Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park View Nursing Care Center during CMS and state inspections, most recent first.
Two residents were involved in a resident‑to‑resident altercation in which a cognitively impaired resident with dementia, known by staff to wander into others’ rooms and sometimes become physically aggressive, entered another cognitively intact resident’s room and was alleged to have kicked her shins and hit her in the face. The aggressive resident’s MDS documented physical and verbal behaviors toward others, but her care plan did not address behaviors directed at other residents. Although staff and multiple facility policies required immediate reporting of suspected abuse to the ADM/DON and timely reporting to state authorities within 2 hours, the allegation was not reported to the state within the required timeframe, and the nurse on duty notified the DON only by text to the on‑call phone, which was not seen at the time.
Two residents were involved in an incident where one cognitively impaired resident with dementia entered another cognitively intact resident’s room and allegedly kicked her in the shins and hit her in the face. A family member notified an RN by phone that the assault was occurring, and nursing staff and a CNA confirmed that the aggressive resident had been found in the other resident’s room and removed. The affected resident reported the physical contact, refused a sleeping pill due to fear of a repeat incident, and was assessed with no visible injury. Despite facility policies and leadership expectations requiring immediate reporting of all abuse allegations to the administrator/DON and timely reporting to state authorities within 2 hours, the allegation was not reported to the state within the required timeframe.
A resident with TBI, seizures, anxiety, and severe functional dependence had multiple 8:00 AM G‑tube/PEG‑tube medications and a 9:00 AM enteral feeding ordered, with facility policy requiring administration within one hour of the scheduled time. The MAR showed these medications and feeding as given on time by an LVN, but camera footage reviewed by the family and DON showed no staff entering the room for several hours, the resident falling from bed, and the LVN not entering until after the fall late in the morning. The LVN later admitted giving the medications late, around mid‑morning, contrary to the expected 7:00–9:00 AM window and the facility’s medication administration policy, resulting in late administration and inaccurate documentation of the resident’s scheduled medications.
The facility failed to maintain accurate accounting and recordkeeping for resident trust funds, affecting two cognitively intact residents who relied on the facility to manage their personal money. One resident reported requesting holiday gifts, snacks, soda, and a replacement cell phone through the Business Office Manager but did not receive or sign receipts, did not know the cost of the phone, and had only ever received a single account statement after specifically requesting it. Another resident stated she had a trust fund and used it as needed but had never received an accounting or quarterly statement. The former Business Office Manager acknowledged that in at least one case involving soda purchased by the Activity Director, no receipt was obtained and the resident did not sign anything. After the Business Office Manager left, corporate leadership found pouches with loose cash and notes but almost no receipts, and record review showed missing or incomplete documentation, unsigned or undated receipts, inconsistent signatures, and transactions not reflected in the trust fund ledger, all contrary to the facility’s own policy requiring complete, filed financial transaction records.
A resident with multiple chronic conditions and moderately impaired cognition died in the hospital after being transferred from the facility following a seizure and hemorrhagic stroke. After the resident’s death, facility leadership was aware that the resident had a substantial balance in a trust fund account but did not convey these funds within the 30-day period required by facility policy. Staff initially believed the resident had no family, then were informed by a former BOM that family existed but had no contact information, and the facility decided instead to return the funds to the state but had not completed this action. Review of records confirmed the unresolved trust fund balance and a written policy requiring refund and final accounting of personal funds within 30 days of death or discharge.
A resident with dementia, seizure disorder, chronic respiratory failure, atrial fibrillation, and on anticoagulant therapy was found unresponsive in bed with only minimal response to a sternal rub and later noted to have blood in the mouth from a bitten lip. The DON assessed the resident, documented unresponsiveness with stable VS and no apparent distress, instructed CNAs to monitor more closely, but did not notify the physician despite the resident’s significant neurological change and seizure history. On the following shift, LPN staff noted fluctuating alertness, then a decline in responsiveness, and during peri care the resident had seizure-like activity followed by unresponsiveness with shallow, labored respirations, prompting EMS transfer. The resident’s physician later stated he would have wanted to be notified of the unresponsiveness and lip-biting and would have ordered immediate hospital transfer, and facility policy required physician notification for acute changes in condition and level of consciousness.
A resident with a history of dementia, seizure disorder, atrial fibrillation, chronic respiratory failure, and anticoagulant use was found unresponsive in bed with normal VS and later noted to have blood in her mouth from a bitten lip. The DON assessed the resident, obtained only minimal response to a sternal rub, and documented that the resident remained unresponsive but breathing comfortably; however, the physician was not notified despite the resident’s significant change in LOC and possible seizure activity, contrary to the care plan and facility policy for acute condition changes. Oncoming nursing staff were told the resident had a bad night and was to be monitored; later that morning, the resident’s responsiveness declined further, she had a seizure during peri care, and EMS was called to transfer her to the hospital, where she was diagnosed with a large intracerebral hemorrhage and subsequently died. The resident’s physician stated he would have ordered immediate transfer had he been notified of the unresponsiveness and lip biting, and surveyors cited the facility under F684 for failing to provide care in accordance with professional standards and the resident’s care plan.
Unsafe food storage, preparation, and meal service practices were observed in the kitchen. Multiple frozen foods were found open or unlabeled and undated, staff handled food and serving items with gloved hands in a manner inconsistent with sanitary practice, pureed meat sat uncovered on the prep table for an extended period, and staff were observed without proper hairnets or beard restraints. Menu substitutions were also not documented, and the DON stated food temperatures were being taken after preparation rather than just before service.
