Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paradigm At Westbury during CMS and state inspections, most recent first.
The facility failed to maintain nutrition status for two residents. One resident with CHF, COPD, hepatitis C, and cognitive impairment reported hunger and said he was supposed to receive large portions, but no large-portion order was in place and his significant weight loss was not identified or verified until later. Another resident with ESRD, CHF, malnutrition, and hemodialysis had a daily weight order for fluid overload, yet multiple weights were not obtained or documented, and the resident was not on the dietician follow-up list.
Infection control failures were observed for multiple residents. Two residents with indwelling urinary catheters had drainage bags repeatedly found on the floor, a resident with a G-tube received meds without gown use under EBP, and an LVN performed wound care for a resident with stage IV pressure ulcers without a gown and without following the documented wound care process. Staff acknowledged the catheter bags should not have been on the floor and that the gown use and wound care practices were not followed.
A resident with paraplegia and an indwelling catheter refused the facility’s urinary catheter privacy cover, and staff documented the refusal in notes but did not include that specific issue in the care plan. The resident’s care plan addressed the catheter and refusal to change the catheter bag, but not refusal of the privacy cover. Interviews with the LVN, MDS Nurse, ADON, DON, and RN confirmed that the refusal should have been care planned.
Medication error rate exceeded the allowed threshold after surveyors found 3 errors in 25 opportunities. An RN gave insulin at an inappropriate site for a resident with DM and severe cognitive impairment, and a Med Aide failed to administer ordered eye drops and did not give the full ordered dose of a laxative for another resident with severe cognitive impairment. The DON stated staff were expected to audit and replenish carts and notify nursing if OTC meds were needed.
Medication carts and storage rooms had multiple storage deficiencies. Surveyors found discontinued and expired meds left in carts, including meds for residents who were no longer taking them, along with unopened and unlabeled medication containers. In addition, supplies and equipment were stored under sinks in medication rooms, and staff stated items should not be kept there because of damage risk and that discontinued meds should be removed from carts.
Missing Immunization Documentation for Two Residents: The facility failed to document flu and pneumococcal vaccine education, receipt, refusal, or contraindication for two residents. One resident had acute kidney failure with tubular necrosis and the other had ESRD; both charts lacked immunization data in the EMR and care plan. Staff interviews showed the ADON, DON, DCE, and Administrator each described admission paperwork and EMR entry responsibilities, but the required vaccine documentation was not present.
The facility failed to document COVID-19 vaccine education, vaccination status, or refusal/contraindication information for two residents. One resident had acute kidney failure and the other had ESRD; both records lacked immunization data in the EMR and care plan. Interviews showed the ADON, DON, DCE, and Administrator described shared responsibility for admission paperwork and vaccine documentation, but the required documentation was not found in the records reviewed.
A resident who was fully dependent on staff for ADLs and had multiple serious medical conditions was discharged to the hospital in dirty clothing and a soiled brief, with unclean skin and an odor. Hospital staff and family members reported ongoing issues with the resident's grooming and hygiene, including tangled hair and soiled garments. Facility staff on duty did not recall preparing the resident for discharge, and leadership was unaware of the incident until after it occurred.
A resident with significant cognitive and physical impairments was discharged to the hospital in a soiled and unclean state, despite being fully dependent on staff for ADLs. Hospital staff and family reported the resident arrived in dirty clothing, with unclean skin and an odor, and had a history of inadequate hygiene and grooming while at the facility. Facility staff interviews did not identify who was responsible for preparing the resident for discharge, and facility policies required staff to maintain resident hygiene and dignity.
Several rooms on one hall experienced sustained high temperatures due to HVAC failure, with temperatures recorded above 81°F for multiple days. Residents and staff reported discomfort, and not all residents received fans or adequate cooling. Staff provided water, ice, and offered relocation to cooler areas, but some residents declined. The facility did not meet its policy requirements for proper temperature and ventilation.
The facility failed to ensure accurate medication administration and availability, resulting in multiple residents not receiving prescribed medications as ordered, including missed doses, incorrect dosages, and administration of medications outside of physician-set parameters for blood pressure and blood sugar. Staff did not consistently follow established medication administration protocols, leading to deficiencies in pharmaceutical services.
A medication error rate of 16% was identified when a medication aide nearly administered an incorrect dose of antihypertensive medication, and five prescribed medications for a resident with multiple chronic conditions were not available or administered as ordered. Staff interviews confirmed delays in medication delivery and lack of timely communication with the DON, while required post-administration blood pressure monitoring was not performed until prompted by a surveyor.
Two residents experienced significant medication errors when staff failed to follow physician-ordered parameters for administering Midodrine and Insulin Glargine. One resident received blood pressure medication multiple times despite her systolic BP being above the ordered threshold, while another was given insulin when his blood sugar was below the prescribed limit. Documentation and staff interviews confirmed that these medications were administered outside of the specified parameters.
Surveyors found that the facility did not properly label and seal food items, such as an open bag of shredded cheese and an unsealed bag of flour, and observed a staff member with facial hair working in the kitchen without a beard guard. Staff interviews confirmed awareness of the requirements for food labeling, sealing, and use of beard guards, but these standards were not consistently followed.
The facility did not ensure proper disposal of garbage and refuse, as the dumpster lid was left open and debris was observed outside the dumpster. Staff reported difficulty closing the lid and sometimes used a stick to operate it, despite facility policy requiring dumpsters to be closed at all times to prevent disease transmission and rodent attraction.
A resident with severe cognitive impairment and mobility issues fell from their bed and sustained a minor head injury when a CNA attempted a bed bath alone, despite the resident's care plan requiring a two-person assist. The incident highlighted a failure in following established safety protocols, as the CNA believed she could manage without assistance, leading to the fall.
The facility failed to maintain a safe and comfortable environment due to malfunctioning HVAC units, resulting in cold air blowing in resident rooms and common areas. Temperatures fell below the required 71 degrees Fahrenheit, with some areas as low as 57 degrees. Staff interviews revealed a lack of communication and action to address the issue, and residents expressed feeling cold, with some observed shivering. The facility's emergency preparedness policy was not effectively implemented, leading to an unsafe environment.
