Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rockwall Nursing Care Center during CMS and state inspections, most recent first.
Privacy and confidentiality were not maintained when an RN left residents’ vital signs, blood sugars, and dialysis information exposed on an unattended cart where others could see it. An ADON provided wound care to a resident with a post-surgical abdominal wound without closing the door or pulling the privacy curtain while the roommate was present, and an RN checked a resident’s blood sugar and gave insulin without closing the door. Staff acknowledged the exposed information and open-door care were not private and could be HIPAA violations.
Unclean Resident Rooms and Shower Room: Multiple resident rooms in the memory care unit had built-up dirt and stains on floors, bathroom surfaces, walls, sinks, and around toilets, and a shower room on the 100 Hall had dark stains along the shower floor and entry. Housekeeping, a floor tech, and the Housekeeping Supervisor described ongoing cleaning limitations and inconsistent cleanup of urine and bodily fluids, while the DON and Administrator acknowledged the rooms and shower room were expected to be cleaned and sanitized.
A facility failed to provide safe respiratory care for three residents. One resident on ordered oxygen had her nasal cannula disconnected from the concentrator, connected to an O2 tank, and titrated by a CNA to 3 L/min without a nurse present, while two residents receiving nebulizer treatments had their mask and mouthpiece left hanging or on a walker instead of being properly bagged and stored. Nursing leadership stated oxygen titration was a nursing responsibility and nebulizer equipment should be bagged and dated.
A facility failed to keep medications and biologicals secured and out of resident rooms. Surveyors observed Tylenol, eyedrops, antibiotics, toothache cream, multivitamins, and zinc oxide barrier creams left on overbed tables, sinks, and shelves for several residents, none of whom had documented self-administration assessments. Staff interviews showed inconsistent understanding of medication storage, with some staff acknowledging the items should be secured while one LVN stated residents could keep medications in their rooms.
Kitchen Food Storage and Sanitation Deficiencies: The facility failed to maintain proper food storage and sanitation practices in the kitchen. Surveyors observed a trash can with a hole in the lid, an ice machine with stains, a deep fryer with brownish substances floating in the oil, and sugar/thickener bins with brownish stains. Several frozen food items were not dated when received, and a tea dispenser was left uncovered after brewing. The DM and Administrator acknowledged the concerns and stated they expected food to be labeled, dated, and equipment to be cleaned.
Call Light Not Within Reach: A resident with severe cognitive impairment, muscle weakness, repeated falls, and a fall-risk care plan had her call light observed on the floor and out of reach while lying in bed. RN, DON, and ADON staff stated the call light needed to be within reach so the resident could contact staff if help was needed.
Care plans lacked weekly wound assessment interventions for two residents with active wounds. One resident had venous wounds and severe cognitive impairment, and the other had non-pressure wounds and severe cognitive impairment; both had weekly wound assessments documented in the clinical record, but their comprehensive care plans did not include that intervention. The ADON/Treatment Nurse and DON stated the residents required weekly skin assessments to monitor healing and prevent worsening, but the care plans did not reflect the frequency.
A resident on O2 had a leaking tank that CNA F continued to adjust after hearing hissing, until another CNA called RN B to stop it. In another room, tools including a screwdriver, wrenches, and screws were left unattended and within reach of a cognitively intact resident on hospice. RN B also left a container of germicidal wipes on top of her cart while providing care, leaving chemical wipes unsecured instead of locked inside the cart.
Improper Perineal Care During Incontinence Assistance: A resident with bowel and bladder incontinence, overactive bladder, and moderate cognitive impairment received incontinent care in which a CNA reused a wipe that had already touched the resident’s soiled bottom to clean the perineal area again. Staff interviews and facility policy confirmed that used wipes should not be reused during perineal care and that care should be provided clean to dirty using a new wipe for each stroke.
A CNA reused a wipe during incontinent care for a resident with bowel and bladder incontinence, and a medication aide did not sanitize a BP cuff between checking BP for two residents with HTN. Staff acknowledged the wipe should not have been reused and the cuff should have been sanitized after use, and facility policy required universal precautions and an infection control program to prevent the spread of infection.
Pharmaceutical services were not provided consistently for several residents. Two deceased residents had PRN morphine documented on the controlled med sign-out sheet, but the MARs were not signed after administration. In addition, medication blister packs for two residents did not match the ordered indication for use, one med cart contained personal items such as candy, deodorant spray, and lotion, and another cart contained an expired COVID-19 test strip. Staff stated MARs must be signed for all meds, PRN meds require follow-up assessment, and blister packs should match the physician order.
The facility failed to keep call lights within reach for three cognitively impaired residents with dementia, Alzheimer’s disease, anxiety, mobility limitations, and extensive ADL assistance needs. Observations showed one resident’s call light stored in a closed nightstand drawer blocked by a bedside table, another resident’s call bell lying across a nightstand out of reach, and a third resident’s call bell on a nightstand on the floor, also out of reach. Each resident’s care plan required the call light to be placed within reach and its use encouraged. Staff, including CNAs, LVNs, the DON, and the Administrator, acknowledged that facility policy mandates call bells be accessible to all residents at all times to allow timely assistance, yet the observed call light placements did not follow these requirements.
Surveyors found that two residents with Alzheimer’s disease, severe cognitive impairment, and dependence for ADLs had visibly stained privacy curtains, one with large brown stains and one with red stains, despite staff and leadership (including CNAs, LVNs, the DON, and the Administrator) stating that all staff were responsible for identifying and reporting housekeeping needs during rounds to maintain a clean, homelike environment in accordance with the facility’s infection control program.
Two residents with severe cognitive impairment and significant ADL dependence received perineal care from an LVN who did not follow infection control practices, including failing to change gloves between dirty and clean tasks, not performing hand hygiene between glove changes, and moving a bedside table between rooms without sanitizing it or changing the linen covering, contrary to facility policy and staff training.
The facility failed to maintain an effective pest control program on a secure male hall, where gnats were observed in two residents’ rooms and had reportedly been an ongoing issue. An LVN, a CNA, and housekeeping staff confirmed the persistent presence of gnats on the hall and in resident living areas, and leadership, including the DON and administrator, acknowledged awareness of the problem. Pest control service records over several months showed multiple visits treating for other pests but not specifically for gnats, and internal reports from the hall documented staff observations of water bugs and gnats that were not addressed, contrary to the facility’s insect and rodent control policy.
A resident with cervical spina bifida, paraplegia, and an indwelling urinary catheter was care-planned for enhanced barrier precautions, requiring staff to wear a gown and gloves for high-contact care such as incontinence care. Despite clear signage at the room entrance and available PPE, a CNA provided incontinence care wearing only gloves and later stated she believed gowns were needed only for certain infections or infected wounds. The resident reported that some staff used both gown and gloves during incontinence care while others did not, and nursing leadership confirmed that enhanced barrier precautions and the facility’s policy required gown and glove use for residents with indwelling devices during such care.
