Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Paradigm At Woodwind Lakes during CMS and state inspections, most recent first.
The facility failed to verify and implement resident advance directives and DNR status at admission, resulting in conflicting documentation and treatment that did not align with residents’ expressed wishes. One resident with hospital records and a portal summary clearly indicating DNR status was admitted without an admission packet, listed as full code in the EMR and care plan, and received CPR after being found unresponsive because staff relied on the EMR banner and did not review supporting DNR documents or contact the POA to resolve discrepancies. Another resident with hospital DNR documentation and a completed OOH-DNR form was care planned as full code, and physician orders alternated between full code and DNR without timely clarification or documentation of discussions with the responsible party. Interviews with the DON, social worker, admissions coordinator, marketer, NP, and medical director showed that no single role was clearly accountable for reconciling advance directives at admission, the DON did not review clinicals, the social worker only verified code status at the 72-hour care plan, and the admission packet containing advance directive acknowledgements was not consistently provided or reviewed with responsible parties, leading to systemic failures in honoring residents’ code status.
A resident with multiple medical conditions and mild cognitive impairment was admitted with a family member holding POA present, but the facility failed to provide or review the admission packet that includes resident rights, rules, responsibilities, charges, and advance directive information. The EMR contained no admission packet or agreement, and the advance directives section was left blank. The Admissions Coordinator acknowledged that no packet was created or given, did not review packet contents with residents or representatives, and intentionally withheld the packet pending POA confirmation, despite POA documentation being available. The family member reported never receiving any rights information or documentation, while the Administrator stated the packet is the primary means of communicating rights and resident wishes; later, the resident received CPR despite having DNR wishes handled by the hospital.
A resident with severe dementia, impaired communication, gait instability, and a history of wandering and walking into objects was care planned for frequent checks and supervised ambulation. In the memory care dining area, a CNA placed the resident on a couch and left to care for another resident without handing off supervision, while another CNA and an LVN were at the nurses’ station charting and not maintaining direct visual observation of the dining room. The resident, who was known to walk continuously and not remain seated, sustained an unwitnessed fall and was later found on the floor; a hematoma developed on the right forehead, and the resident was sent to the hospital. Leadership and staff acknowledged that residents in memory care required constant supervision and that the nurses’ station did not allow full visibility of the dining room, but supervision expectations and facility policies on dementia care, fall management, and safety were not followed at the time of the incident.
A resident with severe cognitive impairment, neurogenic bladder, and an indwelling Foley catheter experienced a progressive slit on the penis and urine leakage into an incontinent brief due to inadequate catheter monitoring and care. Orders and the care plan required every-shift assessment of the catheter site for redness, irritation, urethral erosion, leakage, and urine characteristics, but nursing documentation showed no reported issues while the penile slit enlarged from a small, non-bleeding area to a beefy red, bleeding wound extending from the meatus down the shaft. During observed care, the resident’s brief was saturated with urine, dressings were wet and non-adherent, and the catheter tubing contained sediment with cloudy, sediment-filled urine in the bag. Staff interviews revealed that some staff had known about the slit for weeks, the assigned nurse had not assessed the penis or recognized leakage despite making rounds, and the NP had not been informed of the worsening condition or catheter leakage, demonstrating failures to monitor, recognize, and report catheter-related complications.
Two residents did not receive fully developed and implemented person-centered care plans consistent with their assessed needs. One resident with dementia, parkinsonism, and bilateral hand contractures had physician orders for a restorative program that might have included a resting hand splint and specific ROM/stretching interventions, but these device-based interventions were not incorporated into the care plan and were inconsistently applied, with staff unable to locate the devices or documentation of their use. Another resident with advanced dementia, severe cognitive impairment, gait impairment, and documented wandering had a care plan calling for supervision and safety measures, yet she continued to wander with frequent loss of balance and sustained an unwitnessed fall with a facial hematoma, while staff reported only general supervision and non-skid socks as active interventions and uncertainty about specific supervision measures in the care plan.
Failure to supervise two residents during smoking. A resident with cognitive impairment and multiple mobility-related diagnoses and another resident with dementia, repeated falls, and respiratory failure were both assessed as safe to smoke with supervision, with staff to control smoking materials and oversee smoking in designated areas and times. During observation, the two residents were seen smoking outside unsupervised, sharing one cigarette, putting it out, and returning inside. An LVN stated both were safe smokers and that unsupervised smoking could result in burns to themselves or others.
Failure to Secure Foley Catheter and Monitor Penile Skin: A resident with an indwelling Foley, moderate cognitive impairment, and multiple serious diagnoses had catheter care failures during CNA and LPN care. Staff observed no Statlock or leg strap in place, the tubing was left on the bed and not below the bladder during wound treatment, and a slit with redness was found on the penis. Interviews showed staff were unaware of the injury, and prior skin assessments did not document it.
Care plan failed to address hand contractures. A resident with Alzheimer's disease, parkinsonism, stroke, muscle weakness, and moderately impaired cognition had bilateral wrist/hand contractures documented by the MD, with Baclofen ordered for spasms and contractures. The care plan only addressed ADL deficits and PROM during cares, but did not specifically include interventions for the contractures or the ordered medication. Observation showed severe left hand contracture, right hand flexion, and no palm protectors or hand braces in place.
Failure to Maintain Ordered Abdominal Binder for a Resident with a G-Tube: A resident with dementia, severe malnutrition, and gastrostomy status had an order for an abdominal binder at all times, but staff did not always keep the binder on. The resident’s G-tube was found dislodged, a Foley catheter was inserted into the stoma to maintain patency, and the resident was transferred to the hospital. Later observation showed the resident without the binder while staff reported it had been sent to laundry after becoming wet.
Improper tracheostomy suctioning and care: An LVN failed to use sterile technique throughout trach care and suctioning for a resident with a tracheostomy, including handling sterile and dirty fields without changing gloves and suctioning without checking O2 saturation before or during the procedure. The resident was dependent for care, had significant cognitive impairment, and was receiving oxygen via trach mask. The RT and DON confirmed the expected technique, and the facility policy required aseptic trach care and monitoring O2 saturation throughout the procedure.
A resident with moderate cognitive impairment and total-assist ADL needs had incomplete bathing documentation. Her care plan required scheduled showers and grooming, but the POC showed N/A entries for multiple bathing days and the paper shower sheet lacked details of the care provided. CNAs stated they gave bed baths but forgot to document them, and one CNA said she may have selected the wrong option in the POC.
Staff failed to follow infection control practices during resident care. Two CNAs provided catheter-related care to a resident on EBP without wearing the required gowns, and a CNA performing perineal care for another resident removed dirty gloves, did not perform hand hygiene, and used gloves kept in her pocket before touching clean items. The residents involved had significant care needs, including an indwelling Foley catheter, incontinence, moderate cognitive impairment, and assistance with toileting hygiene.
Inaccurate controlled drug counts and delayed narcotic documentation were found on two medication carts. A resident with severe cognitive impairment had Lorazepam stored incorrectly in a cart after it was accidentally pulled, and two other residents with dementia had narcotic count discrepancies tied to incomplete documentation after Lorazepam and Tramadol administration. The DON stated controlled substances should be signed off immediately and wasted narcotics should not be left in the cart.
