Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Ridgmar Medical Lodge during CMS and state inspections, most recent first.
A resident who was bedbound, dependent on staff for Hoyer lift transfers, and diagnosed with osteoporosis and muscle wasting was transferred to the hospital, where imaging revealed multiple traumatic fractures of the ribs, humeral head, scapula/glenoid, and coracoid processes. The resident told hospital staff she had fallen when a Hoyer lift sling split, but facility records contained no documentation of any fall or incident, and the incident/accident log showed no Hoyer-related events. Numerous staff, including CNAs, LVNs, RNs, the DON, NP, physician, therapy staff, and dialysis clinic personnel, reported no knowledge of falls, unexplained bruising, or pain suggestive of fractures, and equipment checks showed slings in good condition. The Administrator acknowledged that the injuries were of unknown origin and that policy required immediate reporting of such alleged violations, but he did not report the fractures to the state agency, resulting in a failure to timely report an injury of unknown source as required.
Food storage and kitchen sanitation deficiencies were identified in the kitchen. The walk-in refrigerator and freezer contained multiple unlabeled and undated items, including eggs, chicken, lemons, prune juice, and frozen mini pizzas, and one lemon was rotten. The deep fryer also had a thick build-up of brown and black grease and food particles, and dietary staff acknowledged it had not been cleaned for two weeks despite a weekly cleaning expectation.
Dumpster Door Left Open Exposing Trash: During observation, one door on Dumpster #1 was open with trash exposed, while another dumpster had both doors and lid closed. The Dietary [NAME] D stated kitchen staff took trash out from the kitchen and that dumpster doors and lids were supposed to be closed and the area kept clean. The Administrator stated staff were responsible for taking trash to the dumpsters and that the doors should be closed all the way and trash picked up.
Failure to Notify RP Before Room Change: A resident with neurological conditions, cerebral palsy, and seizure disorder was moved closer to the nurses' station for safety-related reasons, but the RP was not given written notice or a clear explanation before the room change. The RP later found the resident had been moved and had to ask staff where he was located, while the LVN, SW, ADON, and DON could not confirm that prior notification had been provided.
A resident with cerebral palsy, seizure disorder, NPO status, and g-tube feeding had a swallow study requested by the guardian during a care plan meeting, but the MBSS referral was not completed. Interviews showed the SW knew of the request, while the LVN, DOR, and ST were not aware of it, and the DOR confirmed no referral had been made.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
The facility did not coordinate assessments with the PASRR program and failed to refer a resident for necessary services, resulting in noncompliance with required procedures.
A resident with Parkinson's Disease and moderate cognitive impairment did not receive a needed psychiatric consultation after an NP gave a verbal order for a psych referral due to concerns about depression. The LPN documented the order in progress notes but failed to enter it into the system, and the social worker was not informed, resulting in no psych services being provided.
A resident with severe cognitive impairment was found with fire ant bites due to the facility's ineffective pest control program. Despite regular pest control services, active ant mounds were discovered, indicating a lapse in preventive measures. The incident highlighted the need for more effective pest management to prevent such occurrences.
A facility failed to complete a discharge summary for a resident with moderate cognitive impairment and multiple diagnoses, including orthopedic conditions, cancer, and diabetes. The resident was discharged to receive home health services, but the discharge summary was found incomplete and blank. The DON confirmed that the discharge summary is crucial for post-discharge care instructions.
The facility failed to incorporate PASARR recommendations for two residents. One resident did not receive a customized wheelchair due to missed deadlines and staff changes, while another resident with a new schizoaffective disorder diagnosis was not referred for a PASRR review. The MDS Coordinator was unaware of the need for updates due to a lack of audits and oversight.
Two residents in a LTC facility experienced deficiencies in enteral feeding management. One resident received only half of the prescribed bolus feeding due to a nurse misreading orders, while another resident's tube feeding machine was not turned on as scheduled, resulting in missed nutrition. These lapses were due to miscommunication and lack of adherence to facility policies, posing risks of inadequate nutrition.
