Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park View Care Center during CMS and state inspections, most recent first.
Pest control was not effective in keeping flies out of resident care and dining areas. Flies were observed at the nurses' desk, in resident rooms, and in the dining room, including landing on a resident while he was in bed and on another resident's personal items. Staff said flies were a recurring issue, especially when doors were opened for smoking access, and the facility's policy called for an effective pest control program for seasonal pests such as flies.
A facility failed to keep a privacy curtain clean and sanitary for two residents sharing a room after one resident vomited and the curtain remained stained with dried black substance for days. Staff gave conflicting accounts about who was responsible for changing it, with RN, CNA, EVS, Maintenance, DON, and the Administrator all describing different roles and reporting that the curtain had not been promptly changed after the soiling event.
Staff failed to follow hand hygiene practices during meal tray delivery, as multiple CNAs delivered lunch trays and entered resident rooms without using hand sanitizer or otherwise performing hand hygiene immediately beforehand. Several residents involved had complex medical conditions, including dementia, schizophrenia, respiratory failure, diabetes, and a history of severe sepsis, and some required setup or clean-up assistance for eating. Interviews with residents showed they were generally unaware of whether staff sanitized their hands, while staff interviews revealed inconsistent access to hand sanitizer, differing beliefs about who was responsible for maintaining sanitizer supplies, and acknowledgment that not sanitizing hands placed residents at risk of infection. The DON and Administrator confirmed expectations that staff perform hand hygiene and that hand sanitizer be available, and facility policies required proper hand hygiene for all direct resident contact, but observed practices during meal service did not comply with these policies.
Dirty privacy curtains were observed in three residents’ rooms, with dried brown substances on the curtains and staff unable to say when they were last cleaned. Housekeeping, the ESM, and the Administrator all acknowledged the curtains were stained, with the ESM stating most privacy curtains were stained and that replacements had been ordered but were on back order. In addition, a shower room had cracked and missing wall tiles near the floor, and the Maintenance Director stated the area was not homelike and water could get into the wall if the tiles were not replaced.
Failure to provide nail care for dependent residents: Several residents with ADL deficits, including one with stroke-related hemiplegia, one with dementia and diabetes, one with hemiplegia and diabetes, and one with a contracted hand, were observed with long, dirty, or jagged fingernails despite care plans calling for nail care. Residents stated they wanted their nails cut, and staff interviews showed confusion and inconsistency about who was responsible for completing nail trims, including for diabetic residents.
Failure to Obtain Order and Care Plan for Splint Use: A resident with CVA, encephalopathy, and a left hand contracture was observed with intermittent splint use, but the chart contained no physician order for the splint and the care plan did not address it. Staff gave conflicting accounts about who was responsible for applying the splint, while the resident stated he had used one before but could not recall when it was last applied.
Incomplete Dialysis Monitoring Documentation: A resident with ESRD and dependence on HD had multiple incomplete dialysis communication forms, with only two treatment records fully completed. The resident’s care plan called for monitoring of dialysis-related complications, and the DON and Administrator stated charge nurses were expected to complete the forms, send them with the resident to dialysis, and review them on return, but documentation was missing for multiple treatments.
Dishwasher sanitizer and temperature checks were not consistently logged in the kitchen. Staff observed the low-temp dish machine and confirmed the sanitizer tested within range, but the log had multiple missing entries across several shifts. The Dietary Mgr said checks were supposed to be done 3 times daily, and the Mnt Dir stated the dishwasher had been out of service for part of the week.
Improper Dumpster Waste Disposal and Open Lids: The facility failed to properly dispose of garbage and refuse for 3 of 3 dumpsters. Surveyors observed dumpster #1 with both doors open and trash exposed, used incontinent briefs and a soiled trash bag on the ground nearby, and the lids on dumpsters #1 and #3 not closed. The Dietary Mgr, EVS Mgr, and Admin stated staff were responsible for taking trash out and keeping the dumpster area clean, with doors and lids closed.
Walk-In Freezer Door Seal Not Properly Maintained: The facility failed to keep the walk-in freezer door seal properly maintained in the only kitchen. Surveyors observed ice buildup along the freezer door frame, threshold, and floor, and the Dietary Manager stated the issue had been noticed months earlier and that a replacement seal had not been done properly. The Maintenance Director said the freezer was functioning, while the Administrator said major kitchen repairs were expected to be reported to Maintenance and administration.
Failure to Follow Ordered Enteral Feeding Schedule: A resident with a G-tube, dysphagia, and malnutrition was ordered continuous overnight Jevity 1.5 cal feeds at 60 ml/hr for 16 hours with H2O flushes. RN disconnected the feeding 2 hours early, stated she was unaware of the updated order, and acknowledged she did not follow the physician order; the ADON and DON stated staff were expected to review and follow orders.
Expired Bisacodyl and Acetaminophen suppositories were found in the North med room refrigerator during observation. An LVN, the ADON, and the DON stated nurses were expected to check med rooms for expired meds, but the expired suppositories had not been removed. The facility policy required routine inspection of med carts and med rooms for outdated medications and removal of those medications.
Failure to Perform Hand Hygiene During Incontinence Care: A CNA did not perform hand hygiene before starting incontinence care for a resident with severe cognitive impairment, total care needs, bowel and bladder incontinence, and a feeding tube. During the care, the CNA cleaned the resident, discarded the soiled brief, and then applied a clean brief without changing gloves or washing hands. The CNA, ADON, and DON all acknowledged the expected hand hygiene and glove-change practices, and the facility policy and nursing procedure manual required hand hygiene before gloves, after glove removal, and between dirty and clean incontinent care tasks.
Smoking assessments were not completed on a quarterly basis for two residents who smoked. Both residents had BIMS scores of 15 and were able to make independent decisions, but one resident also had dementia, schizophrenia, and PVD, while the other had ESRD, DM with neuropathy, dialysis dependence, and major upper-extremity amputations requiring staff assistance to smoke. The DON and Administrator stated assessments were expected on admission, quarterly, and with any change in smoking status, but the records showed the assessments were not regularly completed.
Multiple rooms had broken window blinds with missing slats, allowing individuals outside to see into residents' beds and compromising privacy. Some residents expressed dissatisfaction with the lack of privacy. Staff, including a MA-C and an LVN, were unaware of the issue, and no repair requests were found in the Maintenance Logbooks. The Maintenance Director, responsible for repairs, also did not know about the broken blinds, despite the facility's policy emphasizing resident privacy and dignity.
A resident with multiple complex medical conditions and total dependence on staff was hospitalized for shortness of breath and, after receiving treatment, was twice denied reentry to the facility by administration. Despite behavioral concerns, there was no proper discharge process or safe alternative placement arranged, and staff interviews confirmed the resident was not provided with discharge documentation or a safe transition.
A resident with cognitive impairment, total dependence for ADLs, and a history of stroke and poor circulation developed an arterial wound that worsened over time. The care plan did not address the wound or the resident's non-compliance with care, despite staff efforts to educate and reposition her. Staff interviews confirmed ongoing challenges and lack of care plan updates to reflect the resident's needs and behaviors.
A resident with multiple complex diagnoses and hospice care orders had physician orders for PRN oxygen therapy, but staff failed to accurately document and code the oxygen treatment on the MDS. Despite care plans and orders indicating the need for oxygen, records showed no administration during the assessment period, and the facility could not provide its MDS policy when requested by surveyors.
