Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park Bend Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including CKD, neurogenic bladder, and an indwelling Foley, experienced progressively worsening urine changes over several weeks, with staff and family-obtained video showing dark brown to black, foul-smelling urine draining from the catheter. Although an initial episode of blood-tinged urine and hypotension prompted physician notification and orders for UA and IV fluids, subsequent darkening and persistence of abnormal urine were not documented or reported to the physician or NP, and the catheter was not changed despite PRN orders for infection or system compromise. CNAs and LVNs acknowledged observing the abnormal urine color and odor, but some assumed it had become normal or that prior notification was sufficient, and they did not reassess, document, or escalate the change in condition. The resident was ultimately sent to the hospital only after becoming lethargic and confused with hypotension and hypoxia, where she was found to have purulent, nearly black urine from the Foley and was diagnosed with severe sepsis and septic shock likely secondary to UTI.
A resident with multiple comorbidities and a chronic Foley catheter had documented blood-tinged and later dark orange/red urine, critical UA results, and a history of frequent UTIs, yet staff did not change the catheter, consistently assess urine characteristics, or document and report progressive dark brown/black, foul-smelling urine over several weeks. CNAs and LVNs observed abnormal urine color and odor but often assumed it was normal or did not follow up, and the catheter had not been changed for months despite PRN orders for change with signs of infection. Video evidence showed opaque black urine in the drainage bag on multiple nights, and hospital staff later found purulent, black urine and mold on the catheter balloon and tip on admission, where the resident was diagnosed with severe sepsis with septic shock likely from a UTI.
Two residents with urinary catheters were observed with their drainage bags lying on the floor. One resident had a Foley catheter and severe cognitive impairment, while the other had a suprapubic catheter and was alert and oriented. Staff interviews confirmed the bags had been on the floor and that staff were aware this placement could cause infection, but the bags were still found in that condition.
A resident with a Foley catheter, stroke, HF, obstructive uropathy, and DM was observed during catheter care and a brief change when a CNA removed gloves and changed gloves without performing hand hygiene. The CNA said she had been trained to clean her hands between glove changes but thought it was unnecessary unless there was a BM; the IP and DON stated hand hygiene was required after glove removal, and the facility policy said gloves do not replace hand hygiene.
Surveyors found that multiple residents had access to medications and biologicals at their bedsides, including pain relief creams, eye drops, ointments, and oral capsules, despite facility policy and staff statements that all medications must be stored in locked compartments accessible only to authorized personnel. Staff interviews confirmed that medications should not be kept in resident rooms, but observations revealed otherwise. The residents involved had complex medical conditions, including dementia and Parkinson's disease.
A resident with multiple medical conditions was subjected to neglect when staff failed to intervene as her family, including a physician, inserted an unauthorized IV line and administered fluids without proper orders. Staff were aware of the family's intentions but did not prevent the procedure or promptly notify leadership, resulting in a delay in transferring the resident to the hospital. The incident involved miscommunication, delayed reporting, and failure to enforce facility policy prohibiting non-staff from performing medical procedures.
A resident with a history of dementia and substance dependence was found with empty hand sanitizer bottles and aspirin at her bedside, posing significant health risks. The facility failed to implement effective interventions to prevent access to these hazardous substances, resulting in an Immediate Jeopardy situation.
The facility failed to ensure the front door was monitored after the receptionist's shift, allowing unauthorized entry. Residents reported a security concern when a homeless individual entered a resident's room under false pretenses. Staff interviews revealed varying levels of concern about safety, with the administrator initially dismissing security as an issue. The facility's location and nearby homeless presence contributed to staff discomfort.
The facility failed to provide necessary nail care for two residents who required assistance with personal hygiene due to their medical conditions. Both residents, who had diabetes, had long and dirty fingernails, and expressed dissatisfaction with their nail care. Interviews revealed that CNAs and LVNs were responsible for nail care, but only nurses were allowed to provide it for diabetic residents. The DON acknowledged the risk of infection and skin breakdown due to inadequate nail care.
A resident with chronic respiratory issues was found with unlabeled and undated nasal cannula tubing, contrary to physician orders and standard protocols. The responsibility for changing and labeling the equipment was assigned to night shift nurses, but this was not adhered to, posing a risk of infection control lapses.