A facility failed to implement a pharmacist's recommendation to reduce a resident's Olanzapine dose from 10 mg to 5 mg, despite physician agreement. The resident, with intact cognition and multiple diagnoses, continued receiving the higher dose for several months. The DON admitted the oversight, citing a lack of documentation and communication as the cause.
A facility failed to ensure a resident receiving hospice services had a physician order for hospice care, as required by professional standards. The resident, with multiple diagnoses, was on hospice services but lacked a documented physician order. Interviews with staff revealed a lack of awareness and adherence to the facility's policy on hospice care orders, contributing to the deficiency.
The facility failed to report two incidents as per their policy: a resident with severe cognitive impairment was found with fire ant bites, and another resident's personal items went missing after discharge. The administrator did not report these incidents to the State Survey Agency, citing a lack of belief in theft and unfamiliarity with the policy, potentially placing residents at risk of continued neglect and misappropriation.
A facility failed to report two incidents to the State Survey Agency as required. In one case, a resident with severe cognitive impairment was found with fire ant bites, and the incident was not reported. In another case, a resident's personal items were reported missing after discharge, but the administrator did not report the alleged misappropriation, believing the items were not stolen. Both incidents reflect a failure to adhere to the facility's policy on reporting allegations of abuse and misappropriation.
The facility failed to follow proper protocols for fall response and wound care. A resident with severe cognitive impairment fell and was moved by untrained staff before a nurse could assess her, contrary to facility policy. Another resident's wound dressings were not dated, risking missed care. These deficiencies highlight lapses in staff training and adherence to care standards.
A resident with a history of pressure ulcers did not receive necessary treatment for a newly identified sacral wound due to communication and documentation failures. The wound was reported by a CNA to an LVN, who obtained an order from the NP but did not document it in the system, leaving the Wound Care Nurse unaware. This oversight led to a deficiency in care, as the facility's wound care policy was not followed.
A resident with severe cognitive impairment was found with two Scopolamine patches due to an LVN's failure to remove the old patch before applying a new one, risking overmedication. The facility's policy did not address patch administration, and there was no specific training on patch removal.
A resident with a history of dysphagia and malnutrition did not receive pureed bread as part of her prescribed pureed diet during a lunch meal. The facility's dietary staff failed to follow the menu, which required all diet forms to receive the same items in different textures. This oversight was acknowledged by the dietary manager and dietician, who emphasized the importance of adhering to the menu to meet residents' nutritional needs.
A resident with cognitive impairments and a history of inappropriate behavior was discharged from a facility without proper documentation or preparation. The resident was accused of inappropriate actions towards another resident with dementia, leading to an immediate discharge during a state survey. Despite previous warnings and a reversed discharge notice, the facility cited Immediate Jeopardy as the reason for the immediate discharge, failing to follow proper discharge protocols.
A resident was discharged from an LTC facility without proper notification to the Ombudsman, following an incident of inappropriate behavior. The resident, with a history of similar actions, was discharged immediately due to safety concerns, but the facility failed to send the required written notice to the Ombudsman. Interviews revealed confusion and oversight in the notification process, with the social worker unable to confirm sending the notice and the administrator preoccupied with another issue.
