Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rambling Oaks Courtyard Extensive Care Community during CMS and state inspections, most recent first.
Failure to Secure Resident Medical Information on Nurse Cart: An LVN left a paper with resident medical information on top of a nurse's cart in front of the nurses' station with the cart facing the hallway, exposing code status and other details for six residents. The paper showed full code and DNR status, along with information such as a chest X-ray and oral ABT, and staff stated the information should not have been left visible because it was confidential and could be seen by unauthorized individuals.
Dirty Resident Room Bathrooms and Air Vents: The facility failed to keep 8 resident rooms clean and sanitary. Observations found gray, brown, and black dirt stains on bathroom floors around toilets and under sinks, and one room had dirt in the AC vents. A resident said they had to scrub around the toilet because it grossed them out. A housekeeper said daily cleaning was done but the floors had never been deep cleaned, and the housekeeping supervisor and ADM acknowledged the rooms were not in acceptable condition.
Medication Administration and Storage Deficiencies: A resident with dementia was left with oral meds to take on her own, and another resident with dementia was self-administering eye drops without a documented self-med assessment. An LPN also had a personal tumbler on the med cart while passing meds, and expired meds were found in a nurse’s cart during inspection.
The facility failed to maintain infection control during resident care when an LPN left a room with a glove still on, another LPN provided IV and catheter care for a resident on EBP without a gown, and two CNAs used gloves kept in their pockets during incontinent care. The residents involved had diagnoses including depression, urine retention with an IV and indwelling catheter, and bowel and bladder incontinence. Staff acknowledged the glove and gown practices were not followed as expected.
A facility failed to keep call lights within reach for three residents with mobility and cognitive impairments. One resident with ataxic gait and severe cognitive impairment, one resident with muscle weakness and moderate cognitive impairment, and one resident with COPD and severe cognitive impairment were each observed in bed with the call light on the floor or otherwise not accessible. CNA and LVN interviews confirmed staff should ensure call lights are with residents before leaving the room, and the DON and ADON stated all staff were responsible for this.
A resident with acute respiratory failure, hypoxia, severe cognitive impairment, and sleep apnea had a physician order for BiPAP at night, but the comprehensive care plan did not include the BiPAP device. The MDS nurse, DON, and ADON acknowledged the device should have been care planned, and the facility's care planning process did not reflect the resident's ordered respiratory support.
A resident with severe cognitive impairment, muscle weakness, unsteadiness on feet, and recent falls was observed lying in bed while the bed was not in the lowest position, despite the care plan identifying low bed positioning as a fall-prevention intervention. An LVN confirmed the bed should have been lowered and stated it was the LVN’s and CNA’s responsibility to do so after breakfast; a CNA and the DON/ADON also acknowledged the resident was a fall risk and that the bed should have been kept low.
Two residents with g-tubes did not receive fully ordered enteral feeding care. An LVN administered crushed meds through one resident’s g-tube without first checking tube placement, despite an order to verify placement before meds. For another resident, the chart lacked orders for residual checks, placement checks, and flushing before, during, and after med administration, even though the LVN performed those steps and acknowledged the orders were missing. The ADON and DON confirmed placement should be checked and that complete g-tube orders should be in place.
A resident receiving IV Imipenem through a PICC line did not have orders for flushing the line before medication administration, dressing-change timing, or required assessments for infection. During observation, an LPN flushed the line before connecting the IV, and staff later confirmed the chart lacked the IV care orders they expected to be in place. The DON stated orders should exist for all PICC line care, and the facility policy required medication and treatment orders to be recorded on the physician order sheet.
Respiratory Devices Left Unbagged: A resident with acute respiratory failure, hypoxia, and severe cognitive impairment had a BiPAP mask and nebulizer machine observed sitting unbagged on a stand and nightstand when not in use. An LVN stated both items should be bagged to avoid bacteria, and the DON and ADON agreed it was the nurse’s responsibility to ensure the devices were bagged when not in use.
A facility failed to keep medicated powders, zinc oxide, and a skin barrier secured in locked medication storage and instead left them on residents’ tables or in resident rooms. One resident with severe cognitive impairment had nystatin powder, antifungal powder, and zinc oxide on her side table, and another resident had a skin barrier on her overbed table. An LVN stated these items should have been kept in the nurses’ carts, and the DON and ADON confirmed that medicated creams and powders should not be stored where residents could access them.
A resident with COPD and moderate cognitive impairment was found self-administering a nasal spray without a physician's order or assessment for self-administration. The medication was kept at bedside and used without staff knowledge, and there was no documentation or process in place to ensure safe medication management. Staff and administration confirmed that facility policy requires medications to be administered by licensed personnel and only with a physician's order.