A facility failed to label an insulin pen with an open date on a medication cart, risking the use of expired insulin for a resident with diabetes. The LVN and DON acknowledged the oversight, which contradicts the facility's policy requiring routine checks for missing labels.
A resident with multiple health conditions received incontinence care from two CNAs who failed to perform hand hygiene between glove changes, violating the facility's infection control policy. Despite being trained, the CNAs did not adhere to the protocol, risking cross-contamination and infection.
A resident with severe cognitive impairment and significant weight loss was not allowed to have their diet upgraded from pureed to mechanical soft, despite requests from the MPOA. The facility failed to implement the resident's dietary preferences, leading to confusion and lack of clarity in care. Staff interviews revealed inconsistencies in diet implementation and communication with the MPOA.
A resident with Alzheimer's and dysphagia experienced significant weight loss and dietary issues, with grievances filed by her MPOA going undocumented and unresolved. Despite the facility's policy requiring prompt grievance resolution, the social worker's departure left the grievance binder missing, and the Administrator and DON were unable to locate or confirm the resolution of the grievances.
A resident with severe cognitive impairment and on hospice care experienced significant weight loss due to the facility's failure to provide the correct therapeutic diet and administer the prescribed appetite stimulant medication. The facility staff did not consistently assist or encourage the resident to eat, and there were communication issues regarding dietary needs and medication administration.
The facility failed to ensure accurate documentation of pain medication administration for four residents, as discrepancies were found between the Narcotic Administration Record and the Medication Administration Record. Interviews revealed that residents were aware of their pain management needs, but the documentation did not reflect the actual administration of medications. The DON acknowledged the expectation for immediate documentation, and the facility's policy required signing the MAR after administration.
A facility failed to provide accurate pharmaceutical services for a resident, as medications were left at the bedside and not administered as required. Staff interviews and policy reviews confirmed that medications should not be left unattended, and residents should be observed taking their medications.
A facility failed to securely store and administer medications, leaving a resident's morning medications unattended on a bedside table. The resident's care plan did not reflect medication self-administration, and staff confirmed that medications should not be left unattended. This failure was against the facility's policy, placing residents at risk.
Failure to Notify Physician of Worsening Hematuria and Catheter-Related Changes
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a physician when a resident experienced a significant change in condition related to an indwelling urinary catheter. The resident was an elderly female with Alzheimer’s disease, diabetes mellitus, chronic kidney disease, neurogenic bladder, anemia, functional quadriplegia, an ostomy, a feeding tube, and severe cognitive impairment. Her care plan identified her as dependent for all ADLs, at risk for anemia-related complications, and at risk for UTIs due to the presence of a catheter, with specific interventions directing staff to monitor, document, and report abnormal urine characteristics and signs and symptoms of UTI to the physician. Physician orders directed that the Foley catheter be changed PRN for signs and symptoms of infection, obstruction, or compromise of the closed system. Progress notes showed that on one date an LVN documented blood-tinged urine draining from the Foley catheter, low blood pressure, and that the physician was notified, resulting in orders for a urinalysis and IV fluids. A subsequent NP note documented dark orange/red urine, a contaminated UA with mixed microbial growth, the resident’s refusal of IV fluids, and plans for repeat labs. However, from that point through several days later, there was no documentation in the electronic health record of urine color, characteristics, or other changes in condition, and the last documented catheter change had occurred weeks earlier. Despite multiple staff observing that the urine had become dark brown to black, foul-smelling, and remained that way for weeks, there was no evidence that the physician or NP was notified of this worsening change in urine appearance. Video footage provided by the family showed CNAs draining a catheter bag on multiple nights, with the urine in the drainage bag and container appearing dark/black and opaque. Hospital staff later described the catheter from the facility as having mold on the balloon, strings of pus on the tip, purulent urine, and a very dark, almost black appearance with a strong odor, and hospital records documented septic shock likely from a UTI with the indwelling catheter draining purulent urine. Facility staff interviews revealed that CNAs and LVNs had noticed the urine as dark, brown, or black and malodorous for weeks, and some believed it had become “normal” for the resident or assumed prior notification had been sufficient. Several nurses acknowledged they did not consistently assess or document urine characteristics, did not follow up on the worsening urine color, and did not notify the physician again despite recognizing that such changes could indicate infection or kidney issues. The ADON, DON, NP, and Administrator all stated that the dark or black urine color seen in the videos was not normal for the resident and that they would have expected immediate notification and follow-up, but this did not occur until the resident became lethargic and confused with low blood pressure and low oxygen saturation, at which point the physician was notified and the resident was sent to the hospital and diagnosed with severe sepsis and septic shock likely due to UTI.
