Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pebble Creek Nursing Center during CMS and state inspections, most recent first.
Failure to employ a qualified full-time social worker: The facility, licensed for 120 beds, did not maintain a licensed social worker on a full-time basis after the prior social worker’s last day. The new social worker had a master’s degree and was scheduled to take the LMSW exam, but was not yet licensed. He was responsible for discharge planning, social services assessments, care plans, and grievances, and the Administrator stated she was unaware he could not serve in the role before passing the exam.
The facility failed to have a designated IP who had completed the required specialized infection prevention and control training for 2 of 2 nurses reviewed. The DON and Regional Compliance Nurse said the DON and ADONs were handling infection control protocols and surveillance, but an ADON stated she was not the IP and did not track infections. The previous DON had been the designated IP, and the DON and ADON LVN K had started the required training but had not completed it; the facility policy stated the IP would monitor the infection control program and provide education and training.
A resident with severe cognitive impairment, multiple comorbidities, and limited mobility was found with a pillow tucked under the bedsheet in a way that restricted movement, without any corresponding order or care plan indicating a medical need. A hospice nurse observed the pillow already in place and was unaware of who placed it or why. An LVN, the DON, and the Administrator each confirmed that this pillow placement constituted a restraint and was not an approved or trained practice, with the Administrator acknowledging it was used to keep the resident in bed. Facility policy prohibits restraints for discipline or convenience and specifically bans practices that restrict a bedbound resident’s ability to move, indicating the pillow’s use was inconsistent with established restraint policy.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with moderate cognitive impairment and arthritis, care planned for assistance with personal hygiene including shaving as needed, was observed with noticeable facial hair on the upper lip and chin, stating she would shave if able but did not want to bother staff. CNAs, an LVN, the DON, and the Administrator all reported that facial grooming was typically offered on shower days and that staff were responsible for monitoring and ensuring residents’ grooming according to their preferences. Despite this and a facility policy on dressing and personal grooming, staff did not provide needed assistance with facial grooming, resulting in unmet ADL care needs for this resident.
The facility failed to follow its grievance policy by not documenting and tracking resident grievances related to staff care. The Social Worker, who had been the grievance coordinator for an extended period, reported that under the previous Administrator and DON she was instructed to verbally report care-related concerns to them instead of completing grievance forms, resulting in an almost empty grievance binder and no records prior to late in the year. The ADON stated that all care concerns should have been documented on grievance forms, and the current DON confirmed that the prior practice of only verbal reporting did not comply with the written grievance policy, which requires the grievance official to receive, track, investigate, and issue written decisions on grievances, including those involving staff behavior such as concerns about a CNA.
Surveyors found that two residents with indwelling catheters had drainage bags left uncovered and visible, despite physician orders and care plans requiring the bags to be kept in privacy covers while in bed or in a wheelchair. One resident with severe cognitive impairment and multiple medical conditions, including urinary system disorder and liver disease, was observed in bed with family present while her catheter bag lacked a privacy bag. Another cognitively impaired resident with neuromuscular bladder dysfunction and other comorbidities was observed asleep in bed with her catheter bag clipped to the bed and visible from the hallway without a privacy cover. Multiple CNAs, an LVN, the RN, the DON, and the Administrator all stated that catheter bags should always be in privacy bags to protect dignity and privacy, consistent with the facility’s resident rights policy.
The facility failed to maintain catheter drainage bags off the floor in accordance with its infection prevention and control program and residents’ care plans. Three residents with indwelling catheters, including individuals with chronic kidney disease, diabetes, liver disease, dementia, and a history of UTI, were observed with Foley bags either lying on the floor, on a fall mat, or with tubing on the floor, despite orders and policies requiring bags to be kept below bladder level, off the floor, and in privacy bags. Staff, including CNAs, LVNs, an RN, the DON, and the Administrator, acknowledged that catheter bags on the floor constituted an infection control concern and that facility policy required tubing and drainage bags to be kept off the floor, yet these practices were not consistently followed.
Staff failed to maintain resident dignity during meal assistance by not sitting at eye level while feeding and by not offering residents a choice regarding the use of clothing protectors. Several residents with cognitive and physical impairments were assisted with eating by staff who stood over them, and some were not asked if they wanted to wear a clothing protector before it was placed on them. These actions were contrary to facility policy and staff training, as confirmed by observations, interviews, and record reviews.
A Wound Care Nurse did not change gloves between contaminated and clean tasks while providing wound care to a resident with dementia and end stage renal disease, despite facility policy requiring glove changes to prevent cross-contamination. The nurse handled clean wound care supplies after assisting with repositioning and removing the dressing, and acknowledged the lapse. Facility leadership confirmed the expectation for glove changes and noted the nurse had not been trained on this aspect of infection control.
A resident with a seizure disorder and multiple complex conditions did not receive prescribed anticonvulsant medication for several doses, despite staff concerns and physician orders. The DON delayed intervention and failed to initiate protective measures or an immediate investigation, resulting in the resident experiencing a seizure. Staff responsible for medication administration falsely documented that the medication was given, and the incident was not promptly reported as required.
A resident with a seizure disorder did not receive multiple prescribed doses of Levetiracetam, an anticonvulsant, over two days. Medication Aides responsible for administration falsely documented that the medication was given, but later admitted it was not. The omission was discovered after the resident experienced a seizure, and staff confirmed the medication had not been administered as ordered.
A resident with a seizure disorder and multiple comorbidities was not administered prescribed anticonvulsant medication as ordered. An LVN reported suspicions to the DON, but the DON delayed reporting and investigation, instructing staff to gather more evidence instead of initiating immediate protective actions. The resident subsequently experienced a seizure, and interviews confirmed that the facility did not promptly investigate or implement measures to prevent further neglect.