A shower room was found with a blocked and soiled toilet, missing and torn shower curtains, and a leaking shower head hose, resulting in lack of privacy and unsanitary conditions. Staff interviews revealed that the issues were known but not reported, and facility leadership was unaware of the ongoing problems despite policies emphasizing resident privacy and dignity.
The facility did not maintain an effective pest control program, resulting in widespread gnats and flies in multiple areas, including hallways, nurse's stations, the dining room, and the biohazard closet. Residents and staff reported persistent pest issues, with some residents avoiding common areas due to the nuisance. Observations found improperly contained biohazard waste and unclear staff responsibility for cleaning, contributing to the infestation.
A nurse failed to maintain sterile technique during tracheostomy care for a resident on enhanced barrier precautions for ESBL, using non-sterile saline and contaminating the sterile field without restarting the procedure. The resident, who had multiple complex medical conditions and required full assistance, was at risk due to these lapses. Staff interviews revealed inconsistent adherence to sterile technique and gaps in policy familiarity and training.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with multiple medical conditions did not receive a scheduled colonoscopy after a provider order was issued. Although the referral was faxed to an outside provider, there was no documentation of follow-up or confirmation of an appointment, and the resident was not informed of any scheduled procedure. Interviews confirmed that social services was responsible for arranging and following up on such appointments, but the process was not completed or documented.
A Wound Care Nurse failed to wear a gown while providing wound care to a resident on enhanced barrier precautions for a chronic wound, despite clear signage and available PPE. The nurse only wore gloves during the procedure, contrary to facility policy and infection control expectations.
A resident with a history of violent behavior struck another resident in the face at the nurse's station, resulting in redness and requiring ice treatment. The assaulted resident, who has dementia and moderate cognitive impairment, was not protected from abuse despite the facility's policies. The assailant, with severe cognitive impairment and a history of aggression, was taken into custody for a mental health evaluation and did not return to the facility.
A facility failed to assist a resident with severe cognitive impairment in obtaining a follow-up dental appointment for a root canal due to a delay in processing payment to the dentist. The resident experienced dental pain and was only receiving pain medication without further intervention. The facility's social worker did not follow up on the dentist's invoice, leading to a delay in care, contrary to the facility's policy of ensuring continuous care.
A resident was prescribed Seroquel for Schizoaffective disorder, a condition he did not have, in violation of the facility's psychotropic management policy. Despite attempts at Gradual Dose Reduction, the medication was continued without a proper diagnosis, as confirmed by the DON.
The facility failed to maintain an effective pest control program, resulting in a roach infestation affecting several residents. Observations and interviews revealed roaches in multiple resident rooms and common areas, despite weekly visits from a pest control vendor. Staff and residents reported the issue, but measures taken were ineffective, indicating a failure to implement a successful pest control strategy.
Two residents with severe cognitive impairments were fed by staff members who stood while assisting them, contrary to their care plans and facility policy. A CNA and an LVN admitted to not being trained on the importance of sitting during feeding to promote dignity and prevent aspiration. The DON and ADON confirmed that staff should sit at eye level with residents during feeding.
The facility failed to ensure that two residents had their call lights within reach, as required by their care plans. One resident, with significant impairments, was found with her call light attached to the wall and inaccessible, while another resident's call light was tangled under her bed. Staff interviews confirmed the oversight and the facility's policy mandates that call lights be accessible to residents.
A resident with respiratory failure was observed receiving 5 LPM of oxygen instead of the physician-ordered 3 LPM. Despite the facility's policy to follow physician orders, staff failed to administer the correct oxygen level, as confirmed by interviews with RN C, the DON, and the ADON.
A resident with a gastrostomy tube did not receive medications according to prescribed protocols, as LVN D failed to dissolve medications and flush the tube with the correct amount of water. This led to the tube clogging and improper administration of the bolus formula. The resident's care plan required specific procedures due to risks of aspiration and dehydration, which were not followed, as confirmed by interviews with LVN D and the DON.
A facility exceeded the acceptable medication error rate with a 6.06% error rate during a medication pass by an LVN. The LVN failed to dissolve medications properly and left residue in cups, leading to incomplete doses for a resident with a gastrostomy tube. The resident's complex medical history required specific medication administration procedures, which were not followed, resulting in a clogged g-tube. Interviews revealed a lack of awareness and adherence to physician orders and facility policies.
A resident with a history of stroke and right-sided weakness was provided with a bed that had non-functional wheel locks, posing a fall risk. Despite the resident's request for a replacement, the issue was not addressed until after a surveyor's visit, violating the resident's right to a safe environment.
A resident at a LTC facility experienced verbal abuse from the Administrator, who used inappropriate language during a conversation about facility conditions. The resident, who had no cognitive impairment and specific medical conditions, felt unsafe and left the facility. The incident was confirmed through an audio recording and interviews, highlighting a failure to protect residents from abuse.
A resident at a long-term care facility experienced verbal abuse from the Administrator, who used inappropriate language during a conversation about facility conditions. The resident, who had no cognitive impairment and a history of paraplegia, felt unsafe and left the facility. The incident was recorded and confirmed by the DON and the Administrator, who later suspended himself pending an investigation.
The facility failed to maintain a safe and comfortable environment in two dining rooms, with chairs in poor condition, including ripped and frayed seat cushions with exposed foam. Residents expressed discomfort and dissatisfaction, and despite complaints to the administration, no action was taken. The Maintenance Director and Administrator acknowledged the issue, citing cost concerns, but maintenance logs showed no related entries.
Pest Control Program Failed to Control Flies in Resident and Dining Areas
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the North Station nurses' desk and North Dining Room free from flies, and to keep the Central Station nurses' desk and Central Hall dining room free from flies. During observation, flies were seen circling and landing on the North Station nurses' desk and flying into the hall, and flies were also observed in Resident #1's room landing on personal items. The pest control binder documented prior fly issues in resident rooms, including multiple rooms listed on 04/14/26 and a fly issue in a resident room on 03/03/26. On the Central Hall, a fly was observed flying around Resident #4 while he was in bed, and he stated the flies bothered him, had gotten worse, and were everywhere. Three flies were also observed flying around the Central Hall dining room during lunch service. Staff interviews stated flies were a recurring issue, especially when doors were opened for residents to go to the smoking patio, and that pest control visited weekly. The facility's pest control policy stated it was the policy to maintain an effective pest control program and to use indoor and outdoor methods for seasonal pests such as flies.
Soiled Privacy Curtain Left in Resident Room
Penalty
Summary
The facility failed to maintain privacy curtains in a clean and sanitary condition for two residents sharing a room. During observation, the privacy curtain in the room had several areas with a dried black substance, and Resident #3 stated the substance was from when Resident #2 vomited and that it had been there for the past couple of days. Resident #3 said he had told the nurse and maintenance, and that he had to get housekeeping to come change the curtain. Staff interviews showed conflicting understanding of who was responsible for the soiled curtain and when it should have been changed. RN D stated the black substance was vomit and that she had used bleach wipes to try to clean it up, while CNA E said she noticed the stains and remembered using bleach wipes, but did not recall reporting it to anyone. The Maintenance Director stated housekeeping was responsible for changing privacy curtains and Maintenance only adjusted the tracks, while the Environmental Services Director stated his department and Maintenance were responsible for changing stained curtains and said the curtain was changed later that day after a resident mentioned it. The DON and Administrator both stated the curtain should have been changed and that staff should have notified housekeeping right away. The facility’s Resident Rights policy stated residents have the right to a safe, clean, comfortable, and homelike environment.