Removal Plan
- Performed a 100% audit (by DON, ADON, Wound Care Nurse, RN) of residents with catheters to verify catheter placement/securement, urine characteristics, signs/symptoms of UTI, EMAR documentation accuracy, and catheter change documentation.
- Replaced urinary catheters by a licensed nurse for any resident with abnormal catheter-related findings; notified the physician, obtained and implemented new orders, notified the resident’s responsible party, and increased monitoring every shift.
- Provided a 1:1 in-service to the LVN who failed to document catheter change and notify the physician regarding change in condition/urine appearance/consistency, emphasizing reporting to physician/NP and responsible party and documenting in the EMAR; advised further infractions may result in discipline up to termination.
- Provided in-service training for all licensed nurses on catheter care/maintenance, UTI prevention, change-in-condition notification to physician/NP and responsible party, and documentation requirements; staff were not permitted to return to resident care until in-services were completed.
- Implemented DON/designee review of resident changes in condition via SBAR and documentation, and initiated interventions during clinical meetings; addressed issues immediately with physician/NP notification and review with licensed nurses and/or IDT; adopted as standard IDT review process for residents with catheters.
- Conducted a QAPI meeting with the Medical Director to notify of potential noncompliance and obtain approval of the action plan.
- Reported findings to the QI process and QA committee, with immediate follow-up on any concerns or recommendations.
Failure to Assess and Manage Abnormal Catheter Urine Leading to Septic Shock
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with an indwelling urinary catheter received appropriate assessment, intervention, and catheter management in response to persistent abnormal urine characteristics and signs of possible infection. The resident was an elderly female with Alzheimer’s disease, diabetes mellitus, chronic kidney disease, neurogenic bladder, anemia, functional quadriplegia, an indwelling catheter, colostomy, and feeding tube, and was dependent on staff for all ADLs. Her care plan identified her as having a catheter, being at risk for UTIs, and having frequent UTIs, with specific interventions to monitor urine for color, sediment, odor, amount, and to report abnormalities such as blood-tinged urine, cloudiness, no output, deepening of urine color, and other signs of UTI to the physician. Physician orders directed that the Foley catheter and drainage bag be changed PRN for signs of infection, obstruction, or compromise of the closed system. On one date, an LVN documented that the resident’s catheter was draining blood-tinged urine, that her blood pressure was low, and that the physician was notified, resulting in orders for a UA and IV fluids. The resident later refused IV fluids, and a UA collected showed blood, protein, mucus, and WBC clumps, with blood and protein flagged as critical, but there were no documented follow-up orders or interventions after these results. The NP documented dark orange/red urine and noted a contaminated UA with mixed microbial growth, ordering a repeat UA and labs, and recorded that the resident had refused IV fluids. The NP stated that dark orange urine could be normal if related to minor bleeding from catheter movement but that dark brown/black urine would not be normal and should be reported; she also stated that whenever a UA was ordered, staff were supposed to change the catheter. The electronic record showed the resident’s indwelling catheter was last changed several months earlier, with no documentation of catheter changes, urine color/characteristics, or change in condition from that date through the days immediately preceding the resident’s transfer to the hospital. Multiple staff interviews and video evidence showed that the resident’s urine had been dark brown to black and foul-smelling for weeks without appropriate assessment, documentation, or escalation. CNAs and LVNs reported that the urine appeared reddish, like iced tea, brown/blackish, and had a bad odor for approximately a month or a few weeks, and that they assumed it was normal after it remained that way; several nurses acknowledged they did not assess the catheter or urine every shift and did not consistently document or notify the physician about the worsening color. Video footage provided by the responsible party showed dark/black, opaque urine in the drainage bag on multiple nights, and hospital staff described the catheter on admission as draining purulent, very dark/black urine with foul odor, pus in the tubing, and mold on the catheter balloon and tip, suggesting it had not been changed for a long time. The facility’s own catheter policy required timely and appropriate assessments, ongoing monitoring for catheter-associated UTI, recognition and reporting of complications, and catheter and drainage bag changes based on clinical indications such as infection or obstruction. Despite these requirements and the resident’s known history of frequent UTIs and chronic catheter use, the facility did not assess, intervene, or change the catheter while the resident’s urine remained abnormal over an extended period, culminating in her transfer to the hospital where she was diagnosed with severe sepsis with septic shock likely from a UTI.
