Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Ridgecrest Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to follow its abuse reporting policy after a resident-to-resident verbal altercation involving one resident who threatened to punch another while raising a fist. The DON and Administrator were notified that morning, but the report to the state was not submitted until later that day after internal discussion about whether the event was reportable. Interviews showed uncertainty about reporting requirements despite the facility policy requiring abuse allegations to be reported within 2 hours.
Failure to Timely Report Resident-to-Resident Abuse Allegation: Two residents were involved in a verbal altercation when one resident, who had intact cognition and a history of cerebrovascular disease, was observed shouting at another resident with severe cognitive impairment and threatening to punch him. Although the DON and Administrator were notified that morning, the report was not submitted to the state until later that afternoon, beyond the facility’s 2-hour reporting requirement for abuse allegations.
The facility failed to fully document an abuse investigation involving a resident-to-resident verbal altercation. A resident with cerebrovascular disease, DM2, anxiety, and dysthymic disorder was placed on 1:1 supervision as the aggressor, but the hourly monitoring record was missing for one day. The facility also could not produce proof that staff received the resident-to-resident abuse in-service, and staff and leadership were unable to verify attendance or locate the missing documentation.
A resident with multiple chronic conditions and severe cognitive impairment was transferred to the ER due to a change in condition, yet the ADON continued to complete skilled nursing notes for several days after the transfer, documenting identical vital signs on multiple dates and assigning vital sign dates that did not match the note dates. The vitals summary also reflected blood pressure and pulse readings on a date when the resident was no longer in the facility. Interviews with the ADON and DON confirmed that these entries were errors and that facility policy required accurate, timely, resident-specific documentation completed as close to the time of care as practicable.
Surveyors found that dietary staff did not consistently label, date, or properly seal food items in the kitchen refrigerators and freezer, including items such as juices, cheeses, condiments, and various frozen foods. Both the Dietary Manager and Administrator confirmed that facility policy requires labeling with receive, open, and expiration dates, as well as proper sealing, but these procedures were not consistently followed.
Food and drink served to residents were not consistently palatable, attractive, or maintained at a safe and appetizing temperature, as observed during meal service.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with chronic obstructive pulmonary disease was documented as a smoker in multiple records, but the MDS assessment failed to indicate tobacco use. The MDS Coordinator admitted to overlooking this information, resulting in an inaccurate assessment that did not align with the resident's care plan and other documentation.
PASRR Level I Screening Not Completed for Resident Admitted With Schizophrenia: A resident admitted with schizophrenia, anxiety, and depression did not have a PASRR Level I screen completed on admission. The MDS Coordinator stated she was responsible for the PL1 and acknowledged it was not done until after the surveyor questioned it, which meant LIDDA was not alerted for a PE. The DON and Administrator confirmed the PL1 should have been completed for the resident, who was also receiving routine antipsychotic and antianxiety medications and had severe cognitive impairment on the MDS.
The facility did not complete baseline care plans within 48 hours of admission for two residents, resulting in one resident's cognitive diagnosis being omitted and another's care plan being completed late. Staff interviews confirmed that these omissions and delays were due to lapses in communication and adherence to policy, potentially leaving staff unaware of residents' immediate care needs.
Two residents did not have their care plans updated to reflect significant changes in their needs, including a recent fall and cervical collar use for one, and a new order for nectar thickened liquids for another. Staff and management confirmed that care plans were not revised as required by facility policy, despite regular meetings to discuss resident changes.
A resident requiring moderate assistance with bathing did not receive scheduled showers, as evidenced by missing documentation and the resident's own report of inadequate hygiene care. Staff interviews indicated a lack of awareness regarding missed showers, and observation confirmed poor grooming. Facility policy required support for ADLs, but this was not consistently followed.
A resident with a history of falls and multiple medical conditions experienced an unwitnessed fall, but the nurse on duty did not initiate neurological checks as required by facility policy. Staff interviews confirmed that neurological checks should have been started immediately after the fall, but the nurse assumed the resident had not hit her head and did not follow protocol.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors. These lapses resulted in a deficiency related to environmental safety and resident supervision.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, and the facility did not ensure the regimen was free from unnecessary drugs.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care, resulting in a deficiency related to the provision of end-of-life services.
Two residents and two staff were involved in infection control deficiencies, including a nurse failing to change gloves after removing a soiled dressing from a resident with a stage 3 pressure ulcer, and the same nurse not donning PPE before entering the room of a resident under contact isolation for MRSA. The Laundry Supervisor was also unaware of a resident's isolation status. These actions did not follow facility infection control policies and procedures.
Staff failed to follow infection prevention protocols for two residents requiring Enhanced Barrier Precautions, including not wearing gowns during catheter and wound care, and not performing proper hand hygiene or glove changes. These lapses occurred despite existing care plans and facility policies outlining the need for PPE and infection control measures.
