Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Palomino Place during CMS and state inspections, most recent first.
A resident with dementia and moderate cognitive impairment was found in bed with another resident who had severe cognitive impairment and Parkinsonism after he entered her room and engaged in non-consensual sexual contact. The resident reported he got into her bed, tried to move her brief, and she yelled for help while feeling scared and nervous afterward. Staff found the male resident in her bed, and the roommate called 911 after hearing the resident say a man was on top of her and trying to rape her.
Failure to Provide Routine Nail Care and Grooming Assistance: Multiple residents with ADL deficits, including residents with DM, CVA, hemiplegia, weakness, and cognitive impairment, were observed with long, dirty, jagged fingernails, and two residents also had chin hair that had not been shaved. Care plans directed staff to check nail length and trim and clean nails on bath day and as needed, but the residents stated they wanted the care and staff acknowledged the grooming needs had been overlooked.
The facility failed to provide safe and appropriate respiratory care for two residents. An LPN did not maintain sterile/aseptic technique during tracheostomy care for one resident, and another resident received oxygen without a physician order. These events were identified through observation, interview, and record review.
Staff failed to follow infection control practices during resident care, blood glucose checks, and medication preparation. Two CNAs did not use EBP gowns or perform hand hygiene during incontinence care for residents with feeding tubes and incontinence, another resident's check and change involved repeated glove reuse and barrier cream application with the same gloves, two LPNs disinfected glucometers with alcohol prep pads instead of approved germicidal or bleach wipes, and an MA handled tablets with gloved hands before using the same gloves on the computer during med pass.
A resident with severe cognitive impairment and hospice status had spoiled, moldy food and a half-filled coffee cup left in her room refrigerator, along with an undated food container. Staff interviews showed confusion about who was responsible for checking resident refrigerators, and both CNAs and housekeeping staff acknowledged the refrigerator had not been checked for weeks.
Inaccurate MDS Assessment for Oxygen Therapy and Anticoagulant Status: A resident with dementia, ESRD, metabolic encephalopathy, paroxysmal AFib, and COPD had a Quarterly MDS that did not reflect observed oxygen use and incorrectly showed continued anticoagulant therapy after Eliquis had been discontinued. Staff interviews and record review confirmed the resident was receiving oxygen via NC and that the MDS did not match the resident’s current medication and treatment status.
Care Plan Missing ADL Services: A resident with diagnoses including cerebral infraction, COPD, acute respiratory failure with hypoxia, dementia, and lack of coordination had a comprehensive care plan that did not include ADL goals or interventions. The MDS Coordinator stated ADLs should have been included so CNAs would know the resident’s needs, and the DON stated ADLs were needed so staff would know how to care for residents.
Care Plan Not Updated After Anticoagulant Discontinued: A resident with dementia, ESRD, metabolic encephalopathy, and paroxysmal AF had an MDS showing continued anticoagulant therapy even though the MAR/order recap showed Eliquis had ended and no current anticoagulant order was present. The resident's care plan still listed anticoagulant-focused interventions, and the MDS Coordinator stated it should have been revised to remove that therapy because the medication had already been discontinued.
Failure to provide proper incontinence care for a resident with severe cognitive impairment, Huntington’s Disease, aphasia, and frequent urine/bowel incontinence. CNA F and RA D found the resident soiled, turned her before cleaning her peri-area, and did not clean the front peri-area, separate the labia, or clean the inner thighs and groin area; CNA F also handled the resident with soiled gloves and left without hand hygiene. The DON stated staff were expected to clean the peri-area from front to back and then the anal area.
An opened vial of Tuberculin PPD was found undated and stored in a bag labeled hep lock solution in the Whirlaway med room refrigerator instead of in its original package. The DON stated the vial had to be dated when opened, was good for 30 days after opening, and that medications should be kept in their original containers; the facility policy also required drugs and biologicals to be stored in the packaging in which they were received.
Missing Bathroom Call Light Strings: Surveyors observed that two residents shared a toilet area where the call light pull string was missing, leaving the call system inaccessible from the bathroom. A CNA said the cord had been missing and had not been noticed earlier, while the Maintenance Supervisor said he was only informed by the DON just before the interview. The DON and Administrator both stated the call light should be within resident reach at all times for assistance.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with a Foley catheter, who was dependent on staff and had multiple medical conditions, did not have a catheter anchor in place during wound care as required by care plans and facility policy. Staff confirmed the absence of the anchor during care, despite its importance in preventing catheter pulling or trauma.
A facility failed to manage controlled medications properly, resulting in 120 tablets of Oxycodone going missing. A resident with a history of pain was prescribed this medication, and despite receiving doses, the medication was not accounted for during a shift change. Two LVNs were involved in the last known count, but the facility could not determine the cause of the diversion.
A resident with Parkinson's and diabetes, dependent on staff for bathing, did not have his hair washed since admission, leading to oily and itchy hair. Staff interviews revealed the care plan lacked hair washing instructions, and the CNA admitted to not washing the resident's hair. The ADON was unaware of the issue, despite facility policy requiring hair washing during bathing.