Failure to Timely Report Injury of Unknown Origin Involving Multiple Fractures
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an injury of unknown source, as required for alleged abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. A female resident, admitted in January and discharged to the hospital in early April, was bedbound and dependent on staff for transfers, requiring a Hoyer lift and maximal assistance. Her MDS showed active diagnoses of age-related osteoporosis and muscle wasting/atrophy, and no documented falls since admission. Review of her electronic health record, including progress notes, orders, care plan, and assessments from admission through discharge, revealed no documentation of any fall, incident, or event that could explain traumatic injuries. When the resident was hospitalized, imaging identified multiple traumatic fractures, including right ribs 4–6, right humeral head, right glenoid/scapula, and bilateral coracoid fractures. Hospital clinical notes documented that the resident was not clear on how she received the fractures, other than stating that the sling on the Hoyer lift had split and she fell out, hitting her body on the bed and floor. The hospital social worker contacted the facility’s Marketing Director to obtain an explanation, and the Marketing Director reported, after checking with the DON, that no one at the facility knew of the resident falling or having any issues. The facility’s incident/accident log from January through April contained no entries involving a Hoyer lift transfer or any incident with this resident. Multiple staff interviews, including LVNs, RNs, CNAs, the wound care nurse, PTA, van driver, dialysis clinic supervisor, NP, and the physician, consistently reflected that the resident had no reported falls, no observed or reported unexplained bruising, and no complaints or presentation of pain suggestive of fractures while at the facility. The dialysis clinic supervisor stated the resident used a sling from the facility at the clinic and that it was not in disrepair. Central Supply reported that all Hoyer lift slings had been replaced in February and that no damaged slings had been reported since then; observation of laundered slings showed them to be in good condition. A chest x-ray performed in mid-February reportedly showed no fractures, and the NP recalled only one complaint of generalized left shoulder pain, for which a lidocaine patch was ordered. The Administrator acknowledged that he was responsible for reporting such situations to the state agency and confirmed that he did not report the resident’s fractures discovered at the hospital. He stated he was aware that, because the facility did not know how or when the injuries occurred, they were considered injuries of unknown origin. He also stated he was confused about whether to report the situation because he was unsure when or how the injuries happened. The DON reported that the resident’s POA informed her over a weekend that the resident had rib fractures of unknown cause, and that the Marketing Director later spoke with the hospital case manager and confirmed multiple fractures. The facility’s Abuse Investigation and Reporting policy required that alleged violations, including injuries of unknown source, be reported immediately, but not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury. Despite this policy and the Administrator’s acknowledgment that such injuries of unknown origin should have been reported within two hours, the facility did not report the resident’s injuries to the state survey agency as required. This failure to report an injury of unknown source involving multiple fractures, discovered after the resident’s transfer to the hospital, constitutes the cited deficiency in timely reporting of alleged abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to the appropriate authorities.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in its only kitchen. During observation of the walk-in refrigerator, an open carton of 30 eggs was found on the bottom shelf not in a dated box, a cup of prune juice was on the shelf with no date and had turned clear while also leaking, two bags of chicken were not labeled or dated, and a box of lemons was not labeled or dated with one rotten lemon inside. In the walk-in freezer, six bags of frozen mini pizzas were observed without labels or dates. The deep fryer was also observed with a thick build-up of brown and black grease and food particles around the inside edges, with grease running off the edges and down the sides and front of the equipment. A dietary cook acknowledged the fryer had old grease in it and stated it should be cleaned once a week, but the grease had not been changed for two weeks because the kitchen had been short staffed. The dietary cook stated dietary staff were responsible for cleaning the deep fryer every week. The RD acknowledged the fryer needed to be cleaned and stated a dietary aide was assigned to clean it that day. The Administrator later stated he was not aware the deep fryer was not being cleaned by dietary staff and said his expectation was that a cleaning schedule be implemented and the fryer be cleaned on a regular basis. Facility policies and the cited FDA Food Code sections reflected requirements for food storage, labeling, dating, sealing, and kitchen sanitation, including maintaining clean food-contact surfaces and proper storage of refrigerated and frozen foods.
Dumpster Door Left Open Exposing Trash
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster sites, Dumpster #1. During observation on 02/18/2026 at 10:15 AM, the dumpster lid was closed but one door was open, exposing trash, while Dumpster D had both the lid and doors closed. During interview at the same time, the Dietary [NAME] D stated kitchen staff took trash out from the kitchen and that dumpster doors and lids were supposed to be closed and the area should be clean; he stated that if not, it could look bad, be unsanitary, and could bring pests. During interview on 02/20/2026 at 4:00 PM, the Administrator stated staff were responsible for taking trash outside to the dumpsters and that the dumpster doors should be closed all the way and trash should be picked up. The facility policy stated garbage receptacles should have tight fitting lids, doors, or covers, be stored to be inaccessible to insects and rodents, and have doors/lids kept closed with no waste outside the receptacle.