A resident's weight was inaccurately documented in the MDS at an LTC facility, with the admission weight recorded as 119 pounds instead of the facility's recorded 99 pounds. The resident experienced significant weight loss, which was not reflected in subsequent MDS assessments. Interviews revealed the absence of an MDS nurse and acknowledged inaccuracies in the documentation.
A resident with multiple medical conditions experienced significant weight loss, which was not reflected in her care plan. Despite weight fluctuations and a notable loss of 7.9%, the care plan was not updated to address this issue. Interviews revealed that the facility lacked an MDS nurse, and the nurse responsible for care plans was no longer employed, leading to the deficiency.
A facility failed to provide a safe, clean, and homelike environment for two residents, as observed in their shared room. Issues included a stained toilet base, cracked bathroom tiles, a wobbly doorknob, bent window blinds, and a dirty floor. One resident, with moderate cognitive impairment and mobility challenges, expressed dissatisfaction with the room's condition, which contradicted her care plan's emphasis on a clutter-free environment to prevent falls. Interviews with staff revealed a lack of awareness and accountability for the room's upkeep.
The facility was found deficient in food safety practices, with unlabeled and undated food items in storage and improper glove use by dietary staff. Observations revealed that food items in the freezer and refrigerator were not properly labeled or sealed, and a staff member failed to change gloves between tasks, risking cross-contamination. The Dietary Manager acknowledged these lapses, which were contrary to the facility's sanitation policies.
A CNA failed to perform proper hand hygiene while retrieving ice for a resident, touching high-touch areas without sanitizing her hands, which could lead to cross-contamination. Interviews with the CNA, ADMIN, and DON confirmed the breach of the facility's hand hygiene policy, which mandates handwashing before and after resident contact.
The facility failed to provide scheduled showers for several residents due to the absence of shower technicians on weekends. Residents reported not receiving showers on their designated days, and staff interviews confirmed inconsistencies in the shower schedule. This deficiency affected residents' grooming and hygiene care.
The facility failed to remove controlled medications from the medication cart after the discharge of two residents, CR #40 and CR #41, leading to potential drug diversion. CR #40's hydrocodone/APAP was signed out post-discharge, and CR #41's Modafinil remained in the cart for two weeks. The facility's policy on controlled substances was not followed, as medications were not securely stored until destruction.
The facility failed to maintain food safety standards, including improper labeling and dating of food items, inadequate temperature control of milk and steam table items, and improper handling of ready-to-eat foods. These deficiencies were observed in the kitchen, with the Dietary Manager acknowledging the lapses.
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in their treatment. One resident with multiple respiratory and cardiac conditions had an oxygen humidifier bottle with insufficient water, while another resident with a tracheostomy had an oxygen concentrator with a nearly empty water bottle and a dirty filter. Staff interviews revealed lapses in routine checks and maintenance of oxygen equipment, contrary to the facility's policy and care plans.
The facility failed to secure medication carts, leaving them unlocked and unattended on two occasions. On one occasion, RN B left the Hall 100 cart unlocked for 12 minutes, with three residents nearby. On another occasion, RN T left the Hall 300 cart unlocked for 15 minutes, with two residents nearby. The DON confirmed that carts should be locked to prevent unauthorized access to medications.
The facility failed to maintain an effective pest control program, as numerous gnats were observed in four resident rooms on the 300 and 400 halls. Residents reported the gnats as a persistent issue, particularly during meal times. The facility's administrator was unaware of the problem, and the maintenance log showed no recent pest control requests related to gnats, despite the facility's policy requiring immediate reporting of pest sightings.
A resident's dignity and privacy were compromised when the facility failed to place a privacy cover over the resident's urinary catheter bag. The resident was admitted to the facility, and staff interviews revealed that the oversight was due to the resident being a new admission. The ADON and Administrator acknowledged the failure, and the facility's policies on catheter care and resident dignity were not followed.
A resident with legal blindness and severe cognitive impairment was at risk of injury due to broken window blinds and a damaged bed handrail in her room. The facility staff failed to report these issues for repair, despite procedures in place for identifying and addressing such concerns during Angel Rounds. The Administrator and Director of Support Services acknowledged the oversight, noting that no maintenance request had been made.
Failure to monitor weight loss and nutrition status
Penalty
Summary
The facility failed to maintain acceptable nutritional status and electrolyte balance for two residents reviewed for nutrition status. One resident with chronic diastolic CHF, chronic hepatitis C, COPD, and moderate cognitive impairment was observed to appear thin, gaunt, and emaciated, with spindly limbs. He stated he was supposed to receive large portions, that he was not getting them, and that he felt hungry after meals. However, during observation of his lunch tray, the meal ticket showed no note for large portions, the tray contained a regular portion, and the resident ate 100% of the meal. Record review showed no physician order for large portions at that time. The same resident’s weight record showed 118.8 lbs on 05/13/2026, and the facility did not identify or verify the significant weight loss until later. A reweigh on 05/27/2026 showed 116.2 lbs, and the resident’s EMR showed no RD notes since 01/28/2026. The resident’s care plan identified him as at risk for malnutrition and included consultation with the RD and intervention with weight loss, but he was not on the facility’s list of residents being followed by the dietician company. A physician order for RD consult related to weight loss and an order for mirtazapine for appetite stimulation were entered only after the surveyor requested the resident be weighed. The second resident had acute kidney failure, ESRD, acute on chronic systolic CHF, moderate protein calorie malnutrition, and required hemodialysis. The physician order dated 05/01/2026 directed daily weight monitoring for fluid overload, but the MAR-TAR showed multiple dates with no weights documented. The first recorded weight was 126.2 lbs on 05/06/2026 and later 115.7 lbs on 05/27/2026. The resident’s care plan identified malnutrition risk and included weighing as indicated and documenting/intervening with weight loss, but the facility’s weight list did not include this resident, and staff stated there were no weekly weights obtained or logged for any resident because they had been working on the floor as CNAs and had not had time to complete the weights.