Two residents with severe cognitive impairments were involved in an incident where one slapped the other in the face. The resident who committed the act had a history of behavioral symptoms and poor impulse control, and the event was indirectly witnessed by staff after a noise and a report from another resident. Both residents were unable to recall the incident due to cognitive deficits, and the facility failed to prevent this occurrence despite documented behavioral risks.
Two residents with severe cognitive impairment and behavioral issues were involved in an incident where one slapped the other, which was not directly witnessed by staff but reported by a CNA and another resident. The affected resident could not recall the event due to cognitive deficits. The facility did not effectively implement its abuse prevention policies, resulting in a failure to prevent and immediately identify the abuse.
A CNA operated a mechanical lift alone to transfer a resident with obesity and muscle weakness, contrary to the care plan and facility policy requiring two staff. This resulted in the lift collapsing and the resident sustaining five fractured ribs. Staff interviews and documentation confirmed that two-person assistance was required for all mechanical lift transfers.
Two residents with significant physical and cognitive impairments were found without accessible call lights, despite care plans and staff expectations requiring call lights to be within reach. Staff interviews confirmed the importance of call light accessibility and routine checks, but observations showed that both residents' call lights were not accessible at the time of the survey.
Three residents who required respiratory care had their breathing devices, such as nebulizer masks, nasal cannulas, and inhalers, improperly stored when not in use, including being left unbagged on furniture, on the floor, or inside a nightstand. Nursing staff and leadership confirmed that these devices should be bagged to prevent infection, in accordance with facility policy.
Three residents with significant cognitive and physical impairments were found to have call lights placed out of reach, despite care plans requiring accessibility due to their high risk for falls and need for assistance. Staff interviews confirmed the expectation to keep call lights accessible, but lapses occurred during care, and no specific facility policy addressed call light placement.
The facility failed to maintain safe wheelchair conditions for four residents, leading to cracked armrests with exposed foam. Despite routine inspections, there was no documentation of repair requests for these wheelchairs. Staff interviews revealed inconsistencies in the reporting and repair process, indicating a lack of clear procedures and communication.
The facility's kitchen failed to meet food service safety standards, with issues such as unlabeled and undated food items, expired whipping cream, and improperly sealed open food in refrigerators. Interviews with the DM and DC confirmed expectations for proper labeling and storage, emphasizing risks of foodborne illness and allergic reactions. Observations and policy reviews highlighted the need for adherence to food safety protocols.
The facility failed to maintain a safe and functional environment, with deficiencies found in two resident rooms and a hallway. A resident's bathroom had a loose grab bar and exposed flooring, while another resident's sink had no running water. In the secure unit hallway, a handrail was missing endcaps, exposing sharp edges. Staff interviews revealed a lack of awareness and communication regarding these issues, with no reports found in maintenance logs or the new phone app.
The facility failed to protect resident confidentiality when an LVN left a computer unlocked and unattended on a medication cart, displaying resident medications. This occurred on the female locked unit while the LVN assisted residents, leaving the computer exposed to unauthorized access. The LVN acknowledged the need to lock the computer but underestimated the risk. Facility policy requires resident information to be kept confidential.
A resident with Alzheimer's and a history of falls was observed walking with improperly worn shoes, increasing fall risk. Despite a care plan intervention to ensure proper footwear, the resident often dressed herself incorrectly, and staff only intervened if allowed. The facility's policy emphasized the importance of proper footwear to prevent falls.
A medication cart was found unlocked and unattended in a facility, making medications accessible to residents and staff. LVN A, who was responsible for the cart, acknowledged the oversight but did not believe residents would tamper with it. The facility's policy requires carts to be locked when not in use.
A resident with severe cognitive impairment and a history of falls was left unsupervised in the dining room, resulting in a fall from his wheelchair and a bilateral subdural hematoma. Despite having a care plan that identified him as a fall risk, the facility failed to provide adequate supervision and interventions, leading to multiple falls throughout the year.
A facility failed to ensure a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. The resident, with diagnoses including dementia and acute kidney failure, had a care plan indicating a risk for multiple falls. The last care plan conference was held several months prior, and the subsequent quarterly meeting was not conducted. The Social Worker, responsible for scheduling these meetings, admitted to overlooking it, and the Administrator confirmed there was no reason for the oversight.
A resident with severe cognitive impairment and frequent incontinence did not receive a urine analysis (UA) as ordered by a physician due to multiple failed collection attempts and lack of communication with the nurse practitioner. The UA was canceled after three failed attempts, and the facility lacked specific policies for handling such situations. The resident was later diagnosed with a UTI during a hospital visit.
The facility failed to treat two residents with respect and dignity. An LVN yelled and slammed her hand on a table to redirect a cognitively impaired resident, while another resident reported being spoken to in a demeaning manner and often ignored by staff. The administrator confirmed that such actions could violate resident rights.
The facility failed to follow its smoking safety policies, resulting in a resident with severe cognitive impairments being left unsupervised while smoking. Miscommunication and misunderstanding among staff led to the resident being without direct supervision, contrary to the facility's smoking policy.
The facility failed to post daily nurse staffing information, leaving outdated information from April. The ADON admitted responsibility and acknowledged the oversight, which could prevent residents from accessing current staffing data and facility census information.
Privacy and Confidentiality Failures During Care and Documentation
Penalty
Summary
The facility failed to protect residents’ privacy and keep medical information confidential during care and treatment for multiple residents. On 03/24/2026, an untitled paper was observed left on top of an unattended cart in the hallway with residents’ names and medical information written on it, including vital signs and blood sugars for several residents. The cart was facing the hallway while staff and residents passed by, and the Administrator later flipped over the paper. RN B stated she usually wrote residents’ vital signs and blood sugars on paper before entering them into PCC and said she should have flipped the paper over or placed it under her laptop so the information would not be exposed. On 03/25/2026, ADON A was observed providing wound care to a cognitively intact resident with a post-surgical abdominal wound while the roommate was in the room. ADON A did not close the door and did not pull the privacy curtain during the wound treatment. During interview, she stated she should have closed the door and pulled the privacy curtain because the treatment could be seen from the hallway and by the roommate, and she acknowledged the resident might be embarrassed if others could see the wound care being provided. Also on 03/25/2026, RN B was observed checking a resident’s blood sugar and administering insulin without closing the door. The resident had diabetes mellitus and was receiving insulin. RN B entered the room with the glucometer, test strips, alcohol wipes, and lancets, checked the blood sugar, prepared the insulin, and administered it without closing the door. In a separate observation, a dialysis communication report containing another resident’s respiratory rate, access findings, bleeding at the port, pain, and infection status was left on top of a medication cart while the resident’s driver stood beside it. RN B stated she forgot to flip the form over before getting the resident’s blood pressure and acknowledged the information could be a HIPAA violation. The DON and Administrator stated that resident medical information should be protected and that residents should receive privacy during care and treatment.
