Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Parkwood In The Pines during CMS and state inspections, most recent first.
Expired and unidentified medications were found in multiple med carts, including expired aspirin, expired arginaid powder, a bag of white powder identified as thickener with no date or label, and an expired Humulin R insulin vial. Staff said the assigned nurses and med aides were responsible for daily cart checks, while the ADON and DON completed weekly audits. The facility policy stated that outdated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed.
Improper Food Storage and Labeling in Kitchen: Surveyors found multiple food items in the dry storage area and freezer that were open, unlabeled, undated, or improperly stored, including dry mix, gravy mix, enchilada sauce, and corn in a damaged bag. The CDM and ADM stated staff were responsible for checking food storage areas and following the facility policy requiring opened food to be sealed, labeled, and dated.
Failure to Provide Privacy During Wound Care: A resident admitted for rehab after hip surgery received wound care to a skin tear on the buttock while the privacy curtain was not closed and the room door was left open. During the treatment, a male staff member entered the room looking for the roommate and saw the resident exposed. The resident said it was embarrassing, and the TN acknowledged forgetting to close the curtain.
Standing water and a mold/mildew odor were found in a resident’s room after water from an adjacent shower room was leaking under the wall. Staff knew about the leak, and observations showed the shower was still running and hitting the floor despite an out-of-order sign. The resident had significant cognitive impairment and required extensive assistance with transfers.
Surgical Site Not Monitored for Infection: A resident admitted for rehab after hip surgery had a left hip dressing in place, but the chart lacked an order and TAR documentation for each-shift monitoring of the surgical site for redness, drainage, or other signs of infection. The resident stated staff had not changed the dressing since admission, and the DON and Treatment Nurse acknowledged the incision should have been monitored and documented.
Worn Mechanical Lift Slings Left in Service: Three of seven mechanical lift slings in the clean linen area had faded straps, and one had a faded care label attached by only a few threads. The Laundry Supervisor considered the slings usable, while the Administrator, Housekeeping Supervisor, and DON later identified them as damaged/faded and stated they could break during transfers and cause a fall with injury. Manufacturer guidance stated slings with fading, wear, or missing/illegible care labels should be removed from use.
A resident with an indwelling urinary catheter, bladder incontinence, hemiplegia, COPD, type 2 DM, and CKD did not receive proper catheter care. An LVN used normal saline and gauze, cleaned only at the insertion site, and did not clean down the tubing as required by the physician order and facility policy, which called for an approved cleaning agent such as soap and water or wipes and cleansing several inches down the tubing.
Hand hygiene and glove-use failures occurred during care for two residents. A CNA providing incontinent care to a resident with multiple chronic conditions removed gloves and continued care without washing or sanitizing her hands between glove changes, and she handled clean items during the task. An LVN providing catheter care to a resident with an indwelling catheter and impaired cognition also removed gloves and reapplied clean gloves without hand hygiene between glove changes. Staff interviews and the facility policy confirmed hand hygiene was expected before care, after glove removal, and between dirty and clean tasks.
Dining room environment not kept clean and in good repair. Surveyors observed thick cobwebs and dust on the chandelier and ceiling above resident dining tables, along with an area of loose peeling paint on the dining room ceiling. The Housekeeping Supervisor said she was unsure who was responsible for cleaning the chandelier and noted maintenance would need a ladder to reach it. The Administrator said cleaning the chandelier had not been part of the routine and acknowledged some old leak areas, while the facility policy called for a clean, sanitary, and orderly homelike environment.
Failure to post daily nurse staffing information in a prominent location. The facility did not ensure the daily staffing posting was readily accessible to residents and visitors or posted in the main lobby or near the nurse's station during observations. Later, the posting was found on a side hall near staff offices rather than in a prominent area, despite the facility policy requiring staffing numbers for RNs, LPNs, LVNs, and CNAs to be posted within 2 hours of each shift in a clear, readable, accessible location.