Infection Control Failures During Catheter Care, Enteral Feeding, and Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for four residents reviewed for infection control. The deficiency involved two residents with indwelling urinary catheters whose drainage bags were observed touching or lying on the floor, one resident receiving enteral feeding through a G-tube without the required gown use under Enhanced Barrier Precautions, and one resident receiving wound care without a gown and without following the documented wound care protocol. Resident #81 was a female with diagnoses including epilepsy and obstructive and reflux uropathy, severe cognitive impairment, and an indwelling urinary catheter ordered to be maintained in a closed drainage system. Her care plan identified her as at risk for increased urinary tract infections and directed staff to keep the tubing and bag below bladder level. During multiple observations, her catheter bag was seen hanging on the bed rail but tilted onto the floor, lying partly on a floor mat, and later lying on the floor beneath the bedside table wheel. Staff members acknowledged that the bag should not be on the floor and stated it could become contaminated. Resident #101 was a female with diagnoses including traumatic brain injury and peritonitis, with an indwelling urinary catheter ordered in a closed drainage system and a care plan identifying risk for increased urinary tract infections. During observations, her catheter bag and drainage port were seen lying on the floor, and later the bag was again observed on the floor beside the bed. Staff stated the bag should not be on the floor and that it could become contaminated, but the bag was repeatedly found in that condition. Resident #12 had a G-tube, was dependent on staff for all ADL care, and had an order for Enhanced Barrier Precautions for C. auris. During observation, RN B administered medication through the G-tube without wearing a gown and later stated she was not familiar with the EBP protocol. Resident #92 had stage IV pressure ulcers to the sacral and bilateral ischial areas with wound infection and an order for daily wound care and Enhanced Barrier Precautions. During observation, LVN B provided wound care without a gown, removed all dirty dressings at once, changed gloves between wounds, and used the same gloved hands to apply clean dressings after cleaning each wound.
Care Plan Did Not Address Refusal of Urinary Catheter Privacy Cover
Penalty
Summary
The facility failed to ensure that Resident #41’s comprehensive care plan was reviewed and revised by an interdisciplinary team to address his refusal to have a privacy cover on his urinary catheter bag. Resident #41 was a male resident with paraplegia and obstructive and reflux uropathy, admitted with an indwelling catheter. His admission MDS assessment showed a BIMS score of 15, indicating intact cognition, and section H documented the indwelling catheter. Record review showed that nursing staff offered to change the resident’s urinary bag to one with a privacy cover, but the resident refused. Progress notes also documented that he refused the facility privacy bag. On observation, the resident was lying in bed with his blanket over his head and his urinary catheter hanging on the bed with no privacy cover. The physician order listed an indwelling urinary catheter using a closed drainage system to be changed monthly and as needed. The care plan dated 5/29/26 included an intervention to provide a privacy bag and also addressed refusal to let staff change the urinary catheter bag, but it did not include information about the resident refusing the privacy bag for the urinary catheter. During interviews, the LVN, MDS Nurse, ADON, DON, and RN Y all acknowledged that refusal of the privacy bag should have been care planned, and the MDS Nurse stated she had not been informed of that specific refusal. The facility policy stated that care plans would be modified as needed by the MDS Coordinator or other designated staff member.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure that its medication error rate was not 5 percent or greater. Surveyors identified 3 medication errors out of 25 opportunities, resulting in a 12.0% error rate during medication administration observations for two residents. The report states that these failures could place residents at risk for incomplete therapeutic outcomes and decline in health. For one resident with Type 2 DM with hyperglycemia, cerebral infarction, heart failure, and severe cognitive impairment, RN A administered Novolog insulin at the resident’s deltoid area after the resident exposed her right arm, even though RN A stated insulin should be injected into fatty tissue in a subcutaneous area. The resident’s blood glucose was 255, and RN A had prepared both Novolog and Toujeo before entering the room. RN A stated she automatically gave the Novolog on the arm because the resident wanted it there. For another resident with constipation, essential hypertension, cerebral infarction, and severe cognitive impairment, MA A administered several oral medications but did not give the ordered artificial tears because they were not in the cart. MA A said she would get the medication from central supplies, went to an unidentified door, and then returned and signed off the EMAR after no one answered. Medication reconciliation later identified that the resident was also supposed to receive 2 tablets of Sennosides, and the DON stated staff were expected to audit and replenish carts and notify the nurse or unit manager if OTC medications were needed.
Medication Storage and Cart Organization Deficiencies
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles in multiple medication carts and medication storage rooms. On D hall medication aide cart, surveyors found Quetiapine 25 mg with 9 pills remaining for Resident #74 even though the resident was no longer taking it, Potassium Chloride Liquid 10% with directions for Resident #64, and Amlodipine 2.5 mg for Resident #44 even though that medication had been discontinued. The Med Aide stated discontinued medications should be removed from the cart and returned to the pharmacy, and that she audited her cart weekly for expired and discontinued medications. Surveyors also found storage issues in medication rooms and carts. In the D hall medication storage room, a box of mixed supplies was stored under the sink, including IV start kits, feeding tubes, piston syringes, and suction catheters, and the LVN stated items should not be stored there because they could be damaged if the sink leaked. In the D hall nurse cart, two unopened bottles of Ketoconazole 2% shampoo for Resident #75 and a bottle of Ketoconazole 2% cream for Resident #103 were present, and the LVN stated Resident #103's cream had been discontinued. In the B hall nurse cart, Potassium Chloride was found for Resident #3. In the A hall medication storage room, surveyors found urine measuring hats, booties, suction machines, an opened colostomy bag with a hair strand on it, an unlabeled bottle of Sevelamer Carbonate, an opened piston syringe container, and an opened urethral catheterization tray stored under the sink. The Unit Manager and DON stated items should not be stored under the sink and that expired or discontinued medications should be removed from carts; the facility policy on medication storage was requested but not provided.
Missing Immunization Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the medical records for two residents included documentation of education about the benefits and potential side effects of influenza and pneumococcal immunizations, or documentation that the residents received the vaccines, declined them, or had a medical contraindication. For one resident, the record showed the resident was not in the facility during the influenza vaccination season and that the pneumococcal vaccine was not up to date and was offered and declined, but the chart did not contain immunization documentation in the electronic record or care plan. For the other resident, the electronic medical record also showed no immunization data, and the admission and care plan records did not include immunization information. Resident #2 was admitted with acute kidney failure with tubular necrosis and had a BIMS that could not be completed because the resident was rarely or never understood. Resident #115 was admitted with end stage renal disease, and the record review did not reveal cognition or immunization status information in the entry MDS. For both residents, the immunization tab in the electronic medical record showed no data available, and the care plans did not include immunization information. During interviews, the ADON, who said she was the facility’s Infection Preventionist, stated residents were asked on admission about flu, pneumonia, and COVID vaccines and that refusals should be documented. She said immunization information should have been entered in the electronic medical record or admission packet and that she was responsible for entering vaccine information. The DON stated obtaining immunization information fell to the infection control nurse, though nursing management and admitting staff could also assist. The DCE and Administrator stated the admission packet contained vaccine information and consents and that admissions paperwork was the responsibility of the DCE or Admissions, but the DCE was new to the facility and the prior DCE had left before the current one started.