Removal Plan
- Performed a 100% audit (DON, ADON, Wound Care Nurse) of residents with catheters to verify catheter placement/securement, urine characteristics, signs/symptoms of UTI, EMR documentation accuracy, and catheter change dates.
- Replaced any urinary catheter immediately (by a licensed nurse) for residents with abnormal findings; notified physician immediately, implemented new orders promptly, and increased monitoring every shift.
- Provided a 1:1 in-service to the LVN who failed to document catheter change on the importance of documenting all care provided (including catheter changes), with progressive discipline up to termination for further infractions.
- Completed an in-service for all licensed nurses and CNAs on catheter care/maintenance, UTI prevention, change-in-condition notification, documentation requirements, and when to notify the physician; staff were not permitted to return to resident care until in-services were completed.
- Implemented DON/designee review of resident changes in condition via SBAR, documentation, and initiated interventions during clinical meetings; addressed issues immediately with the licensed nurse and/or IDT, resident/RP, and physician as necessary; adopted as standard IDT review process for residents with catheters.
- Implemented DON/designee verification of catheter orders and documentation of catheter care and assessments; adopted as standard IDT review process for residents with catheters.
- Conducted visual checks by DON/designee to ensure catheter care is maintained and without abnormalities until 100% compliance is achieved; communicated potential issues to the IDT, resident/RP, and physician.
- Implemented a questionnaire process to validate effectiveness of the urinary catheter care process with licensed nurses, CNAs, and nurse managers; provided immediate re-education if staff could not answer appropriately.
- Ran a physician orders report to check and verify accuracy of any new catheter orders; immediately corrected issues; adopted as standard IDT review process for residents with catheters.
- Clarified and corrected incomplete/incorrect/conflicting catheter orders/documentation immediately when identified by DON/designee; adopted as standard IDT review process for residents with catheters.
- Conducted an impromptu QAPI meeting with the Medical Director to obtain approval of the action plan.
- Reported findings to the QI process and QA committee monthly (Administrator and DON/designee) and addressed any concerns/recommendations immediately.
Catheter Bags Left on the Floor
Penalty
Summary
The facility failed to ensure two residents with urinary catheters received appropriate catheter care when their drainage bags were observed lying on the floor. Resident #57, a severely cognitively impaired male with a Foley catheter for obstructive uropathy, was observed lying in bed with his catheter bag on the floor, and he said he did not know why it was there. A CNA later stated she had seen the bag on the floor earlier that morning and had picked it up and placed it back on the bed frame. The resident’s care plan reflected increased infection risk related to collection bag placement and independence with bed controls and bag placement. Resident #68, a cognitively intact male with a suprapubic catheter for neurogenic bladder, was also observed sitting upright in bed with his catheter bag on the floor. He said he did not know why it was there, then pulled the tubing and moved the bag off the floor and hung it on a trash can. A CNA stated the resident frequently repositioned himself and hung the bag on the trash can, and that having the bag on the floor or hanging on the trash can could cause infection. The Infection Preventionist stated staff were supposed to ensure catheter bags were placed on the bed rail and not on the floor, and the DON stated the resident liked to mess with his catheter bag.