A resident with cognitive impairments was unable to make private phone calls due to the facility's failure to provide a private area or alternative phone options. The resident used a corded phone in an open lobby, leading to conversations being overheard. Staff interviews revealed a lack of awareness and action to offer private phone use, despite the facility's policy on resident rights.
The facility failed to implement comprehensive care plans for two residents at risk of falls by not ensuring fall mats were in place while they were in bed. Despite care plans indicating the need for fall mats, observations revealed the mats were not used, and staff admitted to forgetting to position them. The DON confirmed the oversight, highlighting a lapse in following the facility's care planning policy.
A resident with cognitive impairments was subjected to verbal and physical abuse by a CNA during perineal care. The CNA was observed on video handling the resident roughly, leading to bruises. Despite the resident's dependency on staff for daily activities, the CNA did not seek assistance and made derogatory remarks. The incident was reported to the DON and local police, highlighting a failure to protect residents from abuse.
Two residents in an LTC facility did not receive proper perineal care, as CNAs failed to change gloves and perform hand hygiene, risking infection. One resident, with Down Syndrome and Dementia, was handled roughly and without proper hygiene measures. Another resident was not provided with adequate hand hygiene during care. These actions violated the facility's perineal care policy, which emphasizes infection prevention and resident dignity.
The facility did not post current nurse staffing information for two days, leaving outdated data from June 29 and June 10 visible. The DON, responsible for posting, had a family emergency and did not delegate the task, resulting in a lack of updated staffing data accessible to residents and visitors.
The facility failed to ensure the safe disposal of sharps, resulting in exposed razors and a syringe in a resident's room. This posed a risk to a cognitively impaired resident with wandering behavior, as well as to other residents and staff. Staff interviews confirmed that the proper procedure for disposing of sharps was not followed.
The facility failed to maintain an infection prevention and control program, as staff did not use gowns while providing care to two residents on enhanced barrier precautions, increasing the risk of infection transmission.
The facility failed to obtain informed consent before administering medications to three residents with severe cognitive impairments. Medications were given without proper documentation of consent, leading to residents receiving treatments without being fully informed.
The facility failed to ensure a resident's call light was within reach, despite the resident's severe cognitive impairment and fall risk. The call light was observed hanging on the wall, out of reach, and staff confirmed the oversight. The facility lacked specific policies addressing call light placement.
The facility failed to ensure that a resident's MDS assessment accurately reflected physical behaviors. The MDS did not document an incident where the resident kicked another resident, which was recorded in progress notes but overlooked during the assessment.
The facility failed to provide necessary hygiene and grooming services for two residents, one with severe cognitive impairment and another with moderate cognitive impairment. Staff did not offer alternative hygiene options or properly document refusals, and failed to address a resident's request for facial hair removal, leading to poor hygiene and discomfort.
A resident with a history of UTIs and other medical conditions had her catheter tubing improperly placed on the floor, increasing the risk of infection. Staff failed to adhere to care protocols, and the issue was confirmed through observations and interviews.
A CNA changed a resident's colostomy bag and wafer without proper training, leading to unsupervised and potentially improper care. The ADON and RN involved did not adequately supervise or stop the CNA, and facility documentation revealed a lack of training and clarity regarding CNA responsibilities for colostomy care.
The facility failed to ensure that medication cart #1 was locked when unattended, leaving it unlocked for approximately eight minutes while an LVN administered insulin. Additionally, discontinued medications were not locked in medication rooms. The DON confirmed that staff were reminded of the requirement to keep medication carts locked, but compliance was not achieved.
The facility failed to adhere to professional standards for food safety, including leaving seasonings and cheese unsealed, storing expired pudding, and allowing staff to wear inappropriate footwear. Dust buildup was also observed on a vent under a tea maker.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed. The facility was licensed for 120 beds, and the census report dated 05/20/2026 showed a capacity of 120 beds with a census of 95 residents. The deficiency began when the previous licensed social worker’s last day was 05/20/2026, and the facility did not have a qualified full-time social worker in place after that date. During a telephone interview on 05/22/26, the current Social Worker J stated he was hired on 05/19/26, had a master’s degree in social services, and was scheduled to take his licensing exam on 06/06/26 for Licensed Master Social Worker. He said he was responsible for discharge planning, social services assessments, care plans, and grievances/concerns, but he was not familiar with Resident #1. The Administrator stated the facility had to have a licensed social worker full time, was not aware that Social Worker J could not work as the social worker prior to taking the licensing exam, and said the previous social worker was licensed. The Administrator did not provide the requested social worker job description prior to exit.
Infection Preventionist Training Not Completed
Penalty
Summary
The facility failed to have a designated Infection Preventionist who had completed the required specialized training in infection prevention and control for 2 of 2 nurses reviewed as designated Infection Preventionists. During an interview on 05/22/26, the DON and Regional Compliance Nurse M stated that the DON and ADONs were implementing and monitoring infection control protocols and surveillance activities. The state surveyor was provided a training certificate showing completion of the Nursing Home Infection Preventionist Training Course for ADON RN L, dated 03/20/26. During a later interview, ADON RN L stated that she was not the Infection Control Preventionist, did not assist with the Infection Control Program, and did not track infections. HR Coordinator N stated that the previous DON’s last day of work was 12/09/25. Regional Compliance Nurse M and the DON stated that the previous DON had been designated as the Infection Control Preventionist, and that the DON, ADON LVN K, and the Administrator were in the process of completing the required Infection Control Preventionist training. The DON stated that she and ADON LVN K had started the training and it had not been completed as of 05/22/26. The facility’s Infection Control Plan stated that the IP would monitor the infection control program, provide education and training, and complete CDC training along with the DON and Administrator.