Missing COVID-19 Immunization Documentation for Two Residents
Penalty
Summary
The facility failed to document COVID-19 vaccination education, vaccination status, or refusal/medical contraindication information for 2 of 9 residents reviewed for immunizations. The deficiency involved Resident #2, a female admitted with acute kidney failure with tubular necrosis, and Resident #115, a female admitted with end stage renal disease who was later discharged. For both residents, the electronic medical record showed no data available in the immunization tab, and the care plans did not include immunization information. For Resident #2, the admission MDS showed she was rarely or never understood and could not complete a BIMS. Her MDS also showed she did not receive the influenza vaccine in the facility and was not present during the influenza vaccination season, and that her pneumococcal vaccination was not up to date and had been offered and declined. However, the record did not show documentation that she or her responsible party received education on the benefits, risks, or potential side effects of COVID-19 immunization, or documentation of receipt, refusal, or medical contraindication for the COVID-19 vaccine. For Resident #115, the entry MDS contained no information related to cognition or immunization status, and the Medicare 5 Day and Death in Facility MDS assessments were still in progress. The ADON, who said she was the Infection Preventionist, stated residents were asked during admission about influenza, pneumonia, and COVID vaccines and that refusals should be documented, but she could not find Resident #115's admission packet and was unsure whether the admission paperwork had been completed within the 72-hour timeframe. Interviews with the ADON, DON, DCE, and Administrator showed that responsibility for admission paperwork and immunization documentation was shared among multiple staff, but the required documentation was not present in the records reviewed.
Failure to Provide Dignified and Hygienic Discharge for Dependent Resident
Penalty
Summary
A deficiency occurred when a female resident with end stage renal disease, acute kidney failure, protein-calorie malnutrition, hypertensive heart and chronic kidney disease, cognitive communication deficit, and aphasia was not provided with appropriate personal grooming and hygiene prior to her discharge to the hospital. The resident was totally dependent on staff for bathing and required moderate assistance for dressing, as documented in her care plan. On the night of her discharge, the resident was sent to the hospital in dirty clothes and a soiled brief, with unclean skin and an odor, as reported by hospital staff upon her arrival. Interviews with hospital staff confirmed that the resident arrived in an unkempt state, requiring immediate cleaning and a change of clothing and brief. Family members also reported ongoing issues with the resident's grooming during her stay, including tangled hair that eventually had to be cut, unbrushed teeth, and frequent observations of the resident in soiled briefs and dirty gowns. Family members stated they had to request clean gowns from staff multiple times per week, though no formal complaint was filed with the facility. Interviews with the facility's CNAs and nursing staff revealed that none of the CNAs on duty during the relevant shift recalled assisting the resident with preparation for discharge or were aware of her transfer to the hospital. The RN responsible for the discharge stated that a CNA should have changed the resident, but could not recall who performed the task. The DON and Administrator both stated that it was their expectation that residents be clean and appropriately dressed when discharged, but neither was aware of the incident until after the fact. Review of the facility's policy confirmed the resident's right to dignity and proper care.
Failure to Provide Necessary ADL Assistance and Hygiene Prior to Hospital Discharge
Penalty
Summary
A resident with multiple complex medical conditions, including acute kidney failure, end stage renal disease, protein-calorie malnutrition, dysphagia, cognitive communication deficit, and aphasia, was admitted to the facility and required significant assistance with activities of daily living (ADLs). The resident's care plan indicated total dependence on staff for bathing and showering, and partial to moderate assistance for dressing. The care plan also addressed oral and dental health, with interventions for monitoring and maintaining oral hygiene. The resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment and a need for staff support in daily care tasks. On the date of a change in condition, the resident was sent to the hospital. Upon arrival, hospital staff observed that the resident was in dirty clothes, a soiled brief, had unclean skin, and an odor, requiring immediate cleaning and changing. Family members also reported multiple instances prior to the hospital transfer where the resident was found in soiled briefs, with unbrushed and tangled hair, unbrushed teeth, and dirty gowns, necessitating requests to staff for basic hygiene care. The family stated that the resident's hair had to be cut due to lack of grooming by facility staff. These observations were corroborated by hospital staff interviews, which indicated the resident was non-communicative and fully dependent on staff for all ADLs. Interviews with facility staff, including CNAs and the RN on duty, revealed that none of the CNAs on the shift when the resident was discharged to the hospital recalled assisting with changing the resident's brief or clothing. The RN stated that a CNA had changed the resident, but could not recall who it was. The Director of Nursing and Administrator both stated that it was their expectation that residents be clean and appropriately dressed when discharged, but were unaware of any issues with this resident's discharge. Review of facility policies confirmed the requirement to provide necessary care for residents unable to perform ADLs, including maintaining proper grooming and hygiene.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents on Hall D, as required by resident rights regulations. Multiple rooms (404, 405, 406, and 407) were observed to have temperatures exceeding 81 degrees Fahrenheit, with some readings as high as 88 degrees. These elevated temperatures persisted for several days, as documented in maintenance logs and confirmed by direct observation. The HVAC system began experiencing cooling issues, and the chillers required replacement, resulting in inadequate cooling for the affected rooms. Residents and staff reported discomfort due to the heat. One resident stated his room had been hot for 6-8 days and did not have a fan, although he did not request one. Another resident reported the air conditioning had been out for several days and had requested and received fans, but still felt hot and preferred to remain minimally clothed. Staff interviews confirmed that residents and staff were aware of the heat issue, with some staff and residents sweating and expressing discomfort. Staff attempted to mitigate the situation by offering water, ice, and the option to move to cooler areas, but some residents declined to leave their rooms or have their doors opened for privacy reasons. Maintenance logs and staff interviews indicated that portable cooling units and fans were distributed, but not all residents received fans, and the cooling provided was insufficient to maintain comfortable temperatures. The facility's own policy required proper temperature and ventilation to create a homelike environment, but this standard was not met during the period in question. No incidents were reported to the state agency, and no residents were hospitalized as a result of the heat, but the deficiency was clearly documented through observations, interviews, and record reviews.