Unclean Resident Rooms and Shower Room
Penalty
Summary
The facility failed to ensure resident rooms in the memory care unit and one shower room were thoroughly cleaned and sanitized. During observations, seven resident rooms had built-up dirt in the corners of door frames and floors, with multiple rooms showing gray, brown, dark, white, and greenish stains on bedroom floors, bathroom floors, walls, sinks, and around toilets. One room also had a toilet tank cover that did not fit properly, exposing part of the inside of the tank. The shower room on the 100 Hall was observed with dark stains along the edges of the shower floor and along the door entry. The observations showed that the cleaning concerns were present in multiple resident rooms and in the shower room, with stains and dirt noted in several areas of the rooms and bathrooms. The report identified these conditions in rooms [ROOM NUMBER], #2, #3, #4, #5, #6, #7, and #8. During interviews, the Housekeeper stated housekeeping was responsible for cleaning the entire resident rooms, including mopping floors and cleaning bathrooms, and said some residents urinated on the floor but nursing staff did not always clean it immediately. She also stated her cleaning tools were not effective and that floor techs were responsible for deep cleaning floors. The Floor Tech stated he cleaned the memory care floors daily and deep cleaned at least weekly, but the machines were too large to clean the corners and he did not have other equipment for that. The Housekeeping Supervisor and Administrator both stated the rooms and shower room were expected to be cleaned and sanitized, and the Administrator stated unclean areas could affect residents' ability to have a clean homelike environment.
Respiratory equipment and oxygen were not managed per orders and facility practice
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for three residents who were receiving oxygen or nebulizer treatments. Resident #9 had diagnoses including dependence on renal dialysis and obesity, a quarterly MDS showing moderately impaired cognition with a BIMS of 11, and a care plan and physician order for oxygen at 2 L/min via nasal cannula. During an observation, CNA F disconnected the resident’s nasal cannula from the oxygen concentrator, connected it to an oxygen tank on the wheelchair, and then adjusted the oxygen to 3 L/min after the resident requested it, while no nurse was present in the room. Resident #38 had COPD and asthma, with a BIMS score of 07 and a physician order for ipratropium-albuterol nebulizer treatments four times daily. During an observation, the resident was awake in bed and his nebulizer mask was seen hanging on a shelf and not properly stored. The resident stated he usually left it there after treatment and that the nurse sometimes put it in the bag. Resident #67 had COPD, a BIMS score of 13, and a physician order for albuterol nebulizer treatments every morning and bedtime. During an observation, the resident was awake in bed and the nebulizer mouthpiece was observed on the walker and not properly stored. The resident stated she usually left it there when the medication in the nebulizer ran out. Interviews with nursing leadership stated that nurses were responsible for titrating oxygen and that nebulizer masks should be bagged and dated, with CNAs expected to notify nurses if equipment was not properly stored.
Medications and Barrier Creams Left in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and kept out of resident rooms for multiple residents. During observations, surveyors found an extra strength Tylenol container, eyedrops, a tube of antibiotics, and a tube of toothache cream on Resident #5’s overbed table; a container of multivitamins in Resident #49’s room; and vials of eyedrops on Resident #67’s shelf. None of these residents had an assessment for self-administration of medications documented in the records reviewed. Surveyors also observed barrier creams left in resident rooms. A tube of zinc oxide was found on Resident #10’s side table, two tubes of zinc oxide were found on Resident #32’s side table, a tube of zinc oxide was on top of Resident #46’s sink, a tube of zinc oxide was on Resident #76’s side table, and a tube of zinc oxide was on Resident #77’s side table. Resident #32 had severe cognitive impairment with a BIMS score of 00 and was incontinent of bowel; Resident #46 was cognitively intact with a BIMS score of 14 and was incontinent of bowel and bladder; Resident #76 was cognitively intact with a BIMS score of 13 and was incontinent of bowel and bladder; and Resident #77 was moderately cognitively impaired with a BIMS score of 12 and was incontinent of bowel and bladder. Interviews with staff showed that the facility expected medications not to be kept in resident rooms and that outside medications should be stored in the medication cart unless properly ordered and assessed. However, an LVN stated residents had the right to keep medications in their rooms, and a CNA stated zinc oxide had been left in the room after incontinent care. The DON, ADON, RN, and Administrator all acknowledged that medications, including eye drops, antibiotics, toothache cream, multivitamins, and barrier creams, should not be left in resident rooms and should be secured in the medication cart or otherwise stored by authorized staff.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. During observations in the kitchen, a large trash can had trash in it and the lid had a large hole cut into it. The ice machine had stains along the inside panel wall, and the deep fryer contained light brownish substances floating on top of the cooking oil. Two large white storage bins containing sugar and thickener had brownish stains along the opening and inside of the bins. The surveyor also observed multiple food storage issues in the freezer. Three large packages of tater tots and one large package of fries were not dated with the month, day, and year they were stored upon receipt from the vendor. During another observation, the tea dispenser in the kitchen area was uncovered and had a small amount of tea remaining in it after brewing. A Kitchen Aide stated he had prepared the tea earlier that morning and did not know how not covering the tea once it was finished brewing could impact residents. The Dietary Manager stated she had only been the DM for two weeks and said the Maintenance Director had placed the trash can with the hole cut into the lid in the kitchen area. She stated she had told the night cook to ensure the deep fryer was cleaned out at the end of the night, that she cleaned the bins weekly, that she cleaned the ice machine weekly, and that she had reminded staff to label and date food when received from the vendor and to cover the tea dispenser once brewing was finished. The Administrator stated he expected all foods to be labeled and dated correctly and kitchen equipment to be cleaned, and that not addressing the concerns could result in food contamination.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure reasonable accommodation of Resident #63’s needs and preferences when the call light in her room was not kept within her reach. Resident #63 was a [AGE]-year-old female admitted on [DATE] with diagnoses of repeated falls and lack of coordination. Her Initial MDS Assessment dated 02/25/26 reflected a BIMS score of 7, indicating severe cognitive impairment, and also noted muscle weakness and the need for moderate assistance with ADLs. Her comprehensive care plan dated 03/18/26 identified her as a fall risk and included an intervention to ensure the call light was within reach. During an observation on 03/24/26 at 11:54 a.m., Resident #63 was lying in bed and her call light was observed on the floor near her nightstand and out of reach. RN P later confirmed that the call light needed to be within reach so the resident could contact staff if help was needed and stated that, as a fall risk, bending down to retrieve it could cause injury. The DON and ADON E were also informed of the observation and stated that all residents were to have their call lights within reach when in bed so they could contact staff if needed.