Surveyors found that medications, including a nasal spray and zinc oxide barrier creams, were left unsecured in the rooms of three residents with cognitive impairments. Staff interviews confirmed that these medications should have been stored in locked carts or otherwise secured, but they were left accessible on side tables after use, contrary to facility policy and professional standards.
A resident with respiratory failure and other complex conditions received oxygen therapy without a current physician order, as staff relied on an outdated order from a previous admission. The error was not identified during admission or order transcription, and the resident's care plan noted confusion and frequent removal of the nasal cannula, requiring ongoing redirection. Facility leadership and staff acknowledged the oversight and the importance of following current orders.
A resident with Parkinson's disease and bed confinement did not receive scheduled bed baths from October 1 to October 16, 2024, despite requiring total assistance for ADLs. The resident expressed dissatisfaction with the lack of care, preferring bed baths over mechanical lifts. Facility staff interviews revealed inconsistencies in documentation and care provision, with a CNA admitting to forgetting to complete shower forms. This failure risked skin breakdown and dignity concerns for the resident.
Two residents were found using scoop mattresses without physician orders or assessments, posing potential accident hazards. Staff believed the mattresses were therapeutic and did not require orders, contrary to facility policy.
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in the storage and maintenance of respiratory equipment. A resident with COPD had an empty humidifier and an unbagged nebulizer mask, another receiving hospice care had a yankauer suction tip improperly stored, and a third with acute respiratory failure had a nasal cannula not in a sealed container. These issues were acknowledged by the attending LVNs, who admitted to neglecting proper storage protocols, risking cross-contamination and infection.
The facility failed to securely store medications for four residents, leaving items like zinc oxide and Miralax accessible on side tables and TV stands. This oversight posed risks of accidental ingestion, especially for residents with cognitive impairments. Staff interviews confirmed the expectation for secure storage, aligning with facility policy.
The facility's skilled nursing kitchen failed to meet food safety standards, with issues such as improperly sealed foods, an unclean ice machine, and unlabeled food items. During lunch service, a cleaning bucket was found empty, compromising sanitation. The Dietary Manager and Administrator acknowledged these deficiencies, which could lead to food contamination.
A LTC facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper hand hygiene and glove use by staff. An LVN did not change gloves or sanitize hands after touching a trash can while administering ointment, and a CNA failed to sanitize hands and change gloves appropriately during incontinent care. These actions could lead to cross-contamination and infection.
A facility failed to accurately assess a resident's impairment, specifically a contracture in the right hand, in the MDS Assessment. Despite the resident's diagnosis of joint contracture and observations by staff, the assessment did not reflect this impairment. The MDS Nurse initially did not recognize the contracture as an impairment, but later acknowledged the oversight. The DON and ADON stressed the importance of accurate assessments for proper care planning.
A facility failed to implement a comprehensive care plan for a resident with a colostomy, despite having a physician's order for ostomy care. The resident, diagnosed with systemic lupus erythematosus, did not have a care plan addressing her colostomy, which was confirmed through observations and staff interviews. The oversight was acknowledged by the MDS Nurse and other staff, highlighting the importance of care plans in ensuring consistent and appropriate care.
A facility failed to provide appropriate colostomy care for a resident due to the absence of comprehensive physician orders. The resident, with a history of systemic lupus erythematous, had a colostomy but lacked a care plan addressing her needs. The only order was to change the colostomy bag twice a week, with no instructions for routine emptying or stoma examination. Interviews with staff confirmed the absence of necessary orders, which could lead to missed care. The facility's policy requires all treatments to have corresponding orders, highlighting the deficiency.
A resident with dementia and on hospice care fell from her bed, suffering a hip fracture. Despite cries of pain and verbal indications of leg pain, the facility failed to promptly notify the physician and responsible party, delaying medical intervention. The resident was later hospitalized with multiple complications.
Failure to Secure Resident Medical Information on Nurse Cart
Penalty
Summary
The facility failed to ensure the confidentiality of residents' personal and medical records for six residents when LVN C left a piece of paper containing medical information on top of his nurse's cart in front of the nurses' station with the cart facing the hallway. The paper included information for Residents #9, #11, #12, #25, #36, and #40, including code status and other medical details such as a chest X-ray for Resident #11 and oral ABT for Resident #40. The report states that the information was visible to unauthorized individuals because it was not secured before the cart was left unattended. Resident #9 was a female with tachycardia and intracranial hemorrhage, and her records reflected that she was full code. Resident #11 was a female with upper respiratory disease and a left fibula fracture, had moderate cognitive impairment with a BIMS score of 11, and her records reflected DNR status. Resident #12 was a female with atrial fibrillation, was cognitively intact with a BIMS score of 13, and was full code. Resident #25 was a female with a left humerus fracture, was cognitively intact with a BIMS score of 15, and was full code. Resident #36 was a male with atrial fibrillation, was cognitively intact with a BIMS score of 14, and had DNR status. Resident #40 was a female with atrial fibrillation, was cognitively intact with a BIMS score of 15, and had DNR status. During interviews, LVN A stated the paper should have been turned upside down because exposed medical information would be a HIPAA violation, LVN C stated he left the cart while attending to someone and did not fully cover the paper, and the ADON, DON, and Administrator stated that resident medical information should not be left unattended and should be protected from unauthorized viewing.
