Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park Manor Of Quail Valley during CMS and state inspections, most recent first.
Two residents were not adequately supervised or provided with proper safety interventions: one continued to smoke while on oxygen despite known risks and repeated staff awareness, and another was found with a detached bed rail despite being a fall risk. Staff interviews and documentation confirmed that interventions were not effectively implemented or monitored, resulting in exposure to potential harm.
A resident with a Foley catheter was observed with an uncovered catheter bag, visible from the bedside, after being readmitted from the hospital. Despite facility policy and recent staff training on maintaining resident dignity and privacy, nursing staff failed to place a privacy cover on the catheter bag, and the omission was not corrected during routine rounds. The resident, who was cognitively intact, expressed a preference for the bag to be covered, and staff acknowledged the oversight was due to a busy shift and not following established protocols.
A resident with moderately impaired cognition and limited mobility was found in bed with her call light on the floor and out of reach, despite her care plan and facility policy requiring it to be accessible. Staff interviews confirmed awareness of the requirement, but the deficiency was observed during the survey.
Two residents receiving anticoagulant medications did not have comprehensive, person-centered care plans addressing this therapy. Both had significant cognitive impairments and required substantial assistance with ADLs, yet their care plans lacked documentation of anticoagulant use or related interventions. The MDS Coordinator and DON confirmed the omission, which was not in accordance with facility policy requiring care plans with measurable objectives and timetables.
Two residents did not receive proper incontinent and catheter care, as CNAs failed to perform hand hygiene and did not clean the perineal or catheter insertion sites according to facility policy. These actions were observed during care for residents with complex medical needs, and staff interviews confirmed the lapses despite prior training.
Surveyors found expired hydrocortisone acetate suppositories in the medication storage room that belonged to a resident who had already been discharged. The medications remained in storage past the resident's discharge and the prescribed administration period, contrary to facility policy requiring discontinued or outdated drugs to be returned or destroyed. Staff interviews confirmed that the process for checking expired medications was not consistently followed.
A medication storage room was found to contain hydrocortisone acetate suppositories labeled for a resident who had already been discharged. The medication, which was no longer needed, remained in the fridge despite facility policy requiring discontinued drugs to be removed. Staff interviews confirmed that checks for expired or discontinued medications were not consistently documented or followed.
The facility did not have an infection prevention and control program in place, as observed and documented by surveyors during their review of facility practices and records.
A COTA used a resident's debit card and cellphone without authorization, resulting in unauthorized withdrawals and a gas station purchase while the resident was admitted and unable to leave the facility. The resident, who was cognitively intact and had significant medical conditions, reported the incident after noticing suspicious transactions and missing funds. Staff statements and bank records confirmed the unauthorized use, with the COTA's first name appearing as the recipient of electronic transfers.
A resident with multiple medical conditions reported that a COTA accessed his debit card and cellphone, resulting in unauthorized Cash App withdrawals and a gas station purchase. The COTA handled the resident's clothing containing the bank card during wound care and later used the resident's phone during therapy. The resident's bank confirmed the transactions, and screenshots showed the COTA's first name as the recipient. The facility failed to prevent the misappropriation of the resident's property.
The facility failed to ensure resident privacy by not securing signed consents for security cameras and not closing the door or pulling the privacy curtain during personal care for a resident with severe cognitive impairment and multiple medical conditions. The resident was exposed and visible from the hallway while being repositioned by a CNA.
The facility failed to complete and transmit the MDS assessments for two discharged residents within the required timeframe. Interviews revealed that the delays were due to personal issues faced by the LVN responsible for the assessments, who was working from home and caring for a sick family member.
The facility failed to accurately code a resident's discharge MDS assessment, documenting the resident as discharged to a hospital instead of home. Interviews revealed the error was due to high discharge volumes and insufficient review processes.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan did not address the use of a foley catheter, and another resident's care plan did not include the use of geri-sleeves as ordered by the physician. These deficiencies could lead to inadequate care for the residents.
A facility failed to ensure proper catheter care and hand hygiene for a resident with severe cognitive impairment and multiple medical conditions. CNA A did not clean the catheter correctly and failed to follow hand hygiene protocols, increasing the risk of infection. The DON and ADON confirmed the lapses in care, and CNA A admitted to not having received proper in-service training.