Failure to Notify RP Before Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for the change, before changing the room assignment of Resident #23, affecting 1 of 5 residents reviewed for room changes. Resident #23 was a male resident with diagnoses including neurological conditions, cerebral palsy, and seizure disorder or epilepsy. His BIMS score was not completed because he was rarely or never understood. A progress note documented that he was adjusting to the room change and had no changes in sleep or behavior. Resident #23's RP stated she visited in January 2026 and found the resident was no longer in the room, requiring her to ask staff where he had been moved. She stated she was never notified by phone or given written notice of the move, and staff only told her it was for safety concerns without explaining the reason. Staff interviews showed the LVN, Social Worker, ADON, and DON each identified room changes as something that should involve family notification, but none could confirm that Resident #23's RP had been notified before the move. The facility policy stated that the resident or resident representative would receive notice, including the reason for the change, before the room or roommate was changed, using the ROOM CHANGE/NOTIFICATION FORM AD-166.
Failure to Complete Requested Swallow Study Referral
Penalty
Summary
The facility failed to complete a swallow study referral for Resident #23 after it was requested during a care plan meeting. Resident #23 was a male resident with diagnoses including neurological conditions, cerebral palsy, and seizure disorder or epilepsy. His quarterly MDS dated 12/24/25 reflected that his BIMS was not completed because he was rarely or never understood, and Section K indicated his nutritional approach was a feeding tube. His care plan, revised 02/02/26, identified a swallowing problem related to cerebral palsy, NPO status, tube feeding status, and mild protein calorie malnutrition. A progress note from the 01/29/26 care plan and PASRR meeting documented that the resident’s guardian attended by telephone and requested a new MBSS study through Speech Therapy services. The note also stated the resident would continue therapy services including PT, OT, and ST. During interviews, the resident’s guardian stated she requested the swallowing study so she could learn whether the resident was able to eat and whether the g-tube could potentially be removed, and she reported she had not heard back from the facility. Staff interviews showed the request was not followed through as expected. The assigned LVN was not aware of the swallow study request, the DOR stated he did not recall the request and confirmed no referral had been made to Speech Therapy, and the Speech Therapist stated she was not aware of any swallow study request. The Social Worker stated she attended the meeting, knew the request was made, and assumed the DOR would follow up. The DON and Administrator stated that when a family requested a swallow study, staff were expected to notify the appropriate department and complete the referral, but the referral had not been completed.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements.
Failure to Provide Ordered Behavioral Health Services Due to Missed Psychiatric Referral
Penalty
Summary
A deficiency occurred when a resident with a history of Parkinson's Disease, cognitive communication deficit, and dysarthria did not receive necessary behavioral health services as ordered. The resident exhibited signs of depression and moderate cognitive impairment, as indicated by a BIMS score of 12 and a mood interview score suggesting moderate anxiety or depression. Family members reported concerns about the resident's mental state, including depression, delirium, confusion, and possible hallucinations. These concerns were communicated to facility staff, and a nurse practitioner (NP) gave a verbal order for a psychiatric consultation after assessing the resident for depression and anxiety. Despite the NP's verbal order for a psychiatric consult, the order was not properly entered into the facility's system. The LPN who received the order documented it in the progress notes but failed to input it into the electronic system, which was necessary for the referral to be processed. The social worker, who would typically arrange for such services, was not made aware of the order and did not receive any complaints or information regarding the resident's need for psychiatric services. As a result, no psychiatric consultation was scheduled or provided, and there was no follow-up documented regarding the order. Interviews with facility staff, including the administrator, DON, social worker, and LPN, revealed a breakdown in communication and process. The staff acknowledged that the verbal order was missed and that the resident did not receive the psychiatric services as intended. The facility's policy required collaboration between nursing and social services to arrange ordered services and documentation of referrals, but this process was not followed in this instance, resulting in the resident not receiving the necessary behavioral health care.