Dirty Resident Room Bathrooms and Air Vents
Penalty
Summary
The facility failed to ensure residents had a safe, clean, comfortable, and homelike environment in 8 of 20 resident rooms observed for cleanliness, including Rooms #1 through #8. During observations, the bathroom floors in multiple rooms had grayish dirt stains, brownish stains, and thick black dirt stains around the toilet area and under the sink. One room also had dirt in the air conditioning vents. The observations showed that the bathroom floors in these rooms were not thoroughly cleaned and sanitized. During interview, a resident stated they had mopped the bathroom floor but had to scrub around the toilet area because it grossed them out. A housekeeper stated staff were trained to clean rooms daily, including bathrooms and air conditioning units, but he had tried to clean the stains without ever attempting to deep clean the floors. The housekeeping supervisor stated the bathroom floors needed to be scrubbed with a machine and that the concerns were fixable. The administrator stated he was informed of the concerns and agreed the condition of the rooms did not present a homelike environment. The facility policy stated housekeeping was intended to keep the facility clean and odor free while providing the safest environment possible.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for residents. During observation, interview, and record review, LVN C left Resident #3’s morning medications in a small plastic cup on the resident’s overbed table instead of administering them directly. Resident #3 had diagnoses including dementia, anxiety, and depression, and her care plan did not indicate that she could self-administer medications. The resident stated the nurse left the medications with her so she could take them after breakfast, and she said this was not the first time medications had been left with her. LVN C later stated he should not have left the medications with the resident and should have stayed until all medications were taken. The facility also failed to ensure Resident #15 was not self-administering eye drops without an assessment. Resident #15 had dementia and moderate cognitive impairment, and her care plan directed staff to administer medications as ordered. During observation, three vials were found on the resident’s side table, and the resident stated they were eye drops that she used every morning because her eyes were itchy and dry. She said she was putting them in her own eyes every morning. The record review showed no order for eye drops and no assessment documenting that the resident was competent to self-administer medications. In addition, LVN A was observed with a personal tumbler on top of the medication cart while passing medications, and she acknowledged it should not be there because it could cause cross contamination and clutter the cart. During medication cart inspection, three bottles of Resident #10’s medications were found expired in Nurse’s Cart #1, including gabapentin and carbidopa-levodopa with a use-by date of 12/10/2025. LVN B stated she did not notice the medications were expired and did not know who placed them in the cart. The DON and Administrator stated staff should not leave medications with residents, residents should not self-administer without assessment, personal beverages should not be on medication carts, and expired medications should not be inside the carts.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents, two LVNs, and two CNAs during observed care activities. The report states that these failures could place residents at risk of cross-contamination and development of infections. The deficiency involved glove use outside a resident room, missing gown use during care for a resident on enhanced barrier precautions, and contaminated gloves kept in staff pockets during incontinent care. For one resident, an LVN exited the room with a glove still on one hand while carrying a disposable cup to the nurse’s station and washing the cup at the sink. The LVN stated he should have disposed of the glove before leaving the room, even though he had not touched the resident, to prevent spread of infection. The resident’s record showed a diagnosis of depression, moderate cognitive impairment with a BIMS score of 11, and a care plan focused on monitoring signs and symptoms of depression. For another resident, who had urine retention, a BIMS score of 15, an indwelling catheter, and an IV order for Imipenem, an LVN connected the resident’s IV antibiotics and later emptied the catheter bag while wearing gloves but no gown. The resident had orders for enhanced barrier precautions, and a sign outside the room indicated PPE was required because of the central line and catheter. The LVN stated that a gown was required for residents on enhanced barrier precautions and acknowledged forgetting to wear one during both tasks. During incontinent care for a third resident, who was cognitively intact with a BIMS score of 13 and incontinent of bowel and bladder, two CNAs were observed using gloves kept inside their pockets when changing gloves during care. Both CNAs had gloves in their pockets while a box of gloves was available on the bedside table. One CNA stated she was not sure whether her pocket was clean, and the other said she kept gloves in her pockets for easy access. The ADON, DON, and Administrator all stated that gloves should be disposed of before leaving a resident’s room, gowns should be worn for residents on enhanced barrier precautions, and gloves should not be kept in pockets because they could become dirty.