The facility failed to ensure proper medication management, including the accurate acquisition, receipt, dispensing, and administration of drugs and biologicals. A resident had unauthorized eye drops at her bedside, and multiple medication carts and storage areas contained discontinued and improperly labeled medications. Staff interviews revealed non-adherence to the facility's policies on medication administration and storage.
The facility failed to ensure that all drugs and biologicals were stored in locked storage areas and limited access to authorized personnel. A resident, who was legally blind, had lubricant eye drops on her bedside table, which were not stored in a locked compartment. The resident reported not receiving her prescribed eye drops, and the facility's staff were unaware of the medication being at the bedside. The facility's policies required medications to be stored in locked compartments and only administered by authorized personnel unless a resident was care planned for self-administration, which was not the case for this resident.
A CNA failed to wash or sanitize her hands after removing dirty gloves and before handling clean linens, placing a resident at risk for infection. The resident had multiple health issues and required frequent care. The facility's policy mandated hand hygiene, which was not followed.
Failure to Prevent Accident Hazards and Ensure Resident Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents. One resident, who was on continuous oxygen therapy and had a history of heart failure, hypertension, and COPD, was repeatedly found smoking while oxygen was being administered. Despite being care planned as a current smoker at risk for adverse effects and having a behavioral contract in place, the resident was observed smoking with oxygen in use on multiple occasions, both on facility premises and in the adjacent building's parking lot. Staff interviews confirmed that the resident continued to smoke with oxygen, and interventions such as education and behavioral contracts did not prevent the behavior. Documentation showed that the resident had cigarettes and a lighter in his room, and staff were aware of his noncompliance but did not implement further effective interventions. Another resident, who had a history of falls, Parkinsonism, and severe cognitive impairment, was found with a bed rail/assistance bar detached and lying on the floor next to his bed. The resident required substantial assistance with activities of daily living and was considered a fall risk. Staff observed the detached bed rail and reported it to the Maintenance Director, who repaired it after being notified. The care plan for this resident included interventions for fall risk, such as a low bed and fall mats, but did not specifically address the secure attachment of the bed rail. Interviews with staff and the Maintenance Director confirmed that the bed rail had become detached due to a missing screw and that all staff were responsible for reporting such hazards. The deficiency was identified through observation, interview, and record review, revealing that the facility did not provide adequate supervision or ensure the implementation and monitoring of interventions to prevent accidents. The lack of effective follow-up and modification of interventions for residents who were noncompliant with safety policies, as well as the failure to ensure the secure attachment of safety devices, exposed residents to potential harm, injury, or death due to inadequate monitoring and hazard prevention.
Failure to Provide Privacy Cover for Foley Catheter Bag
Penalty
Summary
A deficiency occurred when a male resident, recently readmitted from the hospital with a diagnosis including benign prostatic hyperplasia, sepsis, and osteomyelitis, was observed with his Foley catheter bag hanging uncovered and visible from his bed. The resident, who was cognitively intact and able to express his needs, was unaware that his catheter bag was not covered and expressed a preference for it to have been concealed. The facility's staff confirmed that the resident was admitted with the catheter system in place and that the hospital had not provided a privacy cover for the bag. Despite the facility's policy and staff training emphasizing the importance of maintaining resident dignity and privacy, the nursing staff failed to place a privacy cover on the resident's Foley catheter bag upon admission. The responsibility to ensure the catheter bag was covered fell to the nursing staff, who admitted to forgetting this step due to a busy shift with multiple admissions. The omission was not corrected during subsequent rounds, and the bag remained uncovered until it was brought to the attention of the staff during the surveyor's observation. Interviews with the RN, DON, and Administrator confirmed that the oversight was due to staff being occupied with other tasks and not following through with established protocols for resident privacy. The facility's own policies and recent in-service training highlighted the need to protect resident dignity by covering catheter bags, but these were not adhered to in this instance, resulting in a lapse in the resident's right to privacy.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's call light was within reach while the resident was in bed. Observations showed that the call light was on the floor near the nightstand, and the resident, who was lying on her right side facing the window, was unable to reach it. The resident confirmed during an interview that she could not access the call light. The resident's care plan specifically required that the call light be within reach and that she be encouraged to use it for assistance as needed. The resident had moderately impaired cognition, required moderate assistance with transfers, and was at risk for falls due to limited mobility and weakness. Multiple staff interviews, including with CNAs, an LVN, the ADON, and the DON, confirmed that the call light should always be within reach of the resident, as per facility policy and in-service education. Staff acknowledged that failure to provide access to the call light could result in the resident attempting to assist herself, potentially leading to falls. The facility's policy also stated that the call light must be within easy reach when a resident is in bed or confined to a chair. Despite these guidelines and staff awareness, the call light was not accessible to the resident at the time of observation.