Medication storage and labeling were deficient on two med carts. An LVN found expired meds, loose pills in cart drawers, and multiple meds without required open dates, including insulin pens and inhalers. Another LVN found a loose half pill in the narcotic drawer and inhalers with expired dates and no open dates. The DON stated missing open dates could result in expired meds being given and loose pills could mean missed doses.
Failure to provide privacy during wound care: an RN and CNA performed wound care for a resident with myelodysplastic syndrome, schizoaffective disorder, bipolar disorder, and pain without closing the window blinds. The resident had a BIMS of 13 and required extensive assistance with ADLs. The RN and DON both stated the open blinds could expose the resident during treatment and that it was a dignity issue.
A resident’s MDS inaccurately coded insulin use even though there was no insulin order, no care plan mention, and no MAR documentation showing insulin was given. Staff including an LVN, RN, ADON, DON, ADM, MDS LVN, and CEO confirmed the resident did not receive insulin and acknowledged that an inaccurate MDS can negatively affect resident care and facility funding.
Failure to develop a baseline care plan for a resident with Parkinson's disease, DM2, CAD, depression, and a rash. The resident had severely impaired cognition, and no baseline care plan was found in the EHR despite the facility policy requiring one within 48 hours of admission. Staff interviews showed confusion about who was responsible for completing the baseline care plan, and the resident was observed with red legs while the family reported the rash had worsened.
A comprehensive person-centered care plan was incomplete for two residents because one resident’s depression treatment with Paroxetine was not included and another resident’s rash and skin treatment needs were omitted. Records showed both residents had relevant diagnoses, active medication orders, and ongoing symptoms, while staff and leadership acknowledged the missing care plan items and stated that incomplete care plans can affect resident monitoring and care.
Pureed Meal Menu Not Followed: 6 residents on a pureed diet did not receive onions and peppers as listed on the lunch menu and were given carrots instead. The DM stated the item was not served because it could not be pureed, although the facility recipe book contained a recipe for pureed onions and peppers.
The facility failed to maintain infection control practices for two residents. An LVN did not perform hand hygiene before glove use, did not clean a glucometer before a blood glucose check, and a resident with a foley catheter did not have EBP signage on the door; a family member stated staff had not been using PPE for care, while the DON acknowledged the hand hygiene and PPE issues could lead to an infection control issue.
The facility did not have a state-licensed administrator appointed by the governing body for an extended period, as confirmed by staff interviews and record review. The previous administrator was terminated for lacking a current license, and although an interim administrator was present briefly, no permanent replacement had started. Staff reported concerns about lack of leadership and oversight due to this deficiency.
Two residents experienced medication errors when one, who was nonverbal and fully dependent, tested positive for barbiturates without a prescription, while another, prescribed Primidone (a barbiturate metabolite), missed two doses according to the MAR. Medications for both were stored next to each other in the med cart, and staff interviews revealed lapses in medication administration and documentation.
The facility failed to store, prepare, distribute, and serve food according to professional standards, with numerous items in the dry pantry and cold storage found unsealed, unlabeled, and undated. Additionally, dry pantry foods were not stored at the required height above the floor. The absence of a Dietary Manager and lack of policy on storage periods contributed to these deficiencies.
Two residents with cognitive impairments experienced falls resulting in injuries, which were not reported to the state agency within the required timeframe. The facility failed to investigate or report these incidents, despite having policies in place for such occurrences. Video footage showed one resident fell without staff present, and staff walked away shortly after.
Two residents with severe cognitive impairments experienced uninvestigated falls, resulting in injuries. The facility did not adhere to its policies on investigating and reporting incidents, as confirmed by video footage and staff interviews. This lack of action could place residents at risk of abuse and neglect.
The facility failed to ensure that an interim DON, an LVN, and two CNAs received training in essential care areas such as abuse prevention, HIV procedures, fall prevention, use of restraints, emergency procedures, and dementia care before interacting with residents. The administrator was unaware of the lack of training and assumed the agency had provided it, relying on a notebook of PowerPoint slides for training information.
A resident with severe cognitive impairment and multiple diagnoses, including a history of falls, experienced an unwitnessed fall resulting in injuries due to the facility's failure to implement a comprehensive care plan. The care plan required constant supervision, which was not provided, leading to the resident being unsupervised for several minutes. Despite being assessed post-fall, concerns were raised about the lack of x-ray evaluation.
The facility did not have an RN on duty for at least 8 hours on a specific day, as required. This was confirmed by the BOM and noted during a review of the facility's records. Interviews with the ADON, an LVN, and the DON expressed concerns about the lack of RN coverage, including inadequate response to clinical issues and lack of management. The facility's policy for RN coverage was requested but not provided.
