neither the DM nor the ADM provided the resident with a written resolution or communicated the outcome of the grievance. The ADM confirmed that the grievance form was handed to the DM for follow-up, but no resolution was documented or conveyed to the resident as required by policy. This lack of appropriate response and communication constituted a failure to resolve the resident's grievance in accordance with facility policy.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents during a transfer. Specifically, two staff members, an RN and a CNA, transferred a resident from the floor to her wheelchair without using a gait belt and instead lifted her by placing their arms under her armpits. This method of transfer was observed in a video provided by a family member and was reviewed by facility leadership, who confirmed that it was not in accordance with facility policy or standard practice. The resident involved was an elderly female with multiple diagnoses, including coronary artery disease, hypertension, renal insufficiency, hyperlipidemia, and dementia, resulting in severe cognitive impairment. Her care plan indicated she required partial to moderate assistance for transfers and was able to bear weight and pivot with support. Staff interviews and record reviews confirmed that the resident was assessed as a one-person transfer with a gait belt for all transfers, and that staff had been trained and were expected to use gait belts rather than lifting under the arms. Multiple staff members, including the DON, CNA, LVN, and PT, acknowledged that transferring a resident by lifting under the armpits was not appropriate and could cause injury. The facility's policy and in-service training materials also specified the use of gait belts and prohibited lifting residents by or under their arms. Despite this, the observed transfer did not follow these protocols, resulting in a deficiency related to accident prevention and safe transfer practices.
Failure to Provide Palatable and Properly Prepared Food
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Specifically, one resident with multiple medical diagnoses, including diabetes, morbid obesity, and multiple sclerosis, reported receiving an undercooked baked potato and lukewarm vegetable soup. Observations and interviews confirmed that the resident was served a half-baked potato, which he saved to show to staff, and that the quality and temperature of food varied from day to day. The resident had not discussed these issues directly with the dietary manager at the time of the incident. Staff interviews revealed that meal trays were delivered to the dining room and rooms after being checked by a nurse, with drinks passed out first. A test tray prepared for surveyors showed food items at varying temperatures, with some items not at appropriate serving temperatures. The facility's policy required food to be prepared in a way that conserved nutritive value, flavor, and appearance, but the observed practices and resident reports indicated this standard was not consistently met.
Failure to Maintain Functional Resident Call System
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident in her room, resulting in the resident being unable to reliably summon staff assistance. The resident, who had a history of cervical disc disorder, spinal fusion, osteoporosis, and anxiety, required substantial assistance with toileting and was at moderate risk for falls. Despite repeated reports from the resident that her call light was malfunctioning—sometimes not working at all or only intermittently functioning—maintenance checks did not resolve the issue, and the problem persisted for approximately two weeks. Multiple staff interviews confirmed that the call light in the resident's room was unreliable, with some staff noting a possible wiring shortage and delays in response. The resident reported waiting for up to two hours for assistance and ultimately called 911 to have emergency services contact the facility on her behalf. Staff acknowledged the ongoing issue, with maintenance staff indicating that a technician should have been called to inspect the system, but no documentation of repairs or technician visits was provided. The resident was offered a room change, which she declined, and was eventually provided with a manual call bell as a temporary solution. Facility policy required that the call system remain functional at all times and that calls for assistance be answered within five minutes. However, the resident's repeated complaints and the lack of timely resolution to the malfunctioning call light system demonstrated a failure to meet these standards. The deficiency was substantiated through observations, interviews, and record reviews, which consistently indicated that the resident did not have reliable access to staff assistance through the required communication system.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs and preferences for a resident by not maintaining the call light system in an accessible position. On the date of observation, the resident, who had Alzheimer's disease, moderate cognitive impairment, and muscle wasting, was found lying in bed with the call light on the floor, out of reach. The resident confirmed she could not access the call light and requested assistance from the surveyor. The Director of Nursing (DON) entered the room, observed the call light on the floor, and repositioned it within the resident's reach. The DON stated that the call light should always be accessible to the resident. Interviews with facility staff, including a CNA, an LVN, and the Administrator, confirmed the expectation that call lights should be within reach of all residents to ensure they can communicate their needs and request help. The resident's care plan specifically included an intervention to keep the call light within reach due to her risk for falls and need for assistance with self-care and mobility. Facility policy also required that call lights be accessible to residents when in bed.