Failure to Develop Comprehensive Care Plans for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who were receiving anticoagulant medications. For both residents, the care plans did not include anticoagulant use as a focus area, and there were no documented interventions or dates provided to address this aspect of their care. Record reviews confirmed that both residents had significant cognitive impairments and required substantial to maximal assistance with activities of daily living. Despite these needs and the administration of anticoagulants, their care plans lacked any mention of this medication or related care strategies. Interviews with the MDS Coordinator confirmed that she was responsible for completing care plans and acknowledged the absence of care plans addressing anticoagulant use for both residents. The Director of Nursing also confirmed the importance of comprehensive care plans and recognized that not having them could result in negative outcomes, such as bleeding or bruising. Facility policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident, but this was not followed in these cases.
Deficient Incontinent and Catheter Care Leading to Infection Control Lapses
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide proper incontinent and catheter care for two residents, resulting in deficiencies related to infection prevention and appropriate hygiene. For one resident with an indwelling Foley catheter and multiple complex medical diagnoses, including osteomyelitis, pressure ulcer, and functional quadriplegia, a CNA did not perform hand hygiene before care, did not open the labia to clean the catheter insertion site, and inadequately cleaned the resident after a large bowel movement. The CNA acknowledged not following proper technique and recognized that this could contribute to urinary tract infections (UTIs). Another resident with a history of cerebral infarction, hemiplegia, and other chronic conditions also received improper incontinent care. During care, the CNA did not open the labia to clean the perineal area, despite the presence of a strong urine odor. The CNA later admitted she should have opened the labia more thoroughly and had received prior training on the correct procedure. Facility policy requires specific steps for catheter and perineal care, including cleaning from the insertion site outward and performing hand hygiene before and after resident care. Interviews with staff and review of training records confirmed that initial and ongoing training was provided, but the observed care did not meet facility standards or policy requirements. These lapses in care were directly observed by surveyors and confirmed through staff interviews.
Expired Medications Found in Medication Storage Room
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. During an observation of the medication storage room, surveyors found 15 hydrocortisone acetate 25mg suppositories with an expiration date of 05/2025 that belonged to a resident who had been discharged on 04/12/2025. These medications were still stored in the medication room refrigerator despite the resident's discharge and the medication order being for a 30-day period, which had already elapsed. The facility's policy required that discontinued or outdated drugs be returned to the pharmacy or destroyed, but this was not followed in this instance. Interviews with staff revealed that the ADON was responsible for checking the medication storage room for expired medications, with the DON overseeing this process. The ADON stated she last checked the room the previous week but could not recall the specific day. Both the LVN and ADON acknowledged that expired medications could place residents at risk for adverse reactions. The facility's policy, revised in April 2007, specified that nursing staff must maintain medication storage areas in a safe and sanitary manner and not use discontinued or outdated drugs, which was not adhered to in this case.