Failure in Pest Control Program Leads to Resident Ant Bites
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant deficiency involving fire ants. On October 21, 2024, a resident was found in bed with fire ants on his body, having been bitten multiple times on his torso, arms, and legs. This resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was unable to call for help due to his condition. The presence of food crumbs in the resident's bed was noted, which may have attracted the ants. Interviews with staff revealed that the resident was discovered by a CNA, who found numerous ants on the bed and the resident. The Wound Care Nurse, who was present at the time, confirmed the presence of ants and noted bites on the resident's body. Despite the immediate response to clean the resident and remove the ants, the incident highlighted a lapse in the facility's pest control measures, as ants were found in multiple areas of the facility, including active ant mounds outside the building. Further observations and interviews indicated that the pest control service was called after the incident, and treatments were conducted. However, the presence of active ant mounds along various halls and the exterior of the facility suggested that the pest control program was not sufficiently proactive or effective in preventing pest entry and infestation. The facility's pest control policy, which mandates ongoing pest control measures, was not adequately implemented, leading to the deficiency.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a final summary of a resident's status was available for release to authorized persons and agencies at the time of discharge, with the consent of the resident or their representative. This deficiency was identified for one resident who was reviewed for discharge summary. The resident, a male with moderate cognitive impairment, had been admitted to the facility with diagnoses including orthopedic conditions, cancer, and diabetes. Upon discharge, the resident was to receive home health services, including physical therapy and other treatments managed by a home health nurse. However, the discharge summary for this resident was incomplete and blank, as noted in the resident's chart under the Assessments section. The Director of Nursing (DON) confirmed that the discharge summary is typically completed by the discharging nurse and is essential for providing directions for post-discharge care. The absence of a completed discharge summary could result in the resident missing follow-up appointments or not understanding necessary post-discharge care instructions.
Failure to Incorporate PASARR Recommendations
Penalty
Summary
The facility failed to incorporate recommendations from the PASARR Level II determination and evaluation report for two residents. For one resident, the facility did not submit a Nursing Facility Specialized Services (NFSS) form by the required deadline. This resident had a PASRR positive status related to an intellectual disability and required a customized manual wheelchair as part of their treatment plan. Despite the initiation of the process to obtain the wheelchair, the facility did not make progress within the required timeframe, partly due to staff changes and lack of follow-up. Another resident, who was diagnosed with schizoaffective disorder, was not referred to the appropriate state-designated mental health authority for review. The resident's PASRR Level 1 Screening did not reflect the new diagnosis, and the facility failed to update the PASRR evaluation accordingly. The MDS Coordinator, who was responsible for submitting PASRR updates, was unaware of the need for a new evaluation due to the diagnosis change, as she was not employed at the time of the diagnosis. The facility's policy required timely submission of PASRR updates when a resident's diagnosis changed. However, the MDS Coordinator did not complete an audit on PASRRs upon employment, which contributed to the oversight. The administrator confirmed that MDS Coordinators were responsible for updating PASRR assessments but had no information regarding the specific resident's PASRR status.
Deficiencies in Enteral Feeding Management
Penalty
Summary
The facility failed to ensure proper management of enteral feeding for two residents, leading to deficiencies in their nutritional care. Resident #44, a male with a history of stroke, dementia, and dysphagia, was not provided with the prescribed amount of enteral nutrition. RN E, who had recently started working at the facility, misread the physician's orders and administered only one carton of formula instead of the required two during bolus feedings. This error persisted for three days, potentially compromising the resident's nutritional intake. The Director of Nursing (DON) and the dietitian acknowledged the risk of inadequate nutrition due to this oversight. Resident #84, a female with severe cognitive impairment and dysphagia, was also affected by improper enteral feeding management. Her tube feeding machine was observed to be off during scheduled feeding times on multiple occasions. LVN O and LVN SS, responsible for the resident's care, failed to ensure the machine was turned on at the correct times, resulting in the resident not receiving the full 20 hours of prescribed nutrition. This lapse in care was attributed to miscommunication and assumptions between the nursing staff during shift changes. The facility's policies on enteral nutrition and tube feeding were not adequately followed, as evidenced by the discrepancies in the administration of feeding orders for both residents. The DON admitted to a lack of training on g-tube feeding and acknowledged the need for staff to adhere to physician orders to prevent nutritional deficiencies. The facility's failure to provide the necessary nutritional support as per the residents' care plans and physician orders posed a risk of weight loss and inadequate nutrition for the affected residents.