Unauthorized Use of Pillow as Physical Restraint Under Bedsheet
Penalty
Summary
Surveyors identified a deficiency related to the use of a physical restraint when a pillow was found tucked under the bedsheet in a manner that restricted a resident’s movement. The resident was an elderly female with multiple diagnoses, including unspecified dementia, amnesia, ataxia, communication deficit, joint pain, fracture of the right third metacarpal, rectal prolapse, dysphagia, depressive disorder, gait and mobility impairment, osteoarthritis, muscle wasting and weakness, hypothyroidism, type 2 diabetes, hyperglyceridemia, and polyneuropathy. Her Quarterly MDS showed a BIMS score of 01, indicating severe cognitive impairment, and documented impairments in upper and lower extremities. Review of her care plan and physician orders dated 04/22/2026 revealed no focus, goal, interventions, or orders authorizing or explaining a medical use for a pillow tucked under the bedsheet. During an observation on 04/22/2026 at 11:43 AM, the resident was seen lying in bed asleep, tilted on her left side, while a hospice nurse was present. When the hospice nurse removed the blanket to show there was no bruising or swelling, a pillow was observed tucked under the resident’s bedsheet. The hospice nurse stated the pillow was already in place when she arrived, did not know who placed it, and did not know its purpose. Later the same day at 11:59 AM, the resident was observed awake, sitting at a 90-degree angle with a food tray in front of her, and the pillow under the bedsheet was no longer present. An LVN, when shown a photograph of the pillow placement, stated it was not appropriate, should not have been there, and that it caused a restraint to the resident. In an interview, the resident’s responsible party stated he believed the pillow had been placed to keep the resident positioned on her side to prevent wounds and noted that she was unable to move independently, very fragile, and bedbound. The DON, after being shown the photograph, stated that using a pillow in this manner was considered a restraint, that staff were not trained to perform this practice, and that it could cause the resident to feel trapped and be unable to move, especially since she did not ambulate. The Administrator, also shown the photograph, stated the pillow had been keeping the resident in bed, confirmed it would be considered a restraint, and stated staff were not trained to use pillows in this way and only approved devices such as U-bars were permitted. Review of the facility’s restraint policy showed it prohibited restraints for discipline or convenience, defined physical restraints, required assessment and care planning for restraint use, and specifically listed “tucking sheets so tightly that a bed bound resident cannot move” as a prohibited practice, underscoring that the observed pillow placement functioned as an unauthorized physical restraint.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Provide Needed ADL Assistance With Facial Grooming
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for a resident who was unable to fully perform these tasks. The resident was an elderly female with age-related cognitive decline and polyosteoarthritis, and a Quarterly MDS showing a BIMS score of 09, indicating moderate cognitive impairment. Her care plan, revised on 03/13/2026, identified an ADL self-care performance deficit and included interventions for assistance with personal hygiene, including hair, shaving, and oral care as needed. On 03/30/2026 at 9:56 AM, the resident was observed with black hair on her upper lip and black and gray hair on her chin. She stated that she would shave herself if she could, but did not want to ask staff because she did not want to bother them. Staff interviews confirmed that grooming, including facial grooming, was generally performed on shower days, about two days per week, and that CNAs and nurses were responsible for monitoring and ensuring residents’ grooming. CNA A stated that facial grooming was done on shower days and that CNAs were to ask residents if they wanted facial hair shaved, acknowledging that long facial hair in female residents could affect self-esteem. LVN B similarly stated that residents were offered facial grooming on shower days and that nurses were responsible for ensuring residents were well groomed, noting that female residents with long facial hair could be emotionally affected or embarrassed. The DON and Administrator both reported that facial grooming should be done as needed and according to resident preference, and that all staff shared responsibility for ensuring residents were well groomed. Despite these stated responsibilities and the facility policy on dressing and personal grooming, the resident’s facial hair was not addressed, indicating that the facility did not implement the care plan interventions to assist with personal hygiene and grooming as required.
Failure to Document and Track Resident Grievances per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances and to follow its own grievance policy, including proper documentation and tracking of grievances. During an observation, the Social Worker provided the grievance binder, which contained documentation only back to December 2025, despite her having been the appointed grievance coordinator since October 2024. The facility’s written grievance policy, dated 11/2/2016, states that residents have the right to voice grievances regarding care and treatment, staff behavior, and other concerns, and that the grievance official must oversee the grievance process, receive and track grievances to their conclusion, lead investigations, and issue written grievance decisions. In interviews, the Social Worker stated she had no documented grievance forms from residents regarding care from staff prior to the recent period and explained that, under the previous DON and Administrator, she had been instructed not to complete grievance forms for grievances related to staff care. Instead, she was told to verbally report such concerns directly to the previous DON and Administrator, who indicated they would handle them, and she did not document these grievances despite recognizing that resident care concerns qualified as grievances that needed to be documented. She acknowledged that this practice was not in compliance with the facility’s grievance policy and that concerns such as those involving CNA A should have been documented in accordance with that policy. The ADON confirmed that residents could report care concerns to any staff member and that quality-of-care concerns reported to her should have been documented on a grievance form, adding that everything needed to be documented in the system and grievance binder. She stated she was not aware of the previous Administrator’s and DON’s instructions to the Social Worker not to document grievances related to staff care. The current DON observed that the grievance binder appeared empty, with the earliest grievances only dating back to December 2025, and stated that the prior practice of only verbally reporting concerns to the previous DON and Administrator was not aligned with the facility’s grievance policy. She noted that without adherence to the policy and proper documentation, grievances could be lost, the facility could be unaware if grievances were unresolved, and there would be no documentation to support resolution or to reference during investigations, including those related to CNA A’s behavior.