A resident in an LTC facility was receiving scheduled pain medication without proper documentation on the MAR/TAR, leading to a deficiency. The facility's records showed discrepancies in the narcotic count log, with doses of Hydrocodone being signed out without corresponding documentation. The LVN responsible only documented on the narcotic count log, contrary to facility policy. The DON was unaware of the issue, and the physician confirmed there was no order for one of the doses administered.
The facility failed to provide adequate hydration for two residents with severe cognitive impairments, as fluids were not accessible in their rooms and extra fluids were not offered during meals as per their care plans. Staff interviews revealed a lack of awareness and adherence to care plan requirements, contributing to the deficiency.
A resident was prescribed Olanzapine for anxiety without a proper diagnosis of schizophrenia or bipolar disorder. The facility did not follow the consultant pharmacist's recommendation to change the diagnosis or discontinue the medication. The DON discussed the issue with the psychiatric doctor, who refused to change the diagnosis, and the facility lacked a policy for ensuring correct diagnoses for psychotropic medication use.
The facility failed to serve adequate portions of chicken in 7 out of 24 lunch meals, as observed on a specific date. A dietary staff member did not fill the scoop completely, leading to insufficient servings, which residents also reported as a concern. The facility's documentation lacked specific portion instructions, contributing to the inconsistency. Interviews with the Dietary Manager and Dietician confirmed staff training on portion control, yet the error persisted, posing a risk of weight loss.
A facility failed to provide palatable and appetizing food at safe temperatures. A resident with dysphagia expressed dissatisfaction with a puree diet that lacked flavor and was served lukewarm. On another occasion, desserts were not tested for safe temperatures before serving. Test trays revealed puree items lacked flavor, and the consistency was not as expected. Interviews indicated expectations for food quality were not met, highlighting a disconnect between standards and actual service.
The facility failed to prepare and serve meals according to residents' care plans, including incorrect consistency of thickened liquids and inadequate portion sizes. A resident with dysphagia received improperly thickened tea, and pureed bread was not of the required consistency. Additionally, several residents received insufficient portions of chicken during lunch, leading to concerns about meal adequacy.
A CNA failed to follow proper hand hygiene protocols during incontinence care for a resident with dementia and neurogenic bladder, leading to a deficiency in the facility's infection prevention and control program. The CNA did not change gloves or perform hand hygiene after cleaning the resident, which was confirmed as a breach of protocol by both the CNA and the DON.
A resident with severe cognitive impairment and medical conditions received tracheostomy care without privacy, as the bedroom door was open and no privacy curtain was used. Interviews revealed that the resident typically preferred the door open, but staff did not offer privacy during the care session. The facility's policy requires privacy during personal care to prevent dignity issues.
The facility failed to resolve a grievance in a timely manner for a resident who reported an incident involving a CNA. The resident's representative's request to file a grievance was not acknowledged, and the facility did not provide a resolution or written documentation. Additionally, residents and their representatives were not adequately informed about how to file grievances or their rights to receive a written decision. The facility's grievance policy was inconsistently followed, and grievance forms were not easily accessible.
A facility failed to properly receive and secure narcotic pain medication for a resident under hospice care, resulting in drug diversion. The medication was delivered by a general shipping company and left unsecured, leading to it being unaccounted for. Despite this, the resident did not miss any doses due to having a prior supply. The DON acknowledged the responsibility for the oversight.
The facility failed to properly label and store medications on the 800 hall MA cart, with opened medications lacking dates and unidentified loose pills present. Staff interviews revealed a lack of adherence to labeling protocols, and recent changes in practice were noted by the DON.
The facility failed to maintain an effective infection prevention and control program, as evidenced by two staff members not adhering to hand hygiene protocols. A CMA did not perform hand hygiene before and after administering medications, while an LVN entered and exited a resident's room with gloves on without washing hands. Both staff members acknowledged their lapses, and the DON confirmed the expectation for proper infection control practices.
A resident with severe cognitive impairment eloped from the facility due to inadequate supervision and failure to follow the elopement response policy. The RN did not immediately investigate the door alarm, leading to a delay in identifying the resident's absence. The resident was found outside in cold weather, confused, and unable to communicate effectively.
Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was protected from abuse when another resident entered her room and engaged in non-consensual sexual contact with her. The cited resident was an older female with vascular dementia with mood disturbance, depression, anxiety, insomnia, moderate cognitive impairment, and dependence on staff for activities of daily living. The other resident was an older male with severe cognitive impairment, Parkinsonism, and a mood disorder due to a physiological condition; his care plan noted impaired cognition, weakness, and repeated attempts to get out of his wheelchair and ambulate unassisted, with multiple falls documented. According to the record, the incident occurred late at night when staff were responding to call lights on the hall. Staff observed the male resident lying in the female resident’s bed. The female resident reported that he entered her room, shut the door, got into her bed, lay next to her, and placed his hand over her brief while attempting to move it out of the way. She stated she yelled at him to get off of her and yelled for help, and she reported feeling nervous and scared afterward. Her roommate reported hearing the female resident say that a man was on top of her and trying to get into her pants and rape her, and she called 911. Staff interviews reflected inconsistent observations about what occurred before police arrived, but they confirmed the male resident was found in the female resident’s bed and was removed from the room. The female resident had no physical injuries and declined hospital transfer, but she reported fear and worry that he might return. The facility’s records also reflected that the male resident had not been identified as having wandering or sexual behavior issues before the incident, despite his impaired cognition and history of attempting to ambulate unassisted.
