Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rose Haven Retreat during CMS and state inspections, most recent first.
A resident with dementia, diabetes, and spinal stenosis had an order for scheduled hydrocodone-acetaminophen for pain. Staff later found one card of 60 hydrocodone tablets missing after a delivery that was signed for by RN C and the driver. Interviews with the pharmacy, RN, med aide, and DON showed the medication had been counted at delivery, but the facility could not determine what happened to the missing card.
Surveyors found that food items in the kitchen were stored on the floor and not properly labeled or dated, including canned goods, frozen meats, vegetables, and prepared foods. Staff interviews confirmed that these practices did not follow facility policy, and that short staffing and equipment issues contributed to the deficiencies. Facility policies require all food to be stored off the floor and labeled with dates, but these were not followed as observed during the survey.
A resident with dementia and schizophrenia, but no cognitive impairment, was found lying in bed with sheets that were visibly stained and soiled on multiple occasions. The resident reported that linens were not changed as expected on shower days, and staff interviews revealed inconsistencies in linen changing practices and a lack of monitoring. Facility policy required clean linens, but the absence of a system to ensure this led to the resident remaining in unsanitary bedding.
A resident's MDS assessment was inaccurately coded to include schizophrenia, despite no supporting documentation in the medical record or physician orders. The error occurred when the MDS Coordinator, responsible for two facilities and working remotely, miscoded the diagnosis, which was then carried over in subsequent assessments. The resident's actual diagnoses included dementia with psychotic disturbance, neurosyphilis, and depressive episodes.
A resident with PTSD was admitted without a trauma screening or identification of potential triggers, despite facility policy and care plan requirements. Key documentation, such as the social service history and 'Make Me Feel Important' form, lacked trauma-related information, and staff interviews confirmed that trauma-informed care practices were not implemented.
A resident with COPD was administered Budesonide via nebulization by an LVN, who failed to instruct the resident to rinse and spit after use as required by the physician's order. The omission was observed during a medication pass, and staff interviews confirmed that the medication should have been administered according to special instructions to ensure proper care.
A nurse left a medication cart unlocked and unattended while out of sight, and two opened Albuterol Sulfate Inhalation Solution vials on the cart were not dated. The nurse admitted to being distracted and unaware the cart was left unsecured, and could not identify who failed to date the opened medications. Facility policy requires medication carts to be locked when not in use and medications to be properly labeled with open and expiration dates.
A resident with dementia and schizophrenia, but no cognitive impairment, reported a broken tooth causing discomfort and difficulty eating. The Social Services Director attempted to arrange dental care but was unable to secure services due to an outstanding balance and insurance issues, and did not notify nursing staff or the DON. The care plan did not address dental needs, and there was no documented follow-up, resulting in the resident not receiving timely dental care.
A laundry aide delivered clean clothing to residents using an uncovered laundry cart inside the facility, contrary to facility policy and expectations from the DON, Housekeeping Supervisor, and Administrator, who all stated that clean laundry should remain covered during transport to prevent cross-contamination.
Surveyors observed cigarette butts on the ground and trash in the designated smoking receptacle, contrary to facility policy requiring safe smoking practices and proper disposal. Staff interviews revealed inconsistent monitoring and enforcement of smoking area cleanliness and safety.
A resident with severe cognitive impairment and a history of elopement managed to leave a secured unit in an LTC facility, resulting in an unwitnessed fall and minor injuries. The incident occurred when a nurse left the unit to attend to other residents, and the facility's door alarms were found to be off. Despite regular maintenance checks, the malfunctioning alarm was not identified, leading to the resident's escape.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including an opened bag of potato chips not securely closed, a tin pan with stuffed green peppers in beef sauce improperly stored in the freezer, baking sheet pans with carbon buildup, and measuring cups stored with openings facing up. Staff acknowledged the deficiencies and the potential risks to residents.
The facility had a medication error rate of 12.5%, with errors including administering medications at incorrect times and not following specific instructions related to food intake and timing before meals. These errors involved four residents and were confirmed through observations and staff interviews.
The facility failed to ensure proper infection control practices, including glove changes and hand hygiene during incontinent care, adherence to Enhanced Barrier Precautions, and isolation for a resident with ESBL. These lapses were observed and confirmed by staff interviews.