Care plans lacked weekly wound assessment interventions for two residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents with wounds, including measurable objectives and timeframes to meet their identified medical and nursing needs. Resident #47, an older male with anemia and dementia and a BIMS score of 4, had venous wounds on the left dorsal foot, left shin, and right foot, and his clinical record showed weekly wound assessments on 03/17/26 and 03/24/26. Resident #83, an older male with dementia and a BIMS score of 2, had non-pressure wounds on the left toe, left elbow, and right heel, and his clinical record showed weekly wound assessments on 03/11/26, 03/17/26, and 03/24/26. For both residents, the comprehensive care plans did not include an intervention for weekly wound assessments. During observations on 03/24/26, Resident #47 was seen with wounds on both feet and the left shin, and Resident #83 was seen with wounds on the left arm and both feet. The ADON/Treatment Nurse stated both residents required weekly skin assessments because of their wounds, and the DON stated the residents required weekly skin assessments to ensure the wounds were healing and not becoming worse, but the care plans did not reflect the weekly assessment frequency.
Hazards left accessible in resident areas and during care
Penalty
Summary
The facility failed to keep Resident #9’s oxygen equipment free from a leaking condition during a transfer. Resident #9 was a female resident with dependence on renal dialysis, obesity, moderate cognitive impairment with a BIMS score of 11, and an order for oxygen at 2 L/min via nasal cannula. During the transfer to her wheelchair, CNA F replaced the oxygen tank, connected the regulator, and turned the cylinder valve on, which produced a hissing sound. She turned it off, then later turned it on again after the resident was seated, and it again produced a hissing sound. The resident indicated that no oxygen was coming through the nasal cannula, and CNA F continued trying to adjust the tank instead of stopping the process when the hissing continued. CNA G recognized that the tank sounded like it was leaking and left the room to call RN B. RN B then turned off the oxygen tank and fixed the regulator. During interview, CNA G stated she called the nurse because the oxygen tank was making a sound and looked like it had a leak. CNA F stated she should have called the nurse when she first heard the hissing sound because it indicated the regulator was not properly attached. RN B stated CNA F should have called her when she heard the hissing sound because it meant oxygen could be leaking. The facility also failed to keep Resident #46’s room free of tools left in plain view. Resident #46 was cognitively intact with a BIMS score of 14 and had a diagnosis of malignant neoplasm of the lung and hospice services. During observation, a screwdriver, a fixed wrench, an [NAME] wrench, and screws were found on top of the side of the sink inside the resident’s room, unattended and within reach. The resident was awake in bed at the time. ADON A stated the tools should not have been inside the room because they could cause harm or injury, and the Maintenance Supervisor stated the tools should not be in resident rooms because residents might hurt themselves or use them to hurt others. In addition, RN B left a container of germicidal wipes on top of her cart while providing care. During observation, she removed the wipes to clean a glucometer, then left the container on top of the cart while she went into resident rooms to check blood sugars and administer insulin. RN B stated the wipes should have been locked inside the cart when not in use because they contained chemicals that could irritate residents. The DON and ADON A both stated the wipes should be secured inside the cart when not in use, and the Administrator stated the wipes should be locked inside the cart before staff leave their cart.
Improper Perineal Care During Incontinence Assistance
Penalty
Summary
The facility failed to ensure appropriate care for a resident who was incontinent of bowel and bladder and had a diagnosis of overactive bladder. The resident’s MDS assessment reflected moderate cognitive impairment with a BIMS score of 12, and the care plan directed staff to clean the perineal area after each incontinent episode. During an observation of incontinent care, two CNAs provided care to the resident. After washing their hands and donning gloves, they removed the resident’s brief and performed perineal care. CNA D wiped the top and sides of the perineal area and then used the front-to-back technique on the middle portion, but reused a wipe that had already touched the resident’s bottom to clean the middle portion of the perineal area again, doing so three times. During interviews, CNA D stated that a wipe that had already touched the bottom was soiled and should not be used again because it might cause a UTI, and CNA E stated that used wipes should not touch the perineal area again because they were already soiled and could cause infection. The DON and ADON also stated that wipes already used should not be reused during perineal care, especially after touching soiled areas, and the facility policy directed staff to wipe from clean to dirty and use pre-moistened cleansing wipes for each stroke.
Infection Control Lapses During Pericare and BP Monitoring
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents reviewed for infection control. One event involved a CNA providing incontinent care to a resident with bowel and bladder incontinence and moderate cognitive impairment. During observation, the CNA used a wipe that had already contacted the resident’s bottom to clean the perineal area again, and this occurred three times. The CNA later stated she was not aware she had used a soiled wipe again and acknowledged the action could cause an infection. A second event involved a medication aide administering medications and checking blood pressure for two residents with hypertension. One resident had severely impaired cognition and orders for antihypertensive medications, and the other resident had a BIMS score of 13 with orders for lisinopril, metoprolol, and diltiazem. During observation, the medication aide used the same blood pressure cuff for both residents, placing it on the medication cart between uses, and did not sanitize the cuff after checking the first resident’s blood pressure or before using it on the second resident. Interviews confirmed the facility expected the blood pressure cuff to be sanitized after use. The CNA, RN, DON, and ADON all acknowledged that soiled wipes should not be reused and that the BP cuff should be sanitized immediately after checking a resident’s blood pressure to prevent spread of infection. The facility policy stated medication administration requires universal precautions and proper hand hygiene, and the infection control policy stated the facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection.