Failure to Ensure Hand Hygiene During Meal Tray Delivery
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff performed appropriate hand hygiene during meal service, as required by its infection prevention and control program and hand hygiene policy. During a lunch meal delivery on Hall 100, multiple CNAs passed meal trays to residents without using hand sanitizer or otherwise performing hand hygiene immediately before resident contact. Observations on 03/05/26 at approximately 12:19 PM showed two CNAs knocking on doors and entering rooms to deliver meal trays to two residents without sanitizing their hands beforehand. At 12:23 PM, another CNA exited the shower room and began assisting with meal tray distribution without sanitizing her hands. At 12:25 PM, this same CNA adjusted her clothing by pulling on her pants and then continued pushing the meal cart and delivered a tray to another resident. At 12:27 PM, she handed a tray to a fourth CNA, who took the tray into another resident’s room without sanitizing her hands. The residents involved had various medical and functional profiles documented in their records. One male resident had a history of traumatic subarachnoid hemorrhage, major depressive disorder, and anxiety disorder, and required setup or clean-up assistance for eating, with a care plan goal to maintain dignity by being clean, dry, odor free, and well groomed. Another male resident had dementia, peripheral vascular disease, schizophrenia, major depressive disorder, and hypertension, and was care planned for ADL self-care performance deficit related to dementia, with interventions including setup and supervision for eating; his MDS indicated he could eat independently. A third male resident had dementia, paranoid schizophrenia, encephalopathy, anxiety disorder, hypertension, and respiratory failure, and was care planned as being at risk for infection and viral respiratory infection, with interventions including education on signs, symptoms, and precautions. A female resident had type 2 diabetes, severe sepsis, schizophrenia disorder, cognitive communication deficit, and bipolar disorder, and was also care planned as being at risk for infection and viral respiratory infection with similar educational interventions. Several of these residents required setup or clean-up assistance for eating, meaning staff were expected to handle their meal trays and related items. Interviews with residents and staff further described the circumstances surrounding the lack of hand hygiene. Two cognitively intact male residents reported they did not know whether staff sanitized their hands before bringing food into their rooms; one stated staff did not wash their hands before leaving his room, and both acknowledged that clean hands were important, though they reported not having been sick. One cognitively intact female resident was unable to provide relevant information about staff hand hygiene during an interview, instead giving unrelated responses. Staff interviews revealed inconsistent access to and use of hand sanitizer: one CNA stated she did not use hand sanitizer when passing trays and reported that hallway sanitizer stations did not work, claiming she had informed nurses but did not receive sanitizer. Another CNA stated there was no or mostly empty hand sanitizer in the hall, that she usually washed her hands when passing and picking up trays, and that she had washed her hands in the shower room and therefore did not see a need to sanitize again; she denied reporting the lack of sanitizer. A third CNA stated staff were supposed to carry hand sanitizer in their pockets and believed there were sanitizer containers on the halls but would need to check, and she thought housekeeping was responsible for ensuring availability. The DON reported she was new, believed staff should have hand sanitizer at all times, was unsure about the presence of sanitizer receptacles in the halls, and denied being told sanitizer was unavailable. The Administrator stated the expectation was that CNAs practice good hand hygiene and notify her if sanitizer was not available. Facility policies on infection control and hand hygiene required staff involved in direct resident contact to perform proper hand hygiene to prevent the spread of infection, but observations and interviews showed this was not consistently implemented during meal service for the four residents. The facility’s own staff acknowledged that failure to sanitize hands placed residents at risk of infection, cross contamination, and transfer of bacteria. CNAs interviewed stated that residents were at risk of transmission of infection when staff did not sanitize their hands, and the DON stated that when staff did not sanitize their hands they placed residents at risk of transmission of infection. The Administrator similarly stated that residents had been at risk of getting sick with infection or a UTI. These statements, combined with the observed lack of hand hygiene during meal tray delivery and the documented policies requiring hand hygiene, form the basis of the identified deficiency in the facility’s infection prevention and control program. The infection control and prevention in-service record dated 1/5/26 stated that the purpose of the policy was to reduce the spread of infections by using evidence-based techniques and established infection control policies and procedures, and that it was the policy to use precautions to reduce the risk and prevent transmission of infectious agents. The hand hygiene policy dated 11/12/17 specified that staff involved in direct resident contact would perform proper hand hygiene procedures to prevent the spread of infection to personnel, residents, and visitors, and defined hand hygiene as either handwashing or use of an alcohol-based hand rub, to be performed when indicated using proper technique consistent with accepted standards of practice. Despite these written policies and in-service education, the observed practices during the lunch meal service on Hall 100 did not align with the facility’s stated infection prevention and control requirements, resulting in the cited deficiency.
Dirty Privacy Curtains and Damaged Shower Room Walls
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for Residents #95, #86, and #14 because their privacy curtains had several dried brown substances on them. During observations, each resident’s room was inspected and the stained curtains were seen in place. Each resident stated housekeeping cleaned the room, but none could recall when the privacy curtain was last cleaned. Housekeeping staff stated they were responsible for removing and washing privacy curtains, but also said they were not aware of how often the curtains were washed and that stained curtains were a biohazard. The Environmental Service Manager stated most privacy curtains were stained, that he had discussed replacing them with the Administrator about a month earlier, and that the curtains had been ordered but were on back order. The facility also failed to maintain Shower room [ROOM NUMBER] because the walls had cracked tiles near the floor and five missing wall tiles where the wall met the floor. During the observation, the Maintenance Director stated he had fixed those tiles a few months earlier and was not aware they were broken again. He stated the condition was not homelike and that water could get into the wall if the tiles were not replaced. The DON and Administrator both stated staff were expected to report needed repairs to Maintenance, and the Administrator stated the risk could include mold, injury, and the area not being homelike.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to ensure nail care, including trimming and cleaning, was provided for 4 of 32 residents reviewed for ADL care. Residents #12, #27, #81, and #86 all had care plans that included ADL assistance and nail care as needed or per schedule, yet observations showed their fingernails were long and, in several cases, dirty or jagged. The report states the deficiency involved residents who were unable to carry out activities of daily living and were dependent on staff for personal care. Resident #12 had a history of stroke with left hemiplegia and moderate cognitive impairment. During observation, both hands had nails approximately 1/4 to 1/2 inch long, and the resident stated the nails wanted to be cut. Resident #27 had diagnoses including dementia, Type 2 diabetes, and spina bifida, with intact cognition on MDS. Observation showed the resident’s right-hand nails had black and brown substance underneath all nails and were approximately 1/8 to 1/4 inch past the nail bed; the resident stated he wanted his nails cut. A CNA stated CNAs did not cut nails unless the nurse asked them to, while an RN stated nurses and CNAs do nail care but preferred CNAs not do diabetic nail care. Resident #81 had diagnoses including cerebral infarction with hemiplegia, lack of coordination, diabetes, dementia, and hypertension, and was frequently incontinent. Observations showed fingernails on both hands were approximately 1/4 to 1/2 inch long with rough, jagged edges and dark debris underneath. The resident stated he did not like his fingernails long and wanted them shorter, and staff interviews showed the CNA and LVN both acknowledged the nails were long and that they were responsible for nail care, but neither had ensured it was completed. Resident #86 had diagnoses including CVA, encephalopathy, contracture, cognitive communication deficit, and muscle wasting, and was dependent on two or more helpers for personal hygiene. Observation showed the resident’s left hand was contracted, the thumb nail was about half an inch long and curling to the side, and other nails on that hand were also long. The resident stated he wanted his fingernails cut short, while staff stated nail trimming was their responsibility and that long nails on the contracted hand could dig into the hand and cause infection. The DON stated all nursing staff were responsible for nail trims and expected refusals to be documented.