Failure to Implement Abuse Prevention and Reporting Policies After Resident‑to‑Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property, and to follow its own abuse reporting requirements. Resident #1, an elderly female with unspecified dementia and pseudobulbar affect, had a BIMS score of 4 indicating severely impaired cognition and was documented on the MDS as having physical and verbal behavioral symptoms directed toward others 1–3 days during the look‑back period. Despite this, her care plan did not address behaviors directed toward others and only noted wandering behavior. Staff interviews indicated that Resident #1 frequently entered other residents’ rooms and could become physically aggressive or resistive with staff when confused, including hitting and kicking, but there was no corresponding behavioral care planning for aggression toward other residents. On the evening of 03/19/26, an incident occurred involving Resident #1 and Resident #2, an elderly female with COPD, CHF, and Parkinson’s disease who had intact cognition with a BIMS score of 14. According to progress notes and interviews, Resident #2’s family member called RN F and reported that another resident was in Resident #2’s room hitting her in the face. LVN A documented that the co‑nurse and CNAs went to Resident #2’s room, removed Resident #1, and assessed Resident #2, finding no bruising, redness, or pain. Resident #2 later stated that she had ongoing issues with Resident #1 entering her room and that during the most recent episode Resident #1 kicked her in the shins and hit her in the face; Resident #2 then attempted to push Resident #1 in her wheelchair out of the room when Resident #1 caught the partially open door with her foot and kicked it closed. CNA E reported that earlier that evening she had found Resident #1 in Resident #2’s room, with Resident #2 behind Resident #1 in her wheelchair trying to push her out, and that she wheeled Resident #1 back to her own room. Multiple staff, including CNAs, therapy staff, housekeeping, and nursing staff, stated they had been trained to report suspected abuse immediately to the Administrator (ADM) or DON. Facility policies titled “Abuse and Neglect – Clinical Protocol,” “Abuse, Neglect, and Incident Reporting Requirement,” “CMS F600/F609 Abuse Reporting,” and the New Employee Orientation packet all required immediate reporting of suspected or alleged abuse to facility leadership and timely reporting to state authorities, specifying reporting within 2 hours of identification or allegation. Despite these policies, the allegation that Resident #1 hit Resident #2 was not reported to the state within 2 hours. RN F stated she received the call from Resident #2’s family member, went with LVN A to Resident #2’s room, and instructed LVN A to report the allegation. LVN A stated she texted the on‑call phone at 7:24 PM to notify the DON about the incident, and the DON later stated she did not wake up to the text and had to instruct LVN A afterward to call rather than text. The ADM and DON both stated that suspected abuse was to be reported immediately to them and within 2 hours to the state, and acknowledged that failure to report immediately could allow abuse to continue. The facility’s failure to ensure that its abuse policies were fully implemented, including timely reporting to state authorities, and to incorporate Resident #1’s known behavioral risks into her care plan, resulted in the cited deficiency.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of resident‑to‑resident physical abuse to the administrator and state authorities as required. On the evening of 03/19/26, a family member of Resident #2 called RN F and reported that Resident #1 was in Resident #2’s room hitting Resident #2 in the face. LVN A documented that a CNA had removed Resident #1 from Resident #2’s room and that Resident #1 was agitated and scratched the CNA, and that Resident #1 believed Resident #2’s room was her own. Despite this allegation of physical aggression, the incident was not reported to the state within the required 2‑hour timeframe. Resident #1 was an [AGE]‑year‑old female with unspecified dementia and pseudobulbar affect, with a BIMS score of 4 indicating severely impaired cognition. Her MDS documented physical and verbal behavioral symptoms directed toward others on 1–3 days of the look‑back period, but her care plan did not include behaviors directed toward others, only wandering behavior. Staff interviews indicated that Resident #1 frequently entered other residents’ rooms, used their bathrooms, and could become resistive to care and physically aggressive with staff, including hitting and kicking when upset or confused. On 03/19/26, CNA E found Resident #1 in Resident #2’s room, with Resident #2 attempting to push Resident #1 out in her wheelchair, and removed Resident #1 from the room. Resident #2 was an [AGE]‑year‑old female with COPD, CHF, and Parkinson’s disease, with a BIMS score of 14 indicating intact cognition. She reported that Resident #1 had come into her room, kicked her in the shins, and hit her in the face, though she stated it did not hurt. She described attempting to push Resident #1 out of the room in her wheelchair when staff intervened. Progress notes documented that Resident #2’s vital signs and skin were assessed with no bruising or redness, and she denied pain, but she refused a sleeping pill because she did not want the other resident to enter her room again. Resident #2’s family member confirmed receiving a call from Resident #2 about being hit and later observing no marks. Facility leadership, including the DON, ADON, and administrator, stated that suspected abuse was expected to be reported immediately, and facility policies required immediate reporting of all allegations to the administrator/DON and timely reporting to state authorities, including within 2 hours of identification or allegation. Nonetheless, the allegation involving Resident #1 and Resident #2 on 03/19/26 was not reported to the state within the required 2‑hour window.
Late Administration and Inaccurate Documentation of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely and accurate administration of medications for one resident. The resident was an adult male with a history of traumatic brain injury (TBI) with sequelae, post‑traumatic seizures, anxiety disorder, and muscle spasms, who was severely cognitively impaired with a BIMS score of 3 and dependent in all ADLs. His care plan included management of altered comfort due to pain, bilateral upper and lower extremity contractures, a seizure disorder requiring seizure medications as ordered, and a risk for falls, with staff instructed to ensure he was not at the edge of the bed because he would “wiggle and wiggle out of bed to floor.” His physician orders included multiple scheduled medications via G‑tube or PEG‑tube (vitamin D, multivitamin, chlorhexidine mouthwash, diazepam, docusate, levetiracetam, baclofen, buspirone, tizanidine) ordered for 8:00 AM administration, and an enteral feeding ordered for 9:00 AM. On the morning in question, the Medication Administration Record (MAR) showed that all of the resident’s 8:00 AM medications and his 9:00 AM enteral feeding were documented as administered by an LVN at the ordered times. However, progress notes and interviews revealed that the resident’s family member, who had access to camera footage in the room, reported that no staff entered the room from approximately 5:00 AM until around 10:50–11:00 AM, and expressed concern that the 8:00 AM medications had not been given. The DON reviewed the video footage brought in by the family member and stated that the footage showed the resident falling to the floor at 10:53 AM, his roommate briefly interacting with him and leaving, and the LVN entering the room for the first time at 11:09 AM, when the resident was found on the floor between the bed and the wall. The DON stated that the resident had been moving around in bed and kicking the wall, causing the bed to move away from the wall prior to the fall, and that staff should have checked on him sooner. Interviews with staff further clarified the timing and administration of medications. The DON stated that the LVN had told her she gave the resident his medications at 10:50 AM, and that any administration after 9:00 AM would be considered late for 8:00 AM medications, given the facility’s expectation that medications ordered for 8:00 AM be administered between 7:00 AM and 9:00 AM. The ADON similarly stated that 8:00 AM medications were expected to be given between 7:00 AM and 9:00 AM and that late administration could negatively affect a resident’s health. The LVN later acknowledged in an interview that she gave the resident’s medications late, estimating the time as around 10:00 or 10:30 AM, and stated she did not know the exact scheduled time off the top of her head because she was agency staff. The facility’s medication administration policy required medications to be administered in a safe and timely manner, in accordance with prescriber orders and within one hour of the prescribed time, and the enteral tube medication policy directed staff to follow the general medication administration guidelines. The discrepancy between the MAR documentation and the video‑verified timing, along with the LVN’s admission of late administration, demonstrated that the resident’s morning medications were not administered within one hour of the ordered time, constituting the cited deficiency in pharmaceutical services.