Failure to Ensure Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident reviewed for infection control. During incontinence care, a CNA performed hand hygiene and donned gloves before beginning care, but after removing soiled gloves and touching the resident's curtain with bare hands to retrieve new gloves, the CNA did not perform hand hygiene before putting on clean gloves to continue care. The curtain was identified as a potentially contaminated surface. The CNA acknowledged after the incident that she should have used hand sanitizer before putting on new gloves, recognizing the curtain could be dirty. The resident involved was an elderly female with diagnoses including hypertension, hyperlipidemia, and vascular dementia, and was always incontinent of bowel and bladder. The resident's care plan required regular checks and assistance with toileting and incontinence care. Interviews with the DON and an LVN confirmed that facility policy and standard precautions require hand hygiene before and after glove use, and that the observed lapse was inconsistent with both facility policy and recent staff training. Review of the facility's hand hygiene policy further confirmed the expectation for hand hygiene before donning gloves and after glove removal.
Failure to Ensure Accessible Nurse Call System for Multiple Residents
Penalty
Summary
The facility failed to ensure that the nurse call system was accessible for six out of ten residents reviewed for call system access. Observations on the specified date revealed that the call lights in the rooms of these residents were not within their reach. In several cases, the call lights were found hanging from the bed near the floor, on the floor under or behind the bed, or on another bed in the room, making it impossible for the residents to access them when needed. The residents affected had significant medical histories, including severe cognitive impairment, muscle weakness, repeated falls, lack of coordination, and difficulty walking. Their care plans specifically included interventions to ensure the call light was within reach and to encourage use of the call system. Despite these documented needs and interventions, staff did not consistently ensure the call lights were accessible, as evidenced by direct observations and resident interviews. One resident with intact cognition was observed nearly falling while trying to retrieve her call light from the floor. Interviews with staff, including LVNs, CNAs, the ADON, and the DON, confirmed that call lights should be within reach of residents and that staff are expected to check call light placement during rounds. Staff acknowledged the importance of call light accessibility and recognized that the observed situations did not meet facility expectations or policy. The facility's policy states that residents are to be provided with a means to call staff for assistance through a communication system, but this was not consistently implemented.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) independently received the necessary assistance to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, four residents who required varying levels of assistance with bathing did not receive their scheduled showers, and there was no documentation available to confirm that these showers had been provided. The lack of records was confirmed by both the Director of Nursing (DON) and Assistant Director of Nursing (ADON), who were unable to produce any Bath/Shower Sheets for the month in question. Interviews with the affected residents revealed dissatisfaction with the care provided, particularly regarding the infrequency of showers and delayed response to call lights. Residents reported only receiving about one shower per week, despite being scheduled for more frequent bathing, and attributed this to staff shortages and high turnover among Certified Nursing Assistants (CNAs). Some residents stated that they only received showers after making complaints to the DON, and expressed discomfort with feeling unclean. The DON acknowledged receiving complaints about missed showers upon starting her position and confirmed that either showers were not being given or CNAs were not documenting them. The facility had recently experienced a change in ownership, which led to inconsistencies in the system used to track shower provision. The ADON also noted concerns about the lack of documentation and was unable to confirm whether residents were receiving their scheduled showers. The facility's policy required appropriate support and assistance with hygiene for residents unable to carry out ADLs independently, but this was not consistently provided or documented.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four out of seven residents reviewed for respiratory care. Specifically, three residents who required oxygen therapy via nasal cannula were observed to have their nasal cannulas left unbagged and on the floor when not in use, contrary to professional standards and facility policy. Another resident with a tracheostomy was observed to have her trach hose on the floor rather than properly stored. These actions were inconsistent with the residents' comprehensive care plans and physician orders, which specified the need for proper respiratory equipment management. Interviews with facility staff, including an LVN, the DON, and the ADON, confirmed that the expectation was for all respiratory equipment, such as nasal cannulas and trach hoses, to be bagged or properly stored when not in use to prevent contamination. The staff acknowledged that the observed practices did not meet these expectations. Record reviews indicated that the affected residents had significant medical histories, including heart disease, heart failure, tracheostomy, and a history of COVID-19, and required varying levels of assistance with activities of daily living.