Failure to Obtain Order and Care Plan for Splint Use
Penalty
Summary
The facility failed to ensure Resident #86, a male resident with diagnoses including CVA, encephalopathy, contracture, cognitive communication deficit, and muscle wasting/atrophy, received appropriate treatment and services for limited ROM and a left hand contracture. The annual MDS reflected functional limitation in upper extremity ROM, and the care plan addressed ADL self-care deficits related to left side hemiplegia/hemiparesis/contracture, but it did not address the use of a splint. The resident’s physician orders also contained no order for a splint. During observation, Resident #86 was seen in bed with his left hand contracted and without a splint, and he stated he had used a splint at some point but could not recall the last time it had been applied. Later observations showed the resident sometimes had a splint on his left hand and at other times did not. CNA P stated the resident’s left hand was contracted and required a splint, and that nurses applied it. RN Q stated the resident required a splint, that she applied it, and that a physician order was needed before any treatment was provided; she also confirmed the splint use was not care planned. ADON H stated therapy usually put the splint on the resident, but she was not aware nursing staff were applying it or that there was no physician order. The DON stated she was not aware staff were putting a splint on the resident and said nurses were responsible for obtaining physician orders before using a splint. Occupational Therapy stated staff had found the resident’s splint in his room and that nurses had been trained on its use, while also stating the original paper order was no longer available. The MDS Coordinator stated contractures and the use of any device should be care planned, but the resident’s care plan did not include the splint.
Incomplete Dialysis Monitoring Documentation
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with End Stage Renal Disease, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and dependence on renal dialysis. The resident’s care plan indicated hemodialysis every Monday, Wednesday, and Friday, and included monitoring for complications such as shortness of breath, peripheral edema, chest pain, elevated blood pressure, dry itchy skin, nausea and vomiting, and bleeding at the access site. The resident’s quarterly MDS showed a BIMS score of 15, indicating intact memory and the ability to make independent decisions regarding care. Record review of the resident’s Dialysis Communication Forms showed that only two treatment dates were fully completed, while multiple other forms had missing documentation. The incomplete forms included dates in October 2025 through February 2026. The DON stated that the completed Dialysis Communication Records were to be completed and kept in a binder for each dialysis resident, that charge nurses were expected to contact the dialysis center if a form was not returned, and that charge nurses were supposed to complete the form and send it with the resident to dialysis. The DON and Administrator also stated that charge nurses were expected to check the resident’s vitals before leaving for dialysis and upon return. The facility policy stated that dialysis residents would receive dialysis services as per physician orders and would be monitored accordingly, including assessment of vitals, edema, access site, mental status, pain or discomfort, blood sugar if ordered, and medications as directed by the dialysis center.
Dishwasher Sanitizer and Temperature Logs Not Maintained
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in its only kitchen because the dishwasher’s chemical concentration and temperatures were not logged. During an observation on 02/12/26 at 8:59 AM, Dietary Staff M ran a dishwasher cycle and tested the chemical sanitizer, stating she checked the temperature and chemicals once a day before washing dishes. The test strip read 100 parts per million, which was within the stated acceptable range of 50 to 100 parts per million. Record review of the facility’s Low-Temperature Dish machine Sanitizer Log for February 2026 showed no water temperature or chemical concentration checks for multiple shifts on 02/03/26 through 02/09/26. During interview, the Dietary Manager stated staff were supposed to check the dishwasher 3 times a day and record it on the log, and said she or the Assistant Manager would train staff on that procedure. She also stated she checked the dishwasher in the morning and the Assistant Manager ran it at night, and explained that there were 2 days when the dishwasher was down and the log was not used. The Maintenance Director stated the dishwasher was out of service last week, kitchen staff noticed it was not working, and he fixed it the same day. The Administrator stated she expected kitchen staff to report major repairs, including the dishwasher, and said if the dishwasher was not working or chemicals were not being checked there was potential for unsanitary dishes.
Improper Dumpster Waste Disposal and Open Lids
Penalty
Summary
Dispose of garbage and refuse properly: the facility failed to ensure proper disposal for 3 of 3 dumpsters, including dumpster #1, #2, and #3. During observation on 02/10/2026 at 9:12 AM, both doors were open on dumpster #1, exposing trash, used incontinent briefs and a clear trash bag with soiled incontinent briefs were lying on the ground next to dumpster #1, and the lids on dumpsters #1 and #3 were not closed. Interviews on 02/12/2026 with the Dietary Manager, Environmental Services Manager, and Administrator confirmed that kitchen staff and environmental services/floor techs were responsible for taking trash outside, that dumpster doors and lids were supposed to be closed, and that trash should be picked up from the surrounding area.
Walk-In Freezer Door Seal Not Properly Maintained
Penalty
Summary
The facility failed to maintain safe and functional essential kitchen equipment in its only kitchen by not ensuring the seal on the walk-in freezer door was replaced properly. Observation on 02/10/2026 at 8:55 AM revealed ice buildup along the door frame, threshold, and floor of the walk-in freezer. During interview on 02/12/2026 at 9:58 AM, the Dietary Manager stated Maintenance was responsible for ensuring the freezer was clean, said she noticed the ice buildup 3 months earlier, and reported that someone had put a new seal on the door but it was not done properly. She stated the risk was someone could trip and fall, and said kitchen staff used a communication book for repairs and the Maintenance Director would come to check. A later observation on 02/12/2026 at 10:13 AM showed ice buildup was still present along the door frame and threshold of the walk-in freezer. During interview on 02/12/2026 at 11:57 AM, the Maintenance Director stated the freezer was functioning properly and the seal had been replaced in November. He said it was important to ensure the freezer was working to protect food and prevent illness and that the ice could be a hazard to employees. The Administrator stated on 02/12/2026 at 4:38 PM that she expected kitchen staff to report major repairs, including the freezer, stove, or dishwasher, to the Maintenance Director and herself, and said if the freezer was not working it could affect food quality if the temperature got out of range. Record review showed the Maintenance Work Order Log reflected the freezer seal was resolved on 11/20/25, and the U.S. FDA Food Code 2022 requires equipment components such as doors and seals to be kept intact, tight, and adjusted according to manufacturer specifications.