Pharmaceutical Services Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for residents reviewed. For two deceased residents, the controlled PRN morphine sign-out sheets were signed, but the MARs were not signed to show the medications had been administered. One resident had an order for morphine sulfate concentrate 20 mg/mL, 0.25 mL by mouth every 3 hours as needed for pain/dyspnea, and the other had an order for morphine sulfate concentrate oral solution 100 mg/5 mL, 0.25 mL sublingually every 3 hours as needed for pain/shortness of breath. The DON and ADON stated that all medications given must be signed off on the MAR and that PRN medications require a follow-up assessment for effectiveness. The facility also failed to ensure that medication blister packs matched the physician-ordered indication for use for two residents. One resident had Depakote delayed-release tablets ordered for mood disorder, but the blister pack was labeled for seizures. Another resident had Divalproex sodium delayed-release tablets ordered for epilepsy, but the blister pack was labeled for admission; the same resident’s Gabapentin blister pack was also labeled for admission while the physician order listed neuropathy. The ADON stated that all medication blister packs should match the indication for use on the doctor’s orders and that a change-of-indication sticker should be placed on the medication card when the indication changes. During medication cart observations, staff found items that were not supposed to be stored in the carts. One cart in the secure female unit contained a bag of chocolate candy, deodorant spray, and lotion. Another cart on hall 200 contained an expired COVID-19 test strip with a use-by date that had passed. Staff interviews stated that personal items should not be in the medication cart and that expired items should be discarded immediately. The facility’s Medication Administration and General Guidelines stated that medications are administered in accordance with written orders, that the MAR and medication label are compared before administration, and that discrepancies are to be clarified with the physician or PharmcareUSA.
Failure to Keep Call Lights Within Reach for Multiple Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring that call lights were within reach, as required by resident rights and facility policy. For Resident #3, a male with unspecified dementia with agitation, severe cognitive impairment (BIMS score of 3), impaired range of motion in both upper and lower extremities, and extensive assistance needs for all ADLs, the care plan directed staff to keep the call light within reach and encourage its use. During observation, this resident was in bed, awake, and not interviewable, with the call light found inside a closed nightstand drawer, blocked by the bedside table and out of reach. Resident #4, a female with Alzheimer’s disease, anxiety disorder, severe cognitive impairment (BIMS score of 3), extensive assistance needs for all ADLs, limited physical mobility, and impaired visual function, also had a care plan intervention to place the call light within reach and encourage its use. Observation showed her call bell lying across the nightstand and out of her reach. Staff, including an LVN, stated that per facility policy, call bells must be within reach of each resident to enable them to call for assistance when needed and to avoid delays in providing care. Resident #1, a male with dementia, severe cognitive impairment (BIMS score of 6), bilateral lower extremity weakness, and partial to moderate assistance needs for all ADLs, had a care plan noting risk for multiple falls, impaired cognitive function, and the need for timely meeting of needs. Observation revealed his call bell lying on the nightstand on the floor, out of his reach. Multiple staff members, including CNAs, LVNs, the DON, and the Administrator, confirmed that facility policy requires call bells to be within reach of all residents at all times, and that all staff are responsible for ensuring call bells are accessible before leaving the room to prevent delays in care and emergencies. Despite this, the observed placement of call lights for these three residents did not comply with their care plans or facility policy.
Failure to Maintain Clean and Sanitary Privacy Curtains for Two Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain clean and sanitary privacy curtains for two residents. For one resident, an older female with Alzheimer’s disease, anxiety disorder, severe cognitive impairment (BIMS score of 3), and extensive assistance needs for all ADLs, observation showed her privacy curtain had several large brown stains. Her care plan documented risks including falls, dependence on staff for emotional, intellectual, physical, and social needs, ADL self-care deficits, limited physical mobility, and impaired visual function, with instructions to keep her call light within reach and encourage its use. Despite staff statements that everyone was responsible for maintaining a homelike environment and reporting cleaning needs during rounds, the stained curtain remained in place. For another resident, an older male with Alzheimer’s disease, major depressive disorder, severe cognitive impairment (BIMS score of 5), bilateral lower extremity weakness, and dependence to substantial/maximal assistance for all ADLs, observation revealed his privacy curtain had red stains. His care plan noted risk for falls, impaired cognitive function, and ADL self-care performance deficits. Multiple staff members, including a CNA, LVNs, the DON, and the Administrator, stated that all staff shared responsibility for identifying and reporting housekeeping needs through regular rounds to ensure a clean, homelike environment. However, the presence of visibly stained privacy curtains for these two residents demonstrated that housekeeping and maintenance services were not effectively implemented to maintain a sanitary, orderly, and comfortable interior, contrary to the facility’s infection control plan overview, which required a safe, sanitary, and comfortable environment.
Failure to Follow Hand Hygiene and Equipment Sanitization During Perineal Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to incontinence and perineal care for two residents. Resident #1 was an older male with dementia, severe cognitive impairment (BIMS score of 6), bilateral lower extremity weakness, and a need for partial to moderate assistance with all ADLs. During observation of perineal care for this resident, LVN A cleaned the resident’s soiled perineal area and then applied cream to the perineal area without changing gloves between the dirty and clean tasks. LVN A also moved a bedside table from Resident #1’s room to another resident’s room without sanitizing the table or changing the covering linen. Resident #2 was an older male with Alzheimer’s disease, severe cognitive impairment (BIMS score of 5), bilateral lower extremity weakness, and dependence to substantial/maximal assistance for all ADLs. During observation of perineal care for this resident, LVN A applied cream to the perineal area, removed gloves, donned clean gloves without performing hand hygiene, applied cream to the groin area, then again removed gloves and donned clean gloves without sanitizing hands between glove changes. Interviews with LVN A, CNA A, the DON, and the Administrator confirmed that facility policy and staff training required changing gloves when moving from dirty to clean tasks, performing hand hygiene after glove removal and before donning clean gloves, and sanitizing shared equipment such as bedside tables between resident rooms, which did not occur during the observed care.
Failure to Maintain Effective Pest Control on Secure Male Hall
Penalty
Summary
The facility failed to maintain an effective pest control program to keep Hall 300, a male secure unit, and two resident rooms free of pests, specifically gnats. On the survey date, gnats were directly observed in two residents’ rooms on Hall 300. An LVN and a CNA confirmed the presence of gnats in both rooms and reported that pest control had been called, with the last pest control visit occurring earlier in the month. The LVN stated that gnats were an issue and had been reported to the administrator sometime the previous week, and acknowledged that gnats on resident food could cause infection. The CNA reported that gnats had been present in Hall 300 for a while and that she had reported their presence to the LVN. A housekeeper reported that she had notified the housekeeping supervisor about a persistent gnat problem and stated that gnats had been a problem since she began working at the facility about a year earlier, despite monthly pest control visits. The DON acknowledged awareness of the gnats and stated they could bite residents, spread infection, and were a dignity issue. The administrator also acknowledged that gnats were an ongoing issue. Review of pest control service reports for the prior seven months showed nine visits during which the company treated for other pests, including roaches, rodents, bedbugs, fruit, and fruit flies, but not gnats. Review of Hall 300 pest control reports showed that from mid-February to mid-March multiple staff observations of water bugs and gnats were documented but not addressed. The facility’s insect and rodent control policy stated that the facility would maintain an effective pest control program to provide an insect- and vermin-free food service department, but the documented and observed presence of gnats in resident areas demonstrated a failure to implement an effective program.