Failure to Provide Routine Nail Care and Grooming Assistance
Penalty
Summary
The facility failed to provide necessary ADL assistance to maintain good grooming and personal hygiene for five residents who were unable to carry out those activities independently. Surveyors observed that Resident #38, Resident #80, Resident #18, Resident #90, and Resident #57 all had fingernails that were long, dirty, jagged, or untrimmed, and two residents also had unwanted chin hair that had not been shaved. The report states these residents were reviewed for quality of life and that the facility did not ensure their nails were cleaned and trimmed or that facial hair was addressed as part of routine personal care. Resident #38 was a cognitively intact male with diabetes, stroke, hemiplegia, and limited range of motion who required substantial to maximum assistance with personal hygiene. His care plan directed staff to monitor foot care needs and cut long nails, but his CNA task list did not list personal hygiene as a task. During observation, his left-hand nails were about an inch long, jagged, and dirty, and his right thumb nail was also long and jagged. He told surveyors no one had offered to trim his nails. Staff who observed him acknowledged the nails needed trimming, and the DON stated they should not have been left in that condition. Resident #80, a female with diabetes, stroke, hypertension, hyperlipidemia, generalized weakness, and moderate cognitive impairment, required moderate assistance with personal hygiene. Her care plan directed staff to check nail length and trim and clean nails on bath day and as needed, and to provide extensive assistance with personal hygiene and oral care. During observation, both hands had fingernails about 0.75 cm long and she had chin hair; she stated she did not like the long nails or chin hair and wanted them cleaned, trimmed, and shaved. Resident #18, a cognitively intact male with stroke, muscle weakness, and cognitive communication deficit, required moderate assistance with personal hygiene. His care plan also directed staff to check nail length and trim and clean nails on bath day and as necessary. Surveyors observed his fingernails dirty, jagged, and about 0.75 to 1.0 cm long, and he stated he wanted them trimmed and cleaned. Resident #90, a severely cognitively impaired female on hospice with diabetes, stroke, hypertension, peripheral vascular disease, hemiplegia, Parkinson's disease, aphasia, and generalized weakness, required substantial assistance with personal hygiene. Her care plan directed staff to check nail length and trim and clean nails on bath day and as necessary. Surveyors observed her fingernails dirty, jagged, and about 0.75 cm long, and she nodded yes when asked if she wanted them clipped and trimmed. Resident #57, a female with diabetes, stroke, hypertension, and hemiplegia, also had severe cognitive impairment and required substantial assistance with personal hygiene. Her care plan directed staff to check nail length and trim and clean nails on bath day and as necessary. Surveyors observed her fingernails painted and about 0.7 cm long, and she stated she did not like her long nails and chin hair and wanted her nails trimmed. Staff interviews indicated CNAs and nurses were responsible for nail care, with nurses responsible for diabetic residents, and that facial hair should be addressed during shower days.
Respiratory Care Deficiencies
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who required respiratory services. For Resident #50, LVN K did not maintain sterile/aseptic technique during tracheostomy care on 10/02/25, involving care of a surgical opening in the neck that provides a direct airway through the trachea. For Resident #26, the facility failed to ensure there was a physician order before oxygen was administered on 9/30/25. These events were identified through observation, interview, and record review and involved residents who needed respiratory care, including tracheostomy care and tracheal suctioning.
Infection Control Failures During Resident Care and Medication Preparation
Penalty
Summary
The facility failed to maintain an infection prevention and control program during multiple observed care activities involving residents with enhanced barrier precautions, incontinence care, blood glucose monitoring, and medication preparation. Resident #72 was a male with a feeding tube, bowel and urine incontinence, and a care plan requiring enhanced barrier precautions. During a check and change, CNA F and RA D entered his room without hand hygiene or gowns, performed incontinence care while wearing gloves, and left the room without hand hygiene before going to another resident's room. Resident #73 was a severely cognitively impaired female who was dependent for all ADLs, frequently incontinent of urine, always incontinent of bowel, and received all nutrition through a feeding tube. During observed care, CNA F and RA D used hand sanitizer outside the room and entered without gowns despite enhanced barrier precaution signage. The DON entered, turned off and disconnected the G-tube feeding, then left after hand hygiene. CNA F then provided incontinence care while wearing the same gloves, did not clean the resident's perineal area before turning her, and later reused the same gloves while applying barrier cream. CNA F and RA D again left the room without hand hygiene and proceeded to another resident. Resident #79 was cognitively intact, always incontinent of bowel and bladder, and high risk for pressure ulcers. CNA F and RA D entered for a check and change without hand hygiene, used the same gloves while removing the old brief and placing a new one, and applied barrier cream with the same gloves. For blood glucose monitoring, LVN E and LVN B wiped the glucometers with alcohol prep pads instead of the facility's germicidal or bleach wipes and did not follow the manufacturer's instructions requiring validated disinfectant wipes and proper wet contact time. During medication preparation, MA I used gloved hands to pop tablets from blister packs into her hand before placing them in a medication cup and then used the same gloved hand on the computer mouse and keyboard while documenting medications.