A resident admitted with a terminal prognosis and a signed DNR order did not have their code status accurately updated in the medical record or care plan. Although the DNR was signed by both the resident and physician, it was not uploaded into the electronic record, and the physician orders continued to list the resident as full code. This resulted in incomplete and inaccurate documentation of the resident's wishes at the time of death.
The facility failed to remove worn and faded mechanical lift slings from service, posing a risk to residents dependent on staff for transfers. Several residents with conditions such as Alzheimer's, stroke, and quadriplegia were observed using these slings. Staff interviews revealed a lack of awareness about the safety risks associated with faded slings, despite the presence of newer slings in the facility.
The facility failed to ensure medications were stored securely, as three residents had unauthorized medications at their bedside. A resident with moderate cognitive impairment had Total Beets soft chews without a physician's order. Another resident, cognitively intact but needing assistance, had throat spray at her bedside without a self-administration assessment. A third resident with moderate impairment had aspercreme and nasal spray without orders or a care plan for self-administration. Staff were unaware of these medications, indicating a lapse in policy enforcement.
A facility failed to notify a resident's responsible party after the resident experienced leg pain and an X-ray was ordered. The resident, with Alzheimer's and severely impaired cognition, required maximal assistance. The family was not informed by the facility but learned from a sitter. The DON and Administrator acknowledged the nurse should have informed the family directly, as per facility policy.
A resident admitted to hospice care did not receive a significant change MDS assessment within the required 14 days, as mandated by regulations. The oversight was acknowledged by the MDS Coordinator, who failed to complete the assessment despite the resident's significant change in status. Interviews with facility staff highlighted the importance of timely assessments for accurate care planning.
A resident with dementia, epilepsy, and diabetes did not receive necessary nail care, despite having long and dirty fingernails. The facility's staff, responsible for diabetic nail care, failed to adhere to the resident's care plan and facility policy, which required daily cleaning and regular trimming of nails.
The facility failed to maintain accurate records for controlled drug destruction, lacking required witness signatures and page documentation in July 2024. Interviews revealed procedural lapses, with the DON and Pharmacy Consultant acknowledging the missing documentation and the Administrator emphasizing the risk of drug diversion. The facility's policy requires compliance with regulations and proper documentation by the Pharmacy Consultant and DON.
A CNA failed to follow proper infection control practices while providing incontinent care to a resident with cognitive impairment and multiple diagnoses. The CNA did not wash hands or change gloves throughout the care process, including during perineal cleaning and handling of personal items. This failure to adhere to facility policies on hand hygiene and perineal care increased the risk of infection.
A resident with significant medical conditions was improperly transferred without a mechanical lift, contrary to her care plan, resulting in severe leg pain. A CNA, who had seen a therapist transfer the resident without the lift, attempted the transfer alone, leading to the resident's injury and subsequent hospital evaluation. The facility's failure to follow the care plan and ensure proper supervision and use of assistance devices placed the resident at risk.