Call lights left out of reach for three residents
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences when the call light system in the rooms of three residents was not positioned within reach. Resident #7, a female with ataxic gait, difficulty walking, and severe cognitive impairment with a BIMS score of 04, was observed in bed with her call light on the floor at the head of the bed. Her care plan identified her as at risk for falls and included keeping the call light within reach. When asked where it was, she said it was nowhere to be found. Resident #15, a female with muscle weakness, difficulty walking, and moderate cognitive impairment with a BIMS score of 10, was also observed in bed with her call light on the floor on her roommate’s side. Her care plan identified limited physical mobility and a goal of being free from complications including falls. When asked where her call light was, she shrugged her shoulders. Resident #27, a female with COPD and severe cognitive impairment with a BIMS score of 01, was observed in bed with her call light on the floor at the head of the bed. Her care plan identified her as high risk for falls and included keeping the call light within reach. During interviews, CNA F and LVN B stated call lights should be within reach so residents can call staff for assistance and that staff should make sure the call lights are with residents before leaving the room. The ADON and DON stated the call lights should always be with or within reach of residents and that staff were responsible for ensuring this. The facility policy also stated the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.
Failure to Care Plan BiPAP Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #37 that included measurable objectives and timeframes to meet her medical, nursing, and psychosocial needs identified in the comprehensive assessment. Record review showed the resident was a [AGE]-year-old female admitted on [DATE] with acute respiratory failure with hypoxia, and her Quarterly MDS assessment dated 12/02/25 reflected severe cognitive impairment and an active diagnosis of respiratory failure. Physician orders dated 01/07/26 directed BiPAP use at night per home settings at bedtime for sleep apnea, but the resident's Comprehensive Care Plan dated 11/17/25 did not include a plan of care for BiPAP use. During interview, the MDS nurse stated the resident should have been care planned for the BiPAP device and that it was the MDS nurse's responsibility to ensure it was included. The DON and ADON stated they thought there was a care plan for the BiPAP device and acknowledged that the resident's use of the device should have been care planned.
Bed Not Kept in Lowest Position for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure that Resident #36’s environment remained free from accident hazards when his bed was not kept in the lowest position possible while he was lying in it. Resident #36 was a [AGE]-year-old male admitted to the facility with diagnoses including muscle weakness and unsteadiness on feet. His quarterly MDS reflected a BIMS score of 00, indicating severe cognitive impairment, and his care plan identified him as a fall risk with recent falls on 12/29/25 with injury and 11/26/25 without injury. The care plan also included the intervention that his bed be kept in the lowest position possible. During observation, Resident #36 was seen lying in bed sleeping while the bed was not in the lowest position possible. An LVN confirmed the resident was a fall risk and stated the bed should be in the lowest position, then lowered it after the surveyor pointed out the condition. The LVN stated it was his and the CNA’s responsibility to lower the bed after the resident finished breakfast. A CNA later stated the resident’s bed was to be in the lowest position possible with fall mats on both sides of the bed. The DON and ADON were informed of the observation and stated the resident had a history of changing the height of his bed and that the bed should have been in the lowest position possible.
Failure to Verify G-Tube Placement and Maintain Complete Enteral Feeding Orders
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with feeding tubes. For Resident #13, who had dysphagia, severe cognitive impairment, and a g-tube, the care plan required tube feeding and checking for tube placement, and the physician order directed staff to check g-tube placement prior to medication administration every shift. During an observation, an LVN prepared crushed medications and water for administration through the g-tube, disconnected the tube from the formula, flushed the tube, and gave the medications without first checking tube placement. The LVN later stated she forgot to check placement before flushing the g-tube and acknowledged that placement should be checked to ensure the tube was not dislodged. For Resident #39, who had gastrostomy status, severe cognitive impairment, and a feeding tube, the care plan identified the peg tube as needing to remain patent throughout the facility stay. On the day of observation, an LVN administered medications through the g-tube by flushing with water before and after the medications and flushing between medications, but the physician order did not include orders to check residuals, check tube placement, or flush before, during, and after medication administration. When questioned, the LVN confirmed there were no such orders in the chart and stated there should be an order for everything done for the resident to ensure continuity of care. Interviews with the ADON and DON confirmed that g-tube placement should be checked before medication administration and that there should be orders for g-tube care, including flushing instructions. The ADON stated it was an oversight that the resident had been in the facility for almost two weeks without orders related to flushing, placement checks, and residual checks. The DON stated placement should be checked before flushing and medication administration to ensure the medications and fluid enter the stomach and not the lungs, and that staff should verify that g-tube orders are complete.