Pest Control Failure in Kitchen and Dining Areas: Flies were observed on plates prepared for resident lunch, flying around food during meal prep, and landing on residents’ food while they were eating. A roach was also seen on the dining room floor during lunch. The DM, LVN, and CNA all acknowledged the pest issue or its potential impact, while records showed weekly pest control service and documentation of fly light replacement and liquid applications.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with severe cognitive and physical impairments was transferred by a single CNA instead of the required two-person assist, resulting in the resident's head striking the wall. The CNA admitted to performing the transfer alone, contrary to the care plan and facility policy, and staff assessments confirmed the resident sustained a minor injury. Documentation and interviews verified that the transfer was not conducted according to established procedures.
A resident with Alzheimer's disease, altered mental status, repeated falls, and significant mobility dependence had a physician order and consent for a right quarter bed rail, and staff observed the rail in use for positioning. However, the care plan did not include the right-side rail, even though staff stated bed rails should be care planned and the facility policy required care plan updates when status changes occurred.
A resident with end-stage renal disease and multiple comorbidities did not have required Dialysis Hand Off Communication Report forms completed or properly maintained for the majority of her dialysis sessions. Despite physician orders and facility policy mandating the use of these forms to ensure communication between facility staff and the dialysis center, the forms were either missing or incomplete, and oversight by nursing management was inconsistent.
A resident with multiple chronic conditions developed a sacral wound that progressed to a stage 4 pressure injury with infection and severe sepsis after staff failed to follow wound care orders and did not consistently document or perform required treatments. The wound worsened over several weeks, and the resident was ultimately transferred to the hospital after family intervention.
Two residents dependent on staff for ADLs did not consistently receive required showers, baths, or nail care, as evidenced by missed scheduled care and observations of poor hygiene. Staff interviews and documentation revealed lapses in following care plans and facility policy, resulting in unaddressed grooming and hygiene needs.
A Wound Care Nurse failed to change gloves between cleansing a wound and applying treatment and dressing for a resident with a stage 3 pressure ulcer, contrary to facility policy. The resident, who was fully dependent and had multiple health issues including sepsis and chronic pain, received wound care without proper infection control practices, as observed by surveyors.
Two residents requiring oxygen therapy did not receive care consistent with physician orders and facility policy. One resident received continuous oxygen without a current physician order, while another received oxygen at a higher flow rate than ordered. Staff interviews and record reviews confirmed these discrepancies, and the facility's policy requiring verification and documentation of oxygen therapy was not followed.
Surveyors identified that the facility's medication error rate exceeded five percent due to three errors involving two residents. In one case, a nurse administered a stool softener and a multivitamin with minerals instead of the specific medications ordered for a resident with dementia and constipation, citing stock issues. In another case, a medication aide applied a new Rivastigmine patch before removing the old one for a resident with dementia, contrary to facility policy and physician orders. These errors were attributed to staff not following established medication administration protocols.
Two residents in a facility experienced discomfort due to drafty windows in their room, which were not properly sealed, allowing cold air to enter. Despite complaints and the provision of extra blankets, the issue was not addressed promptly, affecting the residents' comfort and safety. The residents, both with severe cognitive impairments and other health conditions, reported feeling cold, and staff interviews confirmed awareness of the problem.
The facility failed to provide palatable and appetizing meals, as observed during a survey. The lunch meal served was bland and poorly prepared, with mushy pasta and chewy squash. Residents expressed dissatisfaction, and there was an increase in requests for alternative meals. The Dietary Manager noted the cook's inexperience and the need for more staff and training to improve meal quality.
The facility failed to follow professional standards for food service safety, as observed in their kitchen. Drinks were stored in the fridge without lids or labels, a pitcher of chopped fruit lacked a date or label, and a bin of flour was not completely sealed. The Assistant Dietary Manager acknowledged these oversights, which could risk foodborne illness.
A resident with multiple health conditions, including dementia and frequent incontinence, did not receive appropriate incontinent care, as a CNA cleaned from back to front and failed to change gloves, contrary to facility policy. This action posed a risk of urinary tract infections, as confirmed by staff interviews and facility procedures.
A medication error occurred when a resident was given blood pressure medications outside of the physician's prescribed parameters, resulting in a 7% medication error rate at the facility. The resident, with a history of hypertension, received Isosorbide and Carvedilol despite a blood pressure reading below the hold threshold. The error was acknowledged by the medication aide, who had recently started working at the facility, and was reported to the nursing staff. The facility's policy required adherence to physician orders, and the management team was responsible for ensuring compliance.
A resident in an LTC facility received blood pressure medications outside the prescribed parameters, leading to a significant medication error. The resident, with a history of heart failure and hypertension, was given Isosorbide and Carvedilol despite having a blood pressure of 107/71 and a heart rate of 67, which were outside the ordered parameters. The error was realized post-administration, and the nursing staff acknowledged the potential risks involved.
A resident with multiple medical conditions and frequent incontinence did not receive proper infection control during care. CNA A failed to change gloves and perform hand hygiene after cleaning the resident's perineal area, risking cross-contamination. Interviews with staff confirmed the breach, and facility policies were reviewed, highlighting the need for proper glove removal and handwashing.
The facility failed to maintain a clean and sanitary environment in a secured unit, with observations of dirty, sticky floors in the hallway, dining room, and activity room. A resident was seen walking barefoot on the dirty floor. The Housekeeping Supervisor and Maintenance Manager acknowledged the issues, citing inadequate oversight and accountability for floor cleanliness. The Director of Nursing was aware of the problem and mentioned plans to address it.
Failure to Verify and Implement Resident Advance Directives and DNR Status at Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ advance directives were accurately identified, clarified, and implemented upon admission, resulting in discrepancies between documented code status and residents’ expressed wishes. For one resident (CR#1), hospital records and the admission portal summary clearly indicated a DNR status and receipt of a living will, yet the facility’s baseline care plan and EMR listed her as full code. Her advance directives section in the facility record was blank, and there was no admission packet or agreement on file. Physician orders initially documented her as full code, and although a physician progress note later reflected both “Full code” and “Advance Directives DNR,” no clear, timely clarification was obtained. Staff did not review the miscellaneous tab in the EMR for DNR paperwork, and no one contacted the POA to reconcile conflicting documentation. On the morning of the event, CR#1 was found unresponsive with no palpable pulse. Nursing staff confirmed her status as full code using the EMR banner and initiated CPR, which continued until EMS arrival and transport to the hospital. EMS continued resuscitative efforts, including intubation and mechanical CPR, until the POA notified hospital staff that the resident’s wishes were DNR, at which point resuscitation was stopped and the resident was pronounced deceased. Interviews with family and the hospital case manager confirmed that the resident had chosen DNR status during her hospital stay and that DNR documentation had been sent to the facility prior to admission. The facility did not clarify the discrepancy between hospital DNR documentation and internal full-code orders before the change in condition occurred. For another resident (Resident #1), hospital nephrology notes and the hospital transfer cover page documented a DNR code status, and an OOH-DNR form had been completed, signed by the legal guardian, witnessed, and notarized. However, the facility’s care plan identified this resident as full code, and physician orders alternated between full code and DNR on multiple dates, with changes verified only by medical record review and without documented prior clarification. The medical director’s signature on the OOH-DNR form was delayed, and there was no documentation addressing the resident’s advance directives prior to a late social worker note confirming the RP’s wish for the resident to remain DNR. Interviews with the DON, social worker, admissions coordinator, marketer, NP, and medical director revealed that no specific staff member was clearly responsible for verifying and reconciling advance directives at admission, that the DON did not review clinicals before or after admission, and that the admissions coordinator did not provide or review the admission packet containing advance directive acknowledgements with CR#1’s POA. These systemic gaps led to residents being treated as full code despite prior DNR designations and without timely clarification of discrepancies in their advance directive documentation. The facility’s own staff acknowledged that the admission process for advance directives was fragmented and that responsibilities were unclear. The DON stated there was no specific staff responsible for ensuring residents’ wishes and code status were accurately entered at admission and that she did not investigate CR#1’s code status concerns or audit advance directives after the incident. The social worker confirmed she only verified code status at the 72-hour care plan and did not review admission documentation or contact CR#1’s POA before the resident’s death. The admissions coordinator admitted she did not send an admission packet to CR#1’s POA, did not review its contents with responsible parties, and did not recognize that the packet contained advance directive acknowledgements. The administrator and medical director both described failures in communication, documentation, and timely clarification of discrepancies, and the facility later identified additional residents whose DNR status could not be confirmed and whose code status had been changed to full code while verification was pending.