Failure to Follow Ordered Enteral Feeding Schedule
Penalty
Summary
Resident #14, a female with gastrostomy status, dysphagia following cerebral infarction, and malnutrition, had a quarterly MDS showing intact cognition with a BIMS score of 13 and a nutritional approach of a feeding tube and mechanically altered diet. Her care plan directed staff to administer tube feedings and water flushes as ordered and to monitor for complications related to tube feedings. The physician order specified Jevity 1.5 cal continuous overnight enteral feeding at 60 ml/hr for 16 hours from 6:00 PM to 10:00 AM with 300 cc H2O flushes every 4 hours. Record review and observations showed the enteral feeding was started at 6:04 PM, but RN G disconnected the resident at 8:00 AM instead of the ordered 10:00 AM. RN G stated she was not aware the physician order had changed on 02/09/26 and acknowledged she failed to follow the physician order. The ADON stated nurses were expected to review physician orders before administering care and that each nurse was responsible for following those orders. The DON stated nurses were expected to follow physician orders and provide the correct quantity and feeding time.
Expired Medications Found in North Medication Room
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals in the North medication room. During observation of the North medication room refrigerator, four 10 mg Bisacodyl suppositories with an expiration date of 01/21/26 and 11 650 mg Acetaminophen suppositories with an expiration date of 01/09/26 were found stored in the refrigerator. LVN A stated the Bisacodyl and Acetaminophen suppositories had expired and that expired medications could be administered if not removed, making the dose ineffective or causing an adverse reaction. Interviews with ADON B and the DON showed that nursing staff were expected to check medication rooms daily for expired medications, and ADONs were expected to round at least weekly to ensure none were present. ADON B stated she checked the medication room most mornings but had missed the expiration date on the suppositories. The DON stated no specific training on auditing storage rooms for expired medications had been completed with floor nurses since she started, although nurses were expected to review storage rooms when retrieving medications and supplies. The facility's Medication Storage policy stated medication carts and medication rooms were to be routinely inspected for outdated medications and that these medications were to be removed and destroyed.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when CNA C did not perform hand hygiene before beginning incontinence care for Resident #45 and did not change gloves or perform hand hygiene before applying a clean brief. Resident #45 was a severely cognitively impaired male with diagnoses including cerebral infarction, degenerative disease of the nervous system, hemiplegia, and aphasia. He was dependent on staff for all care, incontinent of bowel and bladder, and had a feeding tube for nutrition. His care plan also reflected total assistance with all cares, frequent checks for wetness, monitoring for signs of UTI, tube feeding, and enhanced barrier precautions due to wounds. During observation, CNA C entered the resident’s room, did not wash or sanitize her hands, and put on PPE. She transferred the resident from a wheelchair to bed for wound care, checked his brief and found it wet, and prepared incontinent care supplies. She cleaned the resident’s perineal area, turned him to his left side, and cleaned the buttocks with new wipes. After rolling the soiled brief within itself and discarding it, she did not perform hand hygiene or change gloves before obtaining a clean brief and placing it under the resident. She then repositioned the resident, removed her PPE, washed her hands, and exited the room. In interview, CNA C stated she had been working at the facility for one month and acknowledged she forgot to wash her hands before putting on gloves and was expected to change gloves when moving from the dirty brief to the clean one. She stated she was in a hurry to complete care before wound care. The ADON and DON both stated staff were expected to perform hand hygiene when entering and leaving a room and to change gloves and perform hand hygiene between the dirty and clean brief. The facility’s hand hygiene policy stated gloves do not replace hand hygiene and that hand hygiene is required before donning gloves and immediately after removing them. The nursing procedure manual for incontinence care also directed staff to remove and discard gloves, wash hands, and then apply clean incontinent products.
Smoking assessments not completed as required
Penalty
Summary
The facility failed to establish and follow policies regarding smoking, smoking areas, and smoking safety that took into account nonsmoking residents for two residents reviewed for smoking. Resident #11 was a male admitted with diagnoses including unspecified dementia, peripheral vascular disease, and schizophrenia. His quarterly MDS showed a BIMS score of 15, indicating intact memory and the ability to make independent decisions regarding ADL care. His smoking assessments were completed on 06/03/2023, 01/11/2024, 03/08/2024, 06/10/2024, and 09/10/2024, but quarterly smoking assessments were not regularly completed. Resident #72 was a male admitted with diagnoses including ESRD, type 2 diabetes mellitus with diabetic polyneuropathy, dependence on renal dialysis, and loss of the right upper limb below the elbow and right hand at the wrist level. His quarterly MDS also showed a BIMS score of 15, indicating intact memory and the ability to make independent decisions regarding care. His smoking assessments were completed on 12/29/23, 03/08/24, and 03/06/25, but quarterly smoking assessments were not regularly completed. During interview, Resident #72 stated that because he has no hands or arms below the elbows, staff must assist him with smoking. The DON stated that a designated smoke aide is assigned to sit with residents during smoke breaks and that smoking assessments were expected on admission, quarterly, and with any change in smoking status. The Administrator stated the same expectation and said the Social Worker was expected to complete the smoking assessments.
Failure to Maintain Resident Privacy Due to Broken Window Blinds
Penalty
Summary
The facility failed to ensure full visual privacy for residents in six rooms, as window blinds in these rooms had multiple broken slats, allowing individuals outside the facility to see into the residents' beds. Observations on several occasions revealed varying numbers of broken slats in the blinds of these rooms, with some residents expressing dissatisfaction and concern about the lack of privacy. One resident specifically stated that the blinds had been broken for a long time and needed replacement for privacy, while another resident disliked the broken blinds because they allowed people to see inside. Interviews with staff, including a medication aide and an LVN, revealed that they were unaware of any blinds needing replacement and that repairs were typically entered into a Maintenance Logbook at each nurses' station. Review of the Maintenance Logbooks showed no requests for blind repair or replacement. The Maintenance Director stated he was responsible for physical plant repairs and relied on staff to report issues, checking the logbooks regularly and conducting monthly room sweeps. He was unaware of the broken blinds but indicated that replacements were available. The facility's policy emphasized the importance of privacy and dignity for residents, including maintaining a homelike environment.
Failure to Permit Safe Return and Proper Discharge After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to permit a resident to return after a hospitalization, despite the resident requiring extensive assistance with all activities of daily living and having multiple complex medical conditions, including diabetes mellitus, chronic respiratory failure, COPD, major depressive disorder, end stage renal disease, morbid obesity, and a history of seizures. The resident was dependent on staff for care and had a care plan addressing resistance to care, dialysis needs, diabetes management, and congestive heart failure. The resident was sent to the hospital for shortness of breath and chest pain, received necessary treatment, and was cleared for return to the facility on two separate occasions. Upon both attempts to return from the hospital, emergency services and hospital staff reported that the facility refused to readmit the resident. The facility staff, including the Administrator, cited the resident's history of refusing care, medications, and dialysis, as well as being rude and abusive towards staff, as reasons for not allowing reentry. Despite these behavioral concerns, there was no documentation of a proper discharge process, and the resident was not provided with a safe alternative placement. Interviews with facility staff, emergency medical technicians, hospital staff, and the Ombudsman confirmed that the resident was denied reentry and that no discharge paperwork or safe discharge planning was completed. The facility's own policy on discharge planning did not address the process for allowing residents to return after a hospital visit. Multiple staff members, including the ADON and nurses, indicated they were unaware of any formal discharge and anticipated the resident's return. The Administrator acknowledged that the resident was not properly discharged and would not be allowed to return, despite understanding that this placed the resident at risk of not having a safe place to live and receive necessary care. The lack of proper discharge documentation and refusal to readmit the resident constituted a failure to ensure a safe and appropriate transfer or discharge.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Wound and Non-Compliance
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a stroke, poor circulation, and nicotine dependence. The resident was moderately cognitively impaired, totally dependent on staff for activities of daily living, and at risk for pressure ulcers. Despite developing an arterial wound on her left outer ankle, the care plan did not address the wound or the resident's non-compliance with care instructions. Assessments showed the wound worsened over time, and documentation from the wound physician linked poor healing to the resident's smoking and failure to offload pressure. Interviews with staff revealed ongoing challenges in managing the resident's care, including her preference to remain in bed, resistance to repositioning, and repeated removal of positioning aids. Staff and family attempted to encourage mobility and offloading of pressure, but the resident remained largely non-compliant, expressing disbelief in the education provided. The care plan was not updated to reflect these issues, and the Assistant Director of Nursing acknowledged being behind on care plan updates due to being new in the role.