Spoiled Food Left in Resident Room Refrigerator
Penalty
Summary
Resident #64, an elderly female on hospice with a BIMS score of 0 indicating severe cognitive impairment, had a refrigerator in her room that contained spoiled and moldy food. On 09/30/2025 and again on 10/1/2025, surveyors observed a half-filled coffee cup that appeared spoiled and a to-go food container that was not dated or labeled. When the container was opened, the food inside had white and green fungus-like substance on it, and the coffee looked frothy and spoiled. During interview, CNA L stated the refrigerator belonged to Resident #64 and that cleaning resident refrigerators was a joint responsibility of CNAs and housekeeping staff, but she had not checked it for weeks. LVN B stated she did not usually check resident room refrigerators because she thought it was the responsibility of housekeeping and CNAs. The DON stated both housekeeping and nursing staff were expected to check resident refrigerators daily to ensure they were clean and free of spoiled food. The Housekeeping Supervisor stated housekeeping was responsible for checking and cleaning resident refrigerators daily, and a housekeeper stated she forgot to check Resident #64's refrigerator. The facility policy titled Homelike Environment stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
Inaccurate MDS Assessment for Oxygen Therapy and Anticoagulant Status
Penalty
Summary
The facility failed to complete Resident #26’s Quarterly MDS assessment accurately by not reflecting the resident’s oxygen therapy status and by indicating continued anticoagulant therapy when the medication had been discontinued. Resident #26 was admitted with diagnoses including dementia, end stage renal disease, metabolic encephalopathy, and paroxysmal atrial fibrillation. The Quarterly MDS dated 9/1/25 showed the resident as moderately cognitively impaired with a BIMS of 11, but Section O indicated no oxygen use in the facility and Section N indicated continued anticoagulant therapy. Record review showed no physician order for anticoagulants or oxygen on the Order Summary Report dated 10/1/25. However, the Order Recap Report reflected Eliquis 2.5 mg with a start date of 7/26/25 and an end date of 8/14/25. The resident’s care plan reflected oxygen use for COPD and a separate focus for anticoagulant therapy with interventions for administration and monitoring. Observation on 9/30/25 showed the resident asleep with oxygen via nasal cannula at 2 liters per minute, and the resident stated staff checked her oxygen levels before turning on the oxygen machine. Staff interviews confirmed the discrepancy between the MDS and the resident’s actual status. A CNA reported observing the resident with oxygen at bedside almost daily, and an LVN stated the resident required oxygen and that the physician had discontinued anticoagulants, though she was unsure when. The MDS Coordinator stated the resident’s anticoagulant should not have been marked on the 9/1/25 MDS because it had been discontinued in August, and that if oxygen was documented she would have noted it on the MDS and care plan. The DON stated oxygen use and stopping anticoagulants should be reflected accurately on the MDS, and the Administrator stated the MDS assessments were completed by designated MDS coordinators.
Care Plan Missing ADL Services
Penalty
Summary
Resident #40’s comprehensive care plan did not include services, goals, or interventions for ADLs. Record review showed the resident was admitted with diagnoses including cerebral infraction, COPD, acute respiratory failure with hypoxia, dementia, and unspecified lack of coordination. The most recent MDS indicated the resident was cognitively intact with a BIMS score of 12, and the comprehensive care plan dated 05/19/25 contained no plan of care for ADLs. During interview, the MDS Coordinator stated she did not know why ADLs were not included in the care plan and stated that ADLs should have been included so CNAs would have known the resident’s needs. She also stated the MDS Coordinator was responsible for writing the care plans. The DON stated ADLs were needed so staff would know how to take care of residents and that it was important to have interventions that reflected the accurate needs of residents. The Administrator stated the MDS Coordinators and charge nurses were responsible for updating care plans.
Care Plan Not Updated After Anticoagulant Discontinued
Penalty
Summary
Provide care by qualified persons according to each resident's written plan of care was not met for one resident. Resident #26 had diagnoses including dementia, end stage renal disease, metabolic encephalopathy, and paroxysmal atrial fibrillation. The resident's quarterly MDS dated 9/1/25 indicated moderate cognitive impairment with a BIMS of 11 and showed continued anticoagulant therapy in Section N. However, the order summary report dated 10/1/25 showed no physician order for anticoagulants, and the order recap report showed Eliquis 2.5 mg had an end date of 8/14/25. The resident's person-centered care plan was updated on 9/2/25 and still identified anticoagulant therapy with Eliquis as a focus, including interventions for administering anticoagulant medication, monitoring for side effects, teaching about bleeding precautions, daily skin inspection, and lab monitoring. During interview, the MDS Coordinator stated the care plan should have been updated to remove anticoagulant therapy because Eliquis had been discontinued before the care plan update. She also stated the resident's care plan still reflected anticoagulant therapy and that staff would not know how to care for the resident appropriately with an inaccurate care plan. Other interviews confirmed the resident was no longer taking anticoagulants and that the MDS Coordinator and charge nurses were responsible for updating care plans.