Failure to Maintain Resident Dignity by Not Concealing Catheter Bag
Penalty
Summary
A deficiency was identified when a male resident with severe cognitive impairment, renal failure, and a suprapubic catheter was observed with his catheter bag hanging from his bed in clear public view, without a privacy bag covering it. The catheter bag was visible from the entrance to the resident's room, and there was no intervention in the resident's care plan addressing the use of a catheter bag. The resident required full assistance with activities of daily living and had a diagnosis of bladder incontinence, but the care plan did not specify measures to maintain dignity regarding catheter use. During the survey, a Licensed Vocational Nurse (LVN) confirmed that the catheter bag should have been covered with a privacy bag to protect the resident's dignity. The Director of Nursing (DON) also acknowledged the issue, stating that it was a dignity concern and that the catheter bag should always be covered. The facility's policy on dignity emphasized the importance of promoting residents' sense of well-being and self-worth, but this policy was not followed in the observed instance.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dementia, aphasia, anxiety disorder, and major depressive disorder exited the facility without staff knowledge and walked 2.7 miles to a free-standing emergency department. The resident's wandering risk assessment, completed prior to the incident, indicated a low risk for elopement, and the comprehensive care plan noted the need for supervision and assistance with all decision-making due to impaired cognitive function. Staff interviews revealed that the resident was last seen in his room late in the evening, but was not accounted for during subsequent rounds, and his absence was not immediately reported to supervisory staff. The facility's staff did not notice the resident was missing until several hours after he had left the building. During this period, the resident was able to leave through an unknown door, which did not trigger an alarm, and was later found outside a hospital emergency room by a bystander. The resident was unable to communicate his intentions or the reason for his departure due to his aphasia and cognitive impairment. Staff interviews indicated that the resident had not previously displayed exit-seeking behavior, and the facility's criteria for high elopement risk did not identify him as such prior to the incident. The delay in recognizing the resident's absence and the lack of immediate notification to supervisory staff contributed to the failure to provide adequate supervision and prevent the accident. The facility's policies required staff to determine if a resident was on authorized leave, initiate a search if not, and notify appropriate parties if the resident could not be located. However, these procedures were not effectively implemented in this case, resulting in the resident's unsupervised exit and subsequent discovery at an external emergency department.
Failure to Provide Timely Dental Services and Address Denture Concerns
Penalty
Summary
The facility failed to provide or obtain appropriate dental services for a resident who experienced issues with his dentures. The resident, a male with diagnoses including COPD, dysphagia, and bipolar disorder, was admitted to the facility and initially received new dentures, which he reported fit well. However, within a short period, he reported that the bottom denture did not fit, causing him pain and difficulty eating certain foods. Despite informing the ADON about the issue, the resident did not receive timely follow-up or resolution for his denture concerns. The resident stated he communicated his denture problem to the ADON both shortly after receiving the dentures and again approximately two weeks prior to the survey. He expressed a preference to see a dentist outside of the facility's usual provider. The ADON acknowledged being told about the issue but did not check the resident's insurance, notify the Social Worker or DON, or document the concern in the resident's record. The Social Worker and DON were both unaware of the resident's ongoing denture problem until the time of the survey. Facility staff interviews revealed a lack of communication and follow-up regarding the resident's dental needs. The Social Worker indicated she would have arranged for dental services if she had been informed, and the DON stated she would have acted immediately had she known. The facility's policy required routine and emergency dental services to be provided according to the resident's assessment and care plan, but this was not followed in the resident's case.