Failure to Perform Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when CNA A did not perform hand hygiene after removing gloves during Foley catheter care and a brief change for Resident #24. Resident #24 was a female resident with a Foley catheter, diagnoses including stroke, heart failure, obstructive uropathy, and diabetes, and a BIMS score of 11. Her care plan identified her as at risk for urinary tract infection and complications related to catheter use, and she required maximal assistance with rolling and moderate assistance with toilet hygiene. During observation of catheter care and brief change, CNA A washed hands, put on gloves, performed catheter care, removed gloves without hand hygiene, put on new gloves to clean the resident's buttocks, changed gloves again without hand hygiene, and then placed a new brief on the resident. CNA A stated she had been trained to perform hand hygiene between glove changes but believed it was not needed unless the resident had a bowel movement. The Infection Preventionist and DON both stated staff were supposed to perform hand hygiene after removing gloves and that failure to do so could result in infection. The facility policy stated that gloves do not replace hand hygiene and that hand hygiene should be performed immediately after removing gloves.
Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and did not ensure that only authorized personnel had access to the keys, as required by policy and professional standards. During observations and interviews, it was found that three residents had medications and biologicals at their bedsides, including pain relief creams, eye drops, ointments, anti-itch creams, antifungal creams, simethicone capsules, and skin protectants. Staff interviews confirmed that residents were not permitted to keep medications in their rooms and that all medications should be stored on the medication cart, at the nursing station, or in the medication room. However, these procedures were not followed, as evidenced by the presence of various medications and biologicals in the residents' rooms. The residents involved had significant medical histories, including dementia, Parkinson's disease, chronic pain syndrome, and cancer. At the time of the deficiency, one resident was observed using a pain relief cream at her bedside, while another was unaware of the medications and creams present in her room. Staff, including LVNs and the DON, acknowledged during interviews that medications should not be accessible to residents in their rooms and that such access could lead to misuse. The facility's written policy also required all drugs and biologicals to be stored in locked compartments under proper temperature controls, which was not adhered to in these instances.
Failure to Prevent Family from Performing Unauthorized Medical Procedure
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident from neglectful treatment by not intervening when family members performed unauthorized medical procedures. The resident, a female with a history of seizures, stroke, legal blindness, and malnutrition, was dependent on staff for activities of daily living and had impaired communication and vision. Despite being on hospice care, her family members, including a physician, brought in supplies and inserted an intravenous (IV) line into her right neck without orders from her primary doctor or hospice. Staff observed IV fluids hanging from an IV pole but did not witness the administration of fluids. The family member who inserted the IV was later trespassed from the facility by the administrator and police. Prior to this incident, another family member impersonated a hospice director and attempted to give medication orders for the resident, which were not accepted after staff verified her credentials. On the day of the IV incident, staff were made aware by hospice that a family member might attempt to start an IV. The unit manager spoke with the family member, who insisted on starting the IV despite being told that IV therapy would require hospital transfer. The family proceeded to insert the IV after the unit manager left the room. Staff became aware of the IV placement after the fact, and there was a delay in notifying the director of nursing (DON) and in sending the resident to the hospital. During this time, the family kept staff out of the room, and the IV was removed before emergency services arrived. Documentation and interviews revealed inconsistencies in staff reporting and delays in escalating the situation to facility leadership. The resident was eventually transferred to the hospital for evaluation, but the delay in intervention and failure to prevent the unauthorized medical procedure constituted neglect. The facility's policy required protections against abuse and neglect, but staff did not act promptly to prevent or stop the family from performing the procedure or to ensure the resident's immediate safety.
Failure to Prevent Resident Access to Hazardous Substances
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to the consumption of hand sanitizer and the possession of aspirin at the bedside. The resident, who had a history of dementia, chronic pain syndrome, major depressive disorder, and opioid dependence, was found with empty bottles of hand sanitizer in her room. Despite the facility's awareness of the resident's condition and the potential for hazardous behavior, interventions to prevent access to such substances were not effectively implemented. Additionally, the resident was found with a bottle of aspirin at her bedside, which she admitted to purchasing during a facility trip to a store. The resident, who was on a blood thinner, had consumed an unsafe amount of aspirin, as determined by the missing pills from the bottle. This oversight in monitoring and controlling the resident's access to medications posed a significant risk to her health and safety. The facility's failure to monitor and restrict access to potentially harmful substances and medications resulted in an Immediate Jeopardy situation. The resident's actions, including the consumption of hand sanitizer and aspirin, were not adequately addressed through preventive measures, leading to a serious deficiency in the care provided by the facility.