Failure to Provide Admission Packet and Communicate Resident Rights and Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident, both orally and in writing, of her rights, rules, responsibilities, and facility policies at the time of admission. The resident was an elderly female admitted with diagnoses including UTI, history of colon cancer and large intestine, hypertension, irregular heartbeat, presence of a pacemaker, and mild cognitive impairment, with a BIMS score of 12/15 indicating moderately impaired cognition. Her face sheet listed a family member as Emergency Contact and POA for healthcare, and her advance directives section was blank. Progress notes documented that she arrived in the evening by EMS, was A&O x2, oriented to the room and equipment, and did not voice concerns at that time. However, the electronic medical record contained no admission packet or admission agreement for her. Interviews with facility staff revealed inconsistent and incomplete practices regarding the admissions packet, which contained resident rights, rules governing resident conduct, responsibilities, charges, and advance directive information. The Administrator stated that resident rights were communicated through the admissions process and packet, and that the Admissions Coordinator and Marketing were responsible for completion of the packet, which should be provided before or at admission and completed within 72 hours. The DON similarly stated that the packet was sent prior to arrival and completed shortly after admission. In contrast, the Admissions Coordinator initially described her role as getting the room ready and ensuring a good stay, and stated she was not responsible for reviewing documentation. She later stated she was responsible for the admission packet, usually completed after admission and provided via email or in person within 48 hours, but that she did not review the packet contents with residents or their representatives. For this resident, the Admissions Coordinator acknowledged that no admission packet was created or provided, and that the resident’s POA, who was present at admission, never received the packet or any communication of resident rights or other packet contents. She stated she intentionally did not send the packet because she had not yet confirmed the POA status, even though the executed POA was included in documentation received before and after admission. The family member/POA reported that the resident was very confused and distressed on admission, repeatedly stating that people were trying to kill or harm her, and that the family member never received an admission packet or any documentation of rights or other information. The Administrator stated that failure to deliver or communicate the contents of the admissions packet could leave residents unaware of their rights and the facility unaware of residents’ wishes. The record also showed that the resident’s advance directives were not documented in the facility record, and on a later date she received CPR when unresponsive despite her wishes being DNR, with the hospital having handled the DNR paperwork.
Unwitnessed Fall and Head Injury Due to Inadequate Supervision in Memory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a cognitively impaired resident in the memory care unit. The resident was an elderly female with dementia with psychotic disturbance, severe cognitive impairment (BIMS score of 00), altered mental status, restlessness and agitation, gait impairment, lack of coordination, and a history of unintentionally walking into objects and removing footwear. Her care plan identified ADL deficits, the need for staff to anticipate needs and provide prompt assistance, supervision with one staff for walking in the room and corridor, limited assistance for locomotion on and off the unit, frequent checks during high‑risk times, maintaining safety during increased wandering, and offering engaging activities to reduce restlessness. The care plan also noted impaired communication, risk for further decline and injury, and the need to reduce environmental stimuli and use communication tools the resident could understand. On the day of the incident, the resident was wandering in the memory care dining room and was known by staff to walk continuously, not remain seated, and be unable to communicate needs verbally. CNA A reported placing the resident on a couch in the dining area and then leaving to provide care to another resident without notifying other staff or providing a handoff of supervision, despite the expectation that residents in the memory care unit be supervised at all times and that staff verbally pass on supervision responsibilities before leaving an area. CNA B stated she was at the nurses’ station charting and was not directly observing the resident, did not see or hear the fall, and was unaware of the exact whereabouts of other staff. She reported that she had been charting for about five minutes before noticing the resident on the floor in the dining room and was unsure how long the resident had been on the floor. LVN A stated she was seated at the nurses’ station documenting, could only see a portion of the dining room from that position, and was notified by CNA B that the resident was on the floor. The fall was unwitnessed, and the resident was found on the floor in a seated position on her bottom in the dining room. Initial assessment by LVN A documented stable vital signs and no visible injuries or pain at that time, and the environment around the fall was noted to have no notable findings. Later, swelling and a nodule/hematoma developed on the right side of the resident’s forehead, with subsequent discoloration to the right side of the face above the eyebrow, below the eye, and toward the nose. The resident was sent to the hospital, where imaging and tests were described as reassuring, and instructions were given to ice the hematoma. Facility leadership, including the ADON, DON, and Administrator, stated that residents in the memory care unit, and this resident in particular, required constant or continuous supervision due to wandering, inability to ensure their own safety, and communication deficits, and that staff were expected to maintain direct visual observation and communicate supervision coverage. Staff interviews and observations confirmed that at the time of the incident, the resident was not under continuous direct observation, supervision responsibilities were not properly handed off, and the nurse’s station position did not allow full visibility of the dining room, leading to the unwitnessed fall and resulting head injury. Subsequent observation of the resident by the surveyor showed that she ambulated independently but experienced brief losses of balance every few steps or when stopping, did not respond verbally, and did not allow staff to assist for more than a few seconds before moving away. LVN C confirmed that the resident never sat still, including during meals, did not communicate verbally, and required continuous direct observation to ensure safety. The facility’s own policies on Dementia Care, Fall Management, and Standards of Care required person‑centered care, individualized fall prevention plans, supervision during high‑risk activities such as ambulation, and safety measures to prevent accidents and injuries. Despite these policies and the resident’s documented risks and care plan interventions, staff actions and inactions at the time of the incident resulted in the resident being unsupervised in the dining room, an unwitnessed fall, and a hematoma to the forehead requiring hospital evaluation.