Failure to Implement Pharmacist's Dose Reduction Recommendation
Penalty
Summary
The facility failed to act upon drug regimen irregularities reported by the Pharmacist Consultant for a resident reviewed for unnecessary medications. The Pharmacist Consultant recommended a dose reduction for the resident's Olanzapine from 10 mg to 5 mg, which the physician agreed to. However, the medication continued to be administered at 10 mg, contrary to the physician's order. This oversight was identified during a review of the resident's medication administration records, which showed the resident received the higher dose from January through July. The resident, a male with intact cognition, had active diagnoses including heart failure, hypertension, unspecified dementia, schizophrenia disorder, and bipolar disorder. Interviews with the resident and the Director of Nursing (DON) revealed that the resident believed he was receiving all his medications, although he could not recall specifics. The DON acknowledged the oversight, stating there was no documentation explaining why the dose reduction was not implemented and admitted it was a mistake on her part. The facility's policy required gradual dose reductions and behavioral interventions for antipsychotic drugs unless clinically contraindicated, which was not followed in this case.
Lack of Physician Order for Hospice Care
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services had a physician order for hospice care, which is a requirement for proper treatment and care in accordance with professional standards of practice. The resident, a female with a moderate to mild cognitive impairment, was admitted with multiple diagnoses including chronic obstructive pulmonary disease and diabetes mellitus. Despite being on hospice services through a specific company, there was no documented physician order for hospice care in the resident's records. This oversight was confirmed through interviews and record reviews, highlighting a gap in the facility's adherence to its own policy requiring such orders. Interviews with facility staff, including an LVN and the DON, revealed a lack of awareness and adherence to the facility's policy regarding hospice care orders. The LVN acknowledged the importance of having a hospice order to ensure proper communication and medication management, while the DON admitted to not being aware of the policy and acknowledged that the resident was overlooked. The facility's hospice program policy did not address the need for physician orders, further contributing to the deficiency. This lack of documentation and oversight could potentially result in residents not receiving the necessary care as ordered by their physician.
Failure to Report Neglect and Misappropriation Incidents
Penalty
Summary
The facility failed to implement its policies and procedures to prevent neglect and misappropriation in two separate incidents involving residents. In the first incident, a resident with severe cognitive impairment and physical disabilities was found in bed with fire ant bites on his abdomen. Despite the presence of ants and the resident's inability to call for help, the facility did not report the incident to the State Survey Agency as required by their policy. Interviews with staff revealed that the resident was dependent on staff for all activities of daily living and had communication difficulties due to aphasia. The presence of food crumbs in the resident's bed was noted, and pest control measures were taken after the incident. In the second incident, the facility's administrator, who also served as the Abuse Prevention Coordinator, failed to report an allegation of misappropriation of a resident's property to the State Survey Agency. A resident's family reported missing personal items, including a phone and wallet, after the resident was discharged. The administrator conducted an internal search and interviewed staff but did not find the items. Despite the family's filing of a police report, the administrator did not report the incident to the State Survey Agency, citing a lack of belief that the items were stolen and a lack of knowledge of the facility's policy on such allegations. These failures to report incidents of neglect and misappropriation as per the facility's policy could place residents at risk of continued abuse and neglect. The facility's policy requires all alleged violations, including neglect and misappropriation, to be promptly reported to relevant agencies and thoroughly investigated. The administrator's lack of adherence to this policy and the failure to report these incidents highlight significant deficiencies in the facility's handling of such matters.
