Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakmont Healthcare And Rehabilitation Center Of Ka during CMS and state inspections, most recent first.
Failure to Provide Privacy During Resident Care: A resident receiving GT feeding was observed with the door open and blinds open during care, another resident received BG testing and insulin in the hallway near the dining room while other residents passed by, and a third resident had meds given via G-tube without the privacy curtain pulled. Staff acknowledged the lack of privacy during these procedures.
Inaccurate MDS assessments were completed for two residents. One resident with dementia, COPD, depression, and other diagnoses had no behavior coded on the MDS despite nursing notes showing refusal to eat, agitation, yelling, cursing, kicking walls, throwing items, and refusal of care and tx. Another resident with dementia, schizoaffective disorder, and a hx of falls had a quarterly MDS that did not include a fall documented in the lookback period, even though progress notes showed she slipped to the floor and was assessed with no injury.
Medication administration errors exceeded the allowed rate when staff documented several meds as given even though they were not administered, and one nurse failed to give a Parkinson’s med in full. One resident with severe cognitive impairment and a G-tube had multiple ordered meds charted as given despite not receiving them, while another resident with severe cognitive impairment and a PEG tube received only part of an ordered Carbidopa-Levodopa dose. Observations also showed improper G-tube administration technique, including not flushing the tube and not wearing PPE.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed improper thawing of frozen chicken, hot and cold foods held at unsafe temperatures, and multiple items past or missing use-by dates in the fridge. They also found food stored on the floor, a scoop not kept in a separate container, insufficient sanitizing solution in the 3-sink setup, and broken tiles with openings in the kitchen. The Dietary Food Service Manager stated leftover foods should have been discarded by the use-by date and foods in the danger zone should have been discarded.
Multiple infection control lapses were observed during resident care and in a clean linen area. Staff did not wipe a BP cuff between use on several residents, two nurses administered G-tube meds without proper PPE for residents on EBP, a CNA did not fully perform incontinent care for a resident with severe cognitive impairment and bowel/bladder incontinence, and personal staff items were stored in a clean linen closet among clean supplies.
Failure to Update Care Plans for Weight Loss and Behavioral Changes: The facility did not revise comprehensive care plans after changes in condition for two residents. One resident with Alzheimer’s disease and dysphagia had an 18.8-lb weight loss, and another resident with dementia and altered mental status had documented refusal of care, yelling, cursing, kicking walls, and throwing items, yet the care plans were not updated to reflect these changes.
Delayed Incontinent Care and Missing Wound Dressing: A resident who was totally dependent for ADLs, incontinent, and had severe cognitive impairment was observed lying in bed with a brief soaked with urine and feces, and no dressing was in place on a stage 3 left hip pressure ulcer. CNA J said she had been waiting to change the brief until the LVN completed wound treatment, and both CNA J and the LVN stated residents were to be changed every 2 hours and as needed.
Improper incontinent care during perineal cleansing: A female resident with severe cognitive impairment, total ADL dependence, bowel and bladder incontinence, and recent UTI treatment was observed receiving care in which a CNA cleaned between the buttocks but did not clean around the buttocks or open the labia to clean the perineal area. The CNA and another staff member acknowledged the missed steps, and the facility’s skill checklist required labial retraction and proper cleansing during female incontinent care.
Improper G-tube medication and feeding administration was observed for two residents with PEG/GT tubes and severe cognitive impairment. An LVN and an RN crushed and administered medications by plunging them through the tube instead of allowing meds, water, and feedings to flow by gravity, and one nurse did not flush the tube before and after meds as ordered. The facility policy and the RN interview both described gravity administration and flushing procedures for GT care.
The facility failed to ensure opened eye drops in the East Wing nurse med cart were dated. During observation, Ciprofloxacin Ophthalmic, Refresh Tears, and Cipri Dexa eye drops were found open with no open date. RN Z said she was not aware the eye drops were opened and undated, while the Regional Nurse stated opened eye drops should have an open date and are not effective after 30 days. The facility policy required medication labels to include the expiration date when applicable and appropriate instructions and precautions.
Missing Pneumococcal Vaccine Documentation: The facility failed to document that a resident with CHF, dementia, COPD, and other diagnoses was offered pneumococcal immunization or provided education on its benefits and side effects. The resident’s MDS showed the vaccine was not up to date because it was not offered, and the chart contained no record of prior vaccination, refusal, contraindication, or related education.
A resident with a history of traumatic brain injury and high fall risk did not receive required 1:1 supervision when the assigned CNA fell asleep, resulting in the resident being left unsupervised and experiencing a fall. Staff interviews and documentation confirmed that the resident required constant monitoring due to agitation and unsteady gait, but the CNA failed to remain alert and within arm's reach as required by the care plan.