Uncovered Foley Bags Compromise Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident dignity by not keeping urinary catheter drainage bags covered with privacy bags as required by physician orders, care plans, and facility practice. For one resident, an older female with diagnoses including urinary system disorder, chronic Hepatitis C, hypokalemia, acute kidney disease, and cirrhosis, record review showed an indwelling suprapubic catheter and an order specifying that the Foley bag must be in a privacy bag while the resident is in bed or in a wheelchair. Her care plan also directed that the catheter bag and tubing be positioned below the level of the bladder and in a privacy bag. During an observation while the resident was in bed with a family member present, the catheter drainage bag was noted to be uncovered and without a privacy bag. A second resident, an older female with dysphagia, muscle wasting and atrophy, anemia, hyperlipidemia, dementia, hypertension, GERD, and neuromuscular dysfunction of the bladder, also had an indwelling catheter. Her orders required Foley catheter care every shift, including ensuring the Foley was secured on the thigh and the drainage bag was inside a privacy bag attached to the bed rail every shift. Her care plan similarly directed that the catheter bag and tubing be positioned below the level of the bladder and in a privacy bag. During observation, this resident was asleep in bed, non‑responsive to the investigator, and her catheter bag was clipped to the right side of the bed, visible from the hallway, with no privacy bag covering it. Multiple staff interviews confirmed that facility staff were trained that catheter bags should always be in privacy bags to maintain resident dignity and privacy. A CNA with 13 years of employment, another CNA, an LVN, the RN, the DON, and the Administrator each stated that catheter bags were expected to be covered with privacy bags and that failure to do so was a dignity or privacy issue. The facility’s Resident Rights policy stated that each resident must be treated with respect and dignity, including privacy and confidentiality, and that the facility must protect and promote residents’ rights. Despite these expectations, the observed uncovered catheter bags for the two residents demonstrated that the facility did not ensure residents’ right to a dignified existence and privacy as outlined in their orders, care plans, and facility policy.
Failure to Maintain Catheter Drainage Bags Off the Floor Under Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program related to the management of indwelling urinary catheter drainage bags for three residents. For one resident, an older female with diagnoses including disorder of the urinary system, chronic viral Hepatitis C, hypokalemia, acute kidney disease, and cirrhosis of the liver, surveyors reviewed records showing she had an indwelling suprapubic catheter. Her care plan and physician orders directed that the catheter bag and tubing be positioned below the level of the bladder, kept off the floor, and placed in a privacy bag. During an interview and observation while the resident was in bed with a family member present, the resident’s catheter bag was observed lying on the floor, contrary to the documented orders and care plan. A second resident, an older male with diagnoses including type 2 diabetes, thrombocytopenia, and benign prostatic hyperplasia with lower urinary tract symptoms, also had an indwelling catheter. His orders and care plan similarly required that the Foley bag be kept in a privacy bag while in bed or wheelchair, positioned below the bladder, and maintained off the floor with tubing checked for kinks. During observation, this resident was found asleep in bed with the catheter bag inside a blue privacy bag on the right side of the bed. The bag was not hooked to the bedrail and was lying sideways with the tubing on the floor, in direct conflict with the facility’s catheter care policy and the resident’s individualized care plan. A third resident, an older male with chronic kidney disease, conversion disorder with seizures, viral hepatitis C, dementia, type 2 diabetes, and a history of UTI, also had an indwelling catheter. His orders and care plan required that the Foley bag be in a privacy bag every shift, positioned below the bladder, and kept off the floor to prevent catheter-related trauma. During observation, this resident was in bed and became aggressive when the investigator attempted conversation. The catheter bag was found on the right side of the bed inside a blue privacy bag, not hooked to the bedrail, and sitting upright on a fall mat. Staff interviews, including with LVNs, CNAs, the RN, the DON, and the Administrator, confirmed that catheter bags on the floor or touching surfaces were considered an infection control concern and that facility policy required tubing and drainage bags to be kept off the floor. Despite this, the observed practices for these three residents did not comply with the facility’s catheter care and standard precautions policies, resulting in the cited infection control deficiency. Staff interviews further clarified the actions and inactions contributing to the deficiency. One LVN stated that due to the requirement to keep beds in the lowest position for fall risk residents, the catheter bags would always be touching the floor or fall mats, and initially believed this was acceptable. During the same interaction, the LVN was able to adjust two residents’ Foley bags so they were no longer touching the floor mat and were upright to prevent leakage, indicating that proper positioning was feasible but not consistently implemented. Multiple CNAs and an RN acknowledged that catheter bags should not be on the floor and identified this as an infection control issue. The DON and Administrator both stated that catheter bags were to be kept below the bladder, off the floor, and in privacy bags, and that bags on the floor represented an infection control problem, while lack of privacy bags was a dignity concern. Record review of the facility’s catheter care and standard precautions policies confirmed that tubing and drainage bags were to be kept off the floor and that appropriate infection control measures were required for each resident interaction. These observations and statements collectively demonstrate that the facility did not consistently implement its infection prevention and control program for residents with indwelling catheters.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat several residents with respect and dignity during meal assistance, as evidenced by staff not sitting at eye level while assisting with feeding and not offering residents a choice regarding the use of clothing protectors. Observations revealed that multiple staff members, including a student CNA and CNAs, assisted residents with eating while standing, rather than sitting at eye level as required by facility policy and staff training. This practice was observed with at least three residents who had varying degrees of cognitive impairment and required different levels of assistance with eating. Staff interviews confirmed that they were aware of the expectation to sit while assisting with feeding, but some staff cited physical limitations or personal preference as reasons for not following this protocol. Additionally, the facility failed to ensure that residents were asked if they wanted to wear a clothing protector before it was placed on them. One resident reported not being asked and feeling unable to refuse once the protector was already on. Staff interviews indicated that it was common practice for some staff to put clothing protectors on residents without asking, despite being trained to offer residents a choice. The facility's policy and staff training emphasized the importance of promoting resident dignity and self-determination by offering choices and engaging residents in their care. The residents involved had significant medical histories, including dementia, diabetes, impaired mobility, and cognitive communication deficits, which made them dependent on staff for assistance with eating and other activities of daily living. The failure to follow established protocols for meal assistance and resident choice was confirmed through direct observation, staff and resident interviews, and review of facility policies and care plans. These actions and inactions resulted in a failure to maintain an environment that promotes or enhances residents' quality of life and dignity.