A resident with severe cognitive impairment and a history of depression was administered Prozac without the consent of her responsible party. Despite the RP's explicit refusal to give verbal consent over the phone, the medication was given on two occasions. Facility staff admitted to the oversight, acknowledging that the medication should not have been administered without proper consent.
A resident was repeatedly observed without access to their call light, which was found between the mattress and the fitted sheet. Staff interviews confirmed that the call light should have been within reach, as per the care plan and facility policy. The resident expressed concern about not being able to call for assistance.
A resident with severe cognitive impairment and mobility dependence was not assisted out of bed for at least two weeks despite daily requests. Staff misunderstood wound care instructions, leading to the resident's prolonged bed rest, which violated the facility's policy on resident rights and self-determination.
The facility failed to accurately assess a resident's tobacco use, leading to an incomplete MDS and care plan. Despite being listed as a safe smoker and observed waiting for a smoke break, the resident's smoking status was not documented. Interviews with staff confirmed the importance of accurate MDS assessments for proper care planning.
The facility failed to ensure accurate PASRR Level 1 assessment for a resident with schizophrenia, leading to a lack of necessary specialized services. The MDS Nurse did not review the assessment due to the resident's PASRR positive status, and the facility's policy did not address assessment accuracy.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. One resident's smoking habit was not included in the care plan, and another resident's behavioral changes and move to a secured unit were not communicated to the hospice agency, resulting in missed opportunities for timely interventions.
The facility failed to ensure a safe mechanical lift transfer for a resident with severe cognitive impairment and other medical conditions. CNA A operated the lift with the base legs closed, contrary to the correct procedure of keeping them open for stability, which could have led to the lift tipping and causing injury. Multiple staff members confirmed the correct procedure, highlighting a training discrepancy.
Missing Hydrocodone Card
Penalty
Summary
The facility failed to ensure a resident was free from misappropriation of property when a card of 60 tablets of hydrocodone-acetaminophen 10/325 mg was discovered missing. The resident had diagnoses including dementia, diabetes, and spinal stenosis, and had an active order for hydrocodone-acetaminophen 10/325 mg every 6 hours for pain management. The resident’s MDS indicated severe cognitive impairment with a BIMS of 07 and that the resident received a scheduled pain regimen and was taking an opioid. The missing medication was identified during a medication count when staff found that one card of hydrocodone was unaccounted for. A medication error report documented that the medication count sheet and card were missing. Nursing notes stated the refill had not yet been delivered at first, then later that the medication would be delivered that day, and the pharmacy eventually delivered the medication later that afternoon. The resident told staff he had no issues with his pain medication, had not missed any doses, and was not in pain. Records and interviews showed that the pharmacy packing slip for the delivery listed two cards of hydrocodone, each containing 60 tablets, and was signed by RN C and the delivery driver. The pharmacy manager reviewed camera footage and said the correct amount had been placed in the bag and that the bag was not opened again until it reached the facility. RN C stated she counted the medications with the driver and signed after verifying them, while the delivery driver said there were two cards of hydrocodone and two narcotic count sheets in the bag. Medication Aide E said she received two cards of hydrocodone from RN C and placed both in the locked narcotic box, but later the card was missing when a refill was requested and staff could not determine what happened to it. The DON stated the facility had experienced missing medication issues before and that there was no system in place at that time to show how many cards were on hand.
Deficient Food Storage, Labeling, and Dating Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, and dating of food items. Food was found stored directly on the floor in the dry pantry, including boxes of canned goods, chips, coffee, and vegetables, none of which were dated. In the large freezer, several plastic bags containing various foods such as hamburger patties, chicken tender strips, sausage patties, onions, peppers, and French fries were not labeled or dated. The white freezer contained bags of unknown meat that were also not labeled or dated, and there was evidence of a melted and refrozen substance at the bottom of the freezer. In the refrigerator/cooler, a metal container of chicken noodle soup and a bag of sandwiches with resident names were not labeled or dated, nor was a partial bag of biscuits. Interviews with dietary staff and management confirmed that facility policy requires all food items to be labeled and dated when placed in storage, and that food should not be stored on the floor. Staff acknowledged that failure to label and date food could result in serving expired or spoiled food to residents, potentially causing illness. Staff also reported that the kitchen was short-staffed, the dishwasher was out of order, and that these factors contributed to the lapses in proper food storage and labeling. The dietary manager and administrator both stated that they expected staff to follow established policies for food storage, labeling, and dating, regardless of staffing or equipment issues. Record review of facility policies confirmed the requirement for all foods to be stored off the floor, covered, labeled, and dated, with special attention to items belonging to residents. The policies also emphasized the importance of safe food handling practices to prevent foodborne illness. Despite these policies, the observed deficiencies in food storage, labeling, and dating were not addressed at the time of the survey, as confirmed by staff interviews and direct observation.