Security Lapse at Facility Entrance
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by not ensuring the front door was monitored between 5:00 pm and 7:00 pm after the receptionist left for the day. This oversight allowed unauthorized individuals to enter the facility without the staff's knowledge. During a confidential group meeting, residents expressed concerns about security, revealing an incident where an unknown person, claiming to be from Maintenance, entered a resident's room under false pretenses. This individual was later identified as a homeless person, highlighting the security lapse. Interviews with staff members, including the receptionist, administrator, LVN, med aide, and housekeeper, revealed varying levels of concern about safety. The receptionist confirmed the front door was left unlocked until 6:55 pm daily, and no other staff monitored the entrance outside her working hours. The administrator did not initially consider security an issue and speculated that the unknown person might have been a vendor, although no records confirmed this. Staff members expressed discomfort due to the facility's location and the presence of homeless individuals nearby, further emphasizing the need for improved security measures.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in two residents, both of whom required assistance with personal hygiene due to their medical conditions. Resident #138, a male with diabetes mellitus, bilateral above-knee amputation, and anxiety, had long and dirty fingernails with a greenish matter on the nail beds. He expressed a desire for his nails to be trimmed and cleaned, which had not been done for a long time. Resident #19, a female with contracture of the left hand, Alzheimer's disease, and diabetes mellitus, also had long and discolored fingernails with dark brown residue underneath. She did not recall when her nails were last trimmed and expressed dissatisfaction with their length. Interviews with facility staff revealed that CNAs and LVNs were responsible for nail care, but only nurses were allowed to provide nail care for diabetic residents. Both residents were diabetic, and the LVN interviewed was not aware of the need for nail care for these residents. The Director of Nursing (DON) stated that nail care should be provided as needed, especially during shower time, and acknowledged that long and dirty fingernails could pose an infection control issue and risk of skin breakdown. The facility's policy on activities of daily living emphasized the provision of care and services for grooming and personal hygiene, which was not adhered to in these cases.
Failure to Label and Date Nasal Cannula Tubing
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not labeling or dating the nasal cannula tubing used for oxygen therapy. This oversight was observed during a survey when the resident was found sleeping with unlabeled and undated nasal cannula tubing. The resident, a male with chronic obstructive pulmonary disease, stroke, hypertension, dysphagia, and cognitive communication deficit, had a physician's order for oxygen therapy at 2 L/min via nasal cannula as needed. The care plan also noted the resident's history of disruptive behaviors, including refusing to wear oxygen at times. Interviews with facility staff revealed that the responsibility for changing, labeling, and dating the oxygen equipment fell on the night shift nurses every Sunday. However, during the observation, the nasal cannula tubing was not labeled or dated, indicating a lapse in following the established protocol. The Director of Nursing confirmed that there was no specific facility policy for changing and dating the nasal cannula tubing, but it was expected to follow standard nursing protocols and physician orders. The failure to label and date the nasal cannula tubing could lead to lapses in infection control, as it was unknown how long the resident had been using the same tubing.
Failure to Label Insulin Pen with Open Date
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles, specifically on the 600 hall nurses' medication cart. During an observation, it was noted that an insulin pen for a resident with type 2 diabetes mellitus was not labeled with an opened date. This insulin pen, which is crucial for managing the resident's condition, was supposed to be discarded after 28 days of being opened. The absence of an opened date on the insulin pen could lead to the use of expired insulin, which may be ineffective. Interviews with the LVN and the DON revealed that the insulin pen lacked an open date, which is essential for tracking its expiration. The LVN admitted to not checking the pen for an expiration date since she did not use it, while the DON confirmed that insulin pens need to be dated upon opening due to their limited shelf life. The facility's policy mandates routine inspections by the consultant pharmacist to identify and destroy medications with missing labels, but this protocol was not followed in this instance.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of two CNAs during incontinence care for a resident. The resident, a female with a history of stroke, diabetes mellitus, hemiplegia, and aphasia, required extensive assistance with personal hygiene. During an observation, CNA A and CNA B did not perform hand hygiene between glove changes while providing care, which is a critical step in preventing infection and cross-contamination. Interviews with the CNAs revealed that they were aware of the hand hygiene protocol but failed to adhere to it during the care process. CNA A admitted to forgetting the procedure and noted the absence of hand sanitizers in the room, while CNA B was unaware of missing steps. The ADON and DON confirmed the facility's hand hygiene policy and the importance of following it to prevent infections. Both CNAs had previously received training on hand hygiene, as indicated by their participation in a competency validation session.