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care for a resident with significant medical needs, including unspecified dementia and end stage renal disease. During an observed wound care procedure, the Wound Care Nurse did not change gloves between contaminated and clean tasks. Specifically, after assisting with repositioning the resident and removing the dressing, the nurse continued to handle clean wound care supplies, such as Anasept and collagen, with the same gloves. The nurse acknowledged the lapse and stated she was nervous, but recognized that gloves should have been changed prior to touching clean supplies. The resident was unable to respond to questions due to severe cognitive impairment. Interviews with the DON and Administrator confirmed that facility policy requires gloves to be changed between dirty and clean tasks during wound care, and that the Wound Care Nurse had not received specific training on cross-contamination prevention. Review of facility policies further supported the expectation for hand hygiene and glove changes during wound care procedures. The failure to follow these protocols was directly observed and acknowledged by staff, and was not in accordance with the facility's established infection control policies.
Failure to Administer Anticonvulsant Medication and Protect Resident from Neglect
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder, dementia, intellectual disabilities, and other complex medical needs did not receive prescribed anticonvulsant medication (Levetiracetam) as ordered by the physician. The resident was non-verbal and required strict adherence to medication administration to prevent seizures. Despite a physician's order to increase the dosage due to previously low medication levels, the medication was not administered for four consecutive doses over a weekend. Medication Aides responsible for administering the medication failed to do so but documented in the electronic medication administration record that the medication had been given. The charge nurse reported concerns to the DON regarding the resident not receiving the anticonvulsant medication as ordered, based on low lab values. However, the DON did not immediately implement protective measures or initiate an investigation. Instead, the DON instructed the nurse to gather evidence by monitoring the medication bottle, delaying any intervention until after the weekend. During this period, the resident missed multiple doses of the critical medication, and no immediate steps were taken to ensure the resident's safety or to verify medication administration. As a result of the missed doses, the resident experienced a seizure, which was documented by nursing staff. The incident was not promptly reported to the facility administrator or to the state as required. Interviews with staff revealed a lack of immediate action and failure to follow facility policy regarding the reporting and investigation of neglect. The deficiency was identified as Immediate Jeopardy due to the failure to protect the resident from neglect and to ensure medications were administered as ordered.
Failure to Administer Anticonvulsant Medication as Ordered
Penalty
Summary
A significant medication error occurred when a resident with a history of seizure disorder, dementia, dysphagia, intellectual disabilities, Down Syndrome, and anxiety disorder did not receive prescribed doses of Levetiracetam, an anticonvulsant medication. The resident was ordered to receive Levetiracetam 100 mg/ml, 7.5 ml by mouth twice daily for seizures. However, the medication was not administered as ordered on four occasions over two consecutive days. Medication Aides responsible for administering the medication documented in the electronic medication administration record (eMAR) that the doses were given, but later admitted during interviews that the medication was not actually administered. The failure to administer the medication as ordered was discovered after the DON was alerted by an LVN who suspected the medication was not being given. The DON instructed the LVN to take pictures of the medication bottle to compare the amount before and after the weekend, which revealed no change in the medication volume, confirming the medication had not been administered. The resident subsequently experienced a seizure, which was documented by nursing staff, including observations of shaking extremities, eyes rolling back, jerking arms, decreased oxygen saturation, and unconsciousness. The physician was notified following the seizure event. Interviews with the involved Medication Aides revealed that one aide forgot to administer the medication after being distracted by another task, while the other aide did not remove the medication from the drawer and falsely documented administration. One of the aides had a prior history of similar documentation errors. The incident was recognized as neglect by staff and was reported to the facility's Abuse Coordinator and DON. The deficiency was identified as Immediate Jeopardy due to the failure to ensure the resident's drug regimen was free from significant medication errors, specifically the omission of critical anticonvulsant medication.
Failure to Investigate and Prevent Neglect Following Missed Medication Administration
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that measures were taken to prevent further incidents while an investigation was in progress. Specifically, a non-verbal female resident with multiple diagnoses, including seizure disorder, dementia, and intellectual disabilities, was not administered her prescribed anticonvulsant medication (Levetiracetam) as ordered. The resident's care plan required strict adherence to medication administration and documentation of seizure activity, but there was a lapse in ensuring the medication was given as prescribed. On a specific date, an LVN reported to the DON a suspicion that a medication aide was not administering the resident's Keppra as ordered, based on a low medication level. The DON did not immediately report the allegation to the Administrator or initiate an investigation. Instead, the DON instructed the LVN to gather more evidence by monitoring the medication bottle and delayed any intervention until several days later, when audits of anticonvulsant medication administration were initiated. During this period, the resident experienced a seizure, which was observed and documented by the LVN, including a drop in oxygen saturation and loss of consciousness. Interviews revealed that the Administrator, who served as the Abuse Coordinator, was informed of the suspicion but did not recall being told what immediate actions would be taken to protect the resident. The facility did not immediately initiate an investigation or implement protective measures for the resident or others potentially at risk. The delay in reporting and investigating the allegation, as well as the lack of immediate interventions, constituted a failure to respond appropriately to an alleged violation of neglect.