Failure to Provide Clean Bed Linens for Resident
Penalty
Summary
A deficiency was identified when a resident's bed linens were observed to be unclean, with numerous brown stains and a crusty yellow substance present on the top sheet. The resident, a female with a history of dementia and schizophrenia but no cognitive impairment per her most recent MDS, was found lying in the soiled bed linens on multiple occasions. The resident reported that her sheets were typically changed on her scheduled shower days, which were Monday, Wednesday, and Friday, but stated that her sheets had not been changed after her most recent shower. She expressed discomfort and dissatisfaction with the condition of her bedding. Interviews with facility staff revealed inconsistencies and lapses in the process for changing bed linens. Nursing assistants confirmed that linens should be changed on shower days and as needed if visibly soiled, but one NA noted that clean linens from the laundry often arrived stained and that she had not reported this issue. The Housekeeping Supervisor stated that laundry staff were trained to remove stained or torn linens, but also indicated that CNAs were responsible for changing linens if they became soiled. The CNA Supervisor and DON both stated that linens should be changed on shower days and as needed, but there was no system in place to monitor the condition of bed linens, and it was unclear if the resident had refused linen changes. The facility's policy required clean bed and bath linens in good condition to maintain a homelike environment. Despite this, the lack of a monitoring system and failure to ensure linens were changed as required resulted in the resident remaining in soiled bedding, which was directly observed and confirmed by both the resident and staff interviews.
Inaccurate MDS Assessment Due to Miscoded Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's active diagnoses. Specifically, the MDS assessment for one resident incorrectly included a diagnosis of schizophrenia, despite the absence of supporting documentation in the resident's medical record and physician orders. The resident's medical history included dementia with psychotic disturbance, neurosyphilis, and depressive episodes, but not schizophrenia. The error was identified during a review of the resident's face sheet, care plan, and physician orders, which did not list schizophrenia as an active diagnosis. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for assessments at two facilities and often worked remotely, miscoded the diagnosis, possibly due to confusion with another resident with a similar last name. The incorrect diagnosis of schizophrenia was first entered in a previous assessment and subsequently carried over to later assessments. The facility's policy requires that MDS assessments accurately reflect each resident's status, but this was not followed in this instance, resulting in an inaccurate assessment for the resident.
Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of PTSD received trauma-informed and culturally competent care in accordance with professional standards. Upon admission, no trauma screening was completed to identify possible triggers, despite the resident's documented history of PTSD. The initial social service history assessment lacked screening questions related to trauma, and the 'Make Me Feel Important' form, intended to identify specific triggers and de-escalation interventions, was not filled out for the resident. Interviews with facility staff, including the Social Services Director and Administrator, confirmed that trauma screening was not part of the admission process and that staff were unaware of the omission. The resident's care plan noted a history of being fearful and easily annoyed due to PTSD, with a goal to manage symptoms and avoid fearful episodes. However, there was no evidence of trauma-specific services or interventions being provided. The facility's policy required a trauma screening tool to be implemented as part of the admissions process, but this was not followed. Staff interviews revealed a lack of awareness and implementation of trauma-informed care practices, and the necessary documentation to identify and mitigate potential triggers for the resident was incomplete or missing.