A resident with multiple complex medical conditions was admitted without an accurate weight being obtained at the facility. The MDS Coordinator used the hospital discharge weight for the admission MDS assessment instead of a current measurement, as the resident was not weighed upon arrival due to agitation and lack of follow-up by staff. The actual weight was documented several days later, revealing a significant discrepancy. Staff interviews confirmed that facility protocols for accurate assessment and interdisciplinary communication were not followed.
The facility failed to ensure proper disposal of garbage by not keeping the dumpster door closed when not in use, as observed during a survey. A commercial-sized dumpster was found open and three-quarters full, posing a risk of pest entry. The Director of Food and Nutrition acknowledged the issue, and it was noted that staff from dietary, nursing, and housekeeping were responsible for closing the dumpster doors. The facility also lacked a policy for garbage disposal, as confirmed by the Administrator.
The facility failed to maintain privacy for residents by not placing Foley catheter bags in privacy bags and not providing privacy curtains between shared beds. A resident with chronic kidney disease and another with cancer had their catheter bags exposed, contrary to care plans. Additionally, two residents with cognitive impairments shared a room without a privacy curtain, leading to discomfort. Staff were unaware of these oversights, highlighting a lapse in maintaining resident dignity.
The facility failed to store and label food items in accordance with professional standards, as observed in their kitchen. Several food items in the refrigerator were not properly labeled with use-by dates or were past their expiration dates, including cream cheese, deli meats, cheeses, canned beets, and beef stew. The Dietary Food Service Manager acknowledged the responsibility to ensure proper labeling and discarding of expired items, as per the facility's 2012 food safety policies.
A facility failed to submit a final investigation report to the State Survey Agency within the required timeframe following an abuse allegation involving a resident with hemiplegia and cognitive impairment. The initial report was submitted, but the final report was not, due to an oversight by the former DON. The current Administrator confirmed the investigation was completed but not submitted, and the new DON had not been trained in report submission.
A resident with multiple medical conditions, including diabetes, was not provided with a comprehensive care plan addressing foot care needs. Despite a physician's order for podiatry consults, the resident's care plan lacked podiatry services, and observations showed neglected toenail care. Facility staff interviews revealed communication gaps and unclear responsibilities in updating care plans, leading to the oversight.
A resident with diabetes did not receive necessary podiatry services, leading to long and thick toenails. Despite a physician's order for podiatry consults, the resident was not on the list for services due to communication and procedural failures among staff. Observations and interviews revealed systemic issues in the facility's process for ensuring proper foot care.
A resident with severe cognitive impairment and a history of cerebral infarction was found to have her oxygen concentrator set at 3.5 liters, contrary to the physician's order of 1-2 liters. The RN responsible did not verify the setting during rounds, and the NP was not informed of the change, violating the facility's policy on oxygen administration.
A medication aide in an LTC facility failed to adhere to prescribed parameters by attempting to administer Carvedilol to a resident with a heart rate below the ordered threshold. The resident, with conditions such as atrial fibrillation and hypertension, was at risk due to this oversight. The error was identified during a surveyor's observation, and interviews confirmed the aide's failure to follow the facility's medication administration policies.
A facility failed to maintain an effective infection control program, as evidenced by the absence of signage for a resident on enhanced barrier precautions and improper labeling of personal care items in a shared room. A resident with multiple indwelling devices lacked appropriate infection control signage, and a hairbrush was found unlabeled at a sink, risking cross-contamination. Staff interviews confirmed the lapses in protocol adherence.
The facility did not post the most recent survey results in a location accessible to residents and families. The survey results were kept in a binder at the front desk, but residents were unaware of their location. The administrator admitted the signage was missing and later found it, placing it on the wall with the inspection binder.
A resident with a history of muscle weakness, Type 2 Diabetes Mellitus, and a history of stroke did not receive weekly skin assessments over several periods, as required by their care plan. Despite the resident's moderate risk for pressure sores and documented need for regular skin checks, the facility failed to document these assessments. Interviews with staff confirmed the oversight, and the facility's policies on skin integrity management were not followed.
A resident in an LTC facility was left without incontinence care for over seven hours, resulting in skin irritation and discomfort. The resident, who required assistance with daily living activities, was found double-briefed with heavily soiled briefs. Despite the care plan requiring care every two hours, the CNA failed to provide the necessary care, citing the resident's therapy session as a reason. Interviews revealed a lack of adherence to care plans and facility policies, contributing to the deficiency.
A resident on hospice care did not receive prescribed morphine 15mg ER for two days due to the facility's failure to transcribe and administer the medication timely. The DON did not process the hospice orders promptly, and LVN A did not verify the medication orders upon receipt. This oversight risked the resident's comfort and pain management.