Failure to Provide Private Telephone Access
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to a telephone and a private area to make calls without being overheard. The resident, who was admitted with diagnoses including schizoaffective disorder, anxiety, major depressive disorder, and dementia, expressed discomfort using the corded phone located in the open lobby area near the nursing station. This setup did not provide privacy, as conversations could be overheard by staff and others in the vicinity. Despite the resident's cognitive impairment, she was aware of the lack of privacy and expressed discomfort about the situation. Interviews with staff revealed that a portable phone, which could have been used for private calls, was lost, and no alternative private phone options were consistently offered to the resident. The Director of Nursing acknowledged the issue and noted that not all staff were aware of the need to offer a private phone option. The facility's policy on resident rights, which includes the right to private phone use, was not adhered to in this case, leading to a deficiency in respecting the resident's privacy rights.
Failure to Implement Fall Risk Interventions for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and time frames to meet their medical and nursing needs. Specifically, the facility did not adhere to the care plans for fall risk management by failing to ensure that fall mats were in place next to the beds of the residents while they were lying down. This oversight was observed during a survey, where the fall mats were found folded and not in use, contrary to the care plan requirements. Resident #1, a female with severe cognitive impairment and a high risk for falls, was observed without fall mats in place while lying in bed. Despite having a history of self-transferring and a care plan intervention that included fall mats, the staff failed to implement this safety measure. The Director of Nursing (DON) acknowledged the absence of the fall mat and stated it was the responsibility of the staff to ensure its placement. A Certified Nursing Assistant (CNA) admitted to forgetting to put the mat down after the resident had breakfast. Similarly, Resident #8, who had moderate cognitive impairment and required substantial assistance with mobility, was also found without fall mats in place. The DON confirmed that the resident was a fall risk and that the mats should have been in place as per the care plan. A Licensed Vocational Nurse (LVN) and a CNA both acknowledged the oversight, with the CNA admitting to forgetting to reposition the mats after attending to the resident. The facility's policy mandates that each resident's care plan should reflect interventions to meet their needs, which was not adhered to in these cases.
Abuse Incident During Perineal Care
Penalty
Summary
The facility failed to ensure that all residents were free from abuse, as evidenced by an incident involving a certified nursing assistant (CNA) and a resident with Down Syndrome, dementia, and seizures. The incident occurred during perineal care, where the CNA was observed being verbally and physically abusive towards the resident. The CNA was seen on video aggressively handling the resident, including forcefully positioning her limbs and using excessive force while changing her brief. The resident was later found with multiple bruises, although she did not report any pain. The resident involved in the incident was a female with significant cognitive impairments, including dementia and Down Syndrome, and was dependent on staff for activities of daily living. The resident's care plan indicated that she required substantial assistance for mobility and was frequently incontinent. Despite these needs, the CNA did not seek assistance from other staff members and instead handled the resident roughly, which was captured on video by a family member's camera. The CNA involved in the incident had been employed at the facility for six years without prior complaints. However, during the incident, the CNA was heard making derogatory remarks towards the resident and failed to change gloves during the procedure, indicating a lack of adherence to proper care protocols. The facility's Director of Nursing (DON) and other staff members were notified of the incident, and the local police were involved after the bruises were discovered. The facility's policy on abuse and neglect clearly states that residents have the right to be free from abuse, which was not upheld in this case.
Deficient Perineal Care Practices
Penalty
Summary
The facility failed to ensure that two residents who were unable to perform activities of daily living received the necessary services to maintain good grooming and personal and oral hygiene. Specifically, the report highlights deficiencies in the provision of perineal care for two residents. CNA A did not adhere to professional standards while providing perineal care to Resident #2, who was frequently incontinent and dependent on staff for toileting and lower dressing. The video evidence showed that CNA A did not change gloves during the procedure, handled the resident roughly, and did not use wipes, which are essential for infection control. Resident #2, a female with Down Syndrome, Dementia, and Seizures, was admitted to the facility and required substantial assistance for bed mobility and toileting. The care plan indicated that Resident #2 was frequently incontinent and required one staff member for assistance with ADLs. The video recordings provided by the family member showed CNA A mishandling the resident, failing to change gloves, and not using wipes, which was confirmed by the DON and LVN B during interviews. These actions were not in line with the facility's perineal care policy, which emphasizes infection prevention and maintaining resident dignity. Similarly, CNA K failed to change gloves or perform hand hygiene while conducting perineal care for Resident #7. During an observation, CNA K was seen handling the resident's clothing and wheelchair without changing gloves, which could lead to contamination and infection. The facility's perineal care policy outlines the importance of hand hygiene and proper glove use to prevent infections and maintain cleanliness. Both CNAs' actions were inconsistent with the facility's standards and training, posing a risk of infection to the residents.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted and readily accessible to residents and visitors for two specific days, June 30, 2024, and July 1, 2024. Observations on July 1, 2024, revealed that the staffing information posted was outdated, with the most recent data being from June 29, 2024. Further observations showed that information from as far back as June 10, 2024, was still displayed, indicating a lack of current staffing data. This deficiency was confirmed through interviews and record reviews, highlighting that the required information, including the facility name, current date, resident census, and total hours worked by nursing staff, was not maintained as per regulations. During an interview, the Director of Nursing (DON) acknowledged the oversight, explaining that she was responsible for posting the staffing information over the weekend of June 29-30, 2024. However, due to a family emergency, she did not fulfill this duty and failed to delegate the task to others. Consequently, the Assistant Directors of Nursing (ADONs) also did not post the necessary information on July 1, 2024. The DON admitted that the absence of this information could prevent staff members and family members from being informed about the current staffing situation at the facility.
