Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Renaissance Park Multi Care Center during CMS and state inspections, most recent first.
Kitchen Food Storage and Thawing Deficiencies: Surveyors observed a dented can stored with other cans, opened dry goods left improperly sealed or missing discard dates, and frozen meat thawing in standing water with no running water. The DM said dented cans were being set aside for credit, while the Corporate Dietitian and DM acknowledged the labeling and thawing issues.
A staff member stood while feeding a resident with dementia, COPD, anxiety, and severe cognitive impairment during a meal, and continued for several minutes until another staff member told him to sit. Interviews with RN, RA, LVN, and DON confirmed staff should be seated while assisting residents with meals and acknowledged the impact on resident dignity.
A resident with hemiplegia after cerebral infarction, kidney transplant status, and cancer had a BIMS of 15, but the EHR did not contain a code status in the admission record, physician orders, care plan, or progress notes. LVN and admin interviews confirmed the code status should have been entered on admission and reviewed shortly after, and the facility policy stated residents receive full resuscitative measures unless a DNR is written in the record and identified in the advance directive.
Unlocked Treatment Cart Left Unattended: Treatment Cart A was observed unlocked and unattended near the nurse station with wound care biologicals and scissors inside while a nurse and a resident were nearby. The Administrator later locked the cart and stated staff had forgotten to do so. The Wound Nurse, ADON, and DON all stated treatment and medication carts should remain locked when not in use, and the facility policy required medications and biologicals to be stored in a locked cart or cabinet.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with a primary diagnosis of sickle cell pain crisis and a complex medical history did not have a care plan addressing her condition, including no interventions or goals for sickle cell disease management. Staff interviews revealed a lack of awareness and training regarding the disease, and there was no evidence of regular monitoring of hemoglobin levels. The deficiency became apparent when the resident was hospitalized for heart palpitations and critically low hemoglobin, highlighting the facility's failure to follow its own care planning policies.
A resident with burn injuries did not receive Aquaphor ointment to both thighs as ordered by her physician, with staff failing to consistently apply the treatment and follow wound care instructions. The resident reported not receiving the prescribed care for two weeks, and staff interviews revealed confusion and lapses in treatment administration and order transcription.
Two residents were provided bed rails or grab bars without proper assessment, documentation, or informed consent. For one resident with moderate cognitive impairment and a history of falls, grab bars were installed after a fall, but there was no physician's order, side rail assessment, or care plan addressing their use. Another resident with severe cognitive impairment and mobility needs had grab bars in use despite no documented assessment or consent. Staff interviews and record reviews confirmed that required procedures for bed rail use, as outlined in facility policy, were not followed.
The facility did not accurately transcribe and implement physician orders for two residents with complex medical needs. One resident's chart omitted several admitting diagnoses and lacked orders for necessary lab monitoring, while another resident's wound care orders from an outside specialist were not fully transcribed, resulting in incomplete care. Staff interviews confirmed gaps in awareness and documentation, and facility policy for order entry was not followed.
A resident's next-of-kin was unable to obtain the resident's medical records despite multiple formal requests and submission of required documentation. The request was delayed for over two months due to miscommunication and lack of follow-through between the facility and its legal department, resulting in non-compliance with regulations requiring timely release of records.
A resident with a history of serious medical conditions developed a stage 3 pressure ulcer due to the facility's failure to implement preventive measures and conduct thorough skin assessments. Despite having a care plan, the resident's refusals of care were not documented, and assessments were incomplete, leading to hospitalization and a diagnosis of sepsis. The facility's inadequate documentation and reliance on the resident's self-reports contributed to the oversight.
The facility did not ensure the Dietary Manager wore a beard restraint in the kitchen, contrary to professional standards for food service safety. The Dietary Manager was observed without a beard restraint, claiming it was only required when cooking. The facility's policy requires all dietary staff to wear hair restraints to prevent food contamination. The Administrator confirmed the expectation for compliance with the uniform policy.
A facility failed to ensure safe and sanitary storage of food in a resident's personal refrigerator. The resident's fridge contained a buildup of ice with grapes and a paper towel, and the resident reported it was not cleaned by staff. Interviews revealed confusion over responsibilities for fridge maintenance, contrary to facility policy requiring regular checks and discarding of expired or contaminated food.