Failure to Provide Privacy During Resident Care
Penalty
Summary
The facility failed to ensure resident dignity and privacy during care for three residents. During observation on 02/25/2026, RN Z was providing Resident #41’s bolus feeding and water flush with the door open and the blinds opened, and the curtain was not pulled. Resident #41 had a gastrostomy tube and active orders for enteral feeding four times daily with water flushes. RN Z stated she should have pulled the curtains and was unsure why she did not do so that day. During another observation on 02/25/2026, RN Z checked Resident #67’s blood glucose and administered Humalog insulin while the resident was in the hallway near the medication cart and dining room, with other residents passing by. Resident #67 was male, had severe cognitive impairment with a BIMS score of 3 out of 15, and was totally dependent for bed repositioning and personal hygiene. RN Z stated she always checked blood glucose before residents went to the dining room and did not think it was wrong. On 02/24/2026, LVN AF administered medication via Resident #30’s G-tube without pulling the privacy curtain. Resident #30 was lying in bed and visible from the hallway while the LVN aspirated gastric residuals and administered crushed medication and polyethylene glycol through the tube. Resident #30 had a gastrostomy, severe cognitive impairment with a BIMS score of 5 out of 15, and was totally dependent for bed repositioning and personal hygiene. LVN AF stated she forgot about providing privacy and would be careful.
Inaccurate MDS Assessments for Behavior and Falls
Penalty
Summary
The facility failed to ensure that assessments accurately reflected resident status for two residents reviewed. One resident, a 76-year-old female with diagnoses including non-Alzheimer’s dementia, dysphagia, depression, respiratory failure, pain, altered mental status, COPD, and muscle weakness, had an admission MDS that coded her as having no behavior despite nursing progress notes showing refusal to eat, screaming and yelling, agitation, cursing at staff, kicking walls, throwing things on the floor, and refusal of care and breathing treatment. Her care plan, initiated on 1/6/2026, was not reviewed and revised to address these behaviors. Another resident, a female with unspecified dementia, muscle weakness, schizoaffective disorder, extrapyramidal and movement disorder, and a history of falling, had a quarterly MDS that coded her as having no falls since the last assessment even though the record showed a fall in the lookback period, with a progress note documenting that she was found sitting on the floor after slipping down to her bottom and had no noted injuries. During interview, the MDS Coordinator stated the behavior coding for the first resident was incorrect and that the second resident’s fall should have been included in the quarterly MDS because it was within the 3-month lookback period.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors identified a 20% medication error rate, based on 7 errors out of 35 opportunities, involving 2 residents and 2 of 3 staff observed during medication administration. The report states that these errors involved medications being documented as given when they were not fully administered or were not administered at all. For one resident with severe cognitive impairment, multiple ordered medications were initialed as given on the MAR even though they were not administered. These included Polyvinyl Alcohol-Povidone ophthalmic drops, Protonix, Quetiapine, Ascorbic Acid, Thiamine HCl, and Olanzapine. The resident had diagnoses including Parkinson's disease, GERD, dementia, chronic kidney disease, heart failure, hypertension, and a gastrostomy tube. During observation, the LVN administered only the resident's blood pressure medication and bolus feeding via G-tube, did not flush the tube before and after medication, did not close the door, and did not wear PPE while administering medication. In interview, the LVN stated she had only given the blood pressure medications and bolus feeding because the blood pressure was high, and later said she only gave two medications via G-tube because the resident had many blood pressure medications. For another resident with severe cognitive impairment and a PEG tube, RN W did not administer Carbidopa-Levodopa in totality even though it was ordered three times daily. During observation, RN W crushed one tablet, diluted it with water, and administered it via G-tube, but substantial residual medication remained in the cup. After the surveyor intervened, RN W stated she would give the remaining medication and then poured additional water and medication into the tube. In interview, RN W acknowledged the medication had not been given in totality and stated she would be careful. The Regional Nurse and Administrator stated that medications were expected to be administered as ordered and timely according to physician orders.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation, surveyors found thawing frozen chicken in an 8-inch-deep bucket immersed in 78-degree Fahrenheit water in the sink, a pan of mechanical soft sausage at 131.1 degrees Fahrenheit on the steam table, and a tray of milk at 46.5 degrees Fahrenheit and cranberry juice at 53.4 degrees Fahrenheit on the lunch serving table. Surveyors also observed a pan of breakfast sausage with a used-by date of 2/13/2026 in the refrigerator, a pan of Salisbury steak with a used-by date of 1/7/2026 in the walk-in refrigerator, open packages of shredded cheddar cheese and sliced Swiss cheese with no use-by dates in the walk-in refrigerator, and a pan of corn niblets in the walk-in refrigerator without date opened or date discarded labels. Additional kitchen observations showed 1 case of frozen ground beef on the walk-in freezer floor, 2 cases of fruit cocktail on the storeroom floor, a scoop used for food bins not stored in a separate container, insufficient sanitizing solution in the 3-sink compartment, and broken tiles in the kitchen floors and walls with openings. In interview, the Dietary Food Service Manager stated the foods stored for later use should have been discarded by the use-by date and that leftover food in the danger zone between 40 degrees Fahrenheit and 140 degrees Fahrenheit should have been discarded. The facility policy stated potentially hazardous leftover foods are to be covered, labeled, dated, refrigerated immediately, discarded on the used-by date unless otherwise indicated, and stored off the floor.