Failure to Ensure Safe Disposal of Sharps
Penalty
Summary
The facility failed to ensure that the residents' environment remained free of accident hazards and that each resident received adequate supervision to prevent accidents. During observations, it was noted that the sharps container in a resident's room had disposable razors and a syringe exposed and reachable on top of the box. This posed a risk to the resident, who had a history of wandering and cognitive impairment, as well as to other residents and staff members who might come into contact with the exposed sharps. Interviews with staff confirmed that the procedure for disposing of sharps was not followed correctly, leading to the potential for injury and contamination. Resident #2, a male with multiple diagnoses including dementia, anxiety, and delusional disorders, was observed to have severely impaired cognitive status and required substantial assistance with daily activities. His care plan indicated a need for a safe environment and close supervision due to his tendency to wander and impaired safety awareness. Despite these precautions, the presence of exposed sharps in his room created a significant hazard, especially given his propensity to take items he finds. Interviews with the Licensed Vocational Nurse (LVN), Nursing Assistant (NA), and Director of Nursing (DON) revealed that the facility's policy required used sharps to be placed intact into sharps containers immediately after use. However, the staff admitted that the procedure was not followed, resulting in the exposed razors and syringe. The DON acknowledged the risk posed by the exposed sharps to both residents and staff, particularly in a facility where multiple residents exhibit wandering behaviors.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to potential cross-contamination and the spread of infection among residents. Specifically, two residents on enhanced barrier precautions did not receive the required protective measures from the staff. Resident #46, who has multiple diagnoses including cerebral infarction and type 2 diabetes mellitus, was observed receiving care from LVN E without the use of a gown, despite the resident being on enhanced barrier precautions. LVN E administered insulin and checked the resident's blood sugar without donning a gown, contrary to the facility's policy for residents on enhanced precautions. Similarly, Resident #74, who has diagnoses including cerebral infarction and COPD, was also on enhanced barrier precautions. RN F was observed administering medications via a PEG tube without wearing a gown. The resident, who has severely impaired cognition, was in close contact with RN F during the procedure, yet the required protective gown was not used. Both residents' care plans and physician orders clearly indicated the need for enhanced barrier precautions, including the use of gowns and gloves during high-contact activities. Interviews with the staff revealed a lack of understanding and adherence to the enhanced barrier precautions policy. LVN E admitted to being unsure about the necessity of gowning up for activities other than wound care, while the DON confirmed that all staff were trained monthly on infection control and PPE use. Despite the presence of signage and PPE carts outside the residents' rooms, the staff failed to comply with the facility's infection control policies, thereby increasing the risk of infection transmission.
Failure to Obtain Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not obtain informed consent from three residents before administering medications. Resident #29, who had severe cognitive impairment and multiple health conditions including anxiety, was given Lorazepam without consent from 10/8/23 to 10/13/23. The consent was only signed on 10/13/23, after the medication had already been administered for several days. Resident #46, who also had severe cognitive impairment and multiple health conditions including seizures, was administered Valproic Acid without any consent on file from 6/1/23 to 5/15/24. The Director of Nursing (DON) acknowledged the absence of consent and stated that the resident had been receiving the medication for nearly a year without proper documentation. Resident #90, who had severe cognitive impairment and multiple health conditions including depression, was given Fluoxetine without consent from 5/3/24 to 5/8/24. The consent was signed on 5/8/24, after the medication had already been administered. The DON admitted to challenges in the consenting process and stated that the charge nurses were responsible for obtaining consent prior to medication administration, but acknowledged occasional lapses in this process.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that Resident #1's call light was within reach, which is a reasonable accommodation of the resident's needs and preferences. Resident #1, a male with severe cognitive impairment and multiple diagnoses including dementia, muscle weakness, and a history of falls, was observed on 5/15/2024 with his call light hanging on the wall about three feet from his bed, out of his reach. This observation was confirmed by NA D, who acknowledged that the call light should always be within reach, especially given Resident #1's fall risk and history of falls. Further interviews revealed that the Director of Nursing (DON) also acknowledged the risk posed by the call light being out of reach, stating that Resident #1 would not be able to get the help he needed and could potentially fall if he tried to get up to reach the call light. The facility's policies and procedures were reviewed, and it was found that there were no specific policies addressing the placement of call lights. This deficiency could place residents at risk of not having their needs met and a decline in their quality of care and life.
Inaccurate MDS Assessment for Resident's Physical Behaviors
Penalty
Summary
The facility failed to ensure that a resident's MDS assessment accurately reflected the resident's behaviors. Specifically, the MDS for a male resident with a history of cerebral infarction and major depressive disorder did not document an incident where the resident exhibited physical behaviors by kicking another resident, which resulted in bruises. This incident was recorded in the resident's progress notes but was overlooked during the MDS assessment's seven-day look-back period, leading to an inaccurate assessment. During interviews, the MDS Coordinator admitted to overlooking the incident and acknowledged that the MDS did not accurately reflect the resident's behavior. The Director of Nursing (DON) confirmed that the expectation was for MDS assessments to capture all pertinent information accurately. The facility's policy on documentation emphasizes the importance of maintaining complete and accurate records, which was not adhered to in this case.