A resident receiving enteral nutrition did not receive appropriate care when RN R failed to check g-tube placement and used a syringe and plunger instead of the gravity method to administer medication. The resident, with a history of multiple medical conditions, had specific care plan instructions for tube feeding that were not followed. The DON confirmed the correct method was not used, as per facility procedures.
The facility failed to maintain infection control measures, as a nurse did not change gloves or perform hand hygiene during wound care for a resident with a heel injury, and a visitor did not follow PPE protocols during a COVID-19 outbreak. Despite training, these lapses were acknowledged by the ADON and DON, highlighting risks of infection transmission.
A medication error occurred in an LTC facility when a medication aide mistakenly administered medications intended for one resident to another, including a narcotic. The error was discovered when the second resident refused the medications, leading to the realization that the first resident had received the wrong medications. The affected resident required Narcan to reverse the effects of the opioid, highlighting a lapse in verifying resident identity and medication rights.
A medication error occurred when a resident received another's medications, including a narcotic, leading to lethargy and confusion. Narcan was administered, but the facility failed to report the incident to authorities, as they did not consider it reportable due to no perceived harm.
A contracted LVN failed to follow proper infection control procedures during wound care for a resident with severe cognitive impairment and multiple medical conditions. The LVN did not change gloves or perform hand hygiene, reused gauze, and placed soiled items on the bed, risking cross-contamination. Despite being offered assistance, the LVN conducted the procedure alone, causing discomfort to the resident and concern from the family. The facility's DON and ADM acknowledged the breach in infection control policy.
The facility failed to maintain a safe environment in the dining room and employee restroom. Observations revealed drooping, sagging, and bubbled paint on the dining room walls and stained ceiling tiles due to a leak. An unidentified black substance was found in the dietary department's employee restroom, which was reportedly treated but still present. The Maintenance Director acknowledged the issues, citing a leaking air conditioner as the cause, and noted that the damage existed before his employment.
A long-term care facility failed to maintain an effective pest control program, resulting in a persistent issue with gnats and horseflies affecting multiple residents and areas. Despite regular visits from a pest control company, residents reported being bitten by horseflies, and staff confirmed the ongoing problem. The facility lacked a dedicated Maintenance Director, relying on temporary measures to manage the situation, while the Administrator suspected a drain issue and leftover food as contributing factors.
The facility failed to ensure the Activities Director (AD) was a qualified professional, as the AD was not licensed or registered by the state. The AD had been working for two weeks and was in the process of completing a certification course. Despite conducting activities without resident complaints, the facility's job description required the AD to be licensed or registered. This oversight could affect the quality of life for residents due to a lack of individualized activities.
A resident with severe cognitive impairment was sent to the ER for a clavicle fracture, but the LTC facility failed to document the transfer and communicate with the hospital for discharge paperwork and new care orders. Communication breakdowns among staff, including LVNs and the liaison, led to the resident returning without necessary documentation, putting the resident at risk.
A CNA in an LTC facility failed to perform proper hand hygiene before providing ADL care to a resident with metabolic encephalopathy. The CNA entered the resident's room wearing gloves, touched various surfaces, and repositioned the resident without sanitizing hands, contrary to infection control protocols. Interviews revealed a lack of understanding of infection control practices, with the CNA placing gloves in her pocket, believing they remained clean. Facility staff confirmed the risk of cross-contamination and emphasized the need for proper hand hygiene and glove use.
Kitchen Food Storage and Thawing Deficiencies
Penalty
Summary
Food was not stored and handled in accordance with professional standards in the kitchen during survey observations. In the dry storage room, surveyors observed a dented can of fresh vegetables stored on the rack with other cans, a previously opened cake mix in a storage bag exposed to air, and a package of opened powdered sugar with only one date, 03/17/2026, written on the bag. In the dry storage area, a package of opened pasta noodles was also observed in a storage bag with only one date, 04/17/2026, written on the bag. In the hand dish washing area, surveyors observed a package of frozen meat sitting in a pan of water in a sink with no water running over it. During interview, the DM stated there was an area for dented cans and pointed to a cart containing more than 15 dented cans, explaining the vendor had brought dented cans and that he had recently removed dented cans to get credit for them. He stated he was unaware of the single dented can left on the supply cart and said someone forgot to add the discard date on the cake mix. The Corporate Dietitian stated she was unaware the pasta and powdered sugar labels did not list a discard date, and the DM stated the water had been running on the frozen meat before he left. The Administrator stated she was surprised with the finding in the kitchen.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to treat Resident #42 with respect and dignity during mealtime when a staff member stood while feeding her on 04/28/2026. Resident #42 was a female resident with diagnoses including dementia, COPD, and anxiety, and her quarterly MDS dated 02/18/20263 showed a BIMs score of 4, indicating severe cognitive impairment. During observation at 12:20 p.m. in the 2nd floor dining room, Resident #42 was seated in a manual wheelchair while a staff member assisted her with dining and stood while feeding her for about four to five minutes until another staff member noticed and told him to sit down. The staff member then gave up his seat and obtained another seat for himself. During interviews, RN B stated he knew he should have been seated while assisting residents with meals and that standing while feeding them may make them feel awkward or upset. RA D stated staff should always be sitting while feeding residents and that standing over them while they ate would not make them feel comfortable. LVN B stated she always sat while assisting with feeding because no one wanted anyone standing over them while they ate, and that it could be frustrating and cause residents to lash out. The DON stated he expected staff to know how to provide proper care and acknowledged that the situation could affect resident dignity.