Infection Control Lapses During Resident Care and Linen Storage
Penalty
Summary
The facility failed to maintain infection prevention and control practices during multiple resident care activities and in a clean supply area. During observation, RN CC did not wipe the blood pressure cuff between checks on three residents, and MA T did not wipe the blood pressure cuff between checks on two residents. Both staff members stated they forgot to wipe the cuff between residents and acknowledged that this was for infection control and could cause cross-contamination. During medication administration, LVN AF administered crushed and dissolved medications via G-tube to a resident with an EBP sign posted on the door without wearing a gown or gloves. The resident had severe cognitive impairment, was totally dependent for care, and had diagnoses including Parkinson’s disease, dementia, chronic kidney disease, heart failure, and a gastrostomy. RN W also administered G-tube medication to another resident with an EBP sign posted and later stated she forgot to wear PPE during the procedure. During incontinent care, CNA J provided care to a resident who was totally dependent for ADLs, incontinent of bowel and bladder, and had severe cognitive impairment, a stage 3 sacral pressure ulcer, and a recent UTI. CNA J cleaned in between the buttocks but did not clean around the buttocks and did not open the labia to clean. In Linen Closet B, staff personal items including a black purse and gray zip-up hoodie were found hanging among clean linens. The HKS stated staff knew not to put personal items in the clean linen closet, and the Administrator stated staff personal items should be kept in the break room and not in the clean linen closet due to cross-contamination.
Failure to Update Care Plans for Weight Loss and Behavioral Changes
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 2 of 18 residents reviewed. One resident, a 73-year-old male with Alzheimer’s disease and dysphagia, had a documented weight of 142 pounds on 1/9/2026 and 123.2 pounds on 2/2/2026, resulting in an 18.8-pound weight loss. His care plan had last been reviewed on 12/13/2025 and was not revised to address the weight loss. Another resident, a 76-year-old female with non-Alzheimer’s dementia and altered mental status, had a BIMS score of 10 on admission and was coded as having no behavior on the admission MDS. Nursing progress notes documented that she refused staff assistance and food, got out of bed screaming and yelling, cursed staff, kicked walls, threw things on the floor, and refused care and a breathing treatment. Her care plan, initiated on 1/06/2026, was not reviewed and revised to address these behaviors. The record review also included the facility’s comprehensive care planning guidance, which stated that care plans are to be developed within 7 days after completion of the comprehensive assessment and reviewed after each Admission, Quarterly, Annual, and/or Significant Change MDS assessment, with revisions based on changing goals, preferences, needs, and current interventions. Interviews with the MDS Coordinator and Regional Nurse confirmed that care plans should be revised when residents’ conditions change and that the behaviors and weight loss should have been addressed in the care plans.
Delayed Incontinent Care and Missing Wound Dressing
Penalty
Summary
The facility failed to ensure a resident who was totally dependent for personal hygiene and incontinent care received timely assistance with grooming and hygiene. Resident #4 was admitted with diagnoses including a urinary tract infection and a stage 3 sacral pressure ulcer, and the quarterly MDS reflected severe cognitive impairment with a BIMS score of 3 out of 15, total dependence for bed repositioning and personal hygiene, and incontinence of bladder and bowel. The care plan stated the resident was totally dependent on staff for all ADLs and was to remain clean, dry, without odor, and comfortable every shift. On 2/26/26 at 10:35 AM, observation of incontinent care by CNA J and pressure ulcer treatment by LVN TN XX showed the resident lying in bed with a brief soaked with urine and feces, and there was no dressing to the left hip pressure ulcer. CNA J stated she had been waiting to change the resident’s brief until the LVN completed the treatment and said this was the first incontinent care she had performed since starting that shift. CNA J and LVN TN XX both stated residents were supposed to be changed every 2 hours and as needed, and that staff should report if a pressure ulcer dressing came off during incontinent care. The wound order in the record directed daily and as-needed dressing changes for the stage 3 left hip pressure wound.
Improper incontinent care during perineal cleansing
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a resident who was incontinent of both bowel and bladder. The resident was a female with severe cognitive impairment, total dependence for bed repositioning and personal hygiene, and diagnoses that included urinary tract infection and a stage 3 sacral pressure ulcer. Her care plan reflected that she required total assistance with bathing, dressing, bed mobility, eating, and personal hygiene/oral care, and her MAR showed she had recently been treated with ciprofloxacin for a urinary tract infection. During observed incontinent care, CNA J donned gloves, removed the resident’s brief, and cleaned between the buttocks, but did not clean around the buttocks and did not open the resident’s labia to clean the perineal area. CNA J then placed a clean brief under the resident, cleaned the right groin, fastened the brief, and removed her gloves. Both CNA J and TN XX acknowledged that the labia were not opened for cleaning and that the buttocks were not cleaned appropriately. The Regional DON stated that CNAs were to perform incontinent care every 2 hours and as needed, and the facility’s skill checklist directed staff to gently retract the labia to fully expose the urethral meatus and catheter insertion site during female care.