A resident with multiple chronic conditions did not receive a scheduled wound treatment, and after expressing feelings of neglect to staff, the allegation was not reported to the abuse coordinator or DON as required by facility policy. Despite prior in-service training on abuse and neglect reporting, staff failed to notify appropriate authorities in a timely manner, resulting in a breakdown of procedures intended to prevent and address neglect.
A resident with multiple chronic conditions did not receive prescribed wound care to the left axilla as ordered, due to an LVN's failure to recognize responsibility for the treatment when the treatment nurse was absent. The omission was not documented in the MAR, and the resident reported the missed care, which was later confirmed by facility leadership.
A resident with a history of cognitive and physical impairments was found with bruising on her face and leg, which was not reported to the state agency as required. The facility staff, including an LVN and the DON, were notified, but the incident was not considered reportable due to assumptions about the cause. The Administrator was informed but did not report the incident, leading to a deficiency in compliance with reporting regulations.
A facility failed to update a resident's electronic medical records with the correct treatment orders for a right heel arterial wound. The resident, with a history of multiple health issues, was supposed to receive betadine treatment as ordered by the wound care physician, but the records still indicated the use of Xeroform and bordered gauze. The Treatment Nurse did not document the verbal orders, leading to potential incorrect treatments by other staff. The DON and Administrator expected prompt documentation and implementation of physician orders to ensure proper care.
A resident with multiple health conditions developed pressure ulcers that were not treated as ordered by the Wound Care Physician. The treatment nurse failed to document and implement the physician's orders, resulting in incorrect treatments. Interviews revealed a lack of adherence to protocol for documenting and following physician orders, contributing to the deficiency in care.
A resident with COPD and heart failure was observed receiving oxygen therapy without documented physician orders in the facility's records. Despite having a hospice order for oxygen as needed, the facility failed to ensure proper documentation and adherence to its oxygen administration policy, as confirmed by staff interviews and record reviews.
A Treatment Nurse in an LTC facility failed to perform hand hygiene between glove changes during wound care for two residents, despite the facility's hand hygiene policy. This lapse was observed during care for a male resident with diabetes and a female resident with multiple health issues. Interviews with the nurse, DON, and Administrator confirmed the importance of hand hygiene for infection control, but the nurse admitted to being nervous and unaware of the lapses.
The facility failed to maintain professional standards for food service safety, with deficiencies in food storage, labeling, and kitchen sanitation. Observations included undated and unlabeled food items, an unsanitary ice machine, and unclean kitchen equipment. The Dietary Director and Administrator were aware of these issues, which contravened the facility's policy on preventing food contamination.
The facility failed to maintain clean air conditioning units in several resident rooms, leading to unsanitary conditions that could affect residents' respiratory health. Observations revealed dirt and grime on the units, and interviews with staff highlighted a lack of clarity in cleaning responsibilities, contributing to the deficiency.
The facility failed to provide adequate respiratory care for three residents, leading to unsanitary storage and improper maintenance of CPAP and nebulizer equipment. A resident's CPAP machine was not cleaned, and the mask did not fit properly, while another resident's nebulizer mask was stored unsanitarily. Additionally, a third resident's CPAP mask was left unbagged, increasing the risk of infection. The facility lacked a policy for proper storage of respiratory equipment.