Failure to Use Required PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program for a resident on enhanced barrier precautions. The resident was an adult female with cervical spina bifida and paraplegia, with intact cognition and an indwelling urinary catheter. Her comprehensive care plan documented that she was on enhanced barrier precautions, with interventions requiring staff to don both gown and gloves for high-contact care activities such as linen changes, resident hygiene, transfers, dressing, toileting/incontinence care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activities. An enhanced barrier precaution sign was posted at the room entrance instructing staff to wear a gown and gloves during incontinence care, and a plastic cabinet with drawers containing PPE was located outside the room. On the observed date and time, a CNA exited the resident’s room and reported she had just provided incontinence care. When questioned, the CNA stated she wore gloves but not a gown and believed a gown was only required if the resident had a certain type of infection or an infected wound, despite the posted sign specifying gown and glove use for incontinence care and the resident’s known urinary catheter. The resident reported that some staff wore a gown and gloves during incontinence care and some did not. Nursing staff, including an LVN and the ADON, stated that the resident was on enhanced barrier precautions due to the urinary catheter and confirmed that staff should wear appropriate PPE, including a gown and gloves, when providing incontinence care to prevent cross-contamination. The facility’s written Enhanced Barrier Precautions policy required targeted gown and glove use during high-contact resident care activities for residents with wounds and/or indwelling medical devices, including urinary catheters.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to ensure that residents were protected from abuse and neglect, as evidenced by an incident in which one resident slapped another resident in the face. Both residents involved had severe cognitive impairments and resided in the memory care unit. The resident who was slapped had diagnoses including dementia and required assistance with personal care, while the resident who committed the act had dementia, schizophrenia, bipolar disorder, and a cognitive communication deficit. The incident was witnessed indirectly when a staff member heard a slap and another resident pointed out the aggressor. The resident who was slapped touched her face and indicated she was okay, but due to her cognitive status, she did not remember the incident or provide further information during interviews. The resident who committed the act had a documented history of verbal behavioral symptoms and poor impulse control, as reflected in her care plan. Prior to the incident, her care plan included interventions for managing behaviors, but she was not on 1:1 monitoring until after the event. Staff interviews revealed that the resident had previously exhibited verbal aggression but had not been observed physically assaulting others before this incident. The staff member present at the time did not witness the actual slap but responded after being alerted by another resident and by the noise. The facility's policy states that residents have the right to be free from abuse, including abuse by other residents. The incident was reported to the appropriate staff, and documentation confirmed that the event occurred. Both residents were unable to recall the incident during follow-up interviews, likely due to their cognitive impairments. The deficiency centers on the facility's failure to prevent the occurrence of resident-to-resident abuse, despite known behavioral risks and care plans indicating the potential for such behaviors.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to implement written policies and procedures to prohibit and prevent abuse for two residents in the memory care unit. One resident, with diagnoses including dementia and cognitive communication deficit, was assessed as having severely impaired cognition and a history of verbal behavioral symptoms. Another resident, also with severe cognitive impairment and additional psychiatric diagnoses, was identified as having potential for physical behaviors and poor impulse control. An incident occurred in which the second resident slapped the first resident on the face, as reported by a CNA who heard the slap and was informed by another resident. The CNA confirmed that the resident admitted to slapping the other after being told to 'shut up.' Interviews with staff revealed that the incident was not directly witnessed by staff, but was reported by a resident and confirmed by the CNA through resident admission. The affected resident was unable to recall or confirm the incident due to cognitive impairment. Staff interviews indicated that the resident who committed the act had a history of verbal outbursts but had not previously been observed to hit others. The facility's policy required staff to identify, correct, and intervene in situations of possible abuse or neglect, and to provide ongoing education on abuse prevention and reporting. Despite these policies, the facility did not effectively prevent the incident of resident-to-resident abuse. The event was not immediately observed by staff, and the response relied on secondhand reports and post-incident interviews. The facility's failure to ensure adequate supervision and implementation of abuse prevention policies resulted in a resident being physically struck by another resident, with the incident only coming to light after the fact through indirect observation and resident statements.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to follow a resident's care plan and facility policy by operating a mechanical lift alone during a transfer, despite the requirement for two staff members. The resident involved had diagnoses including obesity, lack of coordination, and muscle weakness, and required maximal assistance with activities of daily living, as documented in her care plan and MDS assessment. The CNA attempted to transfer the resident back to bed after a shower using the Hoyer lift without assistance, resulting in the lift collapsing and both the resident and the lift falling to the floor. The incident led to the resident sustaining five fractured ribs, as confirmed by hospital records. The resident initially underwent an x-ray at the facility, which did not reveal concerns, but continued to experience pain and was later diagnosed with rib fractures at the emergency room. The resident reported that the CNA performed the transfer alone both to and from the shower, and that after the fall, additional staff were called to assist in returning her to bed. Interviews with facility staff, including the administrator and DON, confirmed that two staff members are always required to operate the mechanical lift, and that this policy was in place at the time of the incident. The CNA admitted to operating the lift alone, citing staffing shortages and pressure to provide care. Other CNAs on shift denied being asked for assistance. The facility's policy and staff statements consistently indicated that using the lift alone was not permitted and was considered unsafe.
Failure to Ensure Call Light Accessibility for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had access to their call light systems, as required by their care plans and facility policy. For one resident with a history of left femur fracture and moderate cognitive impairment, the call light was found inside her nightstand and not within her reach while she was lying in bed. The resident was unable to identify the location of her call light when asked. For another resident with severe cognitive impairment and muscle weakness, the call light was located on the side of the bed against the wall, also out of reach, and the resident did not know where it was. Both residents required substantial assistance with activities of daily living and had care plans specifying that call lights should be within reach. Multiple staff interviews confirmed that call lights are expected to be within reach of all residents and that staff are responsible for checking this during regular rounds. Despite these expectations and documented in-service training on the subject, observations on the day of the survey revealed that the call lights for both residents were not accessible. Staff acknowledged the importance of call light accessibility for resident safety and indicated that rounds were conducted to check for this, but the deficiency was still observed during the survey.
Failure to Properly Store Respiratory Devices
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents who required it, as evidenced by improper storage of respiratory devices for three residents. Observations revealed that a resident's nebulizer mask was left sitting on top of the nebulizer on a chair after use, another resident's nasal cannula was found on the floor near the oxygen device and not bagged, and a third resident's inhaler was stored unbagged inside a nightstand. These actions were not consistent with professional standards of practice, the residents' care plans, or their goals and preferences. Interviews with nursing staff, including RNs, ADONs, and the DON, confirmed that respiratory devices such as nasal cannulas and breathing masks should be bagged when not in use to prevent infection. Staff acknowledged that it was their responsibility to ensure proper storage of these devices during rounds. The facility's respiratory care policy also indicated the importance of safe and evidence-based respiratory services for residents requiring such care.