Improper G-Tube Medication and Feeding Administration
Penalty
Summary
Feeding tubes were not used in accordance with the physician orders and facility policy for 2 residents who were dependent on gastrostomy tube feeding. Resident #30 had a gastrostomy tube, severe cognitive impairment, and was totally dependent for bed repositioning and personal hygiene. The physician orders required bolus tube feeding, residual checks every shift, and flushing the GT with water before and after medications and between each medication. During observation, LVN AF aspirated milky residual from the GT, poured it into a cup, then plunged medication and the residual back through the GT instead of allowing the medication and feed to flow by gravity. LVN AF also did not flush the GT with water before and after medication administration. Resident #6 also had a gastrostomy tube, severe cognitive impairment, and required total assistance with ADLs. The physician order directed Carbidopa-Levodopa to be given via PEG tube three times daily. During observation, RN W crushed the tablet, diluted it with water, and then used a syringe to plunge water and the medication through the GT rather than allowing the medication and water to flow by gravity. During interview, RN W stated she knew not allowing water and medication to flow by gravity could cause aspiration pneumonia, bloating, and being too full. The facility’s policy for gastrostomy tube care stated to irrigate with water to check patency, allow feeding to flow by gravity, and flush with water to clear the formula. The Regional Nurse stated that tube placement should be checked by visual inspection of aspirated stomach content prior to instilling medication and water, and that feeding and medication should be administered by gravity. The observations and interviews showed that the two residents’ GT medications and feedings were administered by plunging rather than by gravity, and that ordered flushing procedures were not followed for Resident #30.
Undated Open Eye Drops in Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, including the required accessory and cautionary instructions and expiration date when applicable, for 1 of 4 medication carts reviewed. During an observation of the East Wing nurse medication cart, opened medications were found without an open date. The undated medications included Ciprofloxacin Ophthalmic, Refresh Tears, and Cipri Dexa [NAME] 0.3-0.1 eye drops. During interview, RN Z stated she was not aware the eye drops were opened and not dated, and said she checked her medication cart whenever she administered medications. The Regional Nurse stated that opened eye drops should have an open date and that the medicines would not be effective for treatment after 30 days. Record review of the facility policy, revised February 2023, stated medication labels must include, at a minimum, the expiration date when applicable, resident's name, route of administration, and appropriate instructions and precautions.
Missing Pneumococcal Vaccine Education and Documentation
Penalty
Summary
The facility failed to develop and implement policies and procedures for flu and pneumonia vaccinations to ensure the resident medical record included documentation that the resident or resident representative was provided education regarding the benefits and potential side effects of pneumococcal immunization, and that the resident either received the vaccine or did not receive it due to medical contraindication or refusal. This deficiency involved Resident #8, whose record showed diagnoses including chronic congestive heart failure, unspecified dementia, cognitive communication deficit, hyperlipidemia, and chronic obstructive pulmonary disease. Her Quarterly MDS documented a BIMS score of 15, indicating high cognitive intactness, and also indicated that her pneumococcal vaccination was not up to date and was not received because it was not offered. Record review showed no documentation in Resident #8’s immunization record of any current or prior pneumococcal vaccine since admission, and her progress notes contained no record of education or vaccination. The Regional Nurse stated he could not locate pneumococcal vaccination records and confirmed the immunization should have been documented in the medical record, including education and uploaded documentation showing receipt or refusal. The facility’s policy stated residents would be offered the pneumonia immunization unless contraindicated or already immunized, and that documentation would include education and whether the resident received the vaccine or did not receive it due to contraindication or refusal.
Failure to Provide Adequate 1:1 Supervision Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a significant history of falls, traumatic brain injury, and cognitive impairment did not receive adequate supervision as required by their care plan. The resident was on 1:1 supervision due to agitation, unsteady gait, and a recent subdural hematoma, with interventions in place such as a low bed, fall mats, and a helmet. Despite these measures, the assigned CNA responsible for 1:1 supervision fell asleep while on duty, leaving the resident unsupervised. During the period of unsupervised care, the resident was able to get up and subsequently fell. The incident was initially reported by the CNA as an assisted transfer where the resident sat on the floor, but later investigation and interviews revealed that the CNA had dozed off and was not truthful in the initial account. The resident was found on the floor, and the event was later classified as an unwitnessed fall due to the lack of supervision. The resident was assessed and sent to the hospital for evaluation, given his prior history of head injury and the unwitnessed nature of the fall. Interviews with staff confirmed that 1:1 supervision required the staff member to always have the resident in eyesight and remain within arm's reach, and that sleeping while on duty was not permitted. The CNA admitted to falling asleep, and staff interviews corroborated that the resident was at high risk for falls and required constant monitoring. The facility's failure to ensure the CNA remained awake and provided the necessary supervision directly led to the resident's fall while under 1:1 supervision.