Expired and Unidentified Medications Left in Multiple Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs by not maintaining medication carts in an orderly condition and by leaving outdated or unidentified medications in multiple carts. During observation, the medication cart for halls 100 and 200 contained a bottle of aspirin 325 mg that had expired in 1/2026 and had been opened on 7/24/2025, a clear plastic bag of white powder identified by staff as thickener with no date or label, and a box of arginaid powder that had expired on 4/2/2026 with 9 packets and an open date of 12/29/2025. The cart for halls 400, 500, and 600 contained a box of arginaid powder that had expired on 4/12/2026. The nurse cart for odd room numbers on halls 100 and 200 contained an insulin vial of Humulin R 100 units/ml dated 11/1/2023 and opened on 11/6/2023. Staff interviews showed that the assigned nurses and med aides were responsible for checking carts daily, while the ADON and DON also performed weekly audits. The facility policy stated that discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in its only kitchen. During observation of the dry storage area, surveyors found a container labeled thickener with the lid open and off center, a plastic bag with yellow dry mix dated 4/18/26 but with no label of contents, a plastic bag containing opened brown gravy mix with no open date or use-by date, and a container of enchilada sauce with no open or use-by date, half of the contents missing, and a manufacturer label indicating refrigerate after opening. During observation of the freezer, surveyors found a plastic bag of corn that was undated, unlabeled, and had holes in the bag. During interview, the CDM stated it was the responsibility of all kitchen staff to inspect freezers, refrigerators, and food storage areas for open, undated, or unlabeled food and to discard any packages not labeled or dated. She stated signs were posted in the kitchen to remind staff to look for open, undated, or unlabeled food when checking refrigerator and freezer temperatures, and that food storage information was available in two areas of the kitchen. The ADM stated the CDM was responsible for directly supervising kitchen staff and that she was responsible for oversight to ensure kitchen policies were followed. Review of the facility policy titled Food Storage, dated 2018, stated open packages of food are to be stored in closed containers with covers or in sealed bags and dated as when opened.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to ensure Resident #64’s right to personal privacy and dignity during wound care. Resident #64 was an [AGE]-year-old female admitted for rehabilitation after surgery for a displaced fracture of the base of the neck of the left femur. Her baseline care plan did not address any current or historical skin integrity issues, and she had not yet had a comprehensive MDS assessment completed. During observation, the Treatment Nurse performed wound care to a skin tear on Resident #64’s right buttock while the privacy curtain was not pulled and the room door was left open. While the resident was rolled onto her right side with her buttocks exposed, another male staff member entered the open room door looking for the roommate. The Treatment Nurse stated, “Crap, I forgot to close the curtain,” and the staff member then left after seeing the treatment in progress. In interview, the Treatment Nurse said she normally closed the curtain but forgot because she was nervous being watched. Resident #64 said it was a little embarrassing for another staff member, especially a male, to walk in during treatment to her buttocks. The Administrator and DON stated they expected residents to be treated with dignity and privacy, and the facility policy stated residents have a right to a dignified existence and that staff shall protect resident privacy during personal care and treatment procedures.
Standing Water and Odor in Resident Room
Penalty
Summary
The facility failed to ensure Resident #27’s room remained safe, clean, and comfortable when standing water was observed on the floor by the resident’s bed and water was seeping from under the wall. Resident #27 had been admitted to the facility with diagnoses including cerebral infarction, malignant neoplasm of lung, major depressive disorder, and dysphagia. A quarterly MDS assessment indicated severe cognitive impairment with a BIMS score of 5, and the care plan noted dependence on staff for transfers and use of a mechanical lift with 2 staff assistance. During multiple observations, the room continued to have standing water on the floor and a mold/mildew odor. Staff members stated they were aware of the leak and reported that it was coming from the shower room on the other side of the wall. In the shower room on hall 200, one shower had an out-of-order sign, but water was still running and hitting the floor, going underneath the wall into Resident #27’s room. The Maintenance Supervisor stated the shower room had a gap under the wall and that he had tried to seal it, and the Administrator stated she was not aware the shower room was leaking into the resident’s room.
Surgical Site Not Monitored for Infection
Penalty
Summary
The facility failed to ensure Resident #64’s left hip surgical site was monitored for signs and symptoms of infection each shift while a non-removable dressing was in place. Resident #64 was an elderly female admitted for rehabilitation after surgery for a displaced fracture of the base of the neck of the left femur. On 4/19/26, she was observed lying in bed and stated that she had been admitted after hip surgery and that staff had not changed the dressing on her hip since admission. The dressing on her left hip was observed with a date of 4/17/26. Record review showed an order for wound care to change the Aquacell dressing to the left hip surgical site one time only, but there was no order to monitor the site for redness, excess drainage, or signs and symptoms of infection. The Treatment Administration Record also had no documentation of monitoring the surgical area for signs and symptoms of infection. The Treatment Nurse stated there should always be an order to monitor a wound or surgical incision each shift, and the DON stated the surgical incision should have been documented and orders put in place to monitor for signs and symptoms of infection.