Failure to Provide Proper Incontinence Care
Penalty
Summary
The facility failed to ensure appropriate perineal care for a resident who was incontinent of bladder and bowel. The resident was a severely cognitively impaired female with Huntington’s Disease and aphasia, dependent for all ADLs, frequently incontinent of urine, always incontinent of bowel, and receiving all nutrition through a feeding tube. Her care plan directed staff to provide peri-care with each incontinence episode and monitor for signs and symptoms of UTIs. During observation, CNA F and RA D entered the resident’s room, donned gloves but no gowns, and found the resident wet with a soft bowel movement. They turned her onto her side before cleaning her perineal area, and CNA F wiped the anal area from front to back, revealing a small nickel-sized open area near the anus. CNA F stated she needed the treatment nurse to assess the area. CNA F then placed a clean brief under the resident while still wearing soiled gloves and left the room without hand hygiene. When she returned with the treatment nurse, CNA F again only wore gloves, and after the nurse assessed the area and directed barrier cream use, CNA F wiped the anal area again and applied barrier cream without ever cleaning the resident’s perineal area, separating the labia, or cleaning the inner thighs and groin area. CNA F and RA D later stated they should have cleaned the front area first and acknowledged that failing to provide proper incontinence care placed the resident at risk for UTIs. The DON stated staff were expected to clean the peri-area from front to back and then the anal area, and that cleaning only from the back side could not ensure the resident was thoroughly cleaned.
Undated Tuberculin PPD Stored Improperly in Medication Refrigerator
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional principles and state requirements, including appropriate accessory and cautionary instructions and expiration dating when applicable. During observation of the Whirlaway hall medication room refrigerator with the DON, an opened vial of Tuberculin Purified protein derivative was found undated and stored in a bag labeled hep lock solution rather than in its original package. In interview, the DON stated the Tuberculin Purified protein derivative had to be dated when opened and was only good for 30 days after opening. He also stated that all medications should be stored in their original containers to prevent mixing up medications, and that whoever opened the vial was responsible for dating it. Record review of the facility policy titled Storage of Medications, dated April 2007, stated that drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received, and that the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.
Missing Bathroom Call Light Strings
Penalty
Summary
The facility failed to ensure that toileting areas were equipped with a working call system for two residents, Resident #57 and Resident #64, in their shared toilet located inside their room. On 09/30/2025 at 12:12 PM, surveyors observed that the toilet call light pull string was missing in the shared bathroom used by these residents, leaving the call light inaccessible from the toilet area. During interviews on 10/01/2025, a CNA stated the bathroom call light cord was missing and that she had not noticed it earlier. The CNA said she would notify maintenance. The Maintenance Supervisor stated he had just been informed of the missing call light string by the DON and had fixed the issue, and he said he had not known about it before. The DON stated the call light string was supposed to be within the resident's reach and that the missing string was a safety concern. The Administrator stated the call light string should always be within resident reach so residents could call for help when needed, and noted there was no specific policy regarding call light strings, though resident safety required the call light to always be in reach. Review of the facility policy titled Call System: Resident stated each resident is provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Ensure Catheter Anchor in Place During Resident Care
Penalty
Summary
A resident with a history of diabetes, neurogenic bladder, and multiple sclerosis, who was dependent on staff for mobility and used a Foley catheter, did not have a catheter anchor in place during wound care. The resident's care plan and physician orders required the use of a catheter anchor or leg strap to secure the catheter and prevent pulling or trauma. During an observation, it was noted that the resident was lying in bed with the head of the bed slightly elevated and did not have a catheter anchor in place while being turned for wound care, creating a risk for the catheter to be pulled. Staff interviews confirmed that the catheter anchor was last seen in place earlier that morning, but was not present during the observed wound care. The wound care nurse and CNA acknowledged the importance of the catheter anchor and recognized the risk of not having it in place. The Director of Nursing was unaware of why the anchor was missing and stated that both CNAs and nurses were responsible for ensuring it was in place. Facility policy required the catheter to be secured with a leg band or tape, but this was not followed during the observed care.