Failure to Remove Discontinued Medication from Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with professional standards, as evidenced by the presence of 15 hydrocortisone acetate 25mg suppositories in the medication storage room that were labeled for a resident who had already been discharged. The medication, which had an expiration date of 05/2025, was found in the fridge during an observation, despite the resident's discharge on 04/12/2025. Record review confirmed that the medication was prescribed for rectal pain and was administered as ordered during the resident's stay. Interviews with staff revealed that the ADON was responsible for checking the medication storage room for expired medications, with the last check reportedly occurring the previous week, though the exact date was not recalled. The DON confirmed that the ADON was tasked with weekly checks and that she was responsible for ensuring this process was followed. Facility policy required that discontinued or outdated drugs be returned to the pharmacy or destroyed, but this was not adhered to in this instance, resulting in the continued storage of medication belonging to a discharged resident.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors during their review of facility practices and documentation. No specific residents or staff members were identified in the report, and no additional details regarding individual medical histories or conditions at the time of the deficiency were provided.
Unauthorized Use of Resident's Debit Card and Cellphone by COTA
Penalty
Summary
A deficiency occurred when a Certified Occupational Therapist Assistant (COTA) used a resident's debit card and cellphone without authorization, resulting in the loss of $45.00 from the resident's bank account and $250.00 through electronic fund transfers. The resident, who was cognitively intact and had diagnoses including cerebrovascular disease and bladder cancer, reported that the COTA requested to use his cellphone under the pretense of playing music during a therapy session. Shortly after, the resident received notifications from his bank regarding suspicious transactions, including Cash App withdrawals and a gas station purchase, all occurring while the resident was admitted and unable to leave the facility. The incident was corroborated by multiple staff statements and documentation. The Director of Rehab Services (DORS) observed the resident showing bank account information with pending withdrawals, and screenshots of the transactions were captured. The resident's bank card had been in his pants, which were handled by the COTA during a wound care session the previous evening. The card was later reported missing, and subsequent bank records confirmed unauthorized transactions, some of which listed the COTA's first name as the recipient. Interviews with staff, including the LVN and DORS, confirmed the sequence of events leading to the loss of funds. The COTA denied making any purchases but admitted to using the resident's phone briefly. The facility's investigation found that the resident's bank card was used at a gas station and for electronic transfers while the resident was in the facility. The resident expressed feeling upset and taken advantage of as a result of these actions.
Failure to Prevent Misappropriation of Resident Property by Staff
Penalty
Summary
A deficiency occurred when the facility failed to protect a cognitively intact male resident from misappropriation of property and exploitation. The resident, who had diagnoses including cerebrovascular disease, atrial fibrillation, and bladder cancer, reported that his debit card was missing after a therapy session and that unauthorized transactions had been made from his account. The resident stated that during a wound care session, his soiled pants containing his bank card were handled by a Certified Occupational Therapist Assistant (COTA), and later, during a therapy session, the COTA requested the resident's phone to play music. Shortly after, the resident received a call from his bank regarding suspicious transactions, including Cash App withdrawals and a gas station purchase. The facility's records and interviews confirmed that the COTA had access to both the resident's phone and his personal belongings during the relevant timeframes. The resident showed screenshots of the unauthorized transactions, which included the COTA's first name as the recipient on the Cash App. The bank confirmed several attempted and successful transactions, including a $34.83 gas purchase and $150 in Cash App withdrawals. The COTA denied any involvement but admitted to using the resident's phone to play music. The missing bank card was not recovered, and the transactions occurred while the resident was admitted and unable to leave the facility. Staff interviews and documentation indicated that the COTA was present during the wound care session and had handled the resident's clothing. The Director of Rehabilitation Services and Social Worker both reviewed the resident's account and confirmed the timing and nature of the transactions. The facility's policies required staff to report any suspected misappropriation of property, and the COTA had previously received training on abuse, neglect, and resident rights. Despite these policies, the facility failed to prevent the wrongful use of the resident's belongings and money.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure personal privacy for residents by not securing signed consents for the use of security cameras for one resident and by not closing the door or pulling the privacy curtain when providing personal care to another resident. Specifically, Resident #52, a male with severe cognitive impairment and multiple medical conditions, was observed lying in bed with the door open and the privacy curtain not pulled while a CNA was repositioning him. The resident was exposed and could be seen from the hallway. The CNA admitted to not remembering to close the door or curtain during the care process. The Director of Nursing (DON) confirmed that staff are expected to provide privacy by either closing the door or pulling the privacy curtain when providing care. The DON mentioned that Resident #52's family did not want the curtain pulled or the door closed during care, but emphasized that the expectation is to maintain privacy and dignity for all residents. The facility's policy on Resident Rights, revised in February 2023, also states that personal privacy includes accommodations and personal care.