Failure to Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report two incidents involving residents to the State Survey Agency as required by state law. In the first incident, a resident with severe cognitive impairment and physical disabilities was found in bed with fire ant bites on his abdomen. The resident was unable to call for help due to his condition. Staff, including a CNA and a wound care nurse, discovered the ants and bites, and the resident was treated with Benadryl. However, the incident was not reported to the State Survey Agency, which is a violation of the facility's abuse and reporting policy. In the second incident, a resident's family reported missing personal items, including a phone and wallet, after the resident was discharged. The facility's administrator, who was also the Abuse Prevention Coordinator, conducted an internal search and interviewed staff but did not report the alleged misappropriation to the State Survey Agency. The administrator believed the items were not stolen and was unaware of the facility's policy requiring such allegations to be reported. This oversight represents a failure to adhere to the facility's policy on reporting allegations of misappropriation. Both incidents highlight the facility's failure to follow established procedures for reporting allegations of abuse, neglect, and misappropriation. The lack of timely reporting to the State Survey Agency could place residents at risk of continued abuse and neglect. The facility's policy clearly states that all alleged violations must be reported promptly to the appropriate authorities, yet this was not done in these cases.
Failure to Follow Fall and Wound Care Protocols
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically for two residents. One resident, who had severe cognitive impairment and a history of falls, fell from her wheelchair onto a hard-wood floor and sustained a head injury. Despite the presence of blood and the resident's moaning, a non-nursing staff member, who was not trained on fall response, picked her up and placed her in a wheelchair before a nurse could assess her. Subsequently, a CNA wheeled the resident away from the scene to the nurse's station, further delaying the necessary medical assessment. The incident revealed a lack of training and understanding among staff regarding the proper protocol for handling falls. Interviews with various staff members, including the DON and the Administrator, confirmed that the non-nursing staff member was not aware of the correct procedure, which is to leave the resident in place until a nurse can perform an assessment. The facility's policy requires that a nurse assess a resident after a fall before any movement to prevent further injury, but this protocol was not followed in this case. Additionally, the facility failed to adhere to its wound care policy for another resident, who had multiple pressure ulcers and arterial wounds. The dressings on this resident's wounds were not dated as per facility policy, which could lead to missed dressing changes and potential worsening of the wounds. The Wound Care Nurse admitted to forgetting to date the dressings, and the DON acknowledged that this oversight could hinder timely dressing changes. The facility's policy mandates that wound dressings be dated to ensure proper monitoring and care.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, specifically for a newly identified wound on the sacral area. The resident, an elderly female with a history of pressure ulcers and multiple health conditions including malnutrition and dementia, was observed to have a wound on the sacral area that was not properly documented or treated according to professional standards. The wound was initially noted by a CNA, who reported it to an LVN, but the information was not effectively communicated to the Wound Care Nurse or documented in the resident's clinical records. The LVN received an order from the Nurse Practitioner to cleanse the wound and apply a dressing, but failed to generate the order in the system, leading to a lack of formal documentation and communication among the nursing staff. The Wound Care Nurse was unaware of the wound until a later date, indicating a breakdown in communication and documentation processes. The facility's 24-hour report and change of condition report mentioned the wound, but the Wound Care Nurse did not review the paper form of the report, contributing to the oversight. The Director of Nursing acknowledged the failure in communication and documentation, noting that the lack of treatment could lead to infection and worsening of the wound. The facility's current wound care policy requires physician orders for wound care procedures, but this was not adhered to in this case, resulting in a deficiency in the care provided to the resident.
Failure in Medication Administration: Patch Removal
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident. Specifically, a Licensed Vocational Nurse (LVN) did not follow physician orders for administering a Scopolamine Transdermal Patch to a resident. The resident, who had severely impaired cognition due to myopathy and dementia, was found with two Scopolamine patches on her right ear, dated three days apart. The LVN admitted to applying the new patch without removing the old one, acknowledging the risk of overmedication and skin irritation. The Director of Nursing (DON) confirmed that the expectation was for nurses to remove the old patch before applying a new one to prevent overdose. However, the facility's current Pharmacy Services policy, dated April 2007, did not address the administration and removal of patches. Additionally, while the LVN had undergone skill checks, there was no dated training specifically on patch removal, and the facility had not provided in-service training on this aspect of medication administration.