A facility failed to include dialysis treatment in a resident's care plan, despite the resident having an active order for dialysis three times a week due to renal failure. Interviews with MDS nurses confirmed the oversight, acknowledging the risk of the resident not receiving necessary care. The facility's policy requires a comprehensive care plan for each resident, which was not followed in this instance.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to implement written policies and procedures prohibiting mistreatment, neglect, and abuse of residents when it did not ensure the Abuse Coordinator followed the policy for reporting abuse to the state agency after a resident-to-resident altercation. The facility policy stated each resident has the right to be free from abuse and required the Abuse Coordinator to report allegations to the state agency within two hours of the allegation. The deficiency involved two residents reviewed for abuse, including one resident with cerebrovascular disease and intact cognition and another resident with severe cognitive impairment and a BIMS score of 0. Record review showed a verbal aggression incident between the two residents on the morning of the event. One resident was in the room receiving a breathing treatment when staff heard a loud verbal altercation from the hallway. The resident was observed rolling into the room, appearing visibly agitated and shouting, then stopping by the other resident’s bed and stating, “I am going to punch him,” while raising his fist. The DON and Administrator were notified that morning, and the incident was later documented as a resident-to-resident allegation. The PIR reflected the incident was reported to the state agency later that day at 5:23 p.m. During interviews, the Assistant Administrator stated she learned of the incident in the afternoon and submitted the report after being notified by the Administrator. She also stated she was not sure whether the incident needed to be reported because there were no lasting psychological effects. The Administrator stated he initially did not feel the incident was reportable, later reviewed it with corporate staff, and then determined it should be reported.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that alleged abuse or mistreatment involving a resident-to-resident altercation was reported immediately, and no later than 2 hours after the allegation was made, for 2 residents reviewed. The incident involved Resident #1, a male with a history of cerebrovascular disease and intact cognition with a BIMS score of 15, and Resident #2, a male with sepsis and severe cognitive impairment with a BIMS score of 0. Resident #1’s care plan identified a potential for physical aggression related to anger, and Resident #2’s care plan addressed verbal aggression and removal from the aggressor. According to the incident documentation, on 11/09/25 at about 9:00 a.m., staff heard a loud verbal altercation in Resident #2’s room while Resident #2 was receiving a breathing treatment. Resident #1 was observed rolling in the room, appeared visibly agitated, shouted, and stopped at the foot of Resident #2’s bed while stating, “I am going to punch him,” and raising his fist. The DON was notified at 9:25 a.m. and the Administrator at 9:30 a.m. The PIR later reflected that Resident #1 was witnessed speaking in a loud tone toward Resident #2 and stated he was frustrated and irritable because of difficulty sleeping since Resident #2’s arrival, citing snoring and vocalization at night as contributing factors. The incident was not reported to the State Survey Agency until 5:23 p.m., after the Administrator later determined it was reportable following review with corporate staff. During interviews, the Assistant Administrator stated she learned of the incident at 3:55 p.m. and then submitted the report, and the Administrator stated he initially did not feel the incident was reportable when notified that morning. The facility policy for Abuse Prohibition stated that the Abuse Coordinator will report allegations to the state agency in accordance with state law within 2 hours of the allegation.
Incomplete abuse investigation documentation and missing 1:1 monitoring records
Penalty
Summary
The facility failed to provide evidence that an alleged resident-to-resident verbal altercation involving Resident #1 was thoroughly investigated and documented. Resident #1 was a male resident with diagnoses including cerebrovascular disease, Type II diabetes, anxiety, and dysthymic disorder. His quarterly MDS indicated intact cognition with a BIMS score of 14, no communication deficits, wheelchair use for mobility, and assistance needs for eating, bed mobility, dressing, bathing, toileting, and transfers. The Provider Investigation Report identified Resident #1 as the aggressor in the verbal altercation with Resident #3 and stated that immediate action included placing Resident #1 on 1:1 supervision. Record review showed the facility could not provide evidence of 1:1 monitoring for one day of the monitoring period. The 1:1 supervision sheets documented hourly monitoring on 11/21/25, 11/22/25, 11/24/25, and 11/25/25, but there was no documentation for 11/23/25. During interviews, facility staff were unable to identify who completed the missing monitoring or produce the tracking sheet for that date. The DON stated that nursing staff were expected to complete hourly tracking sheets when a resident was placed on 1:1 monitoring, but the documentation was not available. The facility also failed to provide evidence that staff received the abuse-related in-service referenced in the investigation. The PIR stated that an all-staff in-service on resident-to-resident abuse was completed, and the facility produced a copy of the training topic, but it did not have an attendance roster, signature sheet, or electronic proof that staff received it. Multiple staff members interviewed could not recall whether they had received the specific in-service, and facility leadership stated they could not locate documentation verifying staff participation. The facility policy required alleged violations to be thoroughly investigated and all pertinent documentation to be collected and maintained.
Inaccurate and Duplicative Nursing Documentation After Resident Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, resident-specific medical records in accordance with professional standards for one resident. The resident was an adult female with diagnoses including seizures, schizoaffective disorder, hypertensive heart disease, diabetes, and hypertension, who was dependent on staff for transfers and had severe cognitive impairment with a BIMS score of 03. Her care plan identified an ADL self-care deficit. Despite these clinical needs, the facility’s documentation of her vital signs and skilled nursing notes contained multiple inaccuracies and duplications. Record review showed that the weights and vitals summary listed a blood pressure of 103/60 and a pulse of 100 for the resident on 3/26/26, even though an SBAR report documented that she had been transferred to the ER on 3/25/26 and had not returned to the facility. Daily skilled nursing notes dated 3/22/26, 3/23/26, and 3/24/26, all completed by the ADON, repeatedly documented the same set of vital signs (blood pressure 103/60 dated 3/26/25, temperature 98.4 dated 3/25/26, pulse 100 dated 3/26/26, respirations 17 dated 3/25/26, and oxygen saturation 96% dated 3/25/26), indicating that vital signs from specific dates were copied into notes for different dates. These entries did not align the vital sign dates with the dates of the skilled nursing notes. Further review showed that the ADON continued to complete daily skilled nursing notes for the resident on 3/26/26, 3/27/26, and 3/28/26, after the resident had been transferred to the hospital on 3/25/26. Each of these notes again contained the same repeated vital sign values and dates. In interviews, the ADON acknowledged familiarity with the resident and stated that skilled nurse notes should not have been completed for days after the resident was admitted to the hospital, and that vital signs on skilled nursing notes should be dated the same as the note date. The DON stated she expected charting to be done in real time with accurate narratives and that the ADON was responsible for ensuring charting accuracy, while the DON was responsible for overseeing the ADON’s review of charts. The facility’s Nursing Documentation Guideline required documentation to be accurate, timely, resident-specific, and completed as close to the time of care as practicable, which was not followed in this case.