Worn Mechanical Lift Slings Left in Service
Penalty
Summary
The facility failed to keep the resident environment free from accident hazards by leaving three mechanical lift slings in service despite visible signs of wear and damage. During observation in the laundry area, three of seven slings hanging on wall racks in the clean linen area had faded straps in light gray, light teal, and light purple, and one sling had a faded care label attached by only a few threads of stitching. The Laundry Supervisor stated the slings had been washed and hung to air dry and considered the three slings still usable, although she acknowledged that if a sling broke it could cause a fall with injury. During later observation and interviews, the Administrator, Housekeeping Supervisor, and DON all identified the three slings as damaged or faded and stated they could break during transfer and cause a fall with injury. The Administrator said the damaged slings should be removed from service and noted replacements were already in the facility. Record review of the facility policy on a homelike environment stated residents are to be provided with a safe, clean, comfortable environment. Manufacturer instructions for full body slings stated that signs of color fading, bleached areas, permanent wrinkles, rips, tears, frays, or missing or illegible care labels indicate unsafe wear or improper laundering and that such slings should be immediately removed from use.
Improper Urinary Catheter Care
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident who was incontinent of bladder and had an indwelling urinary catheter. Resident #7 had diagnoses including hemiplegia, COPD, type 2 diabetes, and chronic kidney disease, and was dependent on staff for toileting hygiene. Her care plan noted an indwelling medical device and EBP related to MDRO, and physician orders directed catheter care with an approved cleaning agent every shift using soap and water or wipes as appropriate. During observation, an LVN provided catheter care by donning gloves and a gown, using normal saline and gauze, and cleaning the catheter tubing at the insertion site in a downward motion twice. She did not clean down the tubing. In interview, the LVN stated she had been taught to clean only at the point of contact and not down the tubing. The ADON and DON stated catheter care should be done every shift using wipes or soap and water and should include cleaning about 3 to 4 inches down the tubing, and the facility policy required cleansing and rinsing the catheter from the insertion site to approximately four inches outward.
Hand Hygiene and Glove Use Failures During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents and two staff members reviewed for infection control. During incontinent care for a resident with COPD, type 2 diabetes, atrial fibrillation, heart failure, bowel and bladder incontinence, and a BIMS score of 12, a CNA washed her hands in the room, donned gloves, and performed perineal care. She removed gloves, placed them in the trash, then removed another pair of gloves from her pocket and continued care without sanitizing or washing her hands between glove changes. She also placed clean items, including wipes and a clean brief, on the bed and later returned the wipes package to the hallway cart. During urinary catheter care for a resident with hemiplegia, COPD, type 2 diabetes, chronic kidney disease, an indwelling catheter, and a BIMS score of 11, an LVN donned a gown and gloves, entered the room with saline and gauze, and cleaned the catheter tubing. After removing her gloves, she did not wash or sanitize her hands before putting on clean gloves and continuing catheter care. She repeated this sequence again, removing gloves and then applying clean gloves without hand hygiene between glove changes. Interviews with the CNA, LVN, ADON, DON, and Administrator confirmed that hand hygiene should be performed before care, after care, between glove changes, and when moving from dirty to clean tasks. The CNA stated she should have sanitized or washed her hands after glove removal and before touching clean items, and the LVN stated she should have washed or sanitized her hands between glove changes but forgot to do so. The facility’s hand hygiene policy stated hand hygiene is the primary means to prevent the spread of infections and requires alcohol-based hand rub or soap and water after removing gloves and before handling clean or soiled dressings or gauze pads.