Failure to Provide Pharmaceutical Services and Adhere to Medication Orders
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by multiple medication administration errors and unavailability of prescribed medications. For one resident with diagnoses including major depressive disorder, muscle weakness, and hypertension, several prescribed medications were not available at the time of administration, including Eliquis, Amlodipine, Isosorbide Mononitrate, Duloxetine, Calcium with Vitamin D, Fenofibrate, and Vitamin D. Medication Aide J nearly administered an incorrect dosage of Amlodipine, initially dispensing only 5 mg instead of the ordered 10 mg, and was only corrected after surveyor intervention. The resident did not receive several of his prescribed medications on the following day due to continued unavailability, and his blood pressure was not rechecked as required after medication administration. Another resident with a history of hypertension and medically complex conditions received Midodrine, a blood pressure medication, outside of the physician-ordered parameters on multiple occasions. The order specified that Midodrine should be held if the systolic blood pressure (SBP) was greater than 110, but the medication was administered 17 times when the SBP exceeded this threshold. Nursing staff interviews confirmed that the medication was given outside of parameters, and documentation on the Medication Administration Record (MAR) supported these findings. The facility's Director of Nursing and other staff acknowledged that the medication should not have been administered under these circumstances. A third resident with Type 2 Diabetes Mellitus and chronic kidney disease was administered insulin outside of the physician-ordered blood sugar parameters. The order specified to hold insulin if blood sugar was less than 120, but insulin was administered when the resident's blood sugar was recorded at 98 and 65. Staff interviews confirmed that insulin was given outside of the prescribed parameters, and the risks of such actions were acknowledged by nursing staff and administration. The facility's policy required adherence to the '8 Rights' of medication administration, but these were not consistently followed in the cases reviewed.
Medication Error Rate Exceeds Acceptable Threshold Due to Dosing and Availability Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate based on 6 errors out of 37 opportunities. During medication administration, a medication aide (MA) was observed preparing to give an incorrect dose of a blood pressure medication, and surveyor intervention was required to prevent the error. Additionally, five prescribed medications for a resident with diagnoses including major depressive disorder, muscle weakness, and hypertension were not available and were not administered as ordered. These medications included Isosorbide Mononitrate, Duloxetine HCl, Calcium 600 + Vitamin D, Fenofibrate, and Vitamin D. The resident did not receive these medications on the specified date, and the medication administration record confirmed the omissions. Interviews with staff revealed that the medications would not be delivered until the following day and that the Director of Nursing was not made aware of the situation. The facility's policy requires medications to be administered within one hour of the scheduled time, which was not met. Blood pressure monitoring after medication administration was also not performed as required until prompted by the surveyor.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
Two residents experienced significant medication errors due to staff failing to follow physician-ordered parameters for medication administration. One resident, a female with a history of traumatic subdural hemorrhage, hypertension, and cognitive impairment, was prescribed Midodrine to manage hypotension, with explicit instructions to hold the medication if her systolic blood pressure (SBP) exceeded 110. Despite this, the medication was administered 17 times in March when her SBP was above the ordered threshold, as documented in the Medication Administration Record (MAR). Interviews with nursing staff and the Director of Nursing (DON) confirmed that the medication was given outside the prescribed parameters, and staff could not explain why the orders were not followed. Another resident, a male with Type 2 Diabetes Mellitus, metabolic encephalopathy, and chronic kidney disease, had a physician's order for Insulin Glargine to be held if his blood sugar (BS) was less than 120. The MAR showed that insulin was administered on two occasions when his BS was below the ordered parameter, with readings of 98 and 65, respectively. The resident reported experiencing low blood sugar and needing to eat candy to correct it. Nursing staff interviews confirmed that insulin was given outside the prescribed parameters, and staff acknowledged the risk of hypoglycemia associated with such errors. Record reviews and staff interviews revealed that both residents had care plans and physician orders specifying medication administration parameters, but these were not consistently followed. The facility's policy required staff to adhere to the '8 Rights' of medication administration, including following physician orders and documenting interventions when parameters were not met. Despite these policies, the errors occurred, as confirmed by MAR documentation and staff statements.
Failure to Adhere to Food Storage and Staff Hygiene Standards in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, surveyors observed an open bag of shredded cheddar cheese in the refrigerator that was not dated, and a 50-pound bag of flour in the dry storage room that was not properly sealed. The Dietary Manager confirmed that food should be dated and sealed, and acknowledged that the unsealed flour was leftover and not properly stored, which could lead to contamination. Additionally, a staff member with facial hair was observed in the kitchen without a beard guard while preparing food. Interviews with the Dietary Manager and other staff confirmed that all kitchen personnel with facial hair are required to wear beard guards, and that in-service training on this requirement had recently occurred. The facility's policy on beard guards was requested but not provided before the survey exit. The FDA Food Code was referenced, indicating the requirement for hair restraints to prevent contamination.
Improper Disposal of Garbage Due to Unsecured Dumpster Lid
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that the dumpster lid was secured. During an observation, the dumpster lid was found open with debris present on the outside of the dumpster. Staff interviews revealed that kitchen staff were responsible for closing the dumpster lid, but some had difficulty doing so and resorted to using a stick to open and close it. The expectation among staff was that the dumpster should always be closed and the surrounding area kept clean, but this was not consistently achieved. The Administrator acknowledged that the dumpster was difficult to close and stated that efforts were being made to obtain a new one. Facility policy required that waste containers and dumpsters be covered and closed at all times to prevent the transmission of disease and to avoid attracting rodents and other vermin. The failure to keep the dumpster closed and the area clean was directly observed and confirmed through staff interviews and policy review.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who required a two-person assist. On the day of the incident, CNA A attempted to perform a bed bath alone for the resident, who had severe cognitive impairment and was dependent on staff for mobility. Despite knowing the resident's need for a two-person assist, CNA A proceeded without assistance, resulting in the resident falling from the bed and sustaining a minor head injury. The resident, who had a history of falls and was on anticoagulant medication, was at risk for increased bleeding and bruising. The resident's care plan clearly indicated the need for a two-person assist due to his impaired cognition and physical limitations. However, CNA A, believing she could manage alone, attempted to reposition the resident, leading to the fall. The incident was witnessed, and the resident was assessed and sent to the hospital for further evaluation. Interviews with facility staff, including the Administrator and RN A, confirmed that CNA A was aware of the two-person assist requirement. The Administrator noted that all CNAs were trained on this protocol, and RN A highlighted the potential risks of not adhering to it. The facility's investigation revealed that CNA A had been suspended and in-serviced following the incident, but the deficiency occurred due to the initial failure to follow the established care plan and safety protocols.