Missing Code Status Documentation for Resident Advance Directive
Penalty
Summary
The facility failed to ensure Resident #45’s right to formulate an advance directive was honored because the resident’s code status was not communicated and was not correctly documented in the EHR. Resident #45 was a [AGE] year-old female admitted for a Medicare Part A stay, with diagnoses including hemiplegia following cerebral infarction affecting the left nondominant side, kidney transplant status, and cancer. Her MDS reflected a BIMS score of 15, indicating she was cognitively intact. Record review showed no code status in the admission record, physician orders, baseline care plan, or progress notes. The facility’s documentation reviewed for the resident did not identify whether she was full code or DNR. During interview, LVN A stated every resident should have a code status in the EHR and that the missing code status was not documented where it should have been. LVN A stated the admitting nurse was responsible for ensuring the code status was entered. The ADON stated the code status should be entered upon admission with the resident’s orders and reviewed the following day to ensure nothing was missed. The DON stated code status should be input by the admission nurse and that if nurses could not find it, they should notify the DON and/or physician and speak with the resident to determine the correct status. The facility policy stated residents receive full resuscitative measures unless a DNR is written in the medical record and identified in the advance directive, and that DNR status is reviewed with the resident and/or family and receiving physician within 72 hours of admission.
Unlocked Treatment Cart Left Unattended
Penalty
Summary
The facility failed to keep Treatment Cart A locked while it was unattended on the downstairs hall. During an observation at 9:00 a.m., the cart was found near the downstairs hall nurse station unlocked and unattended, with one nurse sitting at the nurse station and one resident sitting across from the station. Inside the cart were wound care biologicals and a pair of scissors. At 9:02 a.m., the Administrator walked by and locked the cart. During interviews, the Administrator stated she initially thought Treatment Cart A was empty and then said staff must have forgotten to lock it. The Wound Nurse stated all carts should be kept locked when unattended and that all nurses had keys to access Treatment Cart A. The ADON and DON both stated they expected medication and treatment carts to remain locked when not in use, and the DON stated nurses were responsible for keeping carts locked. The facility policy reviewed stated that medications and biologicals, including treatment items, must be securely stored in a locked cabinet/cart or locked medication room inaccessible to residents and visitors.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Develop and Implement Comprehensive Care Plan for Sickle Cell Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a primary diagnosis of sickle cell pain crisis. Despite the resident's complex medical history, including sickle cell/HB-C disease with crisis, alcoholic cirrhosis, aseptic necrosis of bone, multiple fractures, anemia, and end stage renal disease, the baseline care plan did not include any focus, interventions, or goals related to sickle cell disease or its management. The resident's medical records indicated a history of low hemoglobin levels and multiple blood transfusions, yet there was no evidence of ongoing assessment or care planning for these issues. Interviews with facility staff revealed a lack of awareness and training regarding the specific needs and symptoms associated with sickle cell disease. Nursing staff were not aware of any orders for regular monitoring of the resident's hemoglobin levels, and there was confusion about the process for obtaining and reviewing lab results. The facility's Regional Compliance Nurse and ADON acknowledged the importance of monitoring lab values and care planning for serious conditions but confirmed that these steps were not taken for this resident. The deficiency was further highlighted when the resident experienced heart palpitations and was transported to the emergency room by family, where a critically low hemoglobin level was discovered, resulting in hospital admission. The facility's own policies required individualized care plans based on comprehensive assessments, but these were not followed, placing the resident at risk for not receiving proper care and services due to inaccurate or incomplete care planning.