Dining Room Environment Not Kept Clean and in Good Repair
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in 1 of 1 dining area reviewed for environmental concerns. During observation on 04/19/26 at 12:00 PM, thick cobwebs and dust were noted on the chandelier and extending to the ceiling in the center of the main dining area above resident dining tables. An area of loose peeling paint was also observed on the ceiling between the center island area of the main dining room and a resident dining table. During interview on 04/21/2026 at 10:30 AM, the Housekeeping Supervisor said she was unsure who would be responsible for cleaning the dining room chandelier and stated maintenance would need to assist because a ladder would be required to reach it. She also stated maintenance would be responsible for removing chipped paint and repairing the peeling area on the ceiling. During interview on 04/21/26 at 11:00 AM, the Administrator said maintenance and housekeeping would be responsible for cleaning the chandelier, and that this had not been part of the cleaning routine at the time of the interview. The Administrator stated she was aware of some areas from old leaks but was not aware of peeling paint, and said the areas would be repaired. Record review of the facility policy titled Quality of Life - Homelike Environment, dated May 2017, indicated staff and management shall maximize characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment.
Failure to Post Daily Nurse Staffing Information in a Prominent Location
Penalty
Summary
The facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 3 days reviewed, specifically on 4/19/26. During an observation at 9:30 am upon entrance to the facility, the daily staff posting was not observed in the main entrance lobby. During an observation at 10:00 am during initial rounds, the daily staff posting was not observed at or near the nurse's station for the 400/500/600 hallways. Later that day at 3:30 pm, the daily staff posting was observed posted at each side of the facility near both nurses' stations, but it was located on a short side hall near staff offices and was not in a prominent location. During an interview on 4/21/26 at 1:00 pm, the Administrator said she would be making the night charge nurse responsible for the daily staff posting and said she could not think of any negative outcomes related to the posting not being in a prominent location. The facility policy titled Posting Direct Care Daily Staffing Numbers stated that within two hours of the beginning of each shift, the number of RNs, LPNs, LVNs, and CNAs directly responsible for resident care would be posted in a prominent location accessible to residents and visitors in a clear and readable format.
Failure to Accurately Document and Update DNR Status in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with a terminal prognosis and expressed a clear desire to have Do Not Resuscitate (DNR) status. Although the resident, who was alert and oriented, signed an Out-of-Hospital (OOH) DNR upon admission and the document was subsequently signed by the physician, the DNR order was not updated in the resident's physician orders or uploaded into the electronic medical record. The care plan also did not reflect the resident's code status, and the active physician orders continued to indicate the resident was a full code without an end date. Interviews with facility staff revealed that the admission director facilitated the DNR signing and passed the document to the social worker (SW) for physician signature and family notification. However, the SW was absent during this period, and although the DNR was faxed to and signed by the physician, it was not properly integrated into the resident's medical record. The administrator acknowledged the failure to upload the DNR and update the care plan, noting that the DON or designee was responsible for ensuring medical records were complete. This lapse resulted in incomplete documentation of the resident's code status at the time of death.
Failure to Remove Worn Mechanical Lift Slings
Penalty
Summary
The facility failed to ensure the residents' environment was free from accident hazards by not removing worn and damaged mechanical lift slings from service. This deficiency was observed in four residents who were dependent on staff for transfers and required the use of mechanical lifts. The slings used were faded, which according to the manufacturer's instructions, indicates improper laundering and potential safety risks. Despite the presence of newer slings in the facility, the faded slings continued to be used for resident transfers. Resident #75, who had a history of a femur fracture, osteoporosis, and Alzheimer's disease, was observed with a faded lift sling in her room. Although there was no physician order or care plan for the use of a mechanical lift, staff used the faded sling for her transfers. Similarly, Resident #61, diagnosed with Alzheimer's disease and stroke, was seen sitting on a faded sling in the dining room, despite having an order for mechanical lift transfers. Resident #58, with peripheral vascular disease and dementia, and Resident #79, with a history of stroke and quadriplegia, were also observed with faded slings. Interviews with staff revealed a lack of awareness regarding the safety implications of using faded slings. CNAs reported that most slings in the facility were faded, and there was uncertainty about whether they should be bleached. The Central Supply and Laundry Aide confirmed that slings were washed without bleach and inspected for damage, but faded slings were still in circulation. The DON and Administrator were unaware of the manufacturer's guidelines against using faded slings, which could pose a risk of injury to residents.