Controlled Medication Mismanagement Leads to Missing Oxycodone
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, specifically in the management of controlled medications. The deficiency involved the improper counting and inventory management of controlled substances, leading to the disappearance of 120 tablets of Oxycodone, a controlled narcotic drug, prescribed to a resident. The incident was identified during a review of pharmacy services for six residents, with the missing medication belonging to one resident. The resident involved was a male with a history of hyperlipidemia, muscle spasms of the back, and pain, for which he was prescribed Oxycodone 15mg to be taken orally every four hours as needed. The medication was delivered to the facility, and doses were administered on specific dates. However, during a shift change, the nurses responsible for counting the medication could not confirm the presence of the blister packs, and the medication was later found to be missing. The facility's investigation revealed that the medication went missing between two specific dates, with the last known access by two LVNs who were unable to recall the presence of the medication during their count. Despite notifying the police and conducting drug tests on staff with access to the medication, the facility could not determine the cause of the diversion. The resident did not miss any doses due to the presence of another blister pack, but the incident highlighted a significant lapse in the facility's medication management protocols.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. The resident, a male with Parkinson's disease and diabetes, was totally dependent on staff for bathing and showering. Despite being admitted to the facility, the resident reported not having his hair washed since his arrival, which was confirmed through observations and interviews. His hair appeared oily, and he expressed discomfort due to the lack of hair washing. Interviews with staff revealed that the resident's care plan did not include hair washing, and the CNA responsible for his care admitted to not washing his hair, citing that the resident did not request it. The Assistant Director of Nursing (ADON) was unaware of the situation and stated that hair washing should be completed if the resident wanted it. The facility's policy on bathing and showering included washing the face and shampooing hair, but this was not followed in the resident's case.
Deficiency in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, leading to a deficiency in medication administration and documentation. The resident, who had diagnoses including non-Alzheimer's dementia and diabetes, was receiving scheduled pain medication without proper documentation of administration on the Medical Administration Record (MAR) and Treatment Administration Record (TAR) for August 2024. The facility's records showed discrepancies in the narcotic count log, with doses of Hydrocodone 10 mg-acetaminophen 325 mg and Hydrocodone 7.5 mg-acetaminophen 325 mg being signed out without corresponding documentation on the MAR/TAR. Interviews revealed that the Licensed Vocational Nurse (LVN) responsible for administering the medication only documented on the narcotic count log and not on the MAR/TAR, which is against the facility's policy. The Director of Nursing (DON) was unaware of the lack of documentation and the presence of two different narcotic count logs for the resident. The physician, who was new to the resident's case, confirmed that there was no order for the 7.5 mg dose and expressed concern about the risk to the resident if the ordered dose was not administered and documented. The facility's policy requires that the administration of each PRN medication, including the time, reason, and effectiveness, be documented, which was not adhered to in this case.
Failure to Ensure Proper Hydration for Residents
Penalty
Summary
The facility failed to ensure proper hydration for two residents, leading to a deficiency in maintaining adequate fluid intake. Resident #1, a male with severe cognitive impairment and conditions such as dysphagia and hemiplegia, was not provided with accessible fluids in his room, nor was he offered extra fluids during mealtime as per his care plan. Observations revealed that his room lacked accessible fluids on multiple occasions, and during a lunch service, he was only given one glass of honey-thickened tea without any additional fluids being offered. Similarly, Resident #45, a female with severe cognitive impairment and conditions including non-Alzheimer's dementia and diabetes, was also not provided with accessible fluids in her room. She was completely dependent on staff for eating and hydration. Observations showed that she expressed thirst, had dry lips, and only had half a glass of tea during a meal, with no extra fluids provided as per her care plan. Interviews with staff revealed a lack of awareness regarding the care plan requirements for extra fluids on the tray for both residents. The facility's staff, including CNAs, LVNs, and the DON, were interviewed, and it was revealed that there was a lack of communication and adherence to the care plans. The facility's hydration protocol required water pitchers to be filled and accessible, but this was not followed for the residents with thickened liquid orders. The deficiency was further compounded by the locked nutrition room, which restricted access to thickened liquids, and the lack of updated meal tickets reflecting the residents' hydration needs.
Inappropriate Use of Psychotropic Medication Without Proper Diagnosis
Penalty
Summary
The facility failed to ensure that a resident, who had not previously used psychotropic drugs, was not given these drugs without a necessary and documented diagnosis. Specifically, a resident was prescribed Olanzapine, an atypical antipsychotic, for anxiety disorders without an appropriate diagnosis of schizophrenia or bipolar disorder, which are the conditions typically treated with this medication. The resident's medical record did not support the use of Olanzapine for anxiety, and the facility did not provide a proper diagnosis to justify its use. The consultant pharmacist recommended either changing the diagnosis to support the medication order or tapering and discontinuing the medication. However, the facility did not follow up on these recommendations. The Assistant Director of Nursing (ADON) stated that the resident was under the care of an outside psychiatric doctor, and the Director of Nursing (DON) mentioned discussing the issue with the psychiatric doctor, who refused to change the diagnosis. The facility lacked a policy for ensuring the correct diagnosis for psychotropic medication use, contributing to the deficiency.