Failure to Provide Burn Treatment as Ordered
Penalty
Summary
A deficiency was identified when a resident with significant burn injuries to both thighs did not receive treatment as ordered by her physician. The resident's care plan included interventions for impaired skin integrity, specifically requiring the application of Aquaphor ointment to both thighs twice daily to prevent dryness and promote healing. Physician instructions also included daily gentle washing of the lower extremities and moisturizing the wounds twice a day. However, review of the Treatment Administration Record (TAR) and interviews revealed inconsistencies and lapses in the administration of the prescribed treatment. During observation and interviews, the resident reported that staff had not been applying the Aquaphor treatment as ordered for two weeks, resulting in dry, itchy, and peeling skin on her thighs. The resident showed the surveyor her burns, which appeared dry and lacked the expected moisturized appearance. Staff interviews revealed confusion regarding the application process, with one RN admitting to being distracted and not completing the treatment, and the ADON stating she applied the ointment only after being asked by another nurse. The resident also noted that the area was not washed prior to application, contrary to the specialist's instructions. Further interviews with facility staff, including the Regional Compliance Nurse and the Administrator, confirmed that there were gaps in the transcription and monitoring of physician orders, leading to the resident not receiving care as prescribed. The facility's policy on documentation of new or changed physician orders did not address the need to follow physician orders, contributing to the failure to provide appropriate treatment and care according to the resident's needs and medical directives.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess, document, and obtain informed consent for the use of bed rails and grab bars for two residents. For one resident with a history of stroke, dysphagia, and moderate cognitive impairment, grab bars were installed after a fall at the request of the resident and family. However, there was no evidence of a physician's order, a completed side rail assessment, informed consent, or a care plan addressing the use of bed rails or grab bars for mobility. The resident's care plan only addressed fall risk with interventions such as floor mats and a high back wheelchair, but did not mention bed rails or grab bars. For another resident with severe cognitive impairment, pressure ulcer, and significant mobility needs, grab bars were observed in use despite the comprehensive assessment indicating no bed rail use. While there was a physician's order for quarter side rails to enable bed mobility, there was no documented side rail assessment, informed consent, or care plan addressing the use of bed rails or grab bars for mobility. The care plan focused on combative behavior and risk of injury during care, but did not include interventions related to bed rails or grab bars. Interviews with nursing staff and administration revealed a lack of awareness and inconsistent practices regarding the assessment, documentation, and consent process for bed rail use. The facility's policy required assessment, physician's order, informed consent, and care plan development for bed rail use, but these steps were not followed for the two residents. The absence of these required processes was confirmed through record review, staff interviews, and direct observation.
Failure to Accurately Transcribe and Implement Physician Orders for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents, specifically in the transcription of admitting diagnoses and physician orders. For one resident with a complex medical history including sickle cell disease with crisis, alcoholic cirrhosis, multiple fractures, anemia, and end stage renal disease, the face sheet and order summary did not accurately reflect all admitting diagnoses. The paper chart listed only sickle cell pain crisis as the admitting diagnosis, omitting other significant conditions. Additionally, there were no physician orders for monitoring hemoglobin levels or routine lab work, despite the resident's high risk for complications due to her medical conditions. Interviews with nursing staff revealed a lack of awareness regarding orders for lab monitoring, and the baseline care plan did not address the resident's sickle cell disease with crisis. For another resident admitted with extensive third-degree burns and other diagnoses, the facility failed to transcribe and implement wound care orders as provided by an outpatient surgical specialist. The specialist's instructions included daily bathing and gentle washing of the lower extremities before moisturizing, but the facility's orders only specified the application of Aquaphor ointment to the thighs twice daily, omitting the washing step. Interviews with the resident and staff confirmed that the skin was not washed prior to ointment application, and staff were unaware of the full wound care instructions. The care plan referenced treatment as ordered but did not specify the complete wound care regimen. Facility policy required that new or changed physician orders be entered promptly and completely, including all directions and administration details. However, interviews with the ADON, Regional Compliance Nurse, and ADM revealed that orders from outside providers were not always reviewed or transcribed accurately into the residents' charts. This led to discrepancies between the care provided and the prescribed treatment, as well as incomplete documentation of residents' medical conditions and care needs.