IV PICC Line Care Lacked Required Orders
Penalty
Summary
The facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders for one resident receiving IV antibiotics through a PICC line. Resident #8 was admitted with urine retention, was cognitively intact with a BIMS score of 15, and had a care plan addressing a UTI with an intervention to administer antibiotics as ordered. The physician order dated 01/06/2025 reflected Imipenem 1-gram IVPB every 8 hours for 7 days. During observation, LVN B washed her hands, donned gloves, prepared the antibiotic, connected it to the resident’s PICC line, and flushed the line before connecting the IV. In interview, LVN B stated the PICC line should be flushed before connecting the IV to ensure patency and said the dressing should be changed every seven days, but she found no orders for flushing or dressing changes. The ADON stated there should be an order for flushing the PICC line, when to change the dressing, and what to assess, including signs and symptoms of infection, and said the staff had already entered appropriate IV-related orders after the issue was identified. LVN G stated he entered the antibiotic order but did not enter orders to flush the IV every shift or before medication administration, or to change the dressing. The DON stated there should be orders to flush the PICC line, when to change the dressing, and what to assess, and the facility policy stated IV flushing is intended to maintain catheter patency and function, while medication and treatment orders must be recorded on the physician order sheet.
Respiratory Devices Left Unbagged
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #37 by not keeping the resident’s BiPAP mask and nebulizer machine properly stored in a bag when not in use. Resident #37 was a [AGE] year-old female admitted to the facility with acute respiratory failure with hypoxia and had a Quarterly MDS assessment dated 12/02/25 showing severe cognitive impairment and an active diagnosis of respiratory failure. Physician orders dated 01/07/26 included BiPAP at night per home settings for sleep apnea and Albuterol Sulfate inhalation solution every 4 hours for shortness of breath. During an observation on 01/06/26 at 11:05 AM, the BiPAP mask was seen sitting on top of a stand unbagged and the nebulizer machine was sitting on a nightstand unbagged. In an interview and observation at 11:07 AM, LVN A stated both items should be bagged to avoid bacteria getting on them and said it was the nurse’s responsibility to ensure they were bagged when not in use. The DON and ADON later stated they had been told the items were not bagged and agreed it was the nurse’s responsibility to ensure both devices were bagged when not in use to avoid the resident getting an infection. The facility policy on Oxygen Administration stated the purpose was to provide guidelines for safe oxygen administration and directed staff to review physician orders and the resident’s care plan for special needs.
Medications and Topical Products Left Accessible in Resident Rooms
Penalty
Summary
The facility failed to keep medications and topical biologicals stored in locked compartments and out of resident-accessible areas. During observation on 01/06/2026, Resident #2, a female with a diagnosis of breast neoplasm and severe cognitive impairment with a BIMS score of 7, was found in bed with containers of nystatin powder, antifungal powder, and zinc oxide sitting on top of her side table. The resident stated the medications on the table were hers. In an interview, an LVN stated the nystatin powder, antifungal powder, and zinc oxide should not have been inside the resident’s room and should have been kept in the nurses’ carts, with the nurses administering the nystatin and fungal powder and CNAs applying the zinc oxide. He said he did not know who left the items in the room and had not noticed them when giving morning medications. The resident’s care plan identified a risk for altered skin integrity related to fungal or yeast infections under the breasts, and the physician’s order included nystatin cream for skin irritation. On 01/07/2026, Resident #25, a cognitively intact female with a fractured left humerus and bowel and bladder incontinence, was observed with a tube of skin barrier on her overbed table. The resident said staff used it when changing her and she was unsure who left it there. An LVN removed the tube and stated it should not have been inside the room and belonged in the cart. The DON and ADON both stated that medicated creams and powders should not be stored in resident rooms and should be secured in the carts so residents could not access them.
Failure to Ensure Safe Medication Administration and Oversight
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease and moderate cognitive impairment was found to be self-administering a nasal spray medication without a physician's order or an assessment for self-administration. The resident kept the nasal spray on his side table and used it regularly without informing the nursing staff. There was no documentation in the resident's records of an order for the nasal spray, nor any assessment to determine the resident's competency to self-administer medications. During medication administration rounds, a nurse did not notice the nasal spray in the resident's room and was unaware that the resident was self-administering it. The nurse later acknowledged that medications should not be kept in residents' rooms and that she was unsure if the resident was permitted to self-administer any medication. The Director of Nursing confirmed that medications should be administered by nurses and that a physician's order is required. The facility's policies also require that all medications be administered by licensed personnel and only upon written physician orders. Interviews with staff and the administrator revealed that there was no process in place to ensure that residents were not keeping medications at bedside or self-administering without proper assessment and orders. The administrator stated that residents should not self-administer medications unless assessed as competent, and that staff are expected to check for medications in residents' rooms. The facility's failure to follow these procedures led to the resident self-administering a medication without oversight.
Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored in locked compartments or otherwise secured, as required by professional standards. During observations, surveyors found that a nasal spray belonging to a male resident with moderate cognitive impairment and chronic obstructive pulmonary disease was left on the resident's side table in his room. There was no physician's order for the nasal spray, no assessment for self-administration, and no documentation indicating the resident was competent to manage his own medications. The nasal spray was accessible to the resident and not secured as required. Additionally, a female resident with severe cognitive impairment and protein-calorie malnutrition was observed with a tube of zinc oxide left on her side table. The resident was unable to communicate clearly, and staff assigned to her care did not notice the medication was left at bedside. The physician's order indicated the barrier cream was to be applied as needed, but it was not secured after use. Similarly, a male resident with moderate cognitive impairment and incontinence was found with a tube of zinc oxide on his side table. The staff member responsible for his care could not recall if she had put the cream away after use, and the medication was left accessible in the resident's room. Interviews with staff, including CNAs, an LVN, the DON, and the Administrator, confirmed that medications such as nasal sprays and zinc oxide should not be left in resident rooms and should be stored in locked carts or otherwise secured. The facility's policy also required medications to be stored in a locked medication room or secured after administration. The failure to secure these medications resulted in them being left in plain view and accessible to residents, contrary to facility policy and professional standards.
Failure to Ensure Current Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received such care in accordance with professional standards, the comprehensive care plan, and the resident's goals and preferences. The resident, who had diagnoses including acute respiratory failure, pneumonia, thrombocytopenia, and chronic atrial fibrillation, was admitted with a need for supplemental oxygen. The baseline care plan indicated the resident was confused, removed the nasal cannula, and required frequent redirection for oxygen therapy. However, the facility did not have a current physician's order for oxygen administration during the resident's stay. The only available order was from a previous admission, and staff administered oxygen based on this outdated order. Interviews with nursing staff and facility leadership revealed that the outdated order was mistaken for a current one due to similar admission dates, and the discrepancy was not identified during the admission or order transcription process. The Director of Nursing and other staff acknowledged the importance of verifying and following current physician orders, but the oversight resulted in the resident receiving oxygen therapy without a valid, current order. The facility's policy required medications and treatments to be administered as prescribed, but this was not followed in this instance.
Failure to Provide Scheduled Bed Baths for a Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for a resident who required total assistance due to conditions such as Parkinson's disease and bed confinement. Specifically, the facility did not ensure that the resident received scheduled bed baths from October 1, 2024, to October 16, 2024. The resident, who had a moderate cognitive impairment, expressed dissatisfaction with not receiving her scheduled bed baths, which were supposed to occur on Mondays, Wednesdays, and Fridays. She preferred bed baths over mechanical lifts and reported feeling unclean due to the missed baths. Interviews with facility staff, including an LVN, ADON, and CNA, revealed inconsistencies in the documentation and provision of care. The LVN and ADON believed the resident had received her scheduled bed baths, but acknowledged the lack of documentation. The CNA admitted to forgetting to complete the shower forms and was unsure of the exact dates when the resident received her bed baths. The facility's policy required documentation of all showers or refusals, but this was not adhered to, leading to a risk of skin breakdown and dignity concerns for the resident.
Failure to Obtain Physician Orders for Scoop Mattresses
Penalty
Summary
The facility failed to ensure that the environment for two residents was free from accident hazards by not obtaining physician orders or assessments for the use of scoop mattresses. Resident #12, a cognitively intact female with a history of falling, and Resident #30, a female with moderately impaired cognition and a moderate risk of falling, were both observed using scoop mattresses without the necessary physician orders or assessments. The scoop mattresses had raised sides, which could pose a risk if the residents attempted to get out of bed. Interviews with facility staff, including an LVN, the ADON, and the DON, revealed a misunderstanding regarding the requirement for physician orders and assessments for therapeutic mattresses. The staff believed that since the mattresses were considered therapeutic, they did not require physician orders or assessments. However, the absence of these assessments could result in the residents injuring themselves, as confirmed by the staff. The facility's policy on medication and treatment orders, dated July 2016, requires that orders for treatments be consistent with safe and effective order writing, which was not adhered to in this case.