Failure to Maintain Safe and Comfortable Environment Due to HVAC Malfunction
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in three hallways and common areas due to malfunctioning HVAC units. The heating system was not functioning properly, resulting in cold air blowing from the vents in resident rooms and common areas. Observations revealed that temperatures in these areas were below the required 71 degrees Fahrenheit, with some areas as low as 57 degrees Fahrenheit. The outside temperatures during this period ranged from 33 to 53 degrees Fahrenheit, exacerbating the issue. Interviews with the Acting Maintenance Director and other staff indicated that the HVAC system had been malfunctioning for several weeks, and parts were needed for repairs. However, there was a lack of communication and action to address the immediate discomfort of residents. The Acting Maintenance Director was not instructed to place portable heaters, and the Administrator was not fully aware of the extent of the issue until surveyor intervention. Residents expressed feeling cold, with some observed shivering and inadequately covered with blankets. The facility's policy on emergency preparedness for loss of heating was not effectively implemented. The policy required immediate notification of maintenance and administration, temperature monitoring, and provision of additional clothing and blankets to residents. However, these measures were not adequately executed, leading to an unsafe and uncomfortable environment for residents. The deficiency was identified as Immediate Jeopardy, indicating a severe risk to resident health and safety.
Removal Plan
- DON assessed Residents #1, #2, #3, #4 affected by the uncomfortable temperature and were provided extra blankets and nursing added layers of clothing on affected residents. Residents were offered to be taken to the dining room where the HVAC is operating. Nursing staff immediately began monitoring resident's vitals, temperature, and any other cold-related health concerns. MD was notified and no new orders were given.
- DON assessed 100% of the residents and identified that no other residents were to be at risk.
- Facility purchased anti-tip portal heaters HVAC vendor was contacted to request industrial portable heaters. HVAC vendor arrived and installed 4 industrial portable heaters to compensate for the HVAC failure and will remain in place until HVAC is repaired.
- The administrator and maintenance supervisor routinely rechecked temperatures on Hall B 72, Hall C 70, Hall D 75, room [ROOM NUMBER] room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Common Area B, room [ROOM NUMBER], room [ROOM NUMBER] and readjusted the temporary HVAC unit until the temperatures reached 71 degrees. The maintenance director/trained designee will conduct the temperature checks every 2 hours and make adjustment to the temporary heating unit as needed until HVAC is fixed. The administrator will oversee the temperature log for accuracy.
- A regional contractor assessed the HVAC unit and determined the heater exchange was not functioning, and a certified HVAC specialist conducted a follow-up assessment. Contractor revealed transmitter conductor was not connected. When contractor connected the conductor the HVAC unit started working and hot air started blowing out in the front section of Hall B. The shorter section of Hall B and Hall C require a higher voltage electric wire, requiring electrician to install and then heater exchanger needs to be installed. Electrician will come to the facility to connect the higher voltage that is required on hallway B and C. Anticipated repair date for when the heater exchange needs to be installed and when the contractor connected the conductor.
- Administrator and DON reviewed Policies and Procedures for Emergency Preparedness on Loss of Heating Element which will include Educating Staff on Initial Response, How to Monitor Temperature, Ensuring Resident Safety and Comfort, Completing Resident Assessment and Monitoring, Staffing Coordination, Notifying families, and Regulatory Compliance. No change was needed.
- The Regional Nurse Consultant educated DON and Administrator on emergency preparedness- loss of heating element- topics to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance.
- The Administrator and DON educated all staff on emergency preparedness heating elements to include initial response, temperature monitoring, resident safety and comfort, resident assessment and monitoring, communication and regulatory compliance, and reporting failure of HVAC system and temperatures outside of normal range to administrator immediately. Staff will receive education before start of their next shift and new hires will receive education at orientation.
- The Administrator educated the Acting Maintenance Director on routine temperature check for HVAC failure and reporting temperature outside of normal range. Educated to also include emergency preparedness heating elements.
Inaccurate Resident Weight Assessment in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate assessments of a resident's weight, which led to discrepancies in the Minimum Data Set (MDS) documentation. The resident, a female with multiple medical conditions including hypotension, hypertension, multiple myeloma, and vascular dementia, was admitted with an initial weight recorded inaccurately on the MDS. The admission MDS incorrectly documented the resident's weight as 119 pounds, based on a hospital discharge report, while the facility's records showed an admission weight of 99 pounds. Additionally, the resident experienced significant weight loss, which was not reflected in the quarterly MDS assessments, as they continued to list the weight as 119 pounds with no or unknown weight loss. Interviews with facility staff revealed that there was no MDS nurse at the time, and the previous MDS nurse had left the facility. The Unit Manager acknowledged the inaccuracies in the MDS documentation and noted that the resident had experienced gradual weight loss. The Director of Nursing, who was new to the facility, also recognized the inaccuracies and stated that they were working on addressing MDS and care plan issues. The facility's policy requires a registered nurse to conduct or coordinate each assessment with the interdisciplinary team, ensuring comprehensive and accurate assessments, which was not adhered to in this case.