Failure to Maintain Accurate Trust Fund Accounting and Provide Resident Financial Records
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and account for residents’ personal funds held in trust accounts. Two cognitively intact residents, a 65-year-old male with dementia, Bell’s palsy, depressive disorders, and Parkinson’s disease, and a 52-year-old female with multiple sclerosis, congestive heart failure, heart failure, and chronic pain, both had trust fund accounts managed by the facility. The facility did not maintain an accurate running ledger for these residents, did not consistently retain or associate receipts with trust fund transactions, and did not provide regular or requested account statements as required by policy. The male resident reported that in December he requested the Business Office Manager (BOM) to purchase Christmas presents and later requested snacks and multiple cartons of soda, as well as a replacement cell phone after his phone broke. He stated he did not see or sign receipts for these purchases, did not know the cost of the phone, and had not received receipts for purchases in January or February. He also reported that he had only ever received one account statement, in November, and only after specifically asking for it, and that he had not seen any accounting of what was purchased with his funds. The former BOM stated that when she gave money out she had residents sign receipts and claimed she always had residents sign receipts for purchases, but she acknowledged that in the case of the soda purchased by the Activity Director (AD), the resident was not made to sign a receipt and she did not receive a receipt for that purchase. The female resident stated she had a trust fund account, knew she had money in it, and used it as needed, but had never received an accounting of what was spent or a quarterly statement. The Administrator reported being unaware of any issues with trust fund accounts and noted that shopping duties had been switched from the former AD to the former BOM, though she could not recall when this occurred. The Corporate CEO reported that after the former BOM left, they found several zippered pouches with random $10 bills and little notes, but no receipts other than a few she had provided, and that she and the Administrator could not find further information on trust fund accounts. Record review showed that the facility bank statement for January did not reveal separate purchases for residents with trust funds, and the trust fund records for the male resident in December lacked receipts or itemized purchase information. Receipts that were produced for that resident’s purchases included several phone and snack purchases, some undated or unsigned, with signatures that appeared inconsistent, and these amounts were not listed in the facility’s trust fund paperwork, contrary to the facility’s written policy requiring safeguarding, managing, and accounting for residents’ personal funds and filing copies of all financial transactions in the resident’s permanent record.
Failure to Convey Deceased Resident’s Trust Funds Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to convey a deceased resident’s personal funds within 30 days as required by policy. An 87-year-old female resident with unspecified dementia, chronic kidney disease, convulsions, depression, atrial fibrillation, and anemia was admitted to the facility and had a care plan noting incontinence, fall risk, and pain complaints. A quarterly MDS documented a BIMS score of 8/15, indicating moderately impaired cognition. Review of the admission packet showed no listed family members or power of attorney. Nurse’s notes documented that the resident had a seizure during peri care and was sent to the hospital, where hospital records indicated she had a hemorrhagic stroke and died. Following the resident’s death, the Corporate CEO acknowledged awareness that the resident had a balance in her trust fund account that had not been conveyed. The CEO stated that the resident had no visitors and was believed to have no family, but at the time of death the former BOM suddenly stated the resident did have family and that the money needed to go to them, although the facility had no information on the family. The CEO reported the facility had decided to send the money back to the state but had not yet done so and admitted knowing there was a 30-day timeframe to return the funds. Record review showed the resident’s trust fund account balance was $13,946.81, and the facility’s “Refunds” policy required that within 30 days of death or discharge, the facility refund the resident’s personal funds and provide a final accounting to the resident, the resident’s representative, or the resident’s estate.