Failure to Properly Label, Date, and Seal Food Items in Dietary Services
Penalty
Summary
Surveyors observed that dietary staff failed to consistently label and date all food items in the kitchen's refrigerators and freezer. Specific findings included a gallon of premade orange juice without a label or expiration date, sliced cheese and cream cheese with open dates but no expiration dates, and multiple gallons of condiments and containers of fruit with missing expiration dates. In the walk-in freezer, several items such as hamburger patties, garlic biscuits, frozen turkey meat, chicken thighs, dinner rolls, precooked hamburger patties, pepperoni, and fish patties were found either unsealed, not placed in appropriate containers, or lacking labels and expiration dates. These observations were made during walkthroughs with the Dietary Manager. Interviews with the Dietary Manager and Administrator confirmed that facility policy requires all refrigerated and frozen food items to be labeled with receive, open, and expiration dates, and to be properly sealed. Both acknowledged that these procedures were not consistently followed, as evidenced by the survey findings. Record reviews of facility policies further supported the requirement for proper labeling, dating, and sealing of food items to ensure food safety and compliance with professional standards.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified based on observations that meals did not consistently meet standards for taste, appearance, or temperature, as required for resident satisfaction and safety.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Inaccurate MDS Assessment of Tobacco Use
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the status of a resident with chronic obstructive pulmonary disease. The resident's face sheet and care plan indicated that he was a smoker, and a progress note also documented current tobacco use. However, the Comprehensive MDS assessment did not indicate tobacco use for this resident. The MDS Coordinator responsible for completing the assessment acknowledged that the resident should have been coded for tobacco use and admitted to overlooking this information during the assessment process. The facility's policy requires the use of the most up-to-date Resident Assessment Instrument (RAI) manual to ensure accurate and timely coding of each section of the Resident Assessment. The Administrator confirmed that MDS Coordinators are responsible for accurate coding and stated that if the MDS is not coded according to the resident's plan, the interventions in place would not be beneficial to the patient. The deficiency was identified through interview and record review, which revealed the inconsistency between the resident's documented tobacco use and the information recorded in the MDS assessment.
PASRR Level I Screening Not Completed for Resident Admitted With Schizophrenia
Penalty
Summary
The facility failed to ensure a PASRR Level I assessment was completed for one resident who was admitted with a diagnosis of schizophrenia. Record review showed the resident’s face sheet listed schizophrenia, anxiety, and depression, and the quarterly MDS indicated severe cognitive impairment on decision making. The resident was receiving a routine antipsychotic and an antianxiety medication. Record review of the resident’s electronic medical record did not show that a PASRR Level I screening had been completed after admission. During interview, the MDS Coordinator stated she was responsible for ensuring the PL1 was completed on admission and acknowledged that this resident’s PL1 had not been done until after the surveyor questioned it. She stated the resident had previously been discharged in December 2024 and re-admitted, and because the resident had been discharged for over 30 days, a new PL1 should have been completed. The MDS Coordinator also stated that because the PL1 was not completed, LIDDA was not alerted to complete a PE. The DON and Administrator stated the MDS Coordinator was responsible for ensuring the PL1 was completed on admission, and that a resident admitted with schizophrenia should have had a PL1 completed so a PE could determine eligibility for services. The Regional Compliance Nurse stated the facility did not have a PASRR policy and used the RAI manual guidelines.
Failure to Complete Timely and Comprehensive Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan for each resident within 48 hours of admission, as required by policy. For one resident, the baseline care plan did not include a diagnosis of vascular dementia or any cognitive loss, despite the resident having a history of dementia and a moderately impaired cognition score on the MDS. The omission was noted in the resident's records and confirmed by interviews with family and staff, who acknowledged the importance of including such diagnoses in the care plan to ensure appropriate care. For another resident, the baseline care plan was not completed within the required 48-hour timeframe after admission. The care plan was completed two days late, and staff interviews revealed that the delay was due to the resident being admitted late and the admitting nurse not having time to complete the care plan. The responsibility for completing the care plan was supposed to be communicated to the oncoming nurse, but this did not occur in a timely manner. Facility policy states that a baseline plan of care must be developed within 48 hours of admission to address the resident's immediate health and safety needs. Staff interviews, including those with the ADON, DON, and Administrator, confirmed that the failure to complete and accurately document baseline care plans could result in staff not being aware of residents' specific needs. The records and interviews demonstrate that the facility did not adhere to its own policy and regulatory requirements regarding timely and comprehensive baseline care planning for new admissions.