Failure to Timely Complete and Transmit MDS Assessments for Discharged Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for two discharged residents were completed and transmitted within the required timeframe. Specifically, the discharge MDS for one resident, who was discharged home with multiple diagnoses including rheumatoid arthritis, peripheral vascular disease, and acute kidney failure, was not completed until over a month after the discharge date. Similarly, the discharge MDS for another resident, who was discharged home with home health care and had diagnoses including age-related osteoporosis and type 2 diabetes mellitus, was also completed over two months after the discharge date. Interviews with the Director of Nursing (DON) and the Licensed Vocational Nurse (LVN) responsible for the MDS assessments revealed that the delays were due to personal issues faced by the LVN, who was working from home and caring for a sick family member at the time. The DON acknowledged the importance of timely and accurate MDS coding for ensuring proper resident care and facility reimbursement. The LVN admitted that the MDS assessments should have been completed within 24 to 48 hours of discharge but were delayed due to her personal circumstances.
Inaccurate MDS Assessment Coding
Penalty
Summary
The facility failed to ensure assessments accurately reflected the status for one resident reviewed for MDS assessments. Specifically, the facility inaccurately coded the discharge MDS assessment for a resident who was discharged home with family members. The resident, who had a medical history including gout, chronic kidney disease, type 2 diabetes, hyperlipidemia, hypertension, and gastro-esophageal reflux, was documented as being discharged to a short-term general hospital instead of home. This discrepancy was identified through record reviews and staff interviews. Interviews with the facility's LVNs and DON revealed that the mistake occurred due to the high volume of discharges, leading to a mix-up in the resident's discharge status. The LVN responsible for the MDS admitted to the error, and the DON acknowledged that while the MDS was reviewed for accuracy, it was not checked line by line. The facility's policy for MDS did not address the accuracy of MDS completion, contributing to the oversight.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #52, who had a foley catheter. Despite the resident's medical records and MDS assessment indicating the presence of an indwelling catheter, the care plan did not address this critical aspect of the resident's care. LVN A, responsible for MDS coding and care plans, admitted to missing the inclusion of the catheter in the care plan, although it was coded in the MDS. This oversight could lead to staff not being adequately informed about the resident's catheter care needs, potentially affecting the quality of care provided to the resident. Additionally, the facility failed to ensure that Resident #8's care plan included the use of geri-sleeves, as ordered by the physician. Despite multiple incidents of skin tears and an active physician's order for geri-sleeves, observations revealed that Resident #8 was not wearing them at specified times. RN A noted that Resident #8 often removed the sleeves herself, especially when more alert, and staff would sometimes allow her to keep them off after multiple attempts to reapply them. This inconsistency in following the care plan could lead to further skin injuries for the resident. Both deficiencies highlight a lack of adherence to the facility's policy on comprehensive, person-centered care plans. The care plans for both residents did not include measurable objectives and timeframes to meet their medical needs, as required by the facility's policy. This failure in care planning could result in residents not receiving the appropriate care to address their current medical conditions and needs.
Improper Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, CNA A did not clean Resident #52's indwelling Foley catheter properly and did not follow proper hand hygiene during incontinent care. During an observation, CNA A was seen cleaning the catheter from outward toward the urethral site instead of from the insertion site outward, and did not pull back the foreskin to clean properly. Additionally, CNA A did not change gloves or wash hands between tasks, which could increase the risk of infection. CNA B, who was assisting, confirmed these improper techniques and noted that CNA A placed dirty linen on the bedside table and a trash bag on the floor, further compromising hygiene standards. Resident #52, a male with severe cognitive impairment and multiple medical conditions including cerebrovascular disease, hemiplegia, diabetes, and a history of urinary tract infections, was at risk due to these lapses in care. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the proper technique for cleaning indwelling catheters was not followed. CNA A admitted to not having received in-service training since starting at the facility and stated that her previous training differed from the facility's protocols. The facility's policy for catheter care was reviewed and it was found that the correct procedure was not adhered to during the observed care.