Failure to Notify Physician of Significant Neurological Change and Unresponsiveness
Penalty
Summary
The deficiency involves the facility’s failure to consult a resident’s physician when there was a significant change in the resident’s physical and neurological status. The resident was an older female with multiple serious diagnoses, including dementia, Stage 4 chronic kidney disease, atrial fibrillation, seizure disorder related to prior brain surgery, chronic respiratory failure with hypoxia, multiple fractures, chronic pain, and long-term anticoagulant use. Her care plan included detailed seizure precautions and post‑seizure assessment and documentation requirements, as well as instructions to monitor and immediately notify the physician of signs and symptoms such as altered level of consciousness, changes in mental status, and neurological changes. On the night in question, the DON was working the floor when CNAs called her to the resident’s room at approximately 4:30 a.m. because the resident was unresponsive. The DON documented that the resident was unresponsive, with vital signs within normal limits, no distress, and breathing that was not labored, and that the resident appeared to be resting comfortably. The DON stated in interviews that the resident was not acting right, was unresponsive but still breathing, and only opened her eyes slightly in response to a sternal rub, with no other response to questions. About 20 minutes later, the DON was called back and found blood in the resident’s mouth; after cleaning, she determined the resident had bitten her bottom lip. The DON documented that the lip and mouth were cleansed and no further bleeding was noted, and she instructed CNAs to increase monitoring and report any changes. The DON did not notify the physician at either time, later acknowledging in interviews that she "absolutely should have called the doctor" but did not because it was early in the morning and she did not think the situation was serious. When the day shift began, LVN staff received report that the resident had a "bad night" and that the DON thought the resident might be septic, though vital signs were normal. LVN staff assessed the resident around the start of the shift and found vital signs to be fine and the resident more alert at that time. Later that morning, LVN staff observed that the resident was less responsive and appeared more worrisome, and CNAs were instructed to prepare her for transfer to the hospital. During peri care, the resident had seizure‑like activity lasting about 30 seconds, after which she was unresponsive with shallow, labored respirations and did not respond to tactile or painful stimuli. EMS was called and the resident was transported to the hospital. The resident’s physician stated in interview that he would have wanted to be notified if a resident was found unresponsive but still breathing and not talking after a sternal rub, or if a resident was unresponsive and had bitten her lip, and that if he had known of the unresponsiveness that morning, he would have had her sent to the hospital immediately. The facility’s own policy on acute condition changes required nursing staff to contact the physician based on the urgency of the situation, including for significant changes in neurological status and level of consciousness, which did not occur in this case.
Failure to Notify Physician of Resident’s Acute Neurological Change and Possible Seizure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the resident’s person-centered care plan when a resident experienced a significant change in condition. The resident was an elderly female with multiple serious diagnoses, including dementia, chronic kidney disease stage 4, atrial fibrillation, chronic respiratory failure with hypoxia, seizure disorder related to prior meningioma resection, multiple fractures, COPD, hypertension, and long-term anticoagulant use. Her care plan included detailed interventions for seizure disorder, post-seizure treatment, seizure documentation, and seizure precautions, as well as monitoring and physician notification requirements for hematologic status, cardiac issues, and altered respiratory status. She was a DNR and the only listed responsible party. On the night in question, nursing notes documented that the DON was called to the resident’s room by CNAs at approximately 4:30 a.m. because the resident was unresponsive. The DON documented that the resident would not respond, but vital signs were within normal limits, breathing was not labored, and the resident appeared to be resting comfortably. The DON instructed CNAs to increase monitoring and report any changes. A short time later, around 4:40 a.m., the DON was called back due to blood in the resident’s mouth; after cleaning, it was apparent the resident had bitten her bottom lip. The DON documented that the lip and mouth were cleansed, no further bleeding was noted, and the resident was still sleeping very soundly with no distress noted. The physician was not contacted at either time despite the resident being unresponsive and having bitten her lip. In subsequent interviews, the DON acknowledged that at around 4:30 a.m. the resident was unresponsive but breathing, was not acting right, and only opened her eyes slightly to a sternal rub, with no other response to questions. The DON stated she did not call the physician because it was early in the morning, but that she should have done so at that time and again when blood was noted on the resident’s mouth. The DON reported that she gave report to the oncoming LVNs, told them she thought the resident was septic, and that vital signs were still normal, so the LVNs decided to monitor the resident. Later that morning, the resident’s condition worsened; during peri care she had seizure activity, became unresponsive with shallow, labored respirations, and EMS was called for transport to the hospital. Hospital records documented a large intracerebral hemorrhage and that the resident was minimally responsive and later died. The resident’s physician stated that if he had been notified that the resident was unresponsive and had possibly bitten her lip, he would have had her sent to the hospital immediately. The facility’s own policy on acute condition changes required nursing staff to contact the physician based on urgency, including for significant changes in neurological status and level of consciousness, which did not occur in this case. This failure to notify the physician of the resident’s unresponsiveness and possible seizure activity (evidenced by lip biting) constituted the basis of the deficiency under F684 for not providing care and services in accordance with professional standards and the resident’s care plan. The surveyors determined that because the physician was not contacted or included in the resident’s change of condition, she did not receive the best care available. An Immediate Jeopardy was identified related to this failure, later removed after the facility implemented a plan of removal, but the facility remained out of compliance at a lower severity level pending evaluation of the effectiveness of corrective systems.