Failure to Timely Provide Medical Records to Next-of-Kin After Resident Death
Penalty
Summary
The facility failed to provide a resident's next-of-kin with copies of the resident's medical records after a formal request was submitted. The resident, a male who was his own responsible party, was found unresponsive and later pronounced dead. Following his death, the next-of-kin, listed as Emergency Contact #2, attempted to obtain the resident's medical records. The next-of-kin initially tried to have the person with Medical and Durable Power of Attorney request the records, but was informed that the power of attorney was no longer valid after the resident's death. The next-of-kin then submitted the request directly, providing documentation such as a death certificate, driver's license, and birth certificate to establish kinship. Despite multiple written and email requests, including submission of an Authorization for Release of Medical Information and supporting documents, the next-of-kin did not receive the records for over two months. The facility's Director of Medical Records (DMR) stated that requests are typically processed within 30 days and that she normally ensures timely completion. However, in this case, the request was forwarded to the facility's legal department, and due to a change in legal personnel, the request was not fulfilled. The DMR and Administrator later discovered that the attorney handling the request was no longer with the company, and the new attorney was unaware of the pending request. Throughout the process, the next-of-kin repeatedly contacted the facility for updates and clarification, referencing regulatory requirements for timely release of records. The facility's policy and federal regulations require that such requests be fulfilled within 30 days, and the DMR acknowledged that the next-of-kin, as the resident's personal representative, was entitled to the records. The failure to provide the records in a timely manner was attributed to a lack of communication and follow-through between the facility and its legal department.
Failure to Prevent and Identify Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development of a stage 3 pressure injury. The resident, who had a history of malignant neoplasm of the colon, systemic lupus erythematosus, Parkinson's disease, and neuralgia, was admitted to the facility with intact cognition and was at risk for pressure ulcers. Despite having a care plan that included interventions such as pressure-reducing devices and weekly skin checks, the facility did not implement these measures effectively. The resident's skin assessments were incomplete, and refusals of skin assessments were not documented, resulting in the failure to identify a stage 3 pressure ulcer on the resident's sacrum, which was later discovered at the hospital. The resident was transferred to the hospital after being found lethargic and requiring extensive assistance, where she was diagnosed with sepsis due to a methicillin-resistant Staphylococcus aureus infection, acute renal failure, and a stage 3 pressure injury. Interviews with facility staff revealed that the resident was independent and often refused assistance, which contributed to the lack of thorough skin assessments. The facility's documentation practices were inadequate, as the resident's refusals were not properly recorded, and skin assessments were based on the resident's self-reports rather than actual examinations. The facility's failure to conduct thorough skin assessments and document refusals led to the resident's condition worsening, resulting in hospitalization and subsequent death. The Director of Nursing acknowledged the importance of skin assessments and the risks associated with neglecting them, but the facility's practices did not align with these standards. The lack of consistent and accurate documentation, combined with the resident's modesty and refusal of care, contributed to the oversight and eventual identification of the pressure ulcer at the hospital.
Removal Plan
- Identified resident no longer resides in the facility
- Education will be completed regarding conducting thorough skin assessments, Braden assessments, updating care plans, documenting of refusal of resident care, and implementing resident specific interventions related to pressure ulcers. This education will be provided to all licensed nursing staff by the Director of Nurses or Regional Nurse Consultant.
- Infection Prevention Nurse, Director of Nurses, Staff nurse and Regional Nurse conducted a skin sweep on all residents in the facility
- All residents that reside in the facility will have a completed skin data collection tool, Braden and updated care plan by the Infection Nurse, Director of Nurse, Staff nurse or Regional Nurse
- The DON and IP nurse and Regional Nurse began immediate in servicing of current licensed nursing staff on the following: Completion of a thorough skin assessment upon admission within 24 hours by charge nurse weekly
- Completion of Braden assessment upon admission and then weekly X4 weeks and then monthly.
- Completion of care plan upon admission and updated on any significant change
- Completion of implementation of interventions upon identifying any wound areas
- How to Document refusal of skin assessments by residents, notifying DON of any skin assessment refusals immediately
- Current licensed staff will not be allowed to work until completion of education as noted above
- Director of Nurses, Infection Nurse and Regional Nurse will complete the following until substantial compliance has been achieved and maintained: Review and documented audits for completion of weekly skin assessments for residents
- Review and documented audits for completion of refusal skin sheets
- Review and documented audits for completion of Braden assessments audits
- Review and documented audits for care plans for residents with pressure ulcers identified
- Review and documented audits for interventions for residents with pressure ulcers identified
- The facility will continue to provide on-going in-services as noted above to newly hired licensed nursing staff, annually and as needed.