Failure to Monitor and Manage Indwelling Catheter Leading to Worsening Penile Injury and Urine Leakage
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and monitoring for a male resident with an indwelling urinary catheter, resulting in worsening penile injury and leakage of urine into his incontinent brief. The resident had significant medical conditions including hypertension, stage 3 pressure ulcers, neurogenic bladder, obstructive and reflux uropathy, and used an indwelling catheter. His MDS showed severe cognitive impairment, total dependence for toileting, and incontinence of bowel and bladder. His care plan and physician orders required staff to follow catheter-related orders, monitor the catheter site every shift for signs of infection, irritation, urethral erosion, and leakage, and to monitor urine characteristics and report abnormalities to the physician. Surveyor review of prior documentation showed that during an earlier survey, the resident’s penis had a small slit measuring 0.3 cm by 0.1 cm with slight redness, and there was no leg strap or Statlock securing the catheter. CNAs at that time reported they had not previously seen the slit. Despite ongoing orders to monitor for complications each shift, the March MAR entries indicated nurses signed off that there were no issues with the Foley and skin area. However, during a later observation of catheter and incontinent care, the resident’s penis was found to be slit from the meatus down the shaft, with a beefy red color and fresh bleeding. The slit had increased in size to 1.5 cm by 0.5 cm. When the area was wiped, the wipes showed a substantial amount of blood. Staff interviews indicated that the slit had been present and known to some staff for weeks, but they described it as smaller and not bleeding previously. During the same observation, the resident’s brief was saturated with urine, the wetness indicator was not visible, and the wound dressing near the buttock was wet and non-adhesive, with a second dressing soaked. The Foley tubing contained smears of sediment with no urine visible in the tubing, and the Foley bag held cloudy urine with a significant amount of sediment. The nurse assigned to the resident stated he had made rounds twice that day but had not noticed Foley leakage or assessed the penis, and he acknowledged he was aware of the slit from prior orientation but believed it was regular wear and tear from Foley use. He also stated he was not aware of the leakage until he saw the soaked brief and sediment in the tubing and bag, and he did not identify when to obtain an order to flush the catheter. The NP later reported she had not been informed that the slit had worsened, had not been notified of leakage or balloon issues, and had not given the ointment order the nurse described. Other staff, including CNAs, the ADON, DON, and Corporate Nurse, confirmed the slit had been smaller previously, that the Foley had been leaking onto the brief, and that sediment and potential clogging could cause leakage and skin breakdown, but these changes and complications were not consistently recognized, monitored, or reported as required by the resident’s orders and care plan.
Failure to Integrate and Implement Contracture and Wandering Interventions in Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents whose needs had been identified in their assessments. For one male resident with Alzheimer’s disease, parkinsonism, stroke history, muscle weakness, and dependence in ADLs, the comprehensive assessment and care plan identified bilateral hand contractures and risk for skin breakdown, pain, and worsening contractures. The care plan interventions focused on keeping contractured areas clean and dry, providing PROM without forcing the joints, monitoring for pain and stiffness, and providing medications and treatments as ordered. However, the resident’s physician orders included a restorative nursing program that might have included a left resting hand splint and specific ROM and stretching exercises to prevent further contractures, and these splint/hand device interventions were not incorporated into the care plan. Observations and interviews showed that the ordered hand splint/hand roll interventions were not consistently implemented. During observation, the resident was noted to have contractures in both hands with no splint or hand roll in place, and the resident reported that staff applied the devices only when they wanted and that he had not received them that day. The assigned RN stated he had not seen any hand roll in place, acknowledged the resident was supposed to have one, and indicated that restorative aides or CNAs were responsible for applying them. CNAs and restorative aides confirmed the resident was supposed to have “carrots” or rolled towels in both hands for specified on/off intervals, but reported that the devices were not present in the room at times, that they relied on restorative aides or CNAs to apply them, and that documentation of this care was inconsistent. Facility leadership, including the DON, ADON, and MDS Coordinator, acknowledged that the hand device intervention was not on the care plan, that restorative documentation was not integrated into the electronic plan of care, and that they could not locate documentation showing the ordered intervention had been consistently provided. The deficiency also involves a female resident with dementia with psychotic disturbance, gait impairment, lack of coordination, altered mental status, restlessness, and agitation, who had severe cognitive impairment (BIMS score of 0), fluctuating inattention and disorganized thinking, and documented wandering behavior. Her care plan identified ADL deficits, need for staff to anticipate needs and provide prompt assistance, limited assistance for locomotion, supervision for walking, PROM as needed, and a history of unintentionally walking into objects. Interventions included frequent checks, maintaining safety during increased wandering, offering engaging activities, reducing environmental stimuli, using communication tools she could understand, and addressing her history of removing footwear. Despite these care-planned needs, the resident experienced an unwitnessed fall in the dining room after wandering, later presenting with a hematoma and discoloration on the right side of the face that required hospital evaluation. Subsequent observation showed the resident ambulating independently with frequent brief losses of balance, not responding verbally, and continuing to walk away from staff attempts to assist. Staff interviews indicated that CNAs and nursing staff recognized the resident as nonverbal, continuously walking, not remaining seated, and at high fall risk, and that she required staff to watch her while walking. However, staff also reported there were no specific interventions beyond general supervision and non-skid socks to address her constant movement and wandering, and one CNA was unsure whether the care plan specifically included supervision interventions. Leadership interviews confirmed that staff were expected to follow care plans, that the resident was care planned for supervision due to wandering and fall risk, and that failure to follow or individualize care-planned interventions could result in residents not receiving necessary services. The care plan was only updated after the fall to add non-skid socks, indicating that at the time of the incident, the care plan and its implementation did not fully address the resident’s persistent wandering and supervision needs as identified in her assessments.
Failure to Supervise Residents During Smoking
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for two residents who were smoking outside without staff supervision. Resident #60 had diagnoses including lack of coordination, muscle weakness, falls, difficulty walking, schizoaffective disorder with hallucinations and delusions, dementia, and transient ischemic attack. His MDS annual assessment showed a BIMS score of 10 out of 15, indicating moderate cognitive impairment and possible need for support with decision-making or understanding instructions. His smoking assessment and care plan indicated he was safe to smoke with supervision, with staff to store and distribute smoking materials and supervise smoking in designated areas and times. Resident #134 had diagnoses including respiratory failure, muscle weakness, dementia, cognitive communication deficit, repeated falls, lack of coordination, and presbyopia. His smoking assessment and care plan also indicated he was safe to smoke with supervision, with staff to perform smoking assessments and explain designated smoking areas and times. During observation, two residents identified as Resident #60 and Resident #134 were seen smoking outside unsupervised, sharing one cigarette, putting it out, and returning to the building. In interview, an LVN stated both residents were safe smokers and that unsupervised smoking could result in burning themselves or someone else. The facility's safe smoking policy stated that residents requiring supervision while smoking would be supervised by an employee throughout the designated smoke break.