Unsafe Food Storage, Preparation, and Meal Service Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. During observation of the walk-in freezer, multiple food items were found open to air or removed from their original packaging without labels or dates, including an opened box of biscuits and several bags of waffles, hamburger patties, pancakes, and chicken strips that had no identifying information. The facility’s food storage practices did not match its policy requiring foods to be covered, labeled, and dated, and frozen food wrappers to remain intact until thawing. During meal preparation and service, kitchen staff were observed handling food and food-contact items in ways that did not follow sanitary practices. One staff member touched kitchen surfaces with gloved hands, then handled serving dishes and tongs, and later used gloved hands to tear sausage links into pieces and place them into a blender for pureeing. At another point, six plates of pureed meat sat uncovered on the prep table for over 30 minutes before being covered and placed into the warmer. During plating, the same staff member touched plates, tray cards, the counter, and serving utensils with gloved hands and used her gloved hand to pick up dinner rolls instead of using tongs, despite the director of maintenance stating that tongs should have been used for bread. The observation also showed staff in the kitchen without required hair and beard restraints. The director of maintenance had braids not contained by a hairnet, and two staff members were in the kitchen without beard coverings. In interview, staff and the director of maintenance acknowledged that beard covers should have been worn and that hair should have been fully covered. Record review showed the facility’s menu substitution list did not include January meal items and did not document substitutions such as carrots for onions and peppers for residents on a pureed diet for the lunch meal. The director of maintenance also stated that food temperatures had been taken after preparation and when food was first placed on the steam table, not just before service, and that food sometimes sat on the tray line for over an hour.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles on two medication carts, Hall 100 and Hall 200. During observation of the Hall 200 medication cart with an LVN, a bottle of Probiotic was found with an expiration date of 11/2025, a bottle of Tylenol was found with an expiration date of 10/2019, two loose pills were found in the bottom of the medication cart drawers, and Resident #1's Novolog flex pen did not have an open date. Resident #36's Novolog and Lantus insulin pens also did not have open dates. During interview, the LVN stated that missing open dates on insulin could mean the medication was expired and not as effective, and loose pills could lead to a missed dose. During observation of the Hall 100 medication cart with another LVN, a half pill was found loose in the bottom of the narcotic medication drawer, and Resident #37 had two Wexela inhalers with no open dates written on them and expiration dates of 07/2023 and 10/2023. During interview, the LVN stated that missing open dates on medications could lead to the medication being expired and having decreased effectiveness, and loose pills in the cart could lead to a missed dose. The DON later stated that not having open dates on medications that required one could lead to residents receiving expired medications, and loose pills could mean residents were missing doses.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to ensure that a resident was provided privacy during medical treatment for 1 of 13 residents reviewed for privacy. Resident #8, a [AGE]-year-old male admitted on [DATE], had diagnoses including myelodysplastic syndrome, schizoaffective disorder, bipolar disorder, and pain. His most recent MDS assessment dated 10/03/2025 showed a BIMS score of 13 with no cognitive impairment, and he required total dependence for showering/bathing, upper and lower body dressing, footwear, and personal hygiene, with maximal assistance for toileting hygiene. During an observation on 01/14/2026 at 11:52 AM, RN G and CNA I provided wound care to Resident #8 without closing the window blinds. In an interview shortly afterward, RN G stated that someone could walk by the window and see the resident's bloody wound. The DON later stated that not closing the blinds during wound care could allow someone to see the resident in a compromising situation and that it was a dignity issue. Facility policy stated that residents have the right to a dignified existence, privacy, confidentiality, and privacy regarding medical treatment.
Inaccurate MDS Coded Insulin for Resident Without Insulin Use
Penalty
Summary
The facility failed to ensure Resident #2’s assessment accurately reflected her status when the annual MDS coded her as receiving insulin during the 7-day look-back period, even though record review showed no insulin order, no insulin on the care plan, and no insulin administration documented on the MAR. Resident #2 was an elderly female admitted with diagnoses including unspecified dementia, chronic kidney disease, and unspecified atrial fibrillation, and her annual MDS dated 10/14/25 included a BIMS score of 12, indicating moderately impaired cognition. Surveyor review found that Section N, N0350 Insulin, was coded with a “1,” indicating insulin injections were received one day from 10/07/25 to 10/14/25. However, the resident’s active, discontinued, struck out, and completed orders contained no insulin order, and the October 2025 MAR showed no insulin administration. During interviews, LVN F, RN G, the ADON, the DON, the ADM, the MDS LVN, and the CEO all stated that Resident #2 did not receive insulin and acknowledged that an inaccurate MDS could negatively affect resident care and facility funding.
Failure to Develop Baseline Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #28 within 48 hours of admission. Record review showed the resident was admitted on [DATE] with diagnoses including Parkinson's disease, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery without angina pectoris, depression, and rash and other nonspecific skin eruption. The admission MDS completed on 12/31/25 showed a BIMS score of 7, indicating severely impaired cognition. Review of the resident's EHR under the Assessments and Miscellaneous tabs revealed no baseline care plan. The resident's care plan was initiated/created on 12/31/25 by CEO. During an observation and interview on 01/13/26 at 11:26 PM, Resident #28 was seated in his recliner with his legs elevated and stated staff were trying to find out what was wrong with his legs and why they were red. During an interview on 01/13/26 at 06:58 PM, the resident's family member stated he had a rash that he left the hospital with and that it had gotten worse. Interviews with facility staff showed confusion about who was responsible for completing baseline care plans. CNA H stated a resident could be negatively affected by not having a baseline care plan. LVN F, RN G, ADON, DON, ADM, MDS LVN, and CEO each described different understandings of responsibility and purpose for the baseline care plan, with some stating it should be completed by the admitting or charge nurse and others stating it had been done by the CEO or ADON. The facility policy titled Care Plans - Baseline and dated December 2016 stated a baseline plan of care to meet the resident's immediate needs shall be developed within 48 hours of admission and used until the comprehensive assessment and interdisciplinary person-centered care plan are developed.