Failure to Ensure Accessible Call Light Systems for Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of three residents were accessible, as required to reasonably accommodate their needs and preferences. Observations revealed that the call lights for these residents were not within their reach while they were in bed. Specifically, one resident's call light was placed on the nightstand next to the bed, another's was wrapped around the wall fixture, and a third resident's call light was found inside a nightstand drawer. These placements made it impossible for the residents to access the call lights when needed. The residents involved had significant cognitive and physical impairments. One resident had severe dementia and required substantial assistance with self-care, another had Alzheimer's disease and muscle atrophy with severely impaired cognition, and the third had a history of stroke with hemiparesis and moderately impaired cognition. Their care plans included interventions to keep call lights within reach due to their high risk for falls, impaired mobility, and communication deficits. Despite these documented needs, staff did not ensure the call lights were accessible during the surveyors' observations. Interviews with staff, including a CNA, ADON, RN, and the Administrator, confirmed that it was the facility's expectation and standard practice to keep call lights within reach of residents. Staff acknowledged that call lights were sometimes moved during care and not returned to an accessible position, and that regular rounding should include checking call light placement. The facility did not have a specific policy related to call lights.
Failure to Maintain Safe Wheelchair Conditions
Penalty
Summary
The facility failed to ensure that wheelchairs used by four residents were maintained in a safe condition, which could potentially lead to accidents or injuries. Observations revealed that the wheelchairs of these residents had cracked armrests with exposed foam, which were not reported or repaired in a timely manner. Despite routine inspections being claimed, there was no documentation of repair requests for these specific wheelchairs, indicating a lapse in the maintenance process. Resident #19, a male with dementia and mobility issues, was observed in a wheelchair with cracked armrests. Similarly, Resident #39, who has severe cognitive impairment and is dependent on staff for assistance, was found in a wheelchair with cracked armrests. Resident #15, a female with dementia and hemiplegia, was also observed in a wheelchair with a cracked and missing armrest. Resident #10, who has Alzheimer's and requires supervision for certain activities, reported a loose handle that was fixed but did not report the cracked armrests. Interviews with staff revealed inconsistencies in the reporting and repair process for wheelchair maintenance. The CNA mentioned that repairs were noted in a maintenance log, but the LVN was unaware of the procedure. The Administrator stated that repairs should be reported through an online portal or to a supervisor, but there was no documentation of such reports for the affected residents. The Director of Nursing and Maintenance Supervisor also provided conflicting information about the repair process, highlighting a lack of clear procedures and communication regarding wheelchair maintenance.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specific deficiencies included the failure to label and date food items with their received or expiration dates, the presence of expired whipping cream that was not disposed of, and the storage of open food items in the refrigerator that were not sealed. These lapses were identified through observations of various food storage areas, including a drink dispenser containing an unidentified yellow liquid without a label or preparation date, and refrigerators containing expired and improperly stored food items. Interviews with the Dietary Manager (DM) and Dietary Coordinator (DC) revealed that staff were expected to label and date all food items upon receipt and check expiration dates before storage. The DM acknowledged that the ham exposed to air should have been sealed, and the unidentified lunch meat should have been labeled with an open or use-by date. The DC emphasized the risks associated with improperly labeled or expired food, including potential allergic reactions and foodborne illnesses. The facility's Food Storage and Supplies Policy, as well as the U.S. FDA Food Code, were referenced, highlighting the importance of proper food labeling and storage to prevent contamination and ensure safety.
Facility Fails to Maintain Safe and Functional Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by deficiencies found in two resident rooms and one hallway. In Resident #43's bathroom, the safety grab bar was loose, and the water barrier next to the toilet had separated from the wall, revealing a large gap. Additionally, the tiles around the base of the toilet were separated, exposing the bare floor. Resident #43 was unable to answer questions about the bathroom condition. In Resident #61's bathroom, the sink had no running water, and the stopper was inoperable, keeping it closed. During an observation, Resident #61 asked the ADON where he could wash his hands, as there was no water in his room. The ADON provided hand sanitizer and explained that the water had been turned off to fix the sink. Resident #61 was unable to answer further questions. Additionally, in the 300 Wing (Secure Unit) hallway, a section of the handrail was missing plastic endcaps, exposing sharp edges of sheet metal. Interviews with staff revealed a lack of awareness and communication regarding maintenance issues. The ADM and Maintenance Supervisor were unaware of the deficiencies, and no reports were found in the maintenance logs or the new phone app reporting system. The DON acknowledged the potential risks posed by these deficiencies, such as falls, skin tears, and infection control issues. Record reviews showed no evidence of maintenance issues being reported for the 300-Hall Secure Unit over the past three months.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to protect the confidentiality of personal and medical records for residents on the female locked unit. During an observation, it was noted that the computer on Medication Cart 1 was left unlocked and unattended, displaying resident medications. This occurred while LVN A assisted residents to various locations within the unit, leaving the computer exposed near the front door and facing the common area. Several residents walked past the unlocked computer, which was not secured as required by facility policy. LVN A acknowledged awareness of the need to lock the computer but underestimated the risk of unauthorized access by residents. The facility's policy on resident rights, revised in November 2021, mandates that resident information be maintained as confidential.