Failure to Secure Foley Catheter and Monitor Penile Skin
Penalty
Summary
The facility failed to ensure appropriate catheter care and services for a resident with an indwelling Foley catheter who had multiple medical conditions, including pneumonia, acute respiratory failure with hypoxia, hypertension, schizophrenia, pressure ulcers, diabetes, functional quadriplegia, and obstructive/reflux uropathy. The resident’s MDS showed moderate cognitive impairment and total assistance with toileting. His care plan and physician orders required catheter securement, daily rotation of the securement site, and monitoring for complications such as redness, irritation, infection, obstruction, and urethral erosion. During observation of incontinent care and pressure ulcer treatment, CNA AA and CNA BB observed that the Foley catheter had no leg strap or Statlock securing device in place. The catheter tubing was placed on the bed and was not below the resident’s bladder while LVN CC performed sacral wound treatment. Cloudy urine was noted along the tubing. The resident did not verbalize pain or show facial grimacing during care, but the surveyor and ADON measured a slit on the penis that was 0.3 cm long by 0.1 cm wide, with small redness near the area. Record review showed the resident’s skin assessments from several prior dates did not address the penile slit. Staff interviews indicated CNA AA, CNA BB, LVN CC, and the ADON were not aware of the slit before it was identified by the surveyor, and the ADON stated he had not checked whether the Statlock was in place because he had just been called in to work. The DON stated the resident should have had the Foley secured to prevent tension and that the catheter should be hung below the bladder to prevent backflow of urine and possible UTI. The resident’s physician and NP were notified after the slit was identified.
Care Plan Did Not Address Hand Contractures
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #54 that included measurable objectives and timeframes to meet his medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #54 was admitted with diagnoses including Alzheimer's disease, parkinsonism, stroke, muscle weakness, and need for assistance with personal care. His quarterly MDS showed a BIMS score of 9 out of 15, indicating moderately impaired cognition, and also documented impairment of one upper extremity and both lower extremities. Record review showed a physician note documenting bilateral wrist contractures, with the left wrist severely contracted, and the assessment and plan included continuing Baclofen 10 mg three times daily for muscle spasms and contractures. However, the care plan reviewed on 01/07/2026 addressed ADL self-care deficits and included PROM during ADL cares as needed, but did not specifically address interventions for hand contractures or the ordered Baclofen for contractures. Observation showed the resident's left hand was severely contracted and both hands lacked palm protectors or hand braces. The MDS nurse stated the care plan should include the contractures and later said it was updated on 01/08/2026, and the DON stated the nursing team was responsible for updating the care plan.
Failure to Maintain Ordered Abdominal Binder for G-Tube Resident
Penalty
Summary
Resident #10, who had dementia, severe malnutrition, gastrostomy status, and adult failure to thrive, was dependent on staff for all ADLs and had a BIMS score of 00 out of 15. Her care plan and physician orders required an abdominal binder at all times, with skin checks when removing and replacing it for bathing or showers, to help keep the G-tube in place and prevent dislodgement. The facility’s enteral feeding policy stated that residents with enteral feeding tubes would receive adequate care to prevent complications. On 10/14/2025, the resident’s G-tube was found dislodged, the hospice nurse was notified, and a 16-French Foley catheter was inserted into the stoma to maintain tract patency before the resident was transferred to the hospital. When observed on 01/09/2026, the resident did not have the abdominal binder on while receiving care and was moving her arms and hands freely. An LVN stated the binder had been placed in laundry because it became wet and that the resident should always have the binder on. The DON stated nurses were responsible for following the binder order and that the binder should always be on the resident due to her history of pulling out G-tubes.
Improper tracheostomy suctioning and care
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with a tracheostomy who required tracheostomy care and suctioning. The resident had diagnoses including tracheostomy status, sepsis, hypertension, anxiety disorder, metabolic encephalopathy, persistent vegetative state, and speech and language deficits following a stroke. The resident was dependent on staff for care and had a quarterly MDS indicating cognitive impairment, with staff noting problems with short-term and long-term memory and recall. Physician orders directed tracheostomy care every shift and as needed, tracheostomy site dressing changes daily and as needed if soiled, suctioning of the tracheostomy tube as needed to clear the airway, trach suctioning every shift and as needed, and oxygen at 4-6 L/min via tracheostomy. The care plan identified the resident as having a tracheostomy related to respiratory failure and directed suctioning as necessary with universal precautions as appropriate. During observation, the resident was in bed with oxygen running at 5 L/min via trach mask and had foam coming out of the mouth and dry crusted phlegm on the side of the mouth. During tracheostomy suctioning and care, the LVN washed hands, donned clean gloves, opened the sterile suction kit, removed dirty gloves without washing hands, donned sterile gloves, and then handled the suction catheter and tubing. The LVN removed the oxygen neck mask and suctioned without checking oxygen saturation before or during suctioning. During trach care, the LVN opened the trach kit, donned sterile gloves, handled items from both dirty and sterile fields without changing gloves, and replaced the inner cannula. The LVN later checked oxygen saturation after tracheostomy care. The LVN stated he forgot to maintain a dominant hand and forgot to check oxygen saturation before suctioning. The RT confirmed that changing the inner cannula was aseptic technique, suctioning was sterile technique, and that the LVN should have used a dominant hand and not both hands during suctioning. The DON stated sterile technique should be used throughout tracheostomy care and that not suctioning with sterile technique could result in infection or cardiac arrest. The facility policy also required aseptic tracheostomy care and monitoring oxygen saturation throughout the procedure.
Incomplete Documentation of Resident Bathing Care
Penalty
Summary
The facility failed to ensure medical records were kept in accordance with professional standards and were complete and accurately documented for Resident #125. The resident was admitted and readmitted with diagnoses including encephalopathy, schizoaffective disorder depressive type, Alzheimer's disease with early onset, and morbid obesity. Her 5-day MDS showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment, and she was dependent on staff for showering/bathing. Her care plan directed staff to provide extensive to total assistance with ADLs, including scheduled showers and related grooming care. Record review of the resident’s electronic POC showed a bathing schedule of Tuesday, Thursday, and Saturday on the day shift, but N/A was entered for showers on 1/1/26, 1/3/26, and 1/6/26, with no documentation in the electronic chart showing a shower or bed bath on those days. Paper shower sheets for January 2026 showed one shower documented on 1/3/26, signed by CNA H, but the sheet did not indicate the cleansing activity or expected grooming received. During interviews, the resident said staff sometimes did not give her a shower and that her last shower was the prior week. CNA H stated she gave a bed bath on 1/1/26 but forgot to document it, and CNA I stated she gave a bed bath on 1/6/26 but forgot to document it and also said she may have clicked the wrong button when documenting showers on the POC.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program when staff did not follow required PPE and hand hygiene practices during resident care. One resident had an indwelling Foley catheter, pressure ulcers, and a BIMS score of 10, indicating moderate cognitive impairment. The resident’s physician order required Enhanced Barrier Precautions with gown and gloves during high-contact care activities related to the Foley catheter, and the facility policy stated that gown and gloves were required for activities such as hygiene, changing briefs, assisting with toileting, device care, and wound care. During observation, two CNAs entered the resident’s room and provided incontinent and Foley catheter care without wearing gowns, although EBP signage was posted by the head of the bed. Both CNAs put on gloves after entering the room, but neither donned the required gown. When interviewed, both CNAs stated they forgot to use PPE. The DON stated that any resident with a Foley catheter was placed on Enhanced Barrier Precautions and that contact with such a resident required gown and gloves. A second resident had diabetes, hemiplegia, malnutrition, and a BIMS score of 10, and required substantial assistance with toileting hygiene and was occasionally incontinent of bowel and bladder. During observed perineal care, a CNA washed hands and donned gloves, completed the dirty portion of care, removed the soiled brief, removed gloves, and then took a pair of gloves from her pocket and put them on without performing hand hygiene. She then touched clean briefs and bed linens while continuing care. The CNA stated she should have washed her hands after removing the dirty gloves and stated she should not have used gloves from her pocket. The DON stated staff were expected to wash hands after removing used gloves and before putting on new gloves, and that keeping gloves in pockets was not acceptable.