Incomplete Care Plans Omitted Antidepressant Therapy and Rash Management
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, with the care plans missing identified medical issues and treatments documented in the records. For one resident, the care plan did not include depression or the antidepressant medication Paroxetine, even though the resident had diagnoses including unspecified dementia and other specified depressive episodes, had a BIMS score of 12 indicating moderately impaired cognition, and had active orders for Paroxetine with behavior monitoring and side effect monitoring. The resident’s care plan, completed by the CEO, contained no mention of depression or antidepressant medication. For the second resident, the care plan did not include the resident’s rash or skin issue. The resident had diagnoses including Parkinson’s disease, type 2 diabetes mellitus, and rash and other nonspecific skin eruption, and the admission MDS showed a BIMS score of 7 with skin conditions requiring ointments/medications applied to the skin. The care plan, initiated by the CEO, did not mention the rash or skin issue despite active and recent orders for diphenhydramine at bedtime for rash/itching, cephalexin for rash, hydrocortisone cream for itching, and prior hydrocortisone treatment to the back. Progress notes showed the rash was ongoing and involved multiple body areas, including the back, abdomen, upper thighs, forearms, shins, elbows, and lower legs, with repeated documentation of itching, redness, and treatment use. During observation, the resident’s lower legs appeared red and the lower right leg appeared swollen. Interviews with staff and leadership confirmed that both the antidepressant for the first resident and the rash for the second resident should have been included in the care plans, and multiple staff stated that inaccurate or incomplete care plans could negatively affect resident care and monitoring.
Pureed Meal Menu Not Followed
Penalty
Summary
The facility failed to ensure that menus were followed for residents receiving pureed meals. During an observation and interview on 1/13/26 at 12:40 pm, 6 residents on a pureed diet did not receive onions and peppers on their meal trays as listed on the lunch menu; they were given carrots instead. The DM stated the residents did not receive onions and peppers because they could not be pureed and said the residents received carrots instead. Review of the facility recipe book showed there was a recipe for pureed onions and peppers, and the DM stated she did not know the recipe was in the book and had never tried to puree onions and peppers. Record review of the lunch menu for Cycle 11, Week 1 Tuesday 1/13/26 showed the meal was to include bratwurst links, [NAME] noodles, sauteed onions and peppers, wheat dinner roll, and chocolate cheesecake.
Infection Control Lapses With Hand Hygiene, Glucometer Cleaning, and EBP Signage
Penalty
Summary
The facility failed to maintain an infection prevention and control program for two residents reviewed for infection control. For Resident #1, an LVN did not perform hand hygiene before donning gloves to check blood glucose and administer insulin, and did not clean the glucometer before performing the glucose check. During interview, the LVN stated that not performing hand hygiene and not cleaning the glucometer could lead to infection for residents. For Resident #37, who had a foley catheter, there was no enhanced barrier precautions signage on the door during observation. A family member stated that staff had never put on PPE to assist the resident with care, and during the interview staff entered the room wearing PPE. The DON stated that not performing hand hygiene at the appropriate times and not utilizing PPE for a resident on EBP could lead to an infection control issue. Record review showed facility policies for enhanced barrier precautions, hand hygiene, and insulin administration.
Failure to Appoint Licensed Administrator
Penalty
Summary
The facility failed to ensure that its governing body appointed a state-licensed administrator to manage the facility, as required by policy and regulation. Record review showed that the previous administrator was terminated on 09/02/25 for not having a current license, and since then, the facility had not had a full-time administrator. Interviews with multiple staff members, including the Corporate RN, CNA, LVN, BOM, and DON, confirmed that there was no full-time administrator in place. An interim administrator was present for about two weeks in October, but no permanent replacement had started as of the time of the survey. The Corporate RN, who is not the administrator, was acting on behalf of the facility to hire a new administrator, with a new hire expected to start in January, but no documentation or background checks had been completed for this individual at the time of the review. Facility policy and job descriptions require the administrator to be duly licensed and responsible for the day-to-day operations of the facility. Staff interviews highlighted concerns about the lack of leadership, oversight, and clear reporting lines due to the absence of a full-time administrator. The deficiency was identified through both record review and staff interviews, which consistently indicated that the facility had not maintained compliance with the requirement to have a licensed administrator appointed by the governing body.
Failure to Ensure Accurate Medication Dispensing and Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for two residents. One resident, who was nonverbal, bedridden, and dependent on staff for all care needs, tested positive for barbiturates during a hospital visit. Review of her medical record revealed no current prescription for barbiturates, and her medication orders did not include any drugs that would result in a positive barbiturate test. The resident had a history of Alzheimer's disease, dementia with behavioral disturbances, dysphagia, and muscle weakness, and required total assistance for all activities of daily living. Staff observed a change in her usual behavior, leading to her being sent to the hospital, where the positive barbiturate result was discovered. Another resident, who was cognitively intact and independent in most daily activities, was prescribed Primidone, a medication that metabolizes as a barbiturate. Review of the medication administration record (MAR) showed that this resident did not receive his prescribed Primidone on two consecutive days. The medication cart was organized with each resident's medications behind their respective name cards, and both residents' medications, including Primidone, were stored next to each other. An LVN reported believing she had administered the medication but forgot to sign off, while another nurse could not be interviewed regarding the missed dose. Interviews with staff and the DON confirmed that only the second resident was prescribed Primidone, and there were no barbiturates in the facility. The DON and medical director acknowledged that Primidone could result in a positive barbiturate test. The proximity of the medications in the cart and the lack of documentation for the administration of Primidone contributed to the possibility of a medication error, either through omission or unauthorized administration.