Failure to Update and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through interviews and record reviews. For one resident, who had multiple medical conditions including multiple rib fractures, diabetes, and polyneuropathy, the care plan did not reflect a recent fall that occurred in the bathroom or the requirement for a cervical collar as ordered by the hospital. The care plan also lacked documentation of interventions such as non-slip strips and the use of the cervical collar, despite observations confirming the resident was wearing the collar. The MDS Coordinator, responsible for updating care plans, acknowledged the omission and was unable to explain how the updates were missed, despite daily meetings intended to review such changes. For another resident with diagnoses including dysphagia, dementia, and GERD, the care plan was not updated to reflect a physician's order for nectar thickened liquids. The resident's care plan continued to list a thin liquid consistency, contrary to the updated order for nectar thick liquids. Staff interviews confirmed that the care plan should have been updated to reflect the new dietary requirement, but this was not done. The DON and Administrator both stated that the MDS Coordinator was responsible for ensuring care plans were current and accurate, and that changes in resident needs were discussed in regular meetings. The facility's own policy requires that care plans be comprehensive, person-centered, and revised as resident conditions change, with measurable objectives and timetables. However, in both cases, the care plans were not updated to reflect significant changes in the residents' needs, as identified in assessments and physician orders. This failure was confirmed by staff and management interviews, as well as review of facility documentation.
Failure to Provide Scheduled Showers and Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease, atrial fibrillation, and type 2 diabetes mellitus, who required partial to moderate assistance with bathing, did not receive showers as scheduled. Record review showed that the resident was scheduled for showers on specific days, but there was a missing shower sheet for one of the scheduled days, and the resident reported only receiving one bath since admission, which was a week prior. The resident expressed dissatisfaction with his hygiene and was unaware of his scheduled bath days, stating that he only received a shower after reporting the issue to the DON. During observation, the resident's hair appeared greasy and disheveled. Interviews with staff, including a CNA, LVN, and the DON, revealed that they were not aware of any missed showers or refusals by the resident. The CNA stated that showers were provided according to the schedule and emphasized the importance of maintaining hygiene. The DON and Administrator both indicated that showers should be completed as scheduled and monitored by nursing staff. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain hygiene, but this was not consistently provided in this case.
Failure to Initiate Neurological Checks After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with a history of falls, diabetes, high blood pressure, cerebrovascular disease, and normal pressure hydrocephalus experienced an unwitnessed fall. The resident, who had moderately impaired cognition and was on antiplatelet therapy, was found on the floor beside her bed. According to the facility's policy, neurological checks are required for all unwitnessed falls or if a resident hits their head. However, the nurse on duty did not initiate neurological checks after the fall, assuming the resident had not hit her head based on her position and physical examination. Interviews with facility staff, including the DON, ADON, and the nurse involved, confirmed that neurological checks were not started as required by policy. The DON and ADON both stated that neurological checks should have been initiated immediately following the unwitnessed fall, and the failure to do so could result in missing a change in the resident's condition. The facility's policy clearly outlines the need for neurological checks in such situations, but this protocol was not followed in this instance.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received the necessary respiratory care as required by their condition. Specific actions or omissions by staff that led to this deficiency are not detailed in the report, nor are there additional facts about the resident's medical history or condition at the time of the incident.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents’ drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Deficiency in Drug Labeling and Secure Storage
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions and inactions resulted in a deficiency related to the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care as required.