Improper Storage and Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in the storage and maintenance of respiratory equipment. Resident #2, diagnosed with chronic obstructive pulmonary disease, was observed with an empty humidifier bottle on his oxygen concentrator and a nebulizer breathing mask improperly stored in a drawer without a protective bag. The resident was unaware of these issues, and the attending LVN admitted to neglecting to bag the mask and refill the humidifier, acknowledging the risk of cross-contamination and respiratory infection. Resident #5, who was receiving hospice care for encephalopathy, had a yankauer suction tip improperly stored on a table rather than in a protective bag. The LVN responsible for the resident's care admitted to not noticing the improperly stored yankauer and acknowledged that it should have been bagged to prevent contamination. The yankauer was discarded as it was considered dirty due to improper storage. Resident #15, diagnosed with acute respiratory failure with hypoxia, had a nasal cannula coiled on her bed instead of being stored in a sealed container. The LVN responsible for her care was unsure why the nasal cannula was not properly stored and recognized the risk of infection due to improper storage. The facility's policies on oxygen administration and infection prevention were not followed, leading to potential risks for the residents involved.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications for four residents, leading to potential risks of accidental ingestion or misuse. Observations revealed that medications such as zinc oxide, Miralax, eye drops, and nasal spray were left on top of residents' side tables or TV stands, making them accessible to residents and visitors. This was particularly concerning given the cognitive impairments of some residents, such as Resident #1, who had a severe impairment in cognition due to metabolic encephalopathy. Resident #13, diagnosed with glomerular disease in systemic lupus erythematous, had stoma powder left on her side table, which was not included in her care plan for colostomy care. Similarly, Resident #14, with ulcerative proctitis and altered mental status, had zinc oxide left on her side table. Resident #35, who was cognitively intact but incontinent, had zinc oxide left on her TV stand, visible from the hallway. These medications were not stored in locked compartments as required, posing a risk of accidental ingestion or misuse. Interviews with staff, including LVNs and CNAs, confirmed that medications should not be left accessible and should be stored securely. The DON and ADON acknowledged the risk of adverse reactions if medications were ingested and emphasized the need for proper storage. The facility's policy on medication labeling and storage mandates that all medications be stored in locked compartments, which was not adhered to in these instances.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its skilled nursing kitchen, as observed during a survey. Several deficiencies were noted, including improper sealing of foods in the refrigerator, inadequate cleaning of the ice machine, and failure to label and date food stored in the refrigerator and freezer. Specifically, the ice machine had rust on the inside door hinges and dark stains with mineral deposits on the inside walls. Various food items, such as a stainless-steel container of sauce, cut-up melons, gluten-free bagels, onion rings, frozen carrots, and mixed vegetables, were found without stored dates. Additionally, a large box of frozen catfish was not sealed properly, exposing it to airborne contaminants. During lunch service, it was observed that the cleaning/sanitizing bucket under the serving table was empty, containing only a dried-up cloth, which compromised the cleanliness of the serving area. Interviews with the Dietary Manager and the Administrator revealed that the cooks were responsible for labeling and dating foods, and everyone was expected to ensure foods were covered and sealed. The Dietary Manager acknowledged the condition of the ice machine and the oversight regarding the cleaning bucket. Both the Dietary Manager and the Administrator recognized that these issues could lead to food contamination, as per the facility's policies and FDA guidelines.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of LVN A and CNA C, which could lead to cross-contamination and infection. LVN A did not change her gloves or perform hand hygiene after touching a trash can while administering ointment to a resident's nose. This oversight occurred despite LVN A acknowledging that the trash can was dirty and her actions could cause cross-contamination. CNA C also failed to adhere to proper infection control practices while providing incontinent care to another resident. She did not sanitize her hands after removing gloves and before putting on new ones, nor did she change gloves before handling a new brief after cleaning the resident. These lapses in hand hygiene and glove use were acknowledged by CNA C, who admitted that her actions could result in cross-contamination and infection. Additionally, LVN A did not perform hand hygiene when changing gloves during wound care for the same resident. This was attributed to being in a hurry, but LVN A recognized the importance of hand hygiene in preventing cross-contamination. The facility's policies on hand hygiene and perineal care emphasize the necessity of handwashing and glove changes to prevent infections, which were not followed in these instances.