Failure to Submit PBJ Staffing Data for Q2 2024
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the second quarter of fiscal year 2024, covering January 1 to March 31, 2024. This deficiency was identified through interviews and record reviews, which revealed that the facility did not submit the required Payroll Based Journal (PBJ) staffing data. The failure to submit this data could potentially place all residents at risk for unmet personal needs, decreased quality of care, and a decline in health status and well-being. The deficiency was attributed to a change in ownership of the facility in May 2024. The new management reported that the previous owners, who were bankrupt, did not pay their vendors, resulting in the current owners being unable to access the necessary records to submit the PBJ data. The Chief Operations Officer confirmed that he is responsible for submitting the PBJ data but was unable to do so for the specified quarter due to the lack of access to previous records. The facility also lacked a specific policy for PBJ data submission, relying instead on the CMS PBJ Policy Manual.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide palatable and attractive food for two consecutive lunch meals, as observed by state surveyors. On both occasions, the meals were tasted by four surveyors who found the food to be lacking in flavor. Specifically, the glazed carrots, dinner roll, and noodles were described as tasteless on the first day, while the mashed potatoes were bland and the green beans had a strong vinegar taste on the second day. The kitchen staff was observed plating the food using warmer plates and covers, but this did not seem to improve the taste or temperature of the meals. Multiple residents reported dissatisfaction with the food, citing issues such as meals being served cold, food being overly salty, and desserts being improperly packaged and prepared. One resident mentioned that meals were often late on weekends, and another noted that French fries were frequently cold by the time they reached the dining tables. Despite these complaints, the Dietary Manager was unaware of any resident grievances regarding the food quality. The facility's dietary policies and procedures were reviewed, revealing that food should be prepared to conserve nutritive value, flavor, and appearance, and served at an appetizing temperature. However, the surveyors' observations and resident interviews indicated that these standards were not consistently met. The Dietary Manager and Dietitian confirmed that recipes were followed, but the surveyors' tasting results contradicted the intended flavors, suggesting a disconnect between policy and practice.
Failure to Secure Catheter Puts Resident at Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, identified as Resident #24, who was incontinent of bladder and had a history of urinary tract infections. The resident, a male with severely impaired cognition and dependent on staff for daily activities, had an indwelling suprapubic catheter. The facility's records indicated that the catheter should be secured with a stabilization device every shift to prevent trauma and infection. However, during an observation, it was noted that the catheter tubing was not secured to the resident's body, which was confirmed by a CNA who stated that the tubing was sometimes secured with a strap but was not at that time. Further interviews revealed that the resident's charge nurse, LVN C, had forgotten to replace the catheter stabilization device after the resident's shower. The Director of Nursing (DON) acknowledged the risk of not securing the catheter, which could lead to dislodgement and bleeding. The facility's policy on catheter care emphasized the importance of securing the catheter to reduce friction and movement at the insertion site. Despite this policy, the failure to secure the catheter was documented, and the resident was at risk of urinary tract infections and injury from trauma.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A and CNA B who did not adhere to Enhanced Barrier Precautions while providing care to a resident. The resident, who had a suprapubic catheter, was observed receiving incontinent care without the CNAs donning gowns, despite the presence of signage and PPE supplies indicating the need for such precautions. Both CNAs were aware of the risks associated with improper infection control procedures but were under the impression that the resident's precautions had been lifted. The resident in question was a male with severely impaired cognition, dependent on staff for various activities of daily living, and had multiple medical conditions including a history of urinary tract infections. His care plan specifically required Enhanced Barrier Precautions due to his indwelling catheter, which necessitated the use of gowns and gloves during high-contact care activities. Despite this, the CNAs only used gloves and masks, neglecting the gown requirement, which was a critical component of the precautions. Interviews with facility staff, including the DON, ADON, and the resident's charge nurse, revealed a lack of clarity and communication regarding the resident's ongoing need for Enhanced Barrier Precautions. The staff acknowledged the risk of cross-contamination and infection spread due to the failure to follow proper PPE protocols. The facility's policy and CDC guidelines clearly outlined the necessity of these precautions for residents with indwelling medical devices, yet the oversight occurred, leading to the deficiency.