Unauthorized Medication Storage at Bedside
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and only accessible to authorized personnel, as evidenced by the presence of medications at the bedside of three residents. Resident #17, a female with moderate cognitive impairment, had Total Beets soft chews at her bedside, which were brought by a family member. She did not have a physician's order for this supplement, nor was there an assessment or care plan indicating she could self-administer medications. Resident #18, who was cognitively intact but required substantial assistance for all activities of daily living, had a bottle of over-the-counter throat spray at her bedside. Although there was a physician's order for the throat spray, there was no assessment or care plan allowing her to self-administer medications. She could not recall who provided the spray or when she last used it. Resident #86, with moderate cognitive impairment, had aspercreme with lidocaine and nasal spray at her bedside, which she brought from home. There were no physician orders for these medications, and no care plan or assessment for self-administration was in place. The facility's Director of Nursing and other staff were unaware of these medications being in the residents' rooms, and there was no policy enforcement to prevent unauthorized medication storage at the bedside.
Failure to Notify Responsible Party of Resident's Condition Change
Penalty
Summary
The facility failed to immediately inform a resident's responsible party after the resident experienced pain in her right leg and an X-ray was ordered. The resident, who had Alzheimer's disease and type 2 diabetes mellitus, was admitted to the facility with severely impaired cognition, requiring maximal assistance with all activities of daily living and was incontinent. The comprehensive care plan for the resident included increasing communication between the resident, family, and caregivers about care and living environment. However, when the resident complained of leg pain, and an X-ray was ordered, there was no documentation of notification to the responsible party. Interviews revealed that the family member was not informed by the facility but learned about the X-ray from a sitter. The Director of Nursing and the Administrator acknowledged that the nurse should have directly informed the family member, rather than relying on the sitter to relay the information. The facility's policy required prompt notification of changes in a resident's condition to the resident, their physician, and the resident's representative, which was not adhered to in this instance.
Failure to Complete Significant Change MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after a significant change in the condition of a resident who was admitted to hospice care. This deficiency involved a resident with a history of atherosclerotic heart disease, hypertension, and Alzheimer's disease, who was admitted to hospice services on December 17, 2024. Despite the resident's admission to hospice, which is considered a significant change in status, the facility did not conduct the required significant change MDS assessment, which should have been completed within 14 days of the change. Interviews with facility staff, including the MDS Coordinator, Regional Reimbursement Consultant, Director of Nursing (DON), and the Administrator, revealed that the MDS Coordinator was responsible for completing the assessments but failed to do so in this instance. The MDS Coordinator acknowledged the oversight and mentioned that a significant change assessment was conducted in November 2024, but not in December 2024 when the resident was admitted to hospice. The Regional Reimbursement Consultant confirmed that an in-service training was initiated to address this issue, and the DON and Administrator both emphasized the importance of timely assessments to ensure appropriate care planning. The lack of a significant change assessment could lead to inaccurate assessments and unmet individual needs for residents.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living, specifically in maintaining grooming and personal hygiene. The resident, a male with dementia, epilepsy, and diabetes mellitus, was observed with long and dirty fingernails on multiple occasions. Despite expressing a desire for his nails to be cleaned and trimmed, the resident did not receive the required care. Interviews with staff revealed that nail care for diabetic residents was the responsibility of nurses, but the care was not provided as expected. The resident's comprehensive care plan included an intervention for monitoring and documenting foot care needs, yet this was not adhered to. The facility had identified an issue with nail care in the previous month and had an active Performance Improvement Plan to address it. However, the resident continued to have unclean and untrimmed nails, indicating a lapse in the implementation of the care plan and facility policy, which required daily cleaning and regular trimming of nails.