Failure to Accurately Document and Code Oxygen Therapy on MDS
Penalty
Summary
Facility staff failed to ensure that clinical records for a resident were accurately documented in accordance with accepted professional health information management standards. Specifically, the facility did not properly code the resident's oxygen treatment on the Minimum Data Set (MDS), despite the resident having physician orders for PRN oxygen therapy due to respiratory conditions and being on hospice care. The resident's care plan and physician orders indicated the need for oxygen therapy, and staff were expected to document administration and refusals, as well as notify appropriate personnel when the resident refused treatment. Record reviews revealed that the resident had a history of refusing care and treatment, including oxygen therapy. Interviews with facility staff, including the Hospice RN, NP, ADON, DON, and MDS coordinators, confirmed that the resident had an active order for PRN oxygen and that refusals were to be documented and reported. However, during the lookback period for the MDS, the resident had not received oxygen treatment, and the last documented administration was prior to the most recent physician order. The Treatment Administration Record (TAR) did not reflect any oxygen administration during the relevant period, and the MDS was not coded to indicate oxygen therapy. Additionally, the facility was unable to provide its MDS policy protocol when requested by the surveyor, despite assurances that it would be sent. The administrator acknowledged awareness of the resident's resistance to care and stated that staff were expected to follow facility policy and physician orders. The failure to accurately document and code the resident's oxygen therapy on the MDS constituted a deficiency in maintaining clinical records according to professional standards.
Failure to Maintain Safe, Sanitary, and Private Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of three shower rooms on Central Station. Observations revealed that the toilet in the shower room was blocked by equipment and had a dark substance with an odor. The right-side shower had a torn curtain, limiting privacy, while the left-side shower lacked a curtain entirely, resulting in no privacy for residents. Additionally, the shower head hose on the left side had holes, causing water to leak out the side. These issues were directly observed during a facility survey. Interviews with staff indicated that the CNA working in the area was aware of the missing and damaged shower curtains and broken shower head but had not reported the issues. The CNA stated that such damages should be reported to nursing and maintenance via the maintenance log book. The Maintenance Director confirmed that curtains had been recently ordered and replaced but was unsure why they were disappearing, and stated that nursing staff were responsible for logging maintenance concerns. The DON and Administrator were not aware of the ongoing issues, and both indicated that it was the responsibility of nursing staff to report problems and for maintenance and housekeeping to address them. Record review of the facility's policy emphasized the importance of privacy, dignity, and a homelike environment for residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and flies throughout multiple areas, including all three hall locations, nurse's stations, the Central Station dining room, and the biohazard closet. Observations revealed gnats circling in the Central Station shower room and dining room, as well as flies and gnats flying around the Central Station nursing station. Residents reported being frustrated by the persistent presence of pests, with some choosing to eat in their rooms to avoid them. Staff interviews confirmed that flies and gnats were a widespread issue, with several residents keeping fly swatters in their rooms and expressing dissatisfaction with the living conditions. Further investigation into the biohazard closet revealed a significant infestation of gnats and flies, with dead insects found on the floor and shelves, and biohazard waste not properly contained. The closet was found to be in disarray, with open and improperly sealed biohazard bags and boxes, and a lack of clear responsibility for maintaining cleanliness. Staff interviews indicated confusion and lack of accountability regarding who was responsible for monitoring and cleaning the biohazard closet, leading to the accumulation of waste and pest infestation. The maintenance director acknowledged ongoing concerns with pests, citing contributing factors such as standing water outside the building, frequent opening of the smoke patio door, and delayed removal of biohazard waste. The pest control vendor was reported to be treating the facility weekly, but staff noted inconsistent presence of the vendor. The facility's pest control policy required regular and as-needed pest control services, but observations and interviews indicated that these measures were not effectively implemented, resulting in continued pest problems and negative impact on residents' quality of life.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the provision of tracheostomy care for a resident on enhanced barrier precautions due to ESBL colonization. During an observed tracheostomy care procedure, a nurse did not set up all necessary supplies beforehand and used a previously opened, non-sterile saline bottle instead of sterile saline as required by policy. The nurse also broke sterile technique by reaching into the resident's bedside table with sterile gloves to retrieve additional supplies and did not stop the procedure after contaminating the sterile field. The resident involved had multiple complex medical conditions, including a tracheostomy, hemiplegia, stroke, dysphagia, and depression, and required assistance with all activities of daily living. The care plan indicated the resident was at high risk for further cognitive impairment and psychosocial issues. The resident was on enhanced barrier precautions due to ESBL colonization and required regular tracheostomy care and suctioning every nursing shift. Interviews with facility staff revealed gaps in adherence to sterile technique and inconsistencies in training and competency checks. The nurse involved acknowledged the breach in sterile field and the failure to restart the procedure with new supplies. The DON and a respiratory consultant both indicated that tracheostomy care training was provided, but there was a lack of familiarity with current facility policies and procedures. Review of the facility's tracheostomy care and suctioning policies confirmed the requirement for sterile technique and the use of sterile supplies.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Follow-Up and Scheduling of Medically Necessary Colonoscopy
Penalty
Summary
The facility failed to provide medically related social services necessary for a resident to achieve the highest practicable well-being by not ensuring a colonoscopy referral was properly followed up and scheduled. The resident, a female with a history of diabetes mellitus, cerebrovascular accident, transient ischemic attack, and non-Alzheimer's dementia, had a physician's order for a GI consult and colonoscopy. Documentation showed that the order was communicated to social services, and referral packets were faxed to the outside provider on multiple occasions. However, there was no evidence that an appointment was ever scheduled or that follow-up communication with the provider was documented. Interviews with the resident revealed she was informed months prior that a colonoscopy was recommended but was never given an appointment date or further information. The social worker and social worker assistant confirmed their roles in handling outside provider appointments, with the assistant responsible for sending referrals and following up. Despite sending the referral, the assistant had no documentation of any follow-up calls or actions taken after the initial fax, and the resident remained unaware of any scheduled appointment. Further interviews with nursing staff and the DON clarified that the process involved the NP writing the order, nursing communicating it to social services, and social services arranging the appointment and transportation. The DON stated that social services was expected to ensure appointments were scheduled and to follow up as needed. Despite these established responsibilities and policies, the lack of documented follow-up and communication resulted in the resident not receiving the ordered colonoscopy.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by a Wound Care Nurse not wearing a gown while providing wound care to a resident on enhanced barrier precautions. The resident, a male with a history of cellulitis, lymphedema, and chronic venous hypertension with ulcers, was care planned for enhanced barrier precautions due to a vascular ulcer. Despite clear signage outside the resident's room and the availability of gowns in the room, the Wound Care Nurse only donned gloves and did not wear a gown while applying a bandage to the resident's leg. Interviews revealed that the Wound Care Nurse was initially unaware or had forgotten that the resident was on enhanced barrier precautions, despite prior training and the presence of a posted sign. The facility's Infection Preventionist and DON confirmed that all staff were expected to follow infection control procedures, including wearing gowns and gloves for residents on enhanced barrier precautions. The facility's policy required the use of gowns and gloves during high-contact care activities for residents with chronic wounds, which was not followed in this instance.