Inaccurate controlled drug counts and delayed narcotic documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of residents and failed to maintain controlled drug records in sufficient detail to allow accurate reconciliation for two medication carts. The report identified problems with the LEC MA cart and the East Front Nurse cart, including inaccurate narcotic counts and delayed documentation of controlled substances after administration. Resident #32 was an older female with Alzheimer’s disease, restlessness and agitation, generalized anxiety disorder, and a BIMS score of 0 indicating severe cognitive impairment. She had an order for Lorazepam 1 mg at bedtime. On 8/14/25, the controlled drug record showed 8 pills remaining, but observation of the LEC MA cart showed the blister pack contained 7 pills and an unlabeled cup in the cart contained 1 Lorazepam pill. MA W said she had accidentally pulled the medication around 9 a.m., had not immediately called a nurse to waste it, and had not documented or signed the narcotic book for the morning narcotics. LVN E stated the medication should not have been stored on the cart and had to be wasted with two signatures. Resident #70 was an older female with unspecified severe dementia, heart disease, and anxiety, with a BIMS score of 0 and assistance needed with ADLs. She had an order for Lorazepam 1 mg twice daily. On 8/14/25, the controlled drug record showed 6 pills remaining, but the blister pack on the LEC MA cart contained 5 pills. MA W said she had administered the narcotic that morning but had not documented or signed off because there was a lot going on in the memory care unit. Resident #60 was an older female with dementia, schizophrenia, and chronic pain, with severely impaired cognitive skills. She had an order for Tramadol 50 mg every 8 hours as needed. On 8/14/25, the controlled drug record showed 33 pills remaining, but the East Front Nursing cart blister pack contained 32 pills after LVN J administered a dose and had not yet signed the narcotic book. The DON stated narcotic documentation should occur as soon as the medication is given and that wasted narcotics should be documented immediately.
Pest Control Failure in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen and dining areas. During observation on 08/13/2025 at 11:48 AM, flies were seen on plates that had been prepared for resident lunch in kitchen 1 of 1. In an interview and observation at 11:49 AM, the DM was shown the flies on the plates and removed two plates to the kitchen, stating she did not cover any additional plates from flies. The DM stated the kitchen was being treated by pest control on a weekly basis and acknowledged that flies on residents’ plates or around food being prepared could lead to residents being sick or possibly developing a bacterial infection. Additional observations showed flies flying around while food was being prepared in the kitchen on 08/14/2025 at 10:43 AM, witnessed by kitchen staff. Later that day, a roach was identified on the floor in dining room [ROOM NUMBER] while residents were eating lunch, and flies were seen flying around and landing on residents’ food during the meal. LVN S stated she had not seen roaches in the dining area since working at the facility and said roaches or flies in the dining room while residents were eating could cause infection or make a resident sick. CNA B stated she had not seen flies or roaches in the dining room, although flies and residents waving their hands to keep them off food were pointed out during the observation. Record review showed weekly pest control service, including fly light replacement and liquid applications, and the pest control contract required pest sightings to be documented and communicated to the provider for follow-up.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident who required extensive assistance from two staff members for transfers. The resident, a female with severe cognitive impairment, multiple physical and neurological diagnoses, and limited mobility, was transferred by a single CNA instead of the required two-person assist. During the transfer from her wheelchair to her bed, the CNA lifted the resident alone, resulting in the resident's head bumping against the wall. The CNA admitted to performing the transfer alone, despite the care plan specifying the need for two staff, and stated that he had done so in the past. The incident was witnessed by the resident's roommate, who reported being awakened by the sound of the resident's head hitting the wall. The CNA immediately reported the incident to the unit manager and nurse, who assessed the resident and found a small raised area on the back of her head but no bleeding or discoloration. The resident's vital signs and mentation were at baseline, and she did not display signs of pain or distress during the assessment. The facility's policy and care plan documentation confirmed that the resident required a two-person assist for transfers, and this information was available in the resident's chart and point of care system. Interviews with staff, including the CNA, nurses, unit manager, and director of nursing, confirmed that the transfer was not performed according to the resident's care plan and facility policy. The CNA acknowledged not following the required procedure and indicated that he had previously transferred the resident alone. The facility's transfer and lift policy emphasized the importance of individualized care plans and appropriate staff assistance to ensure resident safety during transfers, which was not adhered to in this case.
Care Plan Missing Right Bed Rail Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #8 that included the use of a 1/4 right rail on the right side of the bed. Resident #8 was a female with diagnoses including Alzheimer's disease with late onset, altered mental status, repeated falls, and lack of coordination. Her quarterly MDS dated 06/16/2025 showed a BIMS score of 7, mild cognitive impairment for decision-making, dependence on a wheelchair for mobility devices, and total dependence for mobility functions. Record review showed a physician order for a right quarter rail and a signed consent form for the 1/4 side rail, but the care plan dated 06/29/2025 did not include the right-side 1/4 rail. Observation on 08/12/2025 at 10:24 a.m. showed a bed rail on the right side of the bed. During interviews, LVN E stated the rail was used for positioning and that bed rails should be care planned, while the DON stated the care plan was updated on 08/14/2025 with family consent and PT notes/recommendations. The facility policy stated the comprehensive care plan would be reviewed and revised every quarter and when a resident experienced a status change, with updates to interventions when changes were identified.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the Dialysis Hand Off Communication Report forms, which are intended to facilitate ongoing communication between the facility and the dialysis center, were either not completed or were incomplete for 22 out of 23 opportunities. Record review showed that for the months reviewed, there were no report forms accounted for in May and only five out of nine forms in July, with only one of those being fully completed. The process required the charge nurse to complete the top portion of the form before sending the resident to dialysis, and the dialysis center to complete the bottom portion upon return, but this process was not consistently followed. The resident involved was a female with multiple diagnoses, including end-stage renal disease, diabetes with neuropathy, heart failure, and atrial fibrillation. She was cognitively intact and required assistance with activities of daily living. Her care plan and physician orders specified regular dialysis sessions and the need for pre- and post-dialysis vital signs. Despite these orders and the facility's policy requiring the use of the Dialysis Communication Form, the forms were not properly completed or maintained in the resident's medical record as required. The interim DON confirmed the process and acknowledged that it was the unit manager's responsibility to ensure compliance, but this was not consistently done.