Inadequate Portion Sizes in Lunch Meals
Penalty
Summary
The facility failed to ensure that the lunch menus were followed to meet the nutritional needs of residents on 08/21/24. Specifically, 7 out of 24 regular diet plates were served with inadequate portions of chicken, which did not align with the facility's portion control guidelines. Observations revealed that the dietary staff member, [NAME] E, did not fill the scoop completely, resulting in insufficient servings of shredded chicken on the plates. This inconsistency in portion sizes was also noted by residents during a confidential group meeting, where they expressed concerns about being served inadequate portions and feeling hungry after meals. The facility's documentation, including the Cycle 18 menu and Portion Control policy, lacked specific instructions on portion sizes or scoops to use, contributing to the inconsistency in meal servings. Interviews with the Dietary Manager and Dietician confirmed that dietary staff were trained on portion control and had access to meal extensions, yet the error occurred. The Dietary Manager acknowledged the risk of weight loss due to insufficient portions, and the Dietician highlighted the potential for inadequate nutrition leading to weight loss or skin breakdown.
Deficiency in Food Quality and Temperature Control
Penalty
Summary
The facility failed to provide palatable and appetizing food at safe temperatures for its residents during meal services. On 08/20/24, a resident with severe cognitive impairment and dysphagia was observed during lunch with a puree diet that was unappetizing and lacked flavor. The resident expressed dissatisfaction with the meal, noting that the pureed items, such as baby back ribs and carrots, had no flavor, and the pureed bread was sticky and difficult to eat. The resident also mentioned that the food was served lukewarm, which was a recurring issue. On 08/21/24, the facility did not ensure that desserts were tested for safe serving temperatures before being served to residents. The Dietary Manager admitted to forgetting to take the temperatures of the desserts before distribution. Additionally, a test tray for the puree diet was evaluated by state surveyors and the Dietary Manager, revealing that the pureed items lacked flavor, and the consistency of the pureed bread was sticky and not pudding-like as expected. The puree dessert was gritty and tasted like thickener, and the pureed beef soup was served cold. Interviews with the Dietary Manager and Dietician revealed that there were expectations for the pureed food items to be tasted before serving and for them to be of a pudding-like consistency. However, the puree bread was sticky due to the gluten content, and the dietary staff were in-serviced on maintaining the consistency of pureed items. Despite these expectations, the Dietary Manager did not identify any issues with the food tray tested on 08/21/24, indicating a disconnect between the expected standards and the actual food quality served to residents.
Deficiencies in Meal Preparation and Service
Penalty
Summary
The facility failed to ensure that food was prepared and served according to the residents' assessments and care plans, specifically for two meals reviewed. On two occasions, the facility did not follow a resident's physician order for nectar thickened liquids, serving them with incorrect consistency and even with ice, which is not appropriate for thickened liquids. The resident, who had a history of dysphagia and severe cognitive impairment, expressed dissatisfaction with the food, noting that the pureed items lacked flavor and the pureed bread was sticky and difficult to eat. Additionally, the facility did not provide pureed wheat bread in a smooth, palatable, and pudding-like consistency as required. Observations revealed that the pureed bread was hard and sticky, not meeting the necessary consistency standards. The dietary manager and dietician acknowledged that the pureed bread should not have been sticky or difficult for residents to consume, indicating a failure in the preparation process. Furthermore, the facility served inadequate portions of chicken to several residents during lunch, as observed by surveyors. The dietary staff did not use full scoops as required, resulting in insufficient portions being served. This inconsistency in portion sizes was also a concern raised by residents during a confidential group meeting, where they expressed that they often felt hungry after meals and had to request additional food. The facility's portion control policy was not adhered to, leading to these deficiencies in meal service.
Infection Control Lapse During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to proper hand hygiene protocols during incontinence care for a resident. The resident, a female with non-Alzheimer's dementia, diabetes, and neurogenic bladder, was completely dependent on staff for toileting and was always incontinent of bladder and bowel. During an observation, CNA B was seen performing incontinence care without changing gloves or performing hand hygiene after cleaning the resident and before applying a clean brief. Interviews with CNA B and the Director of Nursing (DON) confirmed that the staff was aware of the importance of hand hygiene in preventing infections. CNA B acknowledged the lapse in protocol, stating that she should have performed hand hygiene after cleaning the resident. The DON reiterated that staff were expected to perform hand hygiene after incontinence care to prevent infection. The facility's infection control policy, dated November 2017, mandates a system for preventing and controlling infections, which was not followed in this instance.
Failure to Ensure Resident Privacy During Tracheostomy Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during tracheostomy care, which is a violation of resident rights. The incident involved a female resident with severe cognitive impairment and medical conditions including cancer and pulmonary disease. During an observation, it was noted that the resident's bedroom door was open, and no privacy curtain was in use while two staff members, a Speech Therapist and an LVN, provided tracheostomy care. This lack of privacy was contrary to the facility's policy on dignity and privacy. Interviews with the resident and staff revealed that the resident typically preferred her door to remain open, which may have contributed to the oversight. However, both staff members acknowledged that they did not offer privacy during the care session. The Director of Nursing confirmed that the facility's expectation was to provide privacy during personal care to prevent dignity issues. The facility's dignity policy emphasizes the importance of maintaining and protecting resident privacy during personal care and treatment procedures.