Inaccurate Assessment of Resident's Impairment
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the status of a resident, specifically regarding an impairment in the resident's right upper extremity. The resident, an elderly female, was admitted with a diagnosis of unspecified joint contracture, which affects the muscles and joints, causing them to stiffen. Despite this, the resident's Comprehensive MDS Assessment did not indicate any impairment in the upper extremity, contradicting other documentation and observations. Observations and interviews revealed that the resident had a contracture in her right hand, which was consistently noted by various staff members, including a Licensed Vocational Nurse (LVN), a Certified Nursing Assistant (CNA), and a Physical Therapist (PT). The LVN observed the contracture while administering medication, and both the CNA and PT confirmed the presence of the contracture and its impact on the resident's functionality. The MDS Nurse initially did not consider the contracture as an impairment but later acknowledged it should have been recorded as such. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both emphasized the importance of accurate assessments to ensure appropriate care. They noted that the MDS should reflect the actual functionality of residents, and any impairments should be documented to avoid confusion in care provision. The facility's policy on comprehensive assessments also highlighted the need for accurate and standardized assessments to develop person-centered care plans.
Failure to Implement Comprehensive Care Plan for Resident with Colostomy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a colostomy, which was identified during a survey. The resident, a female with systemic lupus erythematosus, was admitted with a colostomy but did not have a care plan addressing this specific need. The absence of a care plan was confirmed through observations, interviews, and record reviews, indicating a lapse in ensuring the resident's medical, nursing, and psychosocial needs were met. During the survey, it was observed that the resident's colostomy care was not documented in her care plan, despite having a physician's order for changing the ostomy bag twice weekly and as needed. Interviews with the resident and staff, including an LVN and the MDS Nurse, revealed that the care plan for the colostomy was overlooked during the interdisciplinary team meeting. The LVN acknowledged the importance of a care plan to ensure consistent care, while the MDS Nurse admitted the oversight and emphasized the necessity of a care plan to guide staff in providing appropriate care. Further interviews with the DON, ADON, and the Administrator highlighted the expectation for all residents to have comprehensive care plans. They acknowledged the importance of care plans in coordinating care and ensuring that all staff members are informed about the specific needs and interventions required for each resident. The lack of a care plan for the resident's colostomy was recognized as a deficiency that could lead to missed care and services.
Lack of Physician Orders for Colostomy Care
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident, as evidenced by the lack of physician orders for comprehensive colostomy care. The resident, a female with a history of glomerular disease in systemic lupus erythematous, was admitted with a colostomy but did not have a care plan addressing her colostomy needs. The only existing order was to change the colostomy bag twice a week and as needed, with no orders for routine emptying, stoma examination, or skin assessment. This oversight was confirmed through interviews with the resident, a Licensed Vocational Nurse (LVN), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), all of whom acknowledged the absence of necessary orders. The deficiency was further highlighted by the facility's policy, which mandates that all treatments and medications must have corresponding orders recorded in the resident's chart. The DON and ADON admitted that the lack of orders could lead to missed care, as new staff might not be aware of the necessary treatments and assessments. The facility's failure to ensure proper documentation and orders for colostomy care placed the resident at risk of inadequate care, as there was no structured guideline for the staff to follow.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify a resident's physician and responsible party following an accident and significant change in the resident's condition. The resident, who had a history of dementia and was on hospice care, fell from her bed and suffered a fracture of the right femoral neck. Despite exhibiting cries of pain and verbally indicating leg pain, the resident did not receive an X-ray until several days later, after a family member sent a video of her in distress to the hospice provider. This delay in medical intervention resulted in the resident being admitted to the hospital with a hip fracture, acute kidney injury, altered mental status, hypernatremia, hypoxic respiratory failure, and sepsis. The incident report completed by an RN noted that the resident was found on the floor beside her bed, which was in the lowest position. Initial assessments by facility staff did not reveal any visible injuries, and the resident was reported to be moving all extremities. However, subsequent observations by various staff members and a video recording by a family member indicated that the resident was in significant pain, particularly in her leg. Despite these signs, the facility staff failed to notify the physician or the responsible party about the resident's cries of pain and change in condition over the weekend. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition. Several staff members, including LVNs and CNAs, noted the resident's pain and changes in behavior, but these observations were not adequately communicated to the physician or hospice provider. The facility's policy required notification of the physician and responsible party in the event of a significant change in condition, but this protocol was not followed, leading to a delay in the resident receiving appropriate medical care.
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.
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What surveyors actually found near you
We read the 952 citations issued within 25 miles in the last 12 months — including the 24 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 Highland Village
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hollymead | 2.5 mi | ★★★★★ | 2 | 0 |
| Cross Timbers Rehabilitation And Healthcare Center | 2.5 mi | ★★★★★ | 17 | 1 |
| Lake Village Nursing And Rehabilitation Center | 3.5 mi | ★★★★★ | 14 | 0 |
| Denton Rehabilitation And Nursing Center | 4.8 mi | ★★★★★ | 4 | 0 |
| Corinth Rehabilitation Suites On The Parkway | 5.3 mi | ★★★★★ | 18 | 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.