- All components of this plan of correction will be submitted to the facility QAPI meeting and additional recommendations will be made until substantial compliance has been achieved.
Dietary Manager Fails to Wear Beard Restraint in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that the Dietary Manager wore a beard restraint while in the kitchen. During an observation and interview, it was noted that the Dietary Manager was not wearing a beard restraint as he walked through the kitchen. He justified his action by stating that a beard restraint was only necessary when cooking food, although he acknowledged that hair could contaminate food if restraints were not worn. The facility's policy, as reviewed, mandates that all dietary staff, including those with facial hair, must wear hair restraints to prevent hair from contacting food. The Administrator confirmed that the expectation was for all employees to follow the uniform policy, which includes wearing hair restraints to avoid food contamination.
Failure to Maintain Safe and Sanitary Storage in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of food items in a resident's personal refrigerator. Specifically, Resident #23's refrigerator was not cleaned, and items were not discarded according to the facility's policy. During an observation and interview, it was noted that the refrigerator contained protein shakes, yogurt cups, and an ice tray with a buildup of ice that included grapes and a paper towel. Resident #23, who has intact cognition, reported that staff did not clean her fridge. Interviews with facility staff revealed inconsistencies in the responsibilities for maintaining the cleanliness of residents' personal refrigerators. A CNA stated that CNAs were responsible for checking the refrigerators and their temperatures, while the Administrator indicated that housekeeping was responsible for cleaning them. The facility's policy requires staff to check for expired food, label and date food items, and discard any suspected contaminated food. The failure to adhere to these procedures could compromise infection control and potentially make residents sick.
Improper Administration of Medication via G-tube
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was provided with appropriate treatment and services to prevent complications. Specifically, RN R did not check the placement of the g-tube before administering medication to a resident. Instead of using the gravity method, RN R used a syringe and plunger to push medication and water directly into the g-tube. This method is contrary to the facility's procedure, which requires allowing medication to flow by gravity to prevent complications. The resident involved was an elderly female with a history of a type 2 dens fracture, type 2 diabetes, chronic kidney disease, and acute cholecystitis. The resident's care plan included specific instructions for tube feeding, including verifying the position of the enteral access device. Despite these instructions, RN R did not follow the correct procedure, which was confirmed by the Director of Nursing, who stated that the gravity method should always be used to administer medication via g-tube. The facility's procedure guide also emphasized the importance of confirming feeding tube placement and using gravity to administer medications.
Infection Control Deficiencies in Wound Care and Visitor Protocols
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as evidenced by two specific incidents involving residents. In the first incident, a registered nurse (RN R) did not adhere to hand hygiene protocols while providing wound care to a resident with a right heel deep tissue injury. The RN did not change gloves or perform hand hygiene after removing a soiled dressing, which was acknowledged by both the RN and the Assistant Director of Nursing (ADON) as a risk for infection transmission. Despite monthly in-services on infection control and hand hygiene, the RN admitted to using only one pair of gloves during the procedure. In the second incident, a visitor for another resident did not follow the facility's infection control policy during a COVID-19 outbreak. The visitor entered and exited the resident's room without using hand sanitizer or wearing the required personal protective equipment (PPE), despite clear signage indicating droplet and contact precautions. The ADON and Director of Nursing (DON) acknowledged the lapse in enforcing PPE use among visitors, noting that while staff were required to wear gowns, masks, eye protection, and gloves, visitors were only encouraged to do so. The DON stated that the visitor should not have left the room to fill a water pitcher, as this posed a risk of infection transmission.