Deficiency in Controlled Drug Destruction Documentation
Penalty
Summary
The facility failed to establish a comprehensive system for recording the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation and compliance with State and Federal laws. Specifically, during the month of July 2024, the facility did not document the number of pages included in the drug destruction records and lacked the required witness signatures for drug destruction on July 12, 2024. This oversight was identified during a review of the facility's drug destruction records for four months, revealing that the cover page did not indicate the number of pages, and the attached pages were only signed by the Director of Nursing (DON) without additional witness signatures. Interviews conducted with the DON, Pharmacy Consultant, and Administrator highlighted the procedural lapses. The DON acknowledged that drug destruction sheets typically required signatures from the Pharmacy Consultant, an Assistant Director of Nursing (ADON), and herself, but noted the absence of an ADON in January 2024. The Pharmacy Consultant, responsible for filling out the cover sheet, admitted uncertainty about the missing page numbers in July 2024, despite usually being meticulous. The Administrator confirmed awareness of the requirement for complete documentation with signatures and dates, emphasizing the risk of drug diversion without proper signatures. The facility's policy on discarding and destroying medications, revised in April 2019, mandates compliance with regulations and requires destruction to be carried out by the Pharmacy Consultant and DON or designee, with records signed by the Consultant Pharmacist and a nurse.
Inadequate Infection Control Practices by CNA
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA D during the provision of incontinent care to Resident #62. CNA D did not wash their hands before starting care and failed to change gloves or wash hands throughout the process. This included handling various items and performing tasks such as retrieving items from the closet, providing perineal care, and assisting the resident with dressing and transferring, all while wearing the same pair of gloves. Resident #62, a male with moderate cognitive impairment and multiple diagnoses including asthma and cancer, required maximum assistance with toileting and personal hygiene due to incontinence. During the observed care, CNA D did not properly clean the resident's perineal area, specifically failing to lift and clean the shaft and tip of the penis. The CNA continued to perform tasks such as dressing the resident and handling the wheelchair without changing gloves or performing hand hygiene. The facility's policies on hand hygiene and perineal care were not followed by CNA D, as they did not wash hands before and after resident contact or change gloves between tasks. The Director of Nursing acknowledged the increased risk of infection due to these lapses in proper infection control practices. Despite having received training, CNA D did not adhere to the established procedures, which could potentially expose residents to infectious diseases.
Improper Transfer Without Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who required a mechanical lift for transfers. The resident, who had a history of hemiplegia, hemiparesis, and other significant medical conditions, was transferred from a wheelchair to a bed without the use of a mechanical lift, contrary to her care plan. This improper transfer was conducted by a CNA who did not wait for assistance and did not follow the care plan, resulting in the resident experiencing severe pain in her right leg. The incident occurred when the resident returned from dialysis and requested to be transferred to her bed. A CNA, who had been working at the facility for a short period, attempted to transfer the resident without the mechanical lift, despite the care plan indicating that a two-person assist with a mechanical lift was required. The CNA claimed to have seen a therapist transfer the resident without the lift and believed it was acceptable. During the transfer, the resident's leg was injured, causing her significant pain, and she was subsequently sent to the hospital for evaluation. Interviews with staff and family members revealed that the CNA had previously transferred the resident without the mechanical lift on other occasions, and the resident had not complained at those times. However, during this incident, the resident expressed pain and distress, and her family insisted on further medical evaluation. The facility's failure to adhere to the care plan and ensure proper use of the mechanical lift placed the resident at risk of injury.
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 80 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lufkin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kennedy Health & Rehab | 0.8 mi | ★★★★★ | 14 | 7 |
| Larkspur | 1 mi | ★★★★★ | 3 | 0 |
| Castle Pines Health And Rehabilitation | 1.1 mi | ★★★★★ | 1 | 1 |
| Pinecrest Retirement Community | 1.9 mi | ★★★★★ | 2 | 0 |
| Southland Rehabilitation And Healthcare Center | 3.4 mi | ★★★★★ | 9 | 0 |
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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.