Failure to Provide Necessary Hygiene and Grooming Services
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and hygiene for two residents who were unable to carry out activities of daily living. Resident #45, a male with severe cognitive impairment and diagnosed with unspecified dementia, was observed to be unshaved, wearing the same clothes from the previous day, and emitting a foul odor. Despite his resistance to care, staff did not offer alternative hygiene options such as bed baths, and there was a lack of proper documentation regarding his refusal to shower. Interviews with staff revealed inconsistencies in the approach to his care and a failure to document refusals and alternative care measures properly. Resident #40, a female with moderate cognitive impairment and diagnosed with diabetes, expressed a desire to have her facial hair removed but was not assisted with this grooming need. Despite her vocal requests, staff failed to address her concern, leaving her with facial hair that made her feel uncomfortable. Observations and interviews indicated that staff were aware of her preference but did not follow through with the necessary grooming assistance. The deficient practices in both cases placed the residents at risk of poor hygiene and a decline in self-esteem. The facility's failure to document refusals and provide alternative care measures, as well as the lack of attention to individualized grooming needs, contributed to the deficiencies observed by the surveyors.
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with urinary incontinence received appropriate treatment and services to prevent urinary tract infections. Specifically, the resident's indwelling catheter tubing was observed laying on the floor, and the subpubic catheter was not properly secured. This failure was noted during observations and interviews with staff, where it was revealed that the catheter bag was inappropriately placed on the floor, covered only by a blue privacy bag. The CNA incorrectly believed that the privacy bag was sufficient to prevent contamination, while the RN later acknowledged the risk of infection and properly secured the catheter bag off the floor. The resident involved was an elderly woman with a history of urinary tract infections, Alzheimer's, dementia, diabetes, and gross hematuria. Her care plan specified that the catheter tubing should remain off the floor and that staff should monitor for signs of urinary infection. Despite these instructions, the catheter bag was found on the floor during multiple observations, and staff interviews confirmed a lack of adherence to proper catheter care protocols. The Director of Nursing also confirmed that the catheter bag should not be on the floor due to the increased risk of infection and emphasized the responsibility of CNAs and nurses to ensure proper catheter placement at every shift change.
Failure to Ensure CNA Competency in Colostomy Care
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in skills and techniques necessary to care for residents' needs, as evidenced by an incident involving a resident with a colostomy. A CNA changed the resident's colostomy bag and wafer without having been trained on the procedure. The CNA noticed the colostomy bag was too full and decided to change it herself, using alcohol prep wipes to cleanse the area around the stoma. She was unaware of the proper steps, such as applying sure-prep, and proceeded without notifying a nurse or having a nurse present during the procedure. The Assistant Director of Nursing (ADON) and a Registered Nurse (RN) were involved but did not adequately supervise or stop the CNA from continuing the procedure. The ADON initially assisted by cutting the wafer to size but did not ensure the CNA was properly trained or that a nurse was present to oversee the procedure. The RN and ADON both left the room, allowing the CNA to complete the colostomy care unsupervised. Interviews with the RN, ADON, and Director of Nursing (DON) revealed confusion and lack of clarity regarding the roles and responsibilities of CNAs in performing colostomy care. The facility's documentation and policies did not indicate that CNAs were trained on colostomy care. The DON confirmed that only nurses were expected to change colostomy bags and wafers, and the CNA should have informed a nurse when the colostomy bag needed changing. The Administrator was unaware of the specific policies regarding CNA responsibilities for colostomy care and indicated he would look into the issue. The facility's coaching forms and proficiency audits further highlighted the lack of training and clarity in the roles of CNAs regarding colostomy care.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls and that only authorized personnel had access to medications. Specifically, medication cart #1 was left unattended and unlocked by an LVN, who walked away from the cart to administer insulin. The cart remained unattended and unlocked for approximately eight minutes before the LVN noticed and locked it. During an interview, the LVN acknowledged that she must have overlooked locking the cart and was aware of the requirement to keep medication carts locked when unattended. Additionally, the facility failed to ensure that discontinued medications were locked in medication rooms. The Director of Nursing (DON) confirmed that the expectation was for all medication carts to be locked when unattended and mentioned that there had been a recent in-service training and a reminder sent out to staff about this requirement. Despite these measures, the staff did not comply with the policy. The facility's policy, dated 2003, clearly states that medication carts should be locked when not in use or under direct supervision and must be secured.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that various seasonings such as Cream of Tartar, Salt, and Dill weed were left opened, and a bag of cheese in the walk-in refrigerator was not sealed correctly. Additionally, expired instant pudding was found in the dry storage room. The facility also had a vent with dust buildup located under a tea maker, which was not in use but still required regular cleaning. Dietary staff were observed wearing inappropriate footwear, specifically Crocs with holes, which is against the facility's dress code policy. Interviews with dietary staff and the dietary manager confirmed these observations. The dietary manager acknowledged that the seasonings should not have been left open and that the expired pudding needed to be discarded. He also admitted that the bag of cheese should have been sealed properly to prevent contamination. Despite the facility's dress code policy prohibiting Crocs with holes, the dietary manager allowed their use, stating that they were non-slip and comfortable, although he recognized the potential risk of burns from dropped items.
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 346 citations issued within 25 miles in the last 12 months — including the 9 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
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 El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| El Paso Health & Rehabilitation Center | 0.4 mi | ★★★★★ | 11 | 0 |
| Vista Hills Health Care Center | 1.9 mi | ★★★★★ | 16 | 1 |
| Oasis Nursing & Rehabilitation Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Center At Zaragoza, Llc | 3.3 mi | ★★★★★ | 3 | 0 |
| Edgemere Estates | 3.4 mi | ★★★★★ | 4 | 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.