Failure to Implement Resident's Dietary Preferences
Penalty
Summary
The facility failed to allow the Medical Power of Attorney (MPOA) the right to participate in the development and implementation of a resident's person-centered plan of care. This included the right to request revisions to the plan of care, particularly concerning the resident's diet. The resident, who had severe cognitive impairment and was on hospice care, experienced significant weight loss. Despite the MPOA's request to upgrade the resident's diet from pureed to mechanical soft to prevent further decline, the facility did not implement this change as a goal for eating. The resident's care plan and physician's orders reflected a pureed diet with the ability to tolerate mechanical soft pleasure feeds. However, the facility did not consistently offer mechanical soft meals, and the resident was observed to eat very little of the pureed meals provided. The MPOA expressed concerns about the resident's rapid weight loss and the lack of clarity regarding the diet orders. Despite the MPOA's requests and the resident's ability to eat mechanical soft foods brought by the family, the facility maintained the pureed diet, citing safety concerns and the need for a waiver to upgrade the diet. Interviews with facility staff revealed inconsistencies in the implementation of the resident's diet orders and a lack of clear communication with the MPOA. The Director of Nursing (DON) and other staff members were unable to provide a clear rationale for the dietary decisions made, and there was confusion about the process for upgrading the resident's diet. The facility's policy on nutritional management emphasized the resident's right to choose and decline interventions, but this was not effectively communicated or implemented in the resident's care.
Failure to Document and Resolve Grievances
Penalty
Summary
The facility failed to maintain evidence demonstrating the resolution of grievances for a period of no less than three years, specifically in the case of a resident who had multiple grievances filed by her medical power of attorney (MPOA). The resident, who was diagnosed with Alzheimer's disease, major depressive disorder, and dysphagia, among other conditions, experienced significant weight loss and had issues with her diet and assistance with eating. Despite the MPOA's repeated attempts to address these concerns through emails and grievances, the facility did not have any documentation of grievance resolutions related to these issues. The resident's care plan indicated she was at risk for nutritional concerns and required setup assistance when eating. Despite this, the resident experienced a notable weight loss over a 12-month period, dropping from 169.4 pounds to 132 pounds. The MPOA expressed concerns about the resident's diet and weight loss in emails to the facility's Director of Nursing (DON) and other staff members, but the facility failed to document or resolve these grievances adequately. The facility's grievance policy required that grievances be recorded, investigated, and resolved promptly, but this process was not followed in the resident's case. Interviews with the facility's Administrator and DON revealed that grievances had been filed for the resident, but the facility's social worker had recently left, and the grievance binder could not be located. The Administrator acknowledged that grievances were typically filed with the social worker and signed off by her once resolved, but she could not find the documentation. The DON also mentioned that a grievance was likely written for the emails from the MPOA, but she was unsure of their current status. This lack of documentation and resolution of grievances could place residents at risk of unresolved grievances and unmet care needs.
Failure to Maintain Nutritional Parameters for Resident
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, leading to significant weight loss and potential malnutrition. The resident, who had severe cognitive impairment and was on hospice care, was not provided with the correct therapeutic diet as ordered by the physician. The facility did not administer the prescribed appetite stimulant medication, Mirtazapine, in the correct dosage, and there were multiple instances where the medication was not available or administered. Additionally, the dietary orders were unclear, leading to confusion about when to provide a mechanical soft diet versus a pureed diet. The resident's care plan included interventions to ensure adequate nutrition and weight stabilization, but these were not effectively implemented. The facility staff failed to offer the resident the correct meals, including ice cream or pudding, which were part of the interventions to prevent weight loss. Observations revealed that the resident was not consistently assisted or encouraged to eat, and no alternate meals were provided when the resident did not consume the pureed meals. The resident's weight had decreased significantly over several months, indicating a failure to address her nutritional needs adequately. Interviews with facility staff and the resident's medical power of attorney (MPOA) highlighted communication issues and misunderstandings regarding the resident's dietary needs and medication administration. The facility's Director of Nursing (DON) and other staff members were unable to provide clear explanations for the dietary decisions made, and there was a lack of consistent monitoring and documentation of the resident's nutritional status. The hospice service's involvement further complicated the situation, as there were discrepancies in medication coverage and dietary recommendations.