Infection Control Lapses During Wound Care and Isolation Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents and two staff members, as evidenced by direct observations and interviews. In one instance, a Treatment Nurse did not change her gloves after removing a soiled dressing from a resident with a stage 3 pressure ulcer before proceeding to cleanse the wound. This action was observed during wound care, and both the nurse and the Director of Nursing (DON) acknowledged that gloves should have been changed to maintain infection control. The resident involved had dementia and muscle weakness, and her care plan required daily wound care with specific infection control measures. In another case, the Treatment Nurse did not don personal protective equipment (PPE) before entering the room of a resident under contact isolation for MRSA exposure. The nurse entered the room, moved items, and cleaned the bedside table without PPE, only applying gown and gloves after exiting and re-entering to perform wound care. Additionally, the room lacked a designated container for soiled linen, and the nurse confirmed that proper procedures were not followed. The DON and Administrator both stated that staff are expected to follow infection control policies, including donning PPE before entering rooms under contact isolation. The Laundry Supervisor was also unaware that a resident was under contact isolation, stating that no residents were currently on such precautions, despite orders indicating otherwise. Facility policies reviewed required implementation of appropriate isolation precautions and adherence to infection control best practices during wound care. These lapses in infection control practices were confirmed through interviews, observations, and record reviews.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents, as evidenced by direct observations and staff interviews. In the first instance, two CNAs provided catheter care to a male resident with chronic kidney disease and an indwelling catheter without wearing gowns, as required by Enhanced Barrier Precautions (EBP). The appropriate signage and PPE were not present at the resident's door, and both CNAs acknowledged during interviews that they should have confirmed the need for PPE and followed EBP protocols. The nurse and DON confirmed that staff are responsible for ensuring EBP signage and PPE availability, and that proper PPE use is essential for infection prevention. In the second instance, an LVN performed wound care on a female resident with an open lesion and a history of arthritis, diabetes, anxiety, and dementia, who was also on EBP due to her wound. The LVN entered the resident's room and performed wound care without wearing a gown, failed to change gloves or perform hand hygiene between tasks, and handled clean and dirty items with the same gloves. The LVN later acknowledged not following proper hand hygiene or PPE protocols, and both the DON and Administrator confirmed that EBP and hand hygiene are required during such care activities. Record reviews confirmed that both residents had care plans and physician orders indicating the need for EBP and specific infection control measures. Facility policies on infection prevention, hand hygiene, and EBP were in place, outlining the requirements for PPE use and hand hygiene to prevent the spread of infection. Despite these policies, staff did not consistently implement the required precautions during high-contact care activities for residents with indwelling devices and open wounds.
Failure to Report and Prevent Neglect Following Missed Wound Treatment
Penalty
Summary
The facility failed to implement and follow its written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for one resident. Specifically, a cognitively intact female resident with multiple diagnoses, including arthritis, diabetes, anxiety, and dementia, did not receive her ordered wound treatment on a scheduled day. The resident's care plan and physician's orders required specific wound care to her left axilla due to an open lesion from hardware protrusion, but the treatment was not documented as completed on the required date. The resident reported to staff that her treatment was missed and expressed feeling neglected. Although a nurse was informed of the resident's allegation of neglect, the nurse did not report this to the abuse coordinator or Director of Nursing (DON) as required by facility policy. The nurse acknowledged being trained on reporting abuse and neglect but failed to act due to being busy and forgetting to report the incident. The DON and Administrator were unaware of the missed treatment and the resident's allegation until informed by the surveyor several days later. Facility policy required immediate reporting of any allegations of abuse or neglect to the abuse coordinator, with further reporting to state authorities within specified timeframes. Despite in-service training on abuse and neglect, the staff did not follow these procedures, resulting in a failure to report the resident's allegation of neglect to the appropriate authorities in a timely manner.
Failure to Provide Wound Care as Ordered
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to perform a prescribed wound treatment for a resident with a left axilla wound as ordered by the physician. The resident, an elderly female with diagnoses including arthritis, diabetes, anxiety, and dementia, required wound care every Monday, Wednesday, and Friday, as documented in her care plan and physician's orders. On the specified date, the treatment was not completed, and the medication administration record was not signed to indicate the treatment had been done. The resident reported that she did not receive her wound care and that her request for assistance was not addressed by the nursing staff. The LVN responsible for the resident's care was unaware that the treatment nurse was off duty and did not review the treatment orders or the medication administration record for that day. The LVN stated she believed the treatment nurse had completed the care and did not realize she was responsible for the treatment. Facility leadership, including the DON and Administrator, confirmed that the treatment was not performed as ordered and that staff are expected to follow physician's orders for wound care. Facility policies reviewed emphasized adherence to infection control practices and the prevention of neglect.
Failure to Report Alleged Abuse or Neglect Timely
Penalty
Summary
The facility failed to report an alleged violation involving potential abuse or neglect in a timely manner, as required by regulations. Specifically, the facility did not report bruising observed on a resident's left brow, temple, and behind the right knee to the state agency. The bruising was discovered during a routine round by a CNA and reported to an LVN, who then notified the RN Supervisor, DON, and the resident's responsible party. Despite these notifications, the incident was not reported to the state agency within the required timeframe. The resident involved was an elderly female with a history of anxiety, hypertension, traumatic brain injury, dementia, and heart failure. She was cognitively intact with a BIMS score of 13 and required substantial assistance with transfers and mobility. The resident was unable to provide an explanation for the bruising, and her responsible party suggested it might have been caused by bumping against an assist bar. The facility staff speculated that the bruising could have been due to the resident's use of a neck pillow and positioning devices, but no definitive cause was determined. Interviews with facility staff, including the LVN, DON, and Administrator, revealed that the bruising was not considered an injury of unknown origin by the DON, who decided it was not reportable. The Administrator was informed of the bruising during a clinical meeting but did not report it to the state agency, relying on the incident report and the responsible party's explanation. The facility's policy required reporting of such incidents within 24 hours, but this was not adhered to, leading to a deficiency in the facility's compliance with reporting requirements.