Food Safety Deficiencies in Kitchen Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food safety in their kitchen, as observed during a survey. Specifically, the facility did not ensure that food items in the dry pantry and cold storage were properly sealed, labeled, and dated. Numerous food items, including corn tortillas, elbow macaroni, white rice, and various canned goods, were found without received dates and were open to air. Additionally, dry pantry foods were not stored at least 18 inches above the floor, as required by the facility's policy. In the cold storage unit, several items such as fresh tomatoes, prepared thickened drink mix, chicken breasts, and fresh cantaloupes were also found without labels or use-by dates and were open to air. An interview with the head staff member revealed that there was no Dietary Manager at the facility at the time, and there was no policy regarding recommended maximum storage periods for dry or cold storage foods. The facility's policy for food receiving and storage mandates that all foods in the refrigerator or freezer be covered, labeled, and dated, and that beverages be dated when opened and discarded after 24 hours.
Failure to Report and Investigate Resident Falls
Penalty
Summary
The facility failed to report allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property within the required timeframe. Specifically, the facility did not report incidents involving two residents to the Administrator and State Survey Agency within two hours of the allegations. This failure was observed in the cases of a male resident with severe cognitive impairment and a female resident with Alzheimer's disease, both of whom experienced falls resulting in injuries. The male resident, who required substantial assistance due to severe cognitive impairment, was found on the floor with injuries after a fall in the dining room. Despite the incident being reported to the nursing staff, it was not reported to the state agency as required. Similarly, the female resident, who was completely dependent on assistance for activities of daily living, experienced an unwitnessed fall resulting in a head laceration and hospital visit. This incident was also not reported to the state agency. Interviews and observations revealed that the facility did not investigate or report these falls to the state for further investigation. Video footage showed that the male resident fell without staff present, and two staff members walked away from him shortly after the fall. The facility's policies on abuse, neglect, and incident reporting were not followed, as evidenced by the lack of investigation and reporting of these incidents.
Failure to Investigate and Report Resident Falls
Penalty
Summary
The facility failed to thoroughly investigate alleged violations of abuse and neglect for two residents, leading to deficiencies in care. Resident #5, a male with severe cognitive impairment and multiple diagnoses including Neurocognitive Disorder with Lewy Bodies and Parkinsonism, fell from his wheelchair unobserved, resulting in a skin tear and abrasion. Despite the care plan indicating the need for constant supervision, the incident was not thoroughly investigated, and there was no evidence of reporting to the state. Resident #27, a female with Alzheimer's disease and complete dependence on assistance for activities of daily living, experienced an unwitnessed fall in the dining room, resulting in a head wound that required hospital treatment. The facility did not conduct a thorough investigation into the fall, and there was no record of the incident being reported to the state. Video footage showed the fall occurred without staff presence, and the facility's Assistant Director of Nursing confirmed that falls were not investigated or reported. The facility's policies on abuse, neglect, and incident reporting require thorough investigation and reporting of all accidents and incidents. However, the facility failed to adhere to these policies, as evidenced by the lack of investigation and reporting for the falls of Residents #5 and #27. This failure to investigate and report falls could place residents at risk of abuse and neglect, as acknowledged by the facility's Administrator.
Lack of Staff Training in Essential Care Areas
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for new and existing staff, including those under contractual agreements. This deficiency was identified for four staff members: the interim Director of Nursing (DON), an LVN, and two CNAs. These staff members were not trained in critical areas such as the prevention of resident abuse, neglect, and exploitation, HIV policy and procedures, fall prevention, use of restraints, emergency procedures, and dementia care before interacting with and caring for residents. The administrator was unaware that these employees had been caring for residents without the necessary training and assumed that the agency providing the employees had already trained them. The administrator had a notebook of PowerPoint slides covering the required training topics but had not confirmed the competency of the four employees in these areas before their employment. The administrator could not provide the facility's policy and procedures regarding training and relied on the regulation guidance from the State Operations Manual (SOM).
Failure to Implement Comprehensive Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, which resulted in a fall with injury. The resident, a male with severe cognitive impairment and multiple diagnoses including Neurocognitive Disorder with Lewy Bodies, Dementia, Parkinsonism, and a history of falling, was admitted to the facility with significant functional limitations. The care plan for the resident included interventions such as keeping the bed in the lowest position, using non-skid socks, and ensuring the resident was within the line of sight at all times due to his tendency to stand alone. Despite these measures, the resident sustained an unwitnessed fall, resulting in a large bruise and a skin tear. The incident occurred when the resident was left unsupervised, contrary to the care plan's requirement for constant supervision. The facility's surveillance tape revealed that the resident was on the floor for 6-7 minutes before being discovered by staff. Although the resident was assessed and deemed not to require medical attention, the family member expressed concerns about the lack of x-ray evaluation. The facility's policy emphasizes the need for person-centered care plans that incorporate risk factors and aim to prevent functional decline, but the failure to adhere to the care plan's interventions contributed to the resident's fall and subsequent injuries.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, on 10/12/2024, there was no RN on duty, which was confirmed by the Business Office Manager (BOM) during an interview. This lapse in RN coverage was identified during a review of the facility's records for the past 90 days, from 07/22/2024 to 10/22/2024. Interviews with the Assistant Director of Nursing (ADON), a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON) highlighted concerns about the potential negative outcomes of not having an RN on staff, such as inadequate response to clinical issues and lack of management or direction. The facility's policy for RN coverage was requested but not provided.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 22 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Muleshoe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Farwell Care And Rehabilitation Center | 20.4 mi | ★★★★★ | 21 | 0 |
| Harmonee House | 23.7 mi | ★★★★★ | 1 | 0 |
| Clovis Healthcare And Rehabilitation Center | 28.2 mi | ★★★★★ | 23 | 0 |
| Prairie Acres | 29.1 mi | ★★★★★ | 0 | 0 |
| St. Anthony Healthcare And Rehabilitation Center | 30.5 mi | ★★★★★ | 37 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.