Failure to Resolve Grievances and Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to resolve a grievance in a timely manner for a resident who had reported an incident involving a night shift CNA. The resident's representative reported the incident to an LVN, who then informed the facility's DON, Administrator, ADON, and Weekend Supervisor. Despite the representative's request to file a grievance, the facility did not acknowledge this request, nor did they provide a resolution or written documentation regarding the grievance. The facility's grievance log did not show any record of the grievance being filed or resolved. Additionally, the facility did not adequately inform residents or their representatives about how to file grievances, including the option to do so anonymously, or their right to receive a written decision regarding their grievances. Interviews with residents and their representatives revealed a lack of awareness about the facility's grievance policy and procedures. The facility's admission agreements and postings did not provide clear information on how to file grievances or identify the grievance official, leading to confusion among residents and their representatives. The facility's grievance policy was not consistently followed, as evidenced by discrepancies in the information provided in grievance postings and the lack of proper documentation in the grievance log. The facility's Social Worker, who was identified as the grievance official in some postings, was unsure why the grievance log did not include the reported grievance. Observations also revealed that grievance forms were not easily accessible to residents, potentially hindering their ability to file grievances.
Failure in Medication Management and Security
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the accurate receiving and securing of narcotic pain medication. The incident involved a resident who was under hospice care and had an active prescription for oxycodone-acetaminophen. The medication was delivered by a general shipping company and was left unsecured, as no staff member received it, leading to the medication not being accounted for and resulting in drug diversion. This failure was identified during a routine audit when the medication was noted as unavailable. Interviews revealed that the Director of Nursing (DON) was aware of the incident and acknowledged that the responsibility for proper medication receipt and storage ultimately fell on her. Despite the missing medication, the resident did not miss any doses as she had medication available from a previous supply. The facility's policy on medication labeling and storage requires medications to be stored in an orderly manner, but this was not adhered to in this instance, leading to the deficiency.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles on the 800 hall Medication Aide (MA) cart. During an observation and audit, it was found that medications such as Fish Oil 500 mg and Ibuprofen 200 mg were opened but not labeled with the date they were initially accessed. Additionally, there were three unidentified pills scattered in various drawers of the cart, which were not properly stored or identified. Interviews with staff, including an LVN and the Director of Nursing (DON), revealed that it was the responsibility of the floor nurses and medication aides to label medications with the date they were opened and to ensure medications were stored safely and sanitarily. The LVN acknowledged that loose medications should be disposed of immediately upon discovery. The DON mentioned that a recent audit by the pharmacist indicated that over-the-counter medications should now be labeled with the date they were opened, a practice that was newly implemented. The facility's policy on medication labeling and storage, dated February 2023, requires medications to be stored in an orderly manner and labeled according to federal and state requirements.
Infection Control Deficiency Due to Staff Non-compliance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two staff members, CMA C and LVN B. CMA C did not perform hand hygiene before and after administering medications to a resident. During the medication administration process, CMA C prepared the medications, delivered them to the resident, and disposed of her gloves without washing her hands. In an interview, CMA C acknowledged forgetting to perform hand hygiene and recognized the risk of exposing residents to germs. Similarly, LVN B did not adhere to safe infection prevention practices. LVN B was observed placing gloves on before entering a resident's room and exiting the room with the gloves still on, without performing hand hygiene. In an interview, LVN B admitted to not following the correct procedure due to being in a hurry, which included washing hands before and after care and removing gloves before exiting the room. The Director of Nursing (DON) confirmed the expectation for staff to maintain safe infection control practices, including hand hygiene.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure an environment free of accident hazards and provide adequate supervision to prevent elopement for a resident with severe cognitive impairment. The resident, who had a history of dementia and other significant medical conditions, was able to elope from the facility. The incident occurred when the door alarm sounded, but the responsible RN did not follow the elopement response policy, which included checking outside the door and conducting a thorough search of the facility and its grounds. The RN assumed that a CNA had opened the door and did not immediately investigate the alarm, leading to a delay in identifying the resident's absence. When the RN eventually noticed a man outside the facility, she did not recognize him as a resident and called for additional staff, who also failed to identify the resident. The police were called, and they identified the resident through a piece of paper in his possession. The resident was then brought back inside the facility. The RN did not turn on the lights in the resident rooms to ensure everyone was in their bed and did not conduct a thorough search of the facility and its grounds as required by the elopement response policy. The facility's failure to follow the elopement response policy and adequately supervise the resident placed him at risk of harm. The resident was found outside in cold weather, confused, and unable to communicate effectively. The incident highlighted lapses in staff training and adherence to protocols designed to prevent such occurrences. The facility's documentation and interviews with staff confirmed these deficiencies, which led to the identification of an Immediate Jeopardy situation that was later corrected through in-service training and other measures.
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.
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What surveyors actually found near you
We read the 1,043 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 Mesquite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbend Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 19 | 0 |
| Town East Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 18 | 2 |
| Edgewood Rehabilitation And Care Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Christian Care Communities And Services Mesquite | 2.3 mi | ★★★★★ | 4 | 1 |
| Mesquite Village Wellness & Rehabilitation | 2.9 mi | ★★★★★ | 6 | 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.