Failure to Update Wound Care Orders in Electronic Medical Records
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not update the electronic medical records with the correct treatment orders for a resident's right heel arterial wound. The resident, a female with a history of anxiety, hypertension, traumatic brain injury, dementia, and heart failure, had an arterial wound on her right heel. The care plan indicated the use of Xeroform and bordered gauze for treatment, but the wound care physician had ordered betadine instead. The Treatment Nurse admitted to not documenting the verbal orders given by the wound care physician during rounds, which led to the incorrect treatment being recorded in the electronic medical records. As a result, staff performing wound care in the nurse's absence would follow the outdated orders, potentially leading to incorrect treatments. The Treatment Nurse acknowledged the importance of following accurate wound care orders for proper wound healing. Interviews with the Director of Nursing (DON) and the Administrator revealed that they expected verbal orders to be documented and implemented promptly. The DON stated that nurses have 24 hours to document late entries in the progress notes, and any changes in treatment orders should be entered into the electronic medical records. The Administrator emphasized the importance of inputting and following physician orders to prevent residents from receiving incorrect treatments.
Failure to Follow Wound Care Orders for Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for a resident, as per the comprehensive assessment and professional standards of practice. The resident, a female with multiple diagnoses including anxiety, hypertension, traumatic brain injury, dementia, and heart failure, was at risk for pressure ulcers. Despite being cognitively intact and requiring substantial assistance with mobility, the resident developed pressure ulcers on her sacrum and left calf, which were not treated as ordered by the Wound Care Physician. The Wound Care Physician had ordered specific treatments for the resident's pressure ulcers, including the use of calcium alginate and bordered dressing for the sacrum and left calf. However, the treatment nurse failed to enter these orders into the electronic medical record, resulting in the absence of documented treatment for the left calf wound. The treatment nurse admitted to not seeing the wound on the left calf until several days after the physician's visit and did not consult the physician's orders or contact the physician for clarification. Interviews with the treatment nurse, DON, and Administrator revealed a lack of adherence to protocol regarding the documentation and implementation of physician orders. The treatment nurse did not document verbal orders or clarify missing treatment orders, leading to incorrect treatments being administered. The facility's policy required weekly skin integrity checks and documentation of new wounds, but these procedures were not followed, contributing to the deficiency in care for the resident's pressure injuries.
Failure to Document Oxygen Therapy Orders
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care was provided with appropriate care consistent with professional standards. Specifically, the resident, a female with a history of anxiety, hypertension, traumatic brain injury, dementia, COPD, and heart failure, did not have documented orders for oxygen therapy despite being observed with oxygen administered via nasal cannula at 2 liters per minute. The resident's medical records, including the physician orders dated October 1, 2024, did not indicate any orders for oxygen therapy, monitoring, or tubing changes, although a hospice assessment noted an order for oxygen as needed for shortness of breath. Interviews with facility staff, including an RN and the DON, revealed that there was an expectation for nurses to obtain and document physician orders for oxygen therapy in the electronic medical records. The RN explained the importance of having dated oxygen tubing and documented orders to ensure proper oxygen administration and monitoring. The facility's policy on oxygen administration emphasized the need for a physician's order and outlined guidelines for safe oxygen administration, which were not followed in this case, leading to the deficiency.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Treatment Nurse during wound care procedures for two residents. The Treatment Nurse did not consistently perform hand hygiene between glove changes while attending to wounds on the residents. This lapse in protocol was observed during wound care for a male resident with a history of diabetes, muscle weakness, and chronic kidney disease, and a female resident with a history of anxiety, hypertension, traumatic brain injury, dementia, and heart failure. During the wound care for the male resident, the Treatment Nurse changed gloves multiple times without performing hand hygiene, which is a critical step in preventing cross-contamination and infection spread. The resident was at risk for pressure ulcers, and the nurse's failure to adhere to proper hand hygiene practices could have compromised the resident's safety. Similarly, while attending to the female resident, the Treatment Nurse again neglected to perform hand hygiene between glove changes, despite handling multiple wound sites and dressing materials. Interviews with the Treatment Nurse, the Director of Nursing (DON), and the Administrator revealed an acknowledgment of the importance of hand hygiene in infection control. The facility's hand hygiene policy, revised in March 2020, clearly outlines the necessity of hand hygiene before and after handling dressings and between glove changes. However, the Treatment Nurse admitted to being nervous during the observed procedures and did not realize the lapses in hand hygiene, which were contrary to the facility's established protocols.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed through various deficiencies in food storage, labeling, dating, and kitchen sanitation. Specifically, the facility did not ensure that food items in the refrigerator and freezer were properly labeled and dated according to guidelines. Observations revealed undated salads, a container of chicken noodle soup past its expiration date, and several unlabeled and undated food items, including shredded cheese, breadsticks, chicken nuggets, pork, meatballs, and frozen biscuits. Additionally, the facility's ice machine was found unsanitary, with the ice scoop stored in an open bag sitting in water, and a tea dispenser was left uncovered, exposing it to air-borne contaminants. The facility's kitchen equipment, such as food storage bins, was also found to be unclean, with dirt particles and brown stains observed on a sugar bin. Interviews with the Dietary Director and the Administrator confirmed awareness of these issues, with the Dietary Director acknowledging the failure to maintain proper food storage and cleanliness standards. The facility's policy on food storage, dated 2012, emphasizes maintaining storage areas in an orderly manner to prevent contamination and foodborne illnesses, which was not adhered to in this instance.