Failure to Follow Wound Care Orders Resulting in Stage 4 Pressure Injury and Sepsis
Penalty
Summary
Facility staff failed to provide pressure ulcer care and prevent new ulcers from developing for a resident with multiple comorbidities, including heart disease, respiratory failure, COPD, diabetes, and end-stage renal disease. The resident was admitted without pressure ulcers but was identified as being at risk for skin breakdown. Despite care plan interventions such as weekly skin checks and use of a pressure-reducing device, the resident developed a sacral wound during her stay. Physician orders for wound care were not followed on multiple documented occasions, as evidenced by gaps in the treatment administration record. The wound, initially noted as a small opening, progressed in size and severity over several weeks. Documentation and interviews revealed that wound care was either not performed or not documented as performed on several dates, and the wound deteriorated to an unstageable and then stage 4 pressure injury. The resident's family ultimately intervened, resulting in the resident's transfer to the hospital, where she was diagnosed with a stage 4 pressure injury, infection, and severe sepsis. Interviews with facility staff, including the ADON, DON, wound care nurses, and other nursing staff, confirmed that there was a failure to follow physician orders for wound care and to document treatments provided. Staff acknowledged the risks associated with not following wound care protocols and the importance of documentation. The wound care nurse responsible for the resident's care was no longer employed at the facility at the time of the investigation, and staff reported recent in-services on wound care and skin assessments.
Failure to Provide Consistent ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, a male with Alzheimer's Disease, dementia, muscle weakness, and impaired mobility, was dependent on staff for all ADLs. Despite a care plan goal for the resident to be well-groomed and clean, observations revealed greasy hair, dirty sheets, and the resident reported not receiving showers or baths three times a week as required. Review of shower sheets confirmed that the resident missed 13 scheduled baths over a two-month period, with only a few bed baths documented and some refusals noted. Staff interviews indicated a lack of clarity regarding shower schedules and issues with linen delivery, but no prior awareness of missed showers. Another resident, with diagnoses including chronic metabolic acidosis, muscle wasting, and a chronic skin ulcer, required supervision or assistance for personal hygiene and bathing. Observation showed this resident had long, yellow fingernails with a dark substance underneath, and the resident reported waiting for a bath and nail care. Documentation revealed missed or unverified showers and nail care, with staff acknowledging the resident could be difficult to bathe or provide nail care for, but also indicating that ADL care should have been provided prior to the resident leaving for a medical appointment if not refused. Record reviews and staff interviews confirmed that the facility's policy required providing necessary care for residents unable to perform ADLs to maintain proper grooming and hygiene. However, the facility did not ensure consistent delivery of showers, baths, and nail care for these dependent residents, as evidenced by missed care opportunities and incomplete documentation.
Failure to Change Gloves During Wound Care
Penalty
Summary
A deficiency was identified when the facility failed to ensure proper infection prevention and control practices during wound care for a resident. Specifically, the Wound Care Nurse did not change gloves between cleansing the wound and applying honey treatment and dressing, instead using the same gloves throughout the procedure. This was observed during a wound care session, where the nurse cleansed the wound, reused gauze on different areas, and then applied the prescribed honey treatment and dressing without changing gloves. The nurse acknowledged during an interview that not changing gloves could lead to infection, and the Director of Nursing confirmed that cross-contamination could occur if gloves are not changed at appropriate stages of wound care. The resident involved was a male with multiple diagnoses, including chronic pain, cellulitis, muscle wasting, cognitive impairment, and sepsis. He was totally dependent on staff for activities of daily living, always incontinent, and had a stage 3 pressure ulcer on his sacrum, with care plans and treatment orders in place for wound management. The facility's own dressing change policy required glove changes and hand hygiene at specific steps, which were not followed during the observed incident.
Failure to Provide Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with a history of COPD, dependence on supplemental oxygen, and other significant medical conditions, there was no current physician order for oxygen therapy despite the resident receiving continuous oxygen via nasal cannula. The care plan indicated a need for oxygen at 4L/min, and records showed ongoing use of oxygen since readmission, but the last documented physician order for oxygen had been discontinued months prior. The Director of Nursing confirmed that an order should have been in place and was not. For another resident with COPD exacerbation and congestive heart failure, the physician's order specified oxygen at 2 LPM via nasal cannula continuously. However, observations revealed that the oxygen concentrator was set at 3.5 LPM, exceeding the ordered flow rate. Multiple staff interviews confirmed that nurses were responsible for setting the oxygen flow rate according to physician orders, but the actual setting did not match the order. There was also confusion among staff regarding standing orders and titration parameters, but documentation and orders reviewed did not support the higher flow rate being used at the time of observation. The facility's own oxygen therapy policy required verification of physician orders for oxygen administration, including method of delivery and flow rate, and documentation of the resident's response. In both cases, the facility did not ensure that oxygen therapy was provided in accordance with physician orders and professional standards of practice, as required by the residents' care plans and the facility's policy.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of eight percent based on three errors out of thirty-five opportunities. These errors involved two residents and were identified through observation, interview, and record review. The first incident involved a resident with dementia, protein-calorie malnutrition, and constipation, who was dependent on staff for activities of daily living. The resident was administered Sennoside 8.6 mg instead of the ordered Sennoside 8.6 mg with Docusate 50 mg, and Multivitamins with minerals instead of the prescribed Multiple Vitamins without minerals. The nurse administering the medication stated that the correct medications were not available in the facility and that substitutions were made based on what was in stock, despite the differences in formulation. The medication supply room was found to have the correct Multiple Vitamins available, but the Sennoside with Docusate was on back order, and staff had been instructed to purchase it from an outside source. The second incident involved a resident with dementia who required assistance with activities of daily living. The medication aide applied a new Rivastigmine transdermal patch before removing the old one, contrary to the physician's order and facility policy, which required the old patch to be removed prior to applying a new one. The aide stated that she believed placing the new patch first would prevent contamination, and did not perceive a risk in having two patches on simultaneously if the old one was removed immediately after. The Director of Nursing confirmed that the correct procedure was to remove the old patch before applying the new one to avoid multiple patches being present at the same time. Facility policy reviews indicated that staff were required to confirm medication orders and follow specific procedures for oral and transdermal medication administration, including removing old patches before applying new ones. The errors observed were due to staff not following these established protocols, either by substituting medications without proper verification or by not adhering to the correct sequence for patch application.
Facility Fails to Maintain Safe and Comfortable Environment Due to Drafty Windows
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in one of the rooms reviewed. Specifically, the windows in the room occupied by two residents were not properly sealed, allowing cold air to enter. Observations revealed that the windows, made of plexiglass, were not secured to the frame, resulting in a strong draft of cool air. This issue was noted during a time when the outside temperature was 38 degrees Fahrenheit, and the residents expressed feeling cold in their room. The residents involved had significant medical conditions that could be exacerbated by the cold environment. One resident, a female with severe cognitive impairment, anemia, and reduced mobility, reported feeling constantly cold and was observed wearing multiple layers of clothing to stay warm. The other resident, a male with severe cognitive impairment, dementia, and other health issues, also reported feeling a draft and expressed a desire for a warmer room. Both residents had their beds positioned approximately four feet away from the drafty window. Interviews with staff, including an LVN, maintenance personnel, and the DON, revealed that complaints about the cold room had been made previously, but the window issue had not been addressed. Maintenance staff acknowledged the need for window repairs, and the facility's grievance records confirmed prior complaints about the room's temperature. Despite the provision of extra blankets, the facility did not take timely action to repair the windows, which compromised the residents' comfort and safety.