Resident Assault and Facility's Failure to Prevent Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident struck him in the face. The incident occurred at the nurse's station where the first resident was eating a snack, and the second resident approached to get a snack as well. The first resident made a statement to the second resident, who then struck him on the left cheek with a closed fist. This resulted in redness to the first resident's cheek, and ice was applied to the affected area. The second resident also received ice for his right fist as a precautionary measure. The residents were immediately separated and treated in their rooms. The first resident, a male with dementia, stroke, and an amputation, had a moderate cognitive impairment and no history of aggression. The second resident, a male with a traumatic brain injury, schizoaffective disorder, and a history of violent behavior, had severe cognitive impairment. Despite his behavioral assessment indicating no issues, the second resident had previously made accusations and complaints about other residents. On the day of the incident, the second resident was verbally aggressive before physically assaulting the first resident. The facility's investigation revealed that the second resident had a history of violent behavior and showed no remorse for his actions. The police were called, and the second resident was taken into custody for a mental health evaluation and did not return to the facility. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents from harm, but the incident demonstrated a failure to prevent abuse and ensure the safety of all residents.
Failure to Ensure Timely Dental Care Due to Payment Delay
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental care, specifically a follow-up appointment for a root canal, due to a delay in processing payment to the dentist. The resident, a male with severe cognitive impairment and a history of a vehicle accident causing brain injury, was experiencing dental pain but was only receiving pain medication without further dental intervention. Despite the resident's expressed desire to see the dentist again, the facility did not ensure timely payment for a previous dental visit, which resulted in the dentist refusing further treatment until the invoice was settled. The resident's records indicated that he had been seen by the dentist previously, where fillings were done, and he was informed that a root canal might be necessary if pain persisted. However, the facility's social worker failed to follow up on the dentist's invoice, leading to a delay in the resident's dental care. The facility's policy required assistance in making appointments and ensuring continuous care, but this was not adhered to, resulting in the resident potentially experiencing unnecessary dental pain.
Inappropriate Prescription of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was not given psychotropic medications unless necessary to treat a specific condition as diagnosed and documented in the clinical record. The resident, a male with a history of dementia, stroke, and unspecified psychosis, was prescribed Seroquel for a condition he did not have, specifically Schizoaffective disorder. The resident's admission record and care plan did not include a diagnosis of Schizoaffective disorder, yet the medication was prescribed for this condition. The resident had been on Seroquel since 2012 for unspecified psychosis, and the medication was later prescribed for Schizoaffective disorder without a proper diagnosis. The Director of Nursing (DON) confirmed that the resident did not have a diagnosis of Schizoaffective disorder but stated that the medication was necessary due to worsening behaviors when attempts were made to wean the resident off Seroquel. Despite several unsuccessful attempts at Gradual Dose Reduction (GDR), the facility continued the medication without a documented diagnosis of Schizoaffective disorder. The facility's policy on psychotropic management requires that such medications are only given when necessary to treat a specific condition as diagnosed and documented, which was not adhered to in this case.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant roach infestation affecting six residents. Observations and interviews revealed that roaches were present in multiple resident rooms, including those of Residents #56 and #99, where roaches were seen along baseboards and behind dressers. Residents reported finding roaches in their personal items, such as cups, and expressed frustration over the lack of effective action despite reporting the issue to staff multiple times. Further observations noted roaches crawling across floors and walls in various areas of the facility, including the South Station and resident rooms. Housekeeping staff and maintenance personnel acknowledged the presence of roaches and reported the issue to their supervisors. Despite the pest control vendor's weekly visits, the problem persisted, with staff and residents continuing to encounter roaches in living areas, which were also observed by surveyors during their inspection. Interviews with staff, including housekeeping, maintenance, and nursing personnel, confirmed the ongoing roach problem. The maintenance department had a procedure for addressing pest issues reported in a logbook at the nursing station, but the measures taken, including spraying and notifying the pest control vendor, were ineffective. The facility's pest control policy aimed to eradicate pests using appropriate chemicals, but the continued presence of roaches indicated a failure to implement an effective pest control strategy.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents during feeding assistance. Resident #82, a female with severe cognitive impairment and a diagnosis of dysphagia following a nontraumatic intracerebral hemorrhage, was fed by CNA A while the CNA stood beside her bed. This action was contrary to the resident's care plan, which required supervised assistance by one staff member. CNA A admitted to not knowing the importance of sitting while feeding and had not received training on this aspect of care. Similarly, Resident #109, a female with severe cognitive impairment and multiple sclerosis, was fed by LVN B while standing in the dining room. The resident's care plan required extensive assistance by one staff member. LVN B acknowledged knowing the importance of sitting to prevent aspiration and promote dignity but had not received specific training on this practice. The Director of Nursing and Assistant Director of Nursing confirmed that staff were expected to sit at eye level with residents during feeding to ensure dignity and proper pacing, but this expectation was not met in these instances.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #26 and Resident #34, had their call lights within reach, which is a necessary accommodation for their needs and preferences. Resident #26, a female with significant impairments including cerebral infarction, aphasia, and hemiplegia, was observed with her call light string not within reach while she was in bed. Her care plan specifically required that the call light be within reach to ensure her needs could be met promptly. Despite this, the call light was attached to the wall and not accessible to her, as confirmed by a CNA who acknowledged the oversight and the potential risk of unmet needs. Similarly, Resident #34, who also had significant mobility and communication impairments, was found with her call light not within reach. The call light was tangled underneath her bed, making it inaccessible. Her care plan also emphasized the importance of having the call light within reach to prevent falls and ensure her needs were met. A CNA responsible for her care admitted to not noticing the call light's position and acknowledged the importance of having it accessible. Interviews with staff, including CNAs and the DON, revealed a consensus that it was the responsibility of all staff to ensure call lights were within reach. The facility's policy also mandated that call lights be placed near residents and never on the floor or bedside stand. The failure to adhere to these policies and care plans placed the residents at risk of injuries and unmet needs, as they were unable to call for assistance when required.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy to a resident as ordered by the physician, which is a deficiency in providing appropriate respiratory care. Resident #102, who was admitted with a diagnosis of respiratory failure and required oxygen therapy, was observed receiving 5 liters per minute (LPM) of oxygen via nasal cannula, contrary to the physician's order of 3 LPM. This discrepancy was noted during multiple observations throughout the day, and the resident was unaware of the correct oxygen level he was supposed to receive. Interviews with the nursing staff, including RN C and the Director of Nursing (DON), revealed that the staff were expected to follow physician orders for oxygen therapy. However, RN C acknowledged the failure to administer the correct oxygen level and expressed concern about the potential harm of excessive oxygen. The DON and Assistant Director of Nursing (ADON) also confirmed the expectation for staff to check and ensure the correct oxygen levels at the start of each shift, but the ADON admitted to not checking the oxygen level during rounds. The facility's policy on following physician orders was reviewed, indicating a requirement to carry out and implement physician orders.