Failure to Update Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the care plan for a resident after each assessment, including both comprehensive and quarterly review assessments. This deficiency was identified for one resident whose records were reviewed. The resident, a female with multiple medical conditions including hypotension, hypertension, multiple myeloma, vascular dementia, and mild protein-calorie malnutrition, experienced significant weight loss that was not reflected in her care plan. The resident's weight records showed fluctuations and a notable weight loss of 7.9% between early July and August. Despite this, the care plan was not updated to address the risk or occurrence of weight loss. The resident's admission MDS and subsequent quarterly MDS assessments did not indicate any weight loss, despite the resident's weight dropping from 119 pounds at admission to 78.04 pounds by October. The facility's policy required that care plans be developed and revised by the interdisciplinary team, but this was not adhered to in this case. Interviews with facility staff, including an LVN and the DON, revealed that there was no MDS nurse at the time, and the nurse responsible for MDS and care plans was no longer employed at the facility. The DON acknowledged the oversight and stated that the facility was aware of issues with care plans, which they intended to address with the hiring of a new MDS nurse. The facility's policy emphasized the need for comprehensive care plans to be developed within seven days of assessment, but this was not followed, leading to the deficiency.
Facility Fails to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as observed in one of the six rooms reviewed. Specifically, the room shared by two residents had several issues, including a toilet base with stains and dirt, a bathroom with cracked and missing tiles, a wobbly doorknob, bent window blinds, and a floor littered with dirt and debris. These conditions were noted during an observation and interview process, highlighting the facility's failure to uphold the residents' right to a dignified living environment. Resident #1, a female with moderate cognitive impairment and mobility challenges, expressed dissatisfaction with the state of her room. Her care plan emphasized the need for a clutter-free environment to prevent falls, yet the room's condition contradicted this requirement. The resident's family member corroborated the concerns, noting persistent trash on the floor and unacceptable stains around the toilet. The resident also mentioned using her cane to navigate around the cracked tiles, indicating a potential safety hazard. Interviews with facility staff, including the ADON, HK A, and the DON, revealed a lack of awareness and accountability for the room's condition. The ADON acknowledged the need for cleaning and repairs, while HK A admitted to not having cleaned the room yet and was unaware of the broken tiles and dirt. The DON, new to her position, was uncertain about the staff responsible for recent room checks. The Regional Consultant Nurse identified the chipped tile as a safety hazard, emphasizing the need for a clean and well-maintained environment, as outlined in the facility's policies.
Deficiencies in Food Safety and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the kitchen's walk-in freezer, several food items were found without proper labeling, dating, or sealing. Specifically, a bag of frozen corn and multiple bags of personal-sized pizzas lacked labels and open dates. Additionally, a bag of shredded mozzarella cheese and a half onion in the refrigerator were not labeled or dated. The Dietary Manager acknowledged the oversight and admitted that opened food items should have been labeled, dated, and sealed to prevent food contamination. Further observations revealed that a dietary staff member, referred to as [NAME] A, did not follow proper glove usage protocols. While working at the steam table, [NAME] A used the same gloves to handle a binder and pen, touch the plate warmer, and then plate food, including bread, for residents. The Dietary Manager confirmed that this practice could lead to cross-contamination, as the gloves had come into contact with unclean surfaces before handling food. The facility's policies on employee sanitation and food handling were reviewed, indicating that employees must wash hands and change gloves between tasks to prevent contamination. Despite having a food handler's certificate and training on hand hygiene, [NAME] A admitted to forgetting to change gloves during the food preparation process. The facility's in-service training records also emphasized the importance of proper handwashing and labeling of food items to ensure safety and prevent foodborne illnesses.
Inadequate Hand Hygiene by CNA Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A, who did not perform appropriate hand hygiene while retrieving ice for a resident. During the observation, CNA A was seen responding to a resident's request for ice without washing or sanitizing her hands before or after entering the resident's room. She touched high-touch areas such as the resident's door handle, bathroom door handle, and the ice chest lid without performing hand hygiene, which could lead to cross-contamination and the spread of infections. Interviews with CNA A, the Administrator (ADMIN), and the Director of Nursing (DON) confirmed the failure to adhere to the facility's hand hygiene policy. CNA A admitted to forgetting to sanitize her hands and acknowledged the risk of spreading germs to residents. The ADMIN and DON reiterated the importance of hand hygiene before providing care and handling items like the ice scoop, emphasizing that staff were trained to prevent cross-contamination. The facility's policy, revised in June 2019, clearly outlines the necessity of hand hygiene before and after resident contact and when handling food or resident items.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining good nutrition, grooming, and personal and oral hygiene. This deficiency was observed in five residents who did not receive showers as per their scheduled days. The residents were supposed to receive showers three times a week, but due to the absence of shower technicians on weekends, showers were not provided on Saturdays. This lack of service was confirmed through interviews with the residents, who reported not receiving showers on their designated days. Resident #5, a cognitively intact individual with multiple health issues including pulmonary hypertension and chronic heart failure, reported not receiving showers on weekends due to the absence of a shower technician. Similarly, Resident #6, who was moderately cognitively impaired, also confirmed missing showers on weekends. Both residents' electronic health records corroborated their statements, showing no documentation of showers on the missed days. Observations confirmed that these residents were clean and groomed at the time of the survey, but the lack of adherence to the shower schedule was evident. Interviews with staff, including a shower technician and CNAs, revealed inconsistencies in the shower schedule and responsibilities. The shower technician confirmed that she did not work on Saturdays, and CNAs were expected to cover these duties. However, CNAs admitted to not providing showers on the weekends, with no reasons given for this lapse. The facility's policy required that residents receive showers according to a set schedule, but this was not adhered to, leading to the deficiency in care for the residents involved.