Medication Management Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were accurately acquired, received, dispensed, and administered in accordance with professional standards. This deficiency was observed in the case of a resident who had Equate lubricant eye drops at her bedside, which were not prescribed or documented for self-administration. The resident, who was legally blind and had a BIMS score indicating intact cognition, reported not receiving her prescribed eye drops and expressed discomfort due to dry eyes. The facility's policy on self-administration of medications was not followed, and the interdisciplinary team did not assess the resident's ability to self-administer medications safely. Additionally, the facility's medication carts and storage areas contained discontinued and improperly labeled medications. The 400-hall nurse's medication cart had discontinued medications and a jar of zinc oxide ointment without an expiration date. The refrigerator in the medication room contained insulin and latanoprost eye drops for residents who had been discharged, and some medications were not in their original delivery packets. The 100-hall medication aide's cart also contained discontinued medication for a resident who had been sent to the hospital. These lapses in medication management were acknowledged by the staff, who admitted that discontinued medications should be removed promptly to prevent errors. Interviews with the facility's staff, including the Administrator, DON, and unit managers, revealed a lack of adherence to the facility's policies on medication administration and storage. The staff admitted that medications found at residents' bedsides should be removed immediately and that discontinued medications should be taken out of the carts to avoid administration errors. The facility's policies on administering medications, self-administration of medications, and medication storage were not consistently followed, leading to potential risks for the residents.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked storage areas and limited access to authorized personnel. This deficiency was observed in the case of a resident who had lubricant eye drops on her bedside table, which were not stored in a locked compartment. The resident, who was legally blind and had a BIMS score indicating intact cognition, reported that she had not received her prescribed eye drops and that the drops were taken by staff without being administered as ordered by her physician. The resident's medical records indicated that she had been prescribed Propylene Glycol Ophthalmic Solution to be administered twice daily, but there were no orders for self-administration of medications. Despite this, the resident had eye drops on her bedside table, which were observed by surveyors on multiple occasions. The resident expressed that she had not received her eye drops as prescribed and that her eyes felt uncomfortable. The facility's policies required medications to be stored in locked compartments and only administered by authorized personnel unless a resident was specifically care planned for self-administration, which was not the case for this resident. Interviews with the facility's staff, including the Administrator and the Director of Nursing (DON), revealed that they were not aware of the medication being at the resident's bedside and emphasized the importance of following the self-administration policy. The DON acknowledged that the resident was not care planned for self-administration and that the eye drops found at the bedside were placed in the medication cart. The facility's policies on medication administration and self-administration were reviewed, highlighting the requirement for medications to be administered safely and as prescribed, and for residents to self-administer only if deemed safe by the interdisciplinary care planning team.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an infection prevention and control program, specifically in the case of a resident and a CNA. The CNA did not wash or sanitize her hands after removing dirty gloves and before handling clean linens, which were then placed on the resident's bedside table. This action was observed during an inspection, and the CNA admitted to not being specifically instructed to wash or sanitize hands when transitioning from dirty to clean surfaces, despite being trained on infection control in general. The resident involved was a severely cognitively impaired male with multiple health issues, including cerebrovascular disease, hemiplegia, hyperlipidemia, type 2 diabetes, severe sepsis, and dehydration. The resident's care plan required frequent checks and assistance with toileting, as well as the application of barrier cream after each incontinent episode. The Director of Nursing confirmed that the facility's policy mandated hand hygiene when moving from dirty to clean surfaces, and failure to do so could lead to infection. The facility's hand hygiene policy was reviewed and found to support this requirement.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Missouri City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Quail Valley Post-acute Healthcare | 1.2 mi | ★★★★★ | 6 | 0 |
| Chelsea Gardens | 1.4 mi | ★★★★★ | 10 | 2 |
| Paradigm At First Colony | 1.4 mi | ★★★★★ | 8 | 0 |
| Ignite Medical Resort Sugar Land, Llc | 4.8 mi | ★★★★★ | 7 | 0 |
| Sugar Land Health Care Center | 4.9 mi | ★★★★★ | 2 | 0 |
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