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure that Resident #24 was treated with respect and dignity, as required by resident rights regulations. During an observation, it was noted that the resident, who has severely impaired cognition and is dependent on staff for various activities, was exposed from the waist down while receiving incontinent care. The resident's bed was positioned close to the door, and there was no privacy curtain to shield him from view when the door was opened by unknown individuals. This lack of privacy was not addressed by the CNAs providing care, who did not call out to prevent entry or indicate that care was being provided. The absence of a privacy curtain was attributed to a recent deep cleaning of the resident's room, during which the curtain was removed but not replaced. Interviews with staff, including the CNAs, DON, ADON, and housekeeping personnel, revealed a lack of awareness and communication regarding the missing curtain. The CNAs admitted they should have noticed the missing curtain and taken steps to ensure the resident's privacy. The DON and ADON acknowledged the violation of privacy and the need for staff to announce care activities to prevent unauthorized entry. The facility's policies on resident rights and privacy were not adhered to, as evidenced by the failure to provide adequate privacy during personal care. The Administrator and Housekeeping Supervisor confirmed that privacy curtains are typically replaced immediately after removal for cleaning, but this procedure was not followed in this instance. The lack of a specific policy on privacy curtains was noted, and the risk of embarrassment and loss of dignity for the resident was acknowledged by multiple staff members.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. On one occasion, Cook F did not log food temperatures for the dinner service, as observed on the Trayline Temperature Log. The Dietary Manager confirmed that Cook F, a new employee, was responsible for logging food temperatures before serving residents but failed to do so. The dinner menu included sausage links, chocolate chip sheet pan pancakes, hashbrown casserole, strawberries and bananas, margarine, syrup, salt and pepper, milk, and water. The facility's food policy required that food temperatures be monitored by food service staff, but this was not adhered to, potentially placing residents at risk for foodborne illness due to unsafe food temperatures or improperly cooked food. Additionally, the facility failed to label and date opened food items. Observations revealed that two loaves of bread, a bag of hot dogs, and six hamburger buns were not labeled with a received or opened date. The Dietary Manager admitted responsibility for labeling and dating food but did not label the bread products, citing uncertainty about whether bread needed to be labeled. The facility's policy required that opened food items be dated and sealed during storage. The Food and Drug Administration Food Code also mandates that refrigerated, ready-to-eat time/temperature control for safety food be clearly marked with the date or day by which the food should be consumed, sold, or discarded. The failure to label and date these food items could lead to foodborne illness from expired or stale food.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for one resident. Specifically, the facility did not clean the bathroom of a resident for three consecutive days. The resident, who has severe obesity, cellulitis, type 2 diabetes, and major depressive disorder, reported that housekeeping staff only cleaned the main room but neglected the bathroom. The resident expressed that this neglect increased her depression and made her feel self-conscious. Observations confirmed the presence of a white powder-like substance and gloves on the bathroom floor over multiple days. Interviews with staff revealed that the issue was communicated to housekeeping, but the bathroom remained uncleaned. The facility's policy requires daily cleaning and sanitization of resident bathrooms, which was not adhered to in this case. The Assistant Director of Nursing (ADON) and other staff acknowledged the oversight and its potential impact on the resident's mental health and infection risk. The facility's Housekeeping Services Policy mandates the use of disinfectants to sanitize all surfaces, including bathroom fixtures, which was not followed in this instance.