Inaccurate MDS Weight Documentation on Admission
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's weight status at admission. Specifically, the admission MDS for a male resident with multiple complex diagnoses, including traumatic brain injury, malnutrition, and dysphagia, documented his weight as 154 pounds, which was taken from hospital records rather than an actual weight measurement at the facility. The resident's weight was not obtained upon admission due to his agitation, and the admitting nurse deferred the task to another staff member, who did not complete it. As a result, the MDS Coordinator used the hospital discharge weight to complete the assessment for billing purposes, without verifying the resident's current weight at the facility. Record reviews showed that the resident's actual weight was not documented until several days after admission, at which point it was recorded as 138 pounds. The nurse's notes at admission indicated that no weight was documented, and the MDS Coordinator later acknowledged that she should have ensured the resident was weighed at the facility before completing the MDS. The facility's policy requires comprehensive and accurate assessments using the RAI process, with all disciplines following the guidelines for coding each assessment, but this protocol was not followed in this instance. Interviews with staff revealed a lack of communication and follow-through regarding the resident's weight assessment. The admitting nurse was unaware that the weight had not been obtained, and the MDS Coordinator admitted to relying on hospital records instead of current facility data. The Director of Nursing stated that nurses are expected to conduct proper assessments, including reviewing CNA documentation and nurse progress notes, but this was not done for this resident's admission weight.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, specifically by not ensuring that the dumpster door was closed when not in use. This was observed during a survey, where a commercial-sized dumpster located behind the dietary department was found to be three-quarters full with its door open. The Director of Food and Nutrition confirmed that the dumpster door should remain closed to prevent pests from entering the dumpster and potentially the facility. It was noted that staff from dietary, nursing, and housekeeping were responsible for ensuring the dumpster doors were kept closed. Additionally, the facility lacked a policy and procedure for the disposal of garbage and refuse, as confirmed by the Administrator.
Privacy Violations in Resident Care
Penalty
Summary
The facility failed to ensure personal privacy for several residents, specifically in the handling of Foley catheter bags and the provision of privacy curtains. For Resident #45, a male with chronic kidney disease and other severe health conditions, the CNA responsible did not place the Foley catheter bag inside a privacy bag as required by the resident's care plan and physician's orders. This oversight was observed on multiple occasions, and the CNA admitted to not being aware of the requirement until informed by the Assistant Director of Nursing (ADON). Similarly, Resident #175, a female with cancer and other health issues, also had her Foley catheter bag left outside of a privacy bag. The resident expressed a preference for the bag to be concealed, especially during family visits. The CNA responsible for her care was unaware of the oversight, and both the ADON and the Director of Nursing (DON) acknowledged the importance of using privacy bags to maintain resident dignity. Additionally, the facility failed to provide a privacy curtain between the beds of Resident #9 and Resident #5, both of whom have cognitive impairments and other health issues. This lack of privacy was noted during an observation, and Resident #9 expressed discomfort with the situation. The facility's administration initially believed the room was private, which led to the absence of a curtain. However, it was later confirmed that the room was shared, and the residents were subsequently moved to different rooms.
Food Safety Deficiency in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen. During an inspection, it was found that several food items in the refrigerator were not properly labeled with use-by dates or were past their expiration dates. Specifically, an open box of cream cheese was dated 10/30/24 without a use date, sliced deli meat and Swiss cheese were dated 11/01/24, shredded mozzarella cheese was found with dates of 10/15 and 11/06/24, and sliced deli ham had no label or date. Additionally, canned beets and beef stew were stored in plastic containers with dates indicating they were past their use-by dates. In an interview, the Dietary Food Service Manager acknowledged her responsibility to ensure that dietary staff label and date food items and discard them before expiration. The facility's policies and procedures for food safety, dated 2012, require that perishable opened food be used within seven days or less to comply with the Texas Food Establishment rules. The failure to follow these procedures could place residents at risk of foodborne illness and disease.
Failure to Submit Final Investigation Report for Abuse Allegation
Penalty
Summary
The facility failed to report the results of an investigation into an allegation of abuse involving a resident to the State Survey Agency within the required five working days. The incident involved a resident who alleged that a CNA was rough during a transfer. Although the initial incident report was submitted, the final investigation report was not submitted as required. The resident involved was an elderly male with a history of hemiplegia and hemiparesis following a stroke, requiring substantial assistance with activities of daily living due to moderate cognitive impairment. Interviews with facility staff revealed that the former Director of Nursing (DON) believed the final report had been submitted, but it was not. The current Administrator confirmed the oversight and acknowledged that the investigation was completed but not submitted. The newly hired DON had not yet been trained to submit reports into the Tulip system. The facility's policy and state guidelines require that such incidents be reported and investigated, with a final report submitted within the specified timeframe.