Deficiency in Maintaining Clean Air Conditioning Units
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, as evidenced by observations of unclean air conditioning units in multiple resident rooms. Specifically, the air conditioning units in the rooms of six residents were found to have dirt particles, black grime, and dust on the vents and filters. This deficiency was identified during observations conducted on various dates, and it was noted that the unclean conditions could potentially impact residents' breathing, particularly those with respiratory conditions such as Chronic Obstructive Pulmonary Disease and Respiratory Failure. Interviews with housekeeping staff and the maintenance director revealed a lack of clarity and execution in cleaning responsibilities. Housekeeping staff admitted to not cleaning the air conditioning filters, citing insufficient training and understanding of their duties. The housekeeping supervisor acknowledged that the vents and filters should have been cleaned and recognized the potential risk to residents' respiratory health. The maintenance director confirmed that cleaning the air conditioning filters was a maintenance responsibility and noted issues with keeping the filters clean in the affected hall. Despite having a monthly cleaning schedule, the filters in the identified rooms were not adequately maintained, contributing to the unsanitary conditions observed.
Inadequate Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, as observed through interviews and record reviews. Resident #76, who had a diagnosis of Chronic Obstructive Pulmonary Disease and Respiratory Failure, reported that her CPAP machine had not been cleaned since she received it, and the mask did not fit properly. The mask was found in an open plastic bag, indicating improper storage. The Assistant Director of Nursing (ADON) acknowledged awareness of the issue but had not followed up on it, despite knowing the risks associated with improper CPAP equipment. Resident #26, also diagnosed with Chronic Obstructive Pulmonary Disease, had her nebulizer mask stored unsanitarily in a nightstand drawer, unsealed in a plastic bag. The Licensed Vocational Nurse (LVN) responsible for the resident's care admitted that the nebulizer should have been serviced more recently and recognized the risk of infection from not changing the tubing and cleaning the mask. Resident #112, with a diagnosis of Sleep Apnea, had her CPAP mask left unbagged on top of a mini fridge. The LVN acknowledged that the mask should have been stored in a sealed bag to prevent contamination. The Director of Nursing (DON) stated there was no policy regarding mask storage, despite the potential for infection. The facility's failure to ensure proper storage and maintenance of respiratory equipment for these residents could lead to respiratory infections and unmet respiratory needs.
Failure to Include Dialysis in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to include dialysis treatment in the care plan. The resident, a cognitively intact female with renal failure, was admitted to the facility and had an active physician order to receive dialysis three times a week. Despite this, the quarterly comprehensive care plan did not include any mention of dialysis treatment, which is a critical component of the resident's medical needs. Interviews with the MDS nurses revealed that the omission was an oversight, with both nurses acknowledging that dialysis should have been included in the care plan. The absence of a care plan for dialysis posed a risk of the resident not receiving the necessary care. The facility's policy mandates that the interdisciplinary team develop a comprehensive care plan for each resident, which was not adhered to in this case.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 653 citations issued within 25 miles in the last 12 months — including the 28 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Forney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Rehabilitation And Healthcare | 7.4 mi | ★★★★★ | 21 | 0 |
| Cheyenne Medical Lodge | 7.6 mi | ★★★★★ | 1 | 0 |
| Mesquite Tree Nursing Center | 8.7 mi | ★★★★★ | 12 | 0 |
| Broadmoor Medical Lodge | 8.9 mi | ★★★★★ | 5 | 0 |
| Terrell Healthcare Center | 9.7 mi | — | 43 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.