Deficiency in Meal Quality and Palatability
Penalty
Summary
The facility failed to ensure that the food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. During a survey, it was observed that the lunch meal served on October 15, 2024, consisting of Beef and Macaroni Casserole, Squash Medley, Peach Shortcake, and Coffee/Hot Tea, was not up to standard. The test tray revealed that the pasta was mushy and bland, the squash was chewy and bland, and the juice was diluted and watery. Interviews with residents confirmed that the meals were subpar, and the lunch served on that day was described as "nasty," leading to a lack of desire to eat it. The Assistant Dietary Manager acknowledged that the cook overcooked the pasta and mentioned the need for more staff and training to improve meal service. The Dietary Manager, who had been at the facility for two weeks, noted that the cook was new and inexperienced, which contributed to the poor quality of the meal. Although no direct complaints were received from residents, there was an unusual increase in requests for alternative meals, such as grilled cheese sandwiches, indicating dissatisfaction with the main meal. The Dietary Manager recognized the need for higher meal quality to ensure residents receive adequate nutrition.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their dietary services, as observed during a kitchen inspection. Specifically, drinks poured into individual cups were stored in the refrigerator without lids or covers and lacked labels. Additionally, a pitcher of chopped fruit was found without a date or label, and a bin of flour was not completely sealed, with gaps in its cover. These lapses in food storage practices could potentially expose residents to foodborne illnesses. During an interview, the Assistant Dietary Manager acknowledged the oversight, stating that the chopped fruit was intended for use as a garnish but was unsure of how long it had been stored in the fridge. She confirmed that all kitchen staff were responsible for ensuring that drinks and flour bins were properly sealed and covered to prevent contamination. A review of the facility's food storage policy, dated December 1, 2011, indicated that all opened and bulk items should be stored in tightly covered containers, labeled, and dated, which was not followed in this instance.
Inappropriate Incontinent Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a potential risk of urinary tract infections. During an observation, a CNA was seen cleaning a female resident from back to front during perineal care, which is against the facility's policy of cleaning from front to back to prevent infection. The CNA also failed to change gloves after cleaning the resident and before touching clean items, which could lead to cross-contamination. The resident involved was a female with multiple health conditions, including stroke, end-stage renal disease, heart failure, and dementia. She was frequently incontinent of bowel and bladder and required substantial assistance with personal hygiene. Her care plan included interventions to monitor and change her promptly to prevent skin breakdown and infection. Interviews with facility staff, including CNAs and LVNs, confirmed that the facility's policy was to cleanse from front to back to prevent infections such as E. coli. The staff acknowledged the importance of changing gloves and performing hand hygiene to prevent the spread of germs. The facility's policy and procedure documents also emphasized the need for proper perineal care to maintain hygiene and reduce infection risk.
Medication Error Due to Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 7% due to two errors out of 28 opportunities. One of the errors involved a resident who was administered medications for high blood pressure outside of the physician's prescribed parameters. The resident, who had a history of multiple health issues including heart failure and hypertension, was given Isosorbide and Carvedilol despite having a blood pressure reading below the threshold set by the physician's orders. The medication aide, MA B, administered the medications to the resident even though the blood pressure reading was 107/71, which was below the hold parameter of 110/60. MA B acknowledged the mistake after the surveyor left and reported it to the nurse and unit manager. The medication aide had recently received training and had been working at the facility for a month. The error was recognized as a potential risk for causing low blood pressure and related complications. Interviews with the nursing staff, including LVN D and LVN E, confirmed that the error was reported and the resident's blood pressure was rechecked. The Director of Nursing (DON) emphasized the responsibility of the nursing staff to follow physician orders and the risks associated with administering medications outside of prescribed parameters. The facility's policy required medications to be administered as prescribed, and the management team was responsible for ensuring compliance through periodic audits and reeducation.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of blood pressure medications. A medication aide, identified as MA B, administered Isosorbide and Carvedilol to a resident despite the resident's blood pressure and heart rate being outside the ordered parameters. The resident's blood pressure was recorded at 107/71, and the heart rate was 67 beats per minute, which did not meet the required parameters of holding the medication if the blood pressure was less than 110/60 and the heart rate was below 60. The resident involved was an elderly male with a history of multiple health issues, including heart failure, hypertension, and the presence of a cardiac pacemaker. His care plan indicated a risk for fluctuations in blood pressure and other complications, with specific interventions to monitor blood pressure and administer medications as ordered. Despite these precautions, the medication aide proceeded with administering the medications, later realizing the error and notifying the nursing staff. Interviews with the nursing staff, including LVN D and LVN E, confirmed that the medication was given outside the ordered parameters. The staff acknowledged the potential risks associated with this error, such as hypotension and dizziness, which could increase the risk of falls. The facility's policies and procedures emphasized the importance of administering medications as prescribed and highlighted the common types of medication errors, including administration errors due to staff shortages or miscommunication.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during incontinent care for a resident, leading to a potential risk of infection. The incident involved a resident who was frequently incontinent of bowel and bladder and required substantial assistance with personal hygiene. The resident had a history of multiple medical conditions, including stroke, end-stage renal disease, heart failure, and dementia, and was at risk for skin breakdown and infections. On the morning of October 16, 2024, CNA A provided incontinent care to the resident but did not change gloves or perform hand hygiene after cleaning the resident's perineal area and before touching clean items such as the brief and clothing. This lapse in protocol was observed during the care process, where CNA A used cleansing wipes to clean the resident but failed to remove the soiled gloves before handling clean items, thereby risking cross-contamination. Interviews with the CNA and other nursing staff, including LVNs and the DON, confirmed the breach in infection control practices. The staff acknowledged that gloves should be removed and hands washed after the dirty part of the procedure to prevent the spread of infection. The facility's policies on perineal care and hand hygiene were reviewed, which clearly outlined the need for proper glove removal and handwashing to maintain infection control standards.
Failure to Maintain Clean and Sanitary Environment in Secured Unit
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in a secured unit. Observations revealed that the hallway, dining room, and activity room floors were dirty, sticky, and covered with dust, dirt, debris, and spilled beverages. A resident was seen walking barefoot on the dirty hallway floor, indicating a lack of cleanliness and sanitation. The Housekeeping Supervisor and Maintenance Manager acknowledged the issues, with the former noting that floor techs were responsible for cleaning and should mop at least once a day, while the latter admitted to not verifying the floor techs' work adequately. Interviews with facility staff revealed a lack of proper oversight and accountability for floor cleanliness. The Housekeeping Supervisor mentioned that floor techs were moved to the maintenance department three months prior, and the Maintenance Manager admitted to only conducting visual checks when complaints arose. The Director of Nursing was aware of the sticky floors and mentioned plans to address the issue with new cleaning products and flooring. The facility's Operations Policies and Procedures manual emphasized the need for a safe and sanitary environment, which was not upheld in this instance.
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What surveyors actually found near you
We read the 664 citations issued within 25 miles in the last 12 months — including the 61 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
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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) |
|---|---|---|---|---|
| Legend Oaks Healthcare And Rehabilitation Center - | 1.8 mi | ★★★★★ | 6 | 0 |
| Fallbrook Rehabilitation And Care Center | 4.3 mi | ★★★★★ | 17 | 4 |
| Park Manor Of Cyfair | 4.3 mi | ★★★★★ | 1 | 0 |
| Houston Heights Nursing And Rehabilitation Center | 4.8 mi | ★★★★★ | 2 | 0 |
| Avir At Arden Wood | 5.5 mi | ★★★★★ | 18 | 0 |
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