Failure to Include Podiatry Services in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident, specifically neglecting to address the resident's need for foot care. The resident, a male with diagnoses including Alzheimer's Disease, cerebral infarction, hemiplegia, hemiparesis, and type 2 diabetes mellitus, was admitted to the nursing facility in October 2023. Despite having a physician's order for podiatry consults as needed, the resident's care plan did not include podiatry services, and he was not listed for podiatry services scheduled for October 2024. Observations revealed the resident's toenails were thick, long, and beginning to curve, indicating a lack of necessary foot care. Interviews with facility staff, including the MDS Coordinator, ADON, DON, and Social Worker, revealed a lack of communication and responsibility in updating the resident's care plan to include podiatry services. The MDS Coordinator was responsible for initial and quarterly care plans, while unit nurses, ADON, or DON were expected to make revisions. However, the Social Worker was not informed of the resident's need for podiatry services, resulting in the omission from the care plan. The facility's policy on comprehensive centered care plans emphasizes the need for interdisciplinary collaboration to meet residents' needs, which was not adhered to in this case.
Failure to Provide Adequate Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident with diabetes mellitus, which placed the resident at risk for injuries and infections. The resident, a male with Alzheimer's Disease, cerebral infarction, hemiplegia, hemiparesis, and type 2 diabetes mellitus, was not included in the list for podiatry services despite having a physician's order for a podiatry consult as needed. Observations revealed that the resident's toenails were thick, long, and beginning to curve, indicating a lack of proper foot care. Interviews with staff members, including CNAs, the ADON, and the Social Worker, revealed a breakdown in communication and procedure. The CNAs were responsible for reporting the need for toenail clipping to the nurses, who would then contact the Social Worker to add the resident to the podiatry list. However, this process was not followed, as the CNAs either forgot to report or could not recall to whom they reported the need for toenail care. The Social Worker confirmed that the resident was not on the list for podiatry services, and the last visit from podiatry services was over a month prior. Further interviews with the LVN and DON highlighted systemic issues in the facility's process for ensuring residents received necessary podiatry care. The LVN admitted to not performing a head-to-toe assessment on the resident due to a lack of system triggers, and the DON acknowledged the need for staff in-servicing and process improvements. The facility's policy on foot care emphasized the importance of regular assessments and referrals to podiatry services, especially for residents with diabetes, but these procedures were not effectively implemented, leading to the deficiency.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in the administration of oxygen therapy. The resident, a female with a history of cerebral infarction, hypertension, and cerebrovascular disease, was supposed to receive oxygen at 1-2 liters per minute via nasal cannula to maintain oxygen saturation levels above 92%, as per physician's orders. However, during an observation, it was found that the resident's oxygen concentrator was set at 3.5 liters, which was higher than the prescribed amount. The resident, who had severely impaired cognition, was unable to confirm if she had changed the setting herself. Interviews with the nursing staff revealed that the registered nurse (RN) responsible for the resident's care was unaware of the correct oxygen setting and admitted to not checking the concentrator during her initial rounds. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the oxygen setting should be checked every two hours during rounds, and the physician should be notified before any changes to the oxygen setting are made. The nurse practitioner (NP) was not informed of the increased oxygen setting, which was against the facility's policy. The facility's policy on oxygen administration requires adherence to the physician's orders, which was not followed in this case.
Failure to Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a medication aide, MA Y, attempted to administer Carvedilol 3.125 mg to a resident with a heart rate of 59, which was below the ordered parameter of holding the medication if the pulse was less than 60. The resident, an elderly female with diagnoses including paroxysmal atrial fibrillation, hypertension, and angina pectoris, was at risk of adverse effects due to this error. The medication order specifically required the medication to be held if the resident's heart rate was below 60, a parameter that was not adhered to during the medication administration process. During the medication observation, the surveyor intervened to prevent the administration of the medication, highlighting the failure of MA Y to follow the prescribed parameters. Interviews with MA Y, the DON, and the ADON revealed that MA Y acknowledged the error and understood the potential consequences of administering the medication under these conditions. The facility's pharmacy policy and procedure manual emphasized adherence to the five rights of medication administration, which MA Y failed to follow, leading to the potential risk of harm to the resident.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of infection control signage on the door of a resident with multiple indwelling devices and wounds. This resident, a male with chronic kidney disease, functional quadriplegia, heart disease, and stage 4 pressure ulcers, was on enhanced barrier precautions due to his medical conditions. Despite the presence of personal protective equipment (PPE) outside the resident's room, there was no signage to alert staff and visitors of the necessary precautions, which was confirmed through observations and staff interviews. Additionally, the facility did not properly label and store personal care items for two residents sharing a semi-private room. A hairbrush belonging to one resident was found at the sink area without any labeling, indicating it as personal property. Interviews with the resident and staff revealed that the brush was mistakenly placed there by a staff member, and there was an expectation that personal items should be stored separately and labeled to prevent cross-contamination. The facility's infection control policy was reviewed, but a specific policy regarding the handling of residents' personal property in rooms was not provided. Interviews with various staff members, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), highlighted the responsibility of ensuring infection control signage and proper labeling of personal items to prevent the spread of infections. However, these protocols were not consistently followed, leading to the identified deficiencies.