Failure to Provide Pureed Bread for Resident on Pureed Diet
Penalty
Summary
The facility failed to adhere to the prescribed menu for a resident on a pureed diet during the lunch meal on November 13, 2024. Specifically, the resident, who had a medical history including congestive heart failure, dysphagia, muscle wasting, malnutrition, and renal insufficiency, did not receive pureed bread as required by her dietary orders. The resident's care plan emphasized the need for a pureed diet with nectar thick liquids to maintain adequate nutritional status and prevent malnutrition. However, observations revealed that the dietary staff did not puree the dinner roll, which was part of the lunch menu. Interviews with the dietary staff and management highlighted a lack of adherence to the facility's policy, which mandates that all diet forms, including regular, pureed, and mechanical soft, should receive the same menu items in different textures. The dietary manager, who was new to the facility, acknowledged the oversight and the importance of following the menu to prevent negative health outcomes. The dietician confirmed that the menu was designed to meet the nutritional needs of residents and that deviations could lead to adverse clinical outcomes.
Inadequate Discharge Protocols for Resident with Alleged Inappropriate Behavior
Penalty
Summary
The facility failed to adhere to proper discharge protocols for a resident, identified as Resident #1, who was discharged without sufficient preparation and documentation. Resident #1, a male with a history of atrial fibrillation, coronary artery disease, diabetes, and cognitive impairment, was accused of inappropriate behavior towards another resident, Resident #2, who had vascular dementia and impaired cognitive skills. Despite the allegations, the facility did not provide adequate documentation or preparation for Resident #1's discharge, which was executed immediately with police assistance, citing him as an immediate threat to other residents. The facility's records indicated that Resident #1 had a history of entering female residents' rooms and engaging in inappropriate behavior, such as hugging and kissing, which led to a 30-day discharge notice in November. However, this notice was appealed and reversed. On the day of the incident, Resident #1 was observed by the Social Worker and DON engaging in behavior deemed inappropriate with Resident #2, who was unable to consent due to cognitive impairments. Despite previous warnings and monitoring, the facility decided on an immediate discharge during a state survey, citing an Immediate Jeopardy situation. Interviews with staff, including the Social Worker, DON, and Administrator, revealed that Resident #1 had been previously warned about his behavior and was under monitoring. However, the facility's decision to discharge him immediately was influenced by the presence of state surveyors and the ongoing Immediate Jeopardy citation. The facility's policy on discharging residents was not followed, as there was no evidence of consultation with Resident #1 about the discharge, and the appeal process was not adequately addressed.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to properly notify a resident, their representative, and the Office of the State Long-Term Care Ombudsman about the resident's discharge, including the reasons for the move, in a language and manner they understood. This deficiency was identified during a review of the discharge process for a resident who was involved in an incident of inappropriate behavior. The resident, an elderly male with a history of atrial fibrillation, coronary artery disease, diabetes, difficulty walking, and a history of prostate cancer, was discharged without the required notifications being sent to the Ombudsman. The incident leading to the discharge involved the resident being observed by a social worker engaging in inappropriate behavior with a female resident who was unable to consent. The facility's administrator was informed, and the resident's son was contacted to arrange for the resident's immediate discharge. The resident had a history of similar behaviors and had previously received a 30-day discharge notice, which he appealed and won. However, due to the immediate nature of the incident and the presence of state surveyors, the facility decided on an immediate discharge. Interviews with the social worker and the administrator revealed that there was confusion and oversight regarding the notification process to the Ombudsman. The social worker believed she had sent the discharge notice but could not find evidence of it, while the administrator admitted to not sending a written notice due to being occupied with another immediate jeopardy situation. The Ombudsman confirmed that she did not receive the required notification, highlighting a lapse in the facility's adherence to its discharge policy.
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What surveyors actually found near you
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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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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) |
|---|---|---|---|---|
| Willow Ridge Wellness & Rehabilitation | 1.5 mi | ★★★★★ | 3 | 1 |
| White Settlement Nursing Center | 1.6 mi | ★★★★★ | 6 | 0 |
| West Side Campus Of Care | 2.1 mi | ★★★★★ | 7 | 0 |
| Arlington Heights Health And Rehabilitation Center | 2.4 mi | ★★★★★ | 12 | 1 |
| Stonegate Nursing And Rehabilitation | 3.2 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.