Failure to Follow Medication Administration Protocols for G-Tube
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident with a gastrostomy tube. LVN D did not follow the facility's policy for flushing the gastrostomy tube with the prescribed amount of water before, between, and after administering medications. Specifically, LVN D administered Vitamin D, Magnesium Oxide, and Sodium Chloride to the resident without dissolving the medications in water as required and did not flush the tube with the correct amount of water between medications. The resident involved was an elderly female with a history of cerebral infarction, cognitive communication deficit, and other related conditions, including gastrostomy status. Her care plan indicated she was at risk for aspirations, weight loss, and dehydration, and required specific procedures for medication administration via her feeding tube. Despite these requirements, LVN D failed to dissolve the medications and used a plunger to administer the bolus formula instead of allowing it to flow by gravity, which led to the gastrostomy tube clogging. Interviews with LVN D and the Director of Nursing (DON) revealed that LVN D was unaware of the specific physician orders for dissolving medications and flushing the tube with the prescribed amount of water. The DON confirmed that the expectation was for nurses to follow physician orders and administer medications and formula via gravity. The facility's policy required verification of medication administration accuracy and adherence to physician orders, which was not followed in this instance.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 6.06%, exceeding the acceptable threshold of 5%. This was observed during a medication pass by LVN D, who was responsible for administering medications to a resident via a gastrostomy tube. The errors were identified when LVN D failed to dissolve the medications properly and did not administer the full contents of the medication cups, leaving residue behind. This resulted in the resident not receiving the full prescribed doses of their medications. The resident involved was a female with a complex medical history, including cerebral infarction, cognitive communication deficit, and gastrostomy status, among other conditions. Her care plan required specific procedures for medication administration via a feeding tube, including dissolving each medication with water and flushing the tube between medications. However, LVN D did not adhere to these procedures, leading to a clogged g-tube and incomplete medication administration. Interviews with LVN D and the Director of Nursing (DON) revealed a lack of awareness and adherence to the physician's orders and facility policies regarding medication administration. LVN D admitted to not dissolving the medications as required and acknowledged the presence of medication residue in the cups. The DON confirmed that the expectation was for nurses to follow the prescribed procedures to ensure effective medication delivery, highlighting a gap in staff training and oversight.
Failure to Provide Safe Bed Equipment
Penalty
Summary
The facility failed to maintain safe operating conditions for mechanical and patient care equipment, specifically for a resident who was provided with a bed that had non-functional wheel locks. This deficiency was identified during an observation and interview with the resident, who was a cognitively intact female with a history of stroke, resulting in right-sided weakness and requiring extensive assistance with transfers. The resident expressed fear and reluctance to attempt self-transfers due to the bed's inability to lock, which posed a risk of falls. The resident reported that the bed had not locked since her admission and that she had requested a replacement from the nursing staff, which had not been addressed until after the surveyor's visit. The facility's failure to provide a bed with functional wheel locks was in violation of the resident's right to a safe environment, as outlined in the facility's Resident Rights policy.
Verbal Abuse by Administrator
Penalty
Summary
The facility failed to protect a resident from verbal abuse by the Administrator, which was identified through observation, interview, and record review. The incident involved a male resident who was admitted to the facility with a BIMS score indicating no cognitive impairment and had diagnoses including paraplegia and hyponatremia. The resident's care plan noted a risk for harm due to verbally abusive behaviors, and interventions included approaching the resident calmly and speaking slowly. The deficiency was highlighted by an audio recording provided by the resident, which captured a conversation between the resident and the Administrator. During the conversation, the Administrator used inappropriate language, including curse words, and dismissed the resident's concerns about the temperature in the facility. The resident expressed feeling unsafe and scared after the interaction, which led to his decision to leave the facility. The recording revealed the Administrator's dismissive and derogatory remarks, which were considered verbally abusive by the Director of Nursing (DON). Interviews with the DON and the Administrator confirmed that cursing at a resident is considered abuse. The Administrator, who was also the Abuse Coordinator, initially denied recalling the use of curse words but later acknowledged the possibility after listening to the recording. Despite the Administrator's claim that the language was used to communicate effectively with the resident, the facility's policy clearly defined such behavior as verbal abuse, emphasizing the need for a safe and comfortable environment for residents.
Verbal Abuse Incident by Administrator
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving verbal abuse directed at a resident by the Administrator. The incident involved a conversation between the Administrator and a resident, during which the Administrator used inappropriate language, including curse words, towards the resident. This interaction was recorded by the resident, who later provided the audio as evidence of the verbal abuse. The resident involved in the incident was a 44-year-old male with a history of paraplegia and hyponatremia, who had been admitted to the facility earlier in the year. The resident had a BIMS score indicating no cognitive impairment and had expressed dissatisfaction with the facility, citing feelings of being unwanted and unsafe. The resident reported that the Administrator cursed at him during a conversation about the temperature in the facility, which made him feel scared and led to his decision to leave the facility. Interviews with the Director of Nursing (DON) and the Administrator confirmed that cursing at a resident is considered abuse. The Administrator, who also served as the Abuse Coordinator, initially denied recalling the use of curse words but later acknowledged the possibility after listening to the recording. Despite this acknowledgment, the Administrator attempted to justify his language as a means of communication with the resident, who frequently interrupted him. Ultimately, the Administrator suspended himself from his duties pending an investigation into the abuse allegation.
Facility Fails to Maintain Safe and Comfortable Dining Room Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in two of its dining rooms, specifically the Main Dining Room and the North Station Dining Room. Observations revealed that chairs in these areas were in poor condition, with ripped, cracked, and frayed seat cushions, some of which had exposed foam. Residents expressed discomfort and dissatisfaction with the chairs, noting that they were uncomfortable and unsightly. Interviews with residents, including the Resident Council president, indicated that complaints had been made to the facility's administration, but no action had been taken to address the issue. The Maintenance Director acknowledged the poor condition of the chairs and stated that the facility was considering options for repair or replacement, but no decision had been made. The Director of Nursing (DON) and the Administrator were aware of the issue, with the Administrator citing cost concerns as a reason for the lack of action. Despite the acknowledgment of the problem, maintenance logs showed no entries related to the condition of the chairs, and the facility's policy on housekeeping standards emphasized the importance of maintaining a clean, safe, and pleasant environment, which was not upheld in this case.
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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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village Creek Nursing & Rehabilitation | 3.1 mi | ★★★★★ | 11 | 0 |
| Arbor Lake Nursing & Rehabilitation, Llc | 3.2 mi | ★★★★★ | 2 | 0 |
| Dfw Nursing & Rehab | 3.3 mi | ★★★★★ | 13 | 4 |
| Downtown Health And Rehabilitation Center | 3.3 mi | ★★★★★ | 10 | 0 |
| James L West Center For Dementia Care | 3.7 mi | ★★★★★ | 0 | 0 |
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