Failure to Remove Controlled Medications Post-Discharge
Penalty
Summary
The facility failed to maintain a proper system for the receipt and disposition of controlled drugs, leading to potential drug diversion. For two residents, CR #40 and CR #41, controlled medications were not removed from the medication cart after their discharge. CR #40 was discharged to an acute care hospital, but her hydrocodone/APAP was still signed out after her departure, indicating possible diversion. The facility's Provider Investigation Report noted that medications for discharged residents were not promptly removed, and staff were subsequently educated on this procedure. Similarly, CR #41 was discharged to a hospital, yet his Modafinil remained in the medication cart for two weeks post-discharge. During an interview, RN T acknowledged the presence of CR #41's medication in the cart, and the DON confirmed that controlled substances should be securely stored until destroyed. The facility's policy on controlled substances was not adhered to, as evidenced by the continued presence of medications in the cart, which were vulnerable to diversion.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas within the kitchen. Observations revealed that food items were not properly labeled and dated, with instances of frozen peas and other items in the dry storage room lacking appropriate labeling. Additionally, the temperature of milk in the refrigerator was found to be above the required holding temperature, and the temperature of menu items on the steam table was below the acceptable level. These lapses in food storage and temperature control could potentially expose residents to foodborne illnesses. Furthermore, during meal preparation, a cook was observed handling baked rolls without wearing gloves, which is against the facility's policy for handling ready-to-eat foods. The Dietary Manager acknowledged these issues during interviews, admitting that the milk temperature was not checked upon delivery and that the steam table items were not maintained at the correct temperature. The facility's policies, which emphasize maintaining safe food temperatures and proper labeling, were not followed, leading to these deficiencies.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in their treatment. Resident #5, a female with multiple respiratory and cardiac conditions, was observed with an oxygen humidifier bottle that contained insufficient water to function properly. Despite her care plan emphasizing the need for supplemental oxygen and monitoring for respiratory distress, the resident reported that staff did not regularly check the water level in her oxygen tank, and she was instructed to notify them when it was empty. An LVN admitted to not checking the oxygen tank that morning due to being busy, highlighting a lapse in routine checks. Resident #4, who has a tracheostomy and requires continuous oxygen therapy, was found with an oxygen concentrator that had a nearly empty water bottle and a dirty filter. The resident's care plan and physician's orders specified the need for continuous oxygen therapy, yet the equipment was not maintained according to these guidelines. A family member noted the absence of water in the bottle during a visit, and a CNA confirmed that nurses were responsible for maintaining the oxygen equipment. An RN acknowledged the oversight and the potential impact on the resident's health, including issues with oxygen concentration and potential respiratory complications. Interviews with facility staff, including the DON, revealed that RNs were expected to check and maintain the oxygen equipment during their rounds. However, the observations and interviews indicated that these responsibilities were not consistently fulfilled, leading to the deficiencies noted in the care of Residents #4 and #5. The facility's policy on respiratory training and oxygen therapy maintenance was not adhered to, as evidenced by the dirty filter and insufficient water levels in the oxygen equipment.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with currently accepted professional principles, specifically in locked compartments. During an observation on June 4, 2024, the Hall 100 medication cart was found unlocked and unattended by the nursing station for approximately 12 minutes. Three unidentified residents were observed near the cart during this time. RN B, who had retrieved items from the cart, left it unlocked and entered a resident's room. In an interview, RN B admitted to not realizing the cart was left unlocked and acknowledged the potential danger of such an oversight. A similar incident occurred on June 6, 2024, when the Hall 300 medication cart was observed unlocked and unattended for 15 minutes. Two unidentified residents were near the cart, and a resident in a wheelchair was propelled past it by a family member. RN T, who was assisting a resident in a room, was responsible for the cart at that time. The Director of Nursing (DON) confirmed in an interview that medication carts should be locked at all times to prevent unauthorized access to narcotics and regular medications. The facility's Nursing Policies and Procedures, revised in June 2019, also state that medication carts must be kept in sight or locked at all times.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous gnats in four out of ten rooms reviewed on the 300 and 400 halls. Observations revealed gnats in the rooms of several residents, including those on their food trays and personal items such as training cup spouts. Interviews with residents indicated that the gnats were a persistent issue, particularly aggravating during meal times, and had been more noticeable with the warmer weather. Despite these observations, the facility's maintenance log showed no recent requests for pest control related to gnats, with the last request dating back to October 2023. The facility's administrator was unaware of the gnat issue, stating that staff conducted daily rounds to address resident concerns and that pest control services were contracted to treat the building monthly or as needed. However, the facility's pest control policy, revised in 2009, mandates immediate reporting of live pest sightings to request emergency services. The lack of communication and action regarding the gnat infestation suggests a breakdown in the facility's pest control program, potentially placing residents at risk of residing in an environment with pests.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident by not placing a privacy cover over the resident's urinary catheter bag. The resident, a male admitted to the facility, was observed lying in bed with his catheter drainage bag exposed and without a privacy cover. This oversight was noted during an observation, and the resident did not respond to questions during an attempted interview. The Assistant Director of Nursing (ADON) acknowledged that the privacy cover should have been placed at the time of admission, and it was the responsibility of the admitting nurse or CNA to ensure this was done. Interviews with staff, including the CNA and the Administrator, confirmed that the lack of a privacy cover was due to the resident being a new admission and the task not being completed. The CNA admitted to seeing the catheter bag earlier but did not place a cover over it, despite being trained on resident rights and catheter care. The Administrator also confirmed that the resident's privacy and dignity were not honored, and it was expected that all nursing staff should ensure the privacy cover was in place. The facility's policies on catheter care and resident dignity emphasize the importance of maintaining privacy and dignity, which were not adhered to in this instance.
Failure to Maintain Safe Environment for Resident
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, specifically in maintaining the window blinds and bed handrail in good repair. The resident, who is legally blind and has severe cognitive impairment, was observed in a room with broken blinds that had sharp, jagged edges within her reach. Additionally, the plastic handrail on her bed was damaged, with plastic peeled upward, creating pointy sharp edges. These conditions posed a risk of injury to the resident, who was seen reaching towards the window blinds while holding onto the damaged handrail. Interviews with the facility's Administrator and Director of Support Services revealed that the staff failed to report the need for repairs through the maintenance log, which is supposed to be updated during Angel Rounds. The Administrator acknowledged that the damaged items could cause injury and stated that staff entering the room should have made a maintenance request. However, the Director of Support Services confirmed that no work order had been received for the repairs, and the last maintenance request was recorded before the resident's admission. The lack of communication and follow-through on maintenance requests contributed to the unsafe environment for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 653 citations issued within 25 miles in the last 12 months — including the 62 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 Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seven Acres Jewish Senior Care Services | 2.4 mi | ★★★★★ | 2 | 0 |
| Bayou Manor | 2.7 mi | ★★★★★ | 4 | 0 |
| Avir At Orem | 3 mi | ★★★★★ | 1 | 0 |
| University Place Nursing Center | 3.7 mi | — | 0 | 0 |
| Houston Transitional Care | 4 mi | ★★★★★ | 1 | 0 |
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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.