Failure to Post Survey Results in Accessible Location
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was readily accessible to residents, family members, and legal representatives. During an observation, it was noted that the last survey results were kept in a binder at the front desk outside the administrator's office. However, residents were unaware of the location of these reports, as revealed during a confidential group meeting. The administrator acknowledged that the signage indicating the location of the inspection reports was missing and stated that it had been taken by a resident earlier that day. The administrator was responsible for ensuring the survey results were available for public review but was unable to locate the signage during the surveyor's visit. The administrator later found the frame and placed it on the wall near the front desk with the inspection binder. The facility's policy mandates the posting of inspection reports and related documents, but the failure to maintain this accessibility placed residents and their families at risk of not being able to review the findings from state surveys and investigations without having to request them.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to provide weekly skin assessments for a resident over several periods, specifically from 2/12/2024 through 3/2/2024, 3/27/2024 through 4/13/2024, and 4/27/2024 through 5/11/2024. This lapse in care was identified through observation, interviews, and record reviews. The resident, an elderly male with a history of muscle weakness, Type 2 Diabetes Mellitus, and a history of stroke, required substantial assistance with daily activities and had a documented need for regular skin assessments due to conditions like incontinence-associated dermatitis and a moderate risk of developing pressure sores. The resident's care plan included interventions for maintaining skin integrity and preventing complications related to diabetes, which necessitated regular skin checks and prompt treatment of any skin issues. Despite these requirements, the facility did not document the necessary weekly skin assessments during the specified periods. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Compliance Nurse, confirmed the absence of these assessments and highlighted the potential risks of missing such evaluations, including skin breakdown and infection. The facility's policies on skin integrity management and pressure injury prevention emphasized the importance of regular assessments and documentation of any changes in skin condition. However, the lack of adherence to these policies was evident in the missing documentation for the resident's weekly skin assessments. The Compliance Nurse acknowledged the oversight and the potential consequences of not conducting these assessments, which could lead to serious health complications for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide necessary care for a resident who was unable to perform activities of daily living, specifically incontinence care. The resident, an elderly male with a history of cerebral infarction, paralytic syndrome, and other medical conditions, was found to have been left without incontinence care for over seven hours. This neglect was observed when the resident was found double-briefed with heavily soiled briefs containing urine and feces, leading to skin irritation and discomfort. The resident's care plan required incontinence care every two hours, which was not adhered to by CNA A, who admitted to not providing the necessary care due to the resident being in therapy and other unspecified reasons. The CNA also acknowledged that double-briefing was not a good hygiene practice and exposed the resident to potential infections. Despite the resident's care plan and physician orders, the facility staff failed to follow through with the required interventions, resulting in the resident experiencing discomfort and skin irritation. Interviews with facility staff, including the LVN and DON, revealed a lack of adherence to the care plan and facility policies. The DON, who was new to the facility, had care planned the resident for double-briefing based on a misunderstanding of the resident's preferences. However, both the resident and their representative denied any request for double-briefing. The facility's failure to provide timely incontinence care and the inappropriate use of double-briefing contributed to the deficiency observed by the surveyors.
Failure to Administer Hospice Medication Timely
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in a delay in medication administration. The Director of Nursing (DON) did not transcribe physician orders received from hospice on October 8, 2024, until October 10, 2024. This delay affected the administration of morphine 15mg ER, which was delivered to the facility on October 8, 2024, but not given to the resident until October 10, 2024. The resident, who was on hospice care, was at risk for unwanted pain and discomfort due to this oversight. The resident involved was an elderly male with a history of dementia, heart disease, diabetes, and chronic kidney disease, among other conditions. He had been admitted to the facility on hospice services after a fall and subsequent hospital transfer. The hospice orders included discontinuation and initiation of specific medications, including morphine for pain management. However, the failure to transcribe and administer the medication as ordered led to a lapse in the resident's pain management plan. Interviews with the hospice nurse and facility staff revealed communication gaps and procedural failures. The hospice nurse had emailed the orders to the DON, who claimed not to have received them. Additionally, LVN A, who received the medication, did not verify the orders or follow up with hospice services. The facility's policy required nurses to check and transcribe new medication orders, but this was not adhered to, contributing to the deficiency.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Katy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mason Creek Transitional Care Of Katy | 0.9 mi | ★★★★★ | 3 | 0 |
| Solera At West Houston | 2.2 mi | ★★★★★ | 3 | 1 |
| Falcon Point Post Acute | 2.6 mi | ★★★★★ | 21 | 0 |
| Ignite Medical Resort Katy, Llc | 3.1 mi | ★★★★★ | 5 | 0 |
| Sterling Oaks Rehabilitation | 3.6 mi | ★★★★★ | 13 | 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 August 2026) and official state health department websites.