Failure to Ensure Proper Footwear Leads to Fall Risk
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that the resident's shoes were worn properly, which could lead to falls. The resident, an elderly female with Alzheimer's, unspecified abnormalities of gait and mobility, and a history of falling, was observed walking around the common area with her heels not completely in her shoes. The resident stated she did not receive assistance with putting on her shoes, and due to her severe cognitive impairment, a full interview was not possible. The resident's care plan, which was revised prior to the observation, included interventions to ensure footwear was worn appropriately when ambulating or mobilizing in a wheelchair. However, a CNA reported that the resident often dressed herself and put on shoes incorrectly, and the CNA would only correct the shoes if the resident allowed. The facility's administrator acknowledged that staff should have been using the resident's care plan to determine fall risk interventions and that improper footwear could lead to falls. The facility's policy on preventive strategies to reduce fall risk emphasized the importance of properly fitting footwear with slip-resistant soles.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During an observation, Medication Cart 1 was found unlocked and unattended on the female locked unit. This cart, containing medications, was accessible to both residents and staff because the drawers could be easily opened. The incident occurred while LVN A was assisting residents in various activities, leaving the cart unattended near the front door of the locked unit. Several residents were observed walking past the unlocked cart, which was facing the common area. In an interview, LVN A, who had been working at the facility intermittently since 2017, acknowledged that the medication cart should have been locked. However, she did not believe that any residents would tamper with the cart. The facility's administrator confirmed that the cart should have been locked whenever it was not in the direct sight of LVN A. A review of the facility's medication administration procedure, revised in 2017, indicated that the medication cart must be completely locked or otherwise secured after the medication administration process is completed.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were in place to prevent accidents for a resident identified as a fall risk. This resident, who had severe cognitive impairment and a history of multiple falls, was left unsupervised in the dining room, resulting in a fall from his wheelchair. The fall led to a bilateral subdural hematoma, requiring hospitalization. Prior to this incident, the resident had also fallen from his bed, sustaining a hematoma, indicating a pattern of inadequate fall prevention measures. The resident's care plan, revised earlier in the year, identified him as at risk for multiple falls and included interventions such as educating the resident, family, and caregivers about safety, using a floor mat while in bed, and reminding the resident to use the call light for assistance. Despite these measures, the resident experienced several falls throughout the year, including incidents in February, April, September, and October, suggesting that the interventions were insufficient or not properly implemented. Interviews with staff revealed that there was typically a nurse present in the dining area during meal times, but on the day of the incident, both the nurse and a CNA were absent from the dining room simultaneously, leaving the resident unsupervised. The staff acknowledged that the resident was impulsive and had a tendency to stand up despite his unsteady gait. The facility's failure to provide continuous supervision and appropriate interventions for the resident's specific fall risk contributed to the incident.
Failure to Review and Revise Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive assessment and quarterly review assessments. This deficiency was identified for one resident who had been admitted with diagnoses including dementia, acute kidney failure, and difficulty in walking. The resident's care plan, which was last revised in August 2024, indicated a risk for multiple falls, with interventions such as educating the resident, family, and caregivers about safety and using a floor mat while the resident is in bed. However, the last care plan conference was held in May 2024, and the subsequent quarterly meeting that should have occurred in August 2024 was not conducted. Interviews with the Social Worker and the Administrator revealed that the Social Worker was responsible for ensuring that care plan meetings were held quarterly. The Social Worker admitted to overlooking the scheduling of the care plan conference, and the Administrator confirmed that there was no reason for the meeting not being held. The facility's policy on comprehensive care plans stated that the resident's care plan should be reviewed after each admission, quarterly, annual, and/or significant change MDS assessment, and revised based on changing goals, preferences, and needs of the resident. The failure to conduct the care plan meeting as scheduled could affect residents by placing them at risk for not having their individual needs met.
Failure to Obtain Laboratory Services for Resident
Penalty
Summary
The facility failed to obtain laboratory services to meet the needs of Resident #13, who was one of the three residents reviewed for laboratory services. The resident, who had severe cognitive impairment and was frequently incontinent, had a physician's order for a urine analysis (UA) on 9/23/24, which was not collected. The Director of Nursing (DON) reported that the UA was canceled on 9/26/24, possibly due to the resident resisting staff, but no alternative actions were taken, and the physician was not notified of the inability to collect the specimen. Multiple attempts to collect the UA were unsuccessful due to contamination, as noted in a progress note by LVN A on 9/26/24. The nurse practitioner (NP) who ordered the UA was unaware of the collection issues, and the facility's staff did not communicate the problem to her. The laboratory service provider confirmed that the UA was canceled after three failed attempts to collect the specimen on consecutive days. The facility lacked a specific policy for handling laboratory services, UAs, or UTIs, and the existing policy on notifying physicians of changes in status was not followed. Resident #13 was later diagnosed with a urinary tract infection (UTI) during a hospital visit for an unrelated event on 10/04/24. The resident was prescribed antibiotics and returned to the facility. Interviews with facility staff, including the DON, LVN C, and ADON D, revealed a lack of clarity and communication regarding the collection and monitoring of laboratory tests, contributing to the deficiency in care for Resident #13.
Failure to Treat Residents with Respect and Dignity
Penalty
Summary
The facility failed to ensure each resident was treated with respect and dignity, specifically in the case of two residents. One incident involved a Licensed Vocational Nurse (LVN) who slammed her hand on a bedside table and yelled 'Sit' at a resident with dementia and cognitive impairment. This resident, who had a history of falls, was standing up when the LVN took this action. The LVN later explained that she was trying to prevent the resident from falling but acknowledged that there were other ways she could have redirected the resident. The resident was unable to fully communicate due to cognitive limitations, but he did not express any concerns during the interview. Another resident expressed dissatisfaction with how the staff treated him and other residents, stating that the staff spoke to them in a demeaning manner and often ignored them. The facility's administrator confirmed that staff should not yell or hit objects in front of residents, acknowledging that such actions could violate resident rights. The facility's policy on resident rights emphasizes the importance of treating residents with dignity, courtesy, consideration, and respect.
Failure to Supervise Resident While Smoking
Penalty
Summary
The facility failed to establish and follow policies regarding smoking safety, which resulted in a resident being left unsupervised while smoking. Resident #3, who has severe cognitive impairments due to dementia and Alzheimer's, was observed smoking outside without staff supervision. The resident's care plan and smoking assessment indicated that she required direct supervision while smoking to prevent injury. However, on the day of the observation, the CNA responsible for supervising the residents left to escort other residents back to their unit, leaving Resident #3 alone. The LVN, who was supposed to take over supervision, was occupied with other tasks and did not maintain a direct line of sight to the resident, contrary to the facility's smoking policy. Interviews with the staff revealed a misunderstanding and miscommunication regarding the supervision responsibilities. The CNA believed the LVN would take over supervision, while the LVN was preoccupied with medication administration and blood sugar checks. The facility's administrator confirmed that residents should be within the direct view of staff while smoking, as per the smoking policy. The failure to adhere to these policies and ensure proper supervision placed Resident #3 at risk for smoking-related injuries.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information on 05/17/24. Observation at 3:15 PM on that day revealed that the posted staffing information was dated 04/23/24. In an interview at 3:40 PM, the Assistant Director of Nursing (ADON) admitted responsibility for the daily posting and acknowledged the oversight. The ADON stated that she usually printed and posted the staffing ratio daily but had forgotten to update the posting for 05/17/24, leaving the outdated information from April. This failure to update the daily staffing information could prevent residents from accessing current staffing data and facility census information.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 838 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockwall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Meadows | 2.3 mi | ★★★★★ | 10 | 0 |
| Beacon Harbor Healthcare And Rehabilitation | 2.8 mi | ★★★★★ | 9 | 0 |
| Rowlett Health And Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Broadmoor Medical Lodge | 3.3 mi | ★★★★★ | 15 | 0 |
| Wylie Oaks Healthcare And Rehabilitation | 7.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rockwall Nursing Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.