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one resident observed for infection control. Specifically, a Licensed Vocational Nurse (LVN) did not don a gown when entering a resident's isolation room to provide care. The resident, a cognitively intact male with a history of pressure ulcers and cellulitis, was on contact isolation precautions due to a multidrug-resistant organism (MDRO). Despite being in-serviced on proper PPE use, the LVN entered the room wearing only a mask and gloves, neglecting to wear a gown as required by the facility's policy and the resident's care plan. This oversight was observed during the administration of IV medication and other care activities, such as handling the resident's urine bag and providing water. Interviews with the LVN and the Director of Nursing (DON) confirmed that full PPE, including a gown, should have been worn when entering the resident's room. The LVN admitted to forgetting to wear the gown due to being busy, acknowledging the risk of infection spread. The DON reiterated the importance of adhering to contact isolation precautions to prevent contamination. The facility's policy on isolation precautions, which mandates the use of gowns for interactions involving contact with the resident or potentially contaminated items, was not followed in this instance.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify and consult with the resident's physician regarding a significant change in the resident's physical status, specifically a deterioration in health due to a pressure ulcer. Resident #1, a female with severe cognitive impairment and multiple health issues, was under hospice care and had existing pressure ulcers. On January 11, 2024, an open area was discovered on her sacrum, which was not reported to the wound physician until January 23, 2024. This delay resulted in the wound developing into an unstageable pressure ulcer, which later required surgical debridement and was categorized as a Stage 4 pressure wound. Interviews and record reviews revealed that the facility's staff, including LVN C and ADON A, did not follow proper procedures for notifying the wound physician. LVN C, who was responsible for implementing care to prevent skin breakdown, assumed that ADON A had informed the wound physician about the open area. However, there was no documentation to confirm this communication. The wound physician was only informed during a routine visit on January 23, 2024, leading to a delay in appropriate wound care and management. The facility's policy on Change of Condition and Physician/Family Notification was not adhered to, as there was no documentation of the communication with the primary physician or the ADON. The lack of documentation and follow-up on the wound consultation request contributed to the delay in addressing the resident's deteriorating condition. This failure placed the resident at increased risk of complications, including pain, infection, and worsening of the existing wound.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development and worsening of pressure ulcers. The resident, who had severe cognitive impairment and was frequently incontinent, was at risk for pressure ulcers and had existing Stage 4 and unstageable pressure injuries. Despite having a care plan in place that included pressure-reducing devices and a turning/repositioning program, the facility did not consistently perform weekly skin assessments as required by the physician's orders. On one occasion, a Licensed Vocational Nurse (LVN) identified a dime-sized open area on the resident's sacrum and notified the primary physician, who ordered treatment and a consultation with a Wound Management Doctor (WMD). However, the facility failed to consult the WMD for 12 days, during which time the wound progressed to an unstageable pressure ulcer with necrotic tissue. The WMD eventually assessed the wound and performed surgical debridement, categorizing it as a Stage 4 pressure ulcer. The facility's documentation and communication were inadequate, as evidenced by discrepancies in skin assessment records and a lack of follow-up on the WMD consultation. Staff interviews revealed confusion and miscommunication regarding the resident's wound care needs, with some staff members unaware of the severity of the sacral wound. This lack of coordination and adherence to professional standards of practice placed the resident at increased risk of complications from pressure ulcers.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,115 citations issued within 25 miles in the last 12 months — including the 40 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carrollton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prestonwood Rehabilitation & Nursing Center Inc | 1 mi | ★★★★★ | 0 | 0 |
| Brookhaven Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 5 | 1 |
| Accel At Willow Bend | 2 mi | ★★★★★ | 24 | 0 |
| The Legacy At Willow Bend | 4.4 mi | ★★★★★ | 4 | 0 |
| The Madison On Marsh | 4.8 mi | ★★★★★ | 2 | 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.