Incomplete Documentation of Pain Medication Administration
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for four residents, specifically regarding the administration of pain medications. The Medication Administration Records (MAR) for these residents did not accurately reflect the administration of pain medications from June 1 to June 18, 2024. This discrepancy was identified through a comparison of the Narcotic Administration Record (NAR) and the MAR, which showed that medications were removed but not documented as administered. Interviews with the residents revealed that they were aware of their pain management needs and had their pain well controlled, yet the documentation did not reflect the actual administration of medications. The Director of Nursing (DON) acknowledged that the expectation was for nurses to document medication administration in the MAR immediately after giving the medication. The failure to do so could lead to residents receiving additional dosages and provide an inaccurate picture of the resident's health to the physician. The facility's Medication Administration policy required signing the MAR after administration and, if the medication was a controlled substance, signing the narcotic book. The lack of documentation could result in the physician making decisions based on incomplete information, such as discontinuing or changing the medication.
Failure to Administer Medications Accurately
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident, specifically for one resident reviewed for medication administration. The medication aide (MA A) did not administer medications accurately, as medications were observed in a medication cup at the resident's bedside, despite MA A signing the Medication Administration Record (MAR) as if they had been administered. This failure was observed during a survey, where the resident confirmed that nursing staff often left medications in his room for him to take at his convenience, which he then consumed in the presence of the surveyor. Interviews with staff, including an LVN and the Director of Nursing (DON), revealed that medications should not be left unattended or for residents to self-administer without proper assessment and authorization. The LVN and DON both stated that staff are required to witness residents taking their medications to ensure they are consumed as prescribed. MA A, however, denied leaving the medications at the bedside and claimed to have witnessed the resident taking them, suggesting the resident might have spit them back into the cup after she left. The facility's policy on administering medications, which was reviewed, mandates that medications be administered safely and timely, with staff required to observe residents taking their medications. The policy also specifies that residents may only self-administer medications if assessed and authorized by the interdisciplinary care planning team. The administrator confirmed that staff are expected to follow this policy to prevent risks associated with unattended medications.
Failure to Securely Store and Administer Medications
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored in accordance with State and Federal laws, specifically by not storing medications in locked compartments and not ensuring proper temperature controls. During an observation, Resident #1's morning medications were found in a medication cup on his bedside table, which he stated was left there by MA A. This practice was confirmed by Resident #1, who mentioned that nursing staff often left his medications in his room for him to take at his convenience. This was corroborated by LVN B, who stated that staff needed to watch all residents take their medications and that medications should never be left unattended. Resident #1's medical history includes unspecified dementia without behavioral disturbance, bipolar disorder, peripheral vascular disease, type 2 diabetes with hyperglycemia and diabetic neuropathy, anemia, and hyperlipidemia. His care plan did not reflect medication self-administration, indicating that staff should administer and monitor his medications. Despite this, MA A left Resident #1's medications unattended, which he later consumed without supervision. This was against the facility's policy, which requires medications to be stored in locked compartments and administered under supervision. Interviews with the DON and the Administrator confirmed that medications should not be left in residents' rooms and that staff are expected to observe residents taking their medications to ensure they receive the correct dosages. The facility's policy on medication storage, revised in November 2020, mandates that all drugs and biologicals be stored in locked compartments and that only authorized personnel have access to these medications. The failure to adhere to these policies placed residents at risk of consuming unsafe medications.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 675 citations issued within 25 miles in the last 12 months — including the 33 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Burleson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allegiant Wellness And Rehab | 1 mi | ★★★★★ | 0 | 0 |
| Crowley Nursing And Rehabilitation | 2 mi | ★★★★★ | 0 | 0 |
| Avir At Burleson | 3.5 mi | ★★★★★ | 3 | 0 |
| Estates Healthcare And Rehabilitation Center | 3.6 mi | ★★★★★ | 29 | 3 |
| Advanced Rehabilitation & Healthcare Of Burleson | 4.8 mi | ★★★★★ | 13 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.