Medication Error Involving Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving two residents. A medication aide, identified as MA D, mistakenly administered medications intended for one resident to another. This error occurred because MA D was unfamiliar with the residents and their bed arrangements, having only worked at the facility for four days. The error was discovered when the resident who received the wrong medications, including a narcotic, became lethargic and required medical intervention with Narcan to reverse the effects of the opioid. The resident who received the incorrect medications had a history of repeated falls, anxiety disorder, chronic kidney disease, diabetes, and heart disease. At the time of the incident, he was cognitively intact with a BIMS score of 15 and required assistance with various activities of daily living. The medications he was supposed to receive were held, and he was mistakenly given medications intended for another resident, who had a different set of medical conditions and required different medications, including oxycodone for pain management. The error was identified when the second resident refused the medications, recognizing that they were not his. This prompted the staff to realize the mistake, leading to an immediate response to assess and treat the affected resident. The incident highlighted a lapse in the medication administration process, particularly in verifying resident identity and medication rights, which could have led to severe medical complications for the resident involved.
Medication Error and Reporting Failure
Penalty
Summary
The facility failed to report an incident of possible neglect to Health and Human Services involving a significant medication error. A medication aide administered the morning medications of one resident to another, including a narcotic and a psychoactive medication. This error was not reported to the state agency, which could place residents at risk of being neglected and lacking oversight by a state agency. The incident involved two residents with complex medical histories. The first resident, who received the incorrect medications, was a male with diagnoses including repeated falls, anxiety disorder, chronic kidney disease, diabetes, and heart disease. He had intact cognition and required assistance with various activities of daily living. The second resident, whose medications were mistakenly given to the first, had a history of metabolic encephalopathy, acute respiratory failure, type 2 diabetes, and other serious conditions. He was moderately cognitively impaired and dependent on staff for most activities of daily living. The error occurred when the medication aide, while in the process of administering medications to the second resident, switched to the first resident due to a therapist waiting to take him to therapy. The aide inadvertently switched the medication cups, leading to the administration of the wrong medications. The first resident became lethargic and confused, prompting the administration of Narcan due to the stronger dose of oxycodone he received. Despite the immediate response, the facility did not initially report the incident as they did not consider it reportable, believing there was no harm to the resident.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during wound care for a resident. LVN A did not change gloves or perform hand hygiene while providing wound care, which is a critical step in preventing the spread of infection. During the procedure, LVN A reused the same gauze to clean the wound multiple times and placed soiled items on the bed next to the resident, further increasing the risk of cross-contamination. The resident involved was an elderly female with a history of severe cognitive impairment and multiple medical conditions, including a stroke, fractures, and sepsis. She required assistance with bed mobility and had an active order for wound care on her sacrum. Despite these needs, LVN A conducted the wound care without assistance, which compromised the resident's safety and comfort. The resident expressed discomfort during the procedure, and her family questioned the appropriateness of the care being provided. Interviews with staff revealed that LVN A was a contracted nurse from an agency and not a regular employee of the facility. Despite being offered assistance by another LVN, LVN A chose to perform the wound care alone, which he later admitted was a mistake. The corporate DON and the facility's ADM both expressed that LVN A's actions were not in line with the facility's infection control policies, and the DON stated that LVN A would not be allowed to return to the facility.
Facility Fails to Maintain Safe Environment in Dining Room and Restroom
Penalty
Summary
The facility failed to maintain a safe environment in the dining room and employee restroom, as observed by surveyors. The dining room outside the dietary department had walls with drooping, sagging, and bubbled paint, and the ceiling tiles above were stained brown due to a leak. Additionally, the dietary department's employee restroom had an unidentified black substance on the ceiling and door facing, which was reportedly treated by the Maintenance Director. However, the black substance was still present during the surveyor's observation. Interviews revealed that the Maintenance Director, who had been employed for one month, was aware of the issues and had treated the area with mold spray. The Maintenance Director mentioned that the air conditioner had been leaking, causing moisture and damage to the wall, which existed before his employment. The Maintenance Repair Log indicated an entry about the AC leaking in the dining room, requesting repair by the Administrator. The facility's policy on Preventative Maintenance Services emphasized the need for timely maintenance to protect the health and safety of residents, personnel, and the public.
Inadequate Pest Control Program Leads to Insect Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent issue with gnats and horseflies in one of the hallways and several residents' rooms. Observations and interviews revealed that residents had been dealing with insect problems for weeks, with some residents reporting being bitten by horseflies, which caused them pain. The presence of insects was noted in the rooms of four residents, with visible gnats and horseflies observed during the survey. The facility's pest control logs indicated regular visits from a pest control company, but the problem persisted. Interviews with staff, including the RN, ADON, and DON, confirmed that the insect issue had been ongoing for several months, with residents frequently complaining about the problem. The facility lacked a dedicated Maintenance Director, relying instead on a Maintenance Director from a sister facility. Despite the pest control company's bi-weekly visits, the insect problem remained unresolved, with staff using temporary measures like electronic bug zappers to manage the situation. The DON and Administrator acknowledged the potential infection control risks posed by the insects, especially for residents with IV lines, wounds, and colostomy bags. The Administrator believed the insects might be entering through a drain and had plumbers working on the issue. Additionally, leftover food in residents' rooms was identified as a potential attractant for flies. The facility's pest control policy required frequent treatment to ensure a pest-free environment, but the ongoing insect problem indicated a failure to adhere to this policy effectively. The Administrator stated that only one resident had formally complained, and they were moved to another room, but the issue was more widespread, affecting multiple residents and areas within the facility.
Unqualified Activities Director in LTC Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. The Activities Director (AD) had been working in the role for two weeks without being licensed or registered as required by state regulations. The AD was in the process of completing a certification course, which was four weeks long, and had one week remaining before taking the certification exam. Despite conducting various activities such as bingo, word searches, and music, the AD was not yet qualified according to the facility's job description, which mandates that the AD must be a qualified activities professional licensed or registered by the state. Interviews with the Director of Nursing (DON) and the Administrator revealed that the AD had been conducting activities without any complaints from residents. However, the Administrator acknowledged that it was expected for staff to have a license before hire, although the AD was not providing direct care to residents. The facility's management roster listed the AD as the Activities Director, and the job description required the AD to be eligible for certification by a recognized accrediting body. The failure to have a qualified AD could potentially impact the quality of life for residents due to a lack of individualized activities.
Failure in Resident Transfer and Discharge Communication
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer and discharge of a resident, identified as Resident #5, who was sent to the hospital for a left clavicle fracture. The resident, a female with severe cognitive impairment and multiple health issues, was transferred to the emergency room (ER) after an unwitnessed fall. The facility did not follow up with the hospital to obtain discharge paperwork or new care orders upon the resident's return, which was facilitated by the resident's family due to communication issues with the facility. Interviews with staff revealed a breakdown in communication and protocol adherence. LVN C sent the resident to the hospital but did not ensure that the necessary follow-up was conducted. LVN B, who was on duty when the resident returned, did not receive or seek out discharge paperwork or new orders from the hospital. The facility's liaison, responsible for obtaining clinical updates, was not informed of the resident's return and thus did not follow up with the hospital. The Director of Nursing (DON) acknowledged the communication failures and the lack of post-hospital care orders, which put the resident at risk. The facility's administrator expected staff to use a group chat for communication about residents sent to the ER but did not require follow-up unless the resident was admitted to the hospital. The administrator also noted that it was unacceptable for a resident to return without discharge paperwork and expected the admitting nurse to obtain a report from the hospital. The facility's policy required obtaining a physician's order for emergency transfers, but the process was not adequately followed, leading to the deficiency.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) who did not perform proper hand hygiene before providing Activities of Daily Living (ADL) care to a resident. The resident, an 81-year-old female with a primary diagnosis of metabolic encephalopathy, was observed in her room without a box of gloves or hand sanitizer. The CNA entered the room wearing gloves, touched various surfaces, and then repositioned the resident without performing hand hygiene. This action was contrary to the facility's infection control protocols, which require hand hygiene before and after resident contact and after touching surfaces in the resident's environment. Interviews with the CNA and facility staff revealed a lack of understanding and adherence to infection control practices. The CNA admitted to placing gloves in her scrub pocket, believing they remained clean, and did not recognize the risk of cross-contamination. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that gloves should be taken directly from the box to prevent contamination and that staff should not enter rooms with gloves on due to the risk of cross-contamination. The facility's infection control policy emphasizes the importance of hand hygiene and the availability of necessary supplies in patient care areas.
What surveyors are citing around you — mapped
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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 746 citations issued within 25 miles in the last 12 months — including the 44 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 Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cityview Nursing And Rehabilitation Center | 1.9 mi | ★★★★★ | 12 | 0 |
| Ignite Medical Resort Fort Worth, Llc | 2.1 mi | ★★★★★ | 17 | 0 |
| Stonegate Nursing And Rehabilitation | 2.1 mi | ★★★★★ | 9 | 0 |
| Garden Terrace Healthcare Center Of Fort Worth | 2.2 mi | ★★★★★ | 7 | 0 |
| Arlington Heights Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 12 | 1 |
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.