Failure to Ensure Proper Administration of Inhalation Medication
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow physician orders and manufacturer guidelines during the administration of Budesonide, an inhalation medication, to a female resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who had intact cognition and was able to communicate clearly, had a physician order specifying that she should rinse and spit after each use of Budesonide via nebulization. During a medication pass, the LVN administered the medication but only provided a glass of water afterward, without instructing the resident to rinse and spit as required. Interviews with the LVN, Director of Nursing (DON), and Administrator confirmed that the medication should have been administered according to the physician's order and that special instructions, such as rinsing and spitting, were necessary to prevent adverse effects. The facility's medication administration policy also required medications to be given per orders and manufacturer guidelines. The failure to follow these instructions was observed and acknowledged by staff, constituting a deficiency in pharmaceutical services for the resident.
Medication Cart Security and Labeling Deficiencies
Penalty
Summary
A deficiency was identified when a nurse failed to lock a medication cart on a secured unit while it was unattended. The nurse entered a resident's room and was engaged in conversation for approximately ten minutes with the privacy curtain pulled, leaving the medication cart out of her line of sight and unlocked. The nurse acknowledged being distracted and not realizing the cart was left unsecured, despite the presence of narcotics on the cart and the risk posed by residents with dementia. Additionally, two Albuterol Sulfate Inhalation Solution vials on the same medication cart were found to be undated after being opened. The nurse was unable to determine who had opened the vials and stated that it was the responsibility of the person opening the medication to date it. Facility policies reviewed indicated that medication carts must be locked when not in use and that medications must be labeled with the date dispensed and expiration date when applicable.
Failure to Provide Timely Dental Services for Resident with Broken Tooth
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental services when she reported a broken tooth causing discomfort. The resident, who had a diagnosis of dementia without behaviors and schizophrenia but was assessed as having no cognitive impairment, communicated her dental issue to staff. Despite her ability to express her needs and the care plan indicating she required assistance with oral hygiene, the care plan did not address any dental issues, and there was no documentation of follow-up for her reported discomfort. The Social Services Director was aware of the resident's dental concern and attempted to arrange care through the facility's mobile dentistry provider. However, the provider refused service due to an outstanding balance. The Social Services Director also attempted to contact other community dental providers, but none accepted the resident's insurance. Documentation showed that after the initial report of dental discomfort, there were no further notes addressing the resident's pain or discomfort, and the nursing staff was not notified of the issue. Interviews revealed that the Social Services Director did not inform nursing staff or the DON about the resident's dental concerns, and the Administrator was not notified until days after the issue was identified. The facility's policy required routine and emergency dental services to be available and for social services to assist with appointments and arrangements, but these procedures were not followed. As a result, the resident experienced ongoing discomfort and difficulty eating due to the lack of timely dental care.
Uncovered Laundry Cart During Clean Linen Delivery
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during the delivery of clean laundry. During observation, a laundry aide was seen transporting an uncovered laundry cart with clean clothes exposed while delivering to residents inside the facility. The laundry aide stated that while she covered the cart when transporting laundry from the outside laundry building, she was not required to keep it covered once inside the facility. This practice was inconsistent with the facility's policy, which requires clean linen to remain covered to protect it from environmental contamination. Interviews with the DON, Housekeeping Supervisor, and Administrator confirmed that the expectation was for clean laundry to be covered at all times during transport, both inside and outside the building, to prevent cross-contamination. The facility's policy also specified that clean linen should be protected from environmental contaminants by keeping carts covered. The failure to follow these protocols was observed and acknowledged by facility leadership.
Failure to Maintain Safe and Clean Smoking Area
Penalty
Summary
The facility failed to follow its established smoking policy for the designated smoking area. During an observation, surveyors found two red-tipped cigarette butts on the sidewalk near the door to the smoking area, despite a posted sign instructing not to throw cigarette butts on the ground. Additionally, a used white tissue was found in the red metal can intended for cigarette disposal. The facility's smoking policy requires that ashtrays be emptied only into designated receptacles and that safe smoking practices be maintained. Interviews with staff revealed a lack of consistent monitoring and enforcement of the smoking area’s cleanliness and safety. The Social Services Director, responsible for supervising a smoke break, did not notice the cigarette butts or tissue during her oversight. The Housekeeping Supervisor and Maintenance Assistant both stated they were responsible for keeping the area clean, but acknowledged that trash and cigarette butts were sometimes left unattended. The Administrator confirmed that staff were expected to ensure proper disposal of cigarette butts and trash to maintain fire safety, in accordance with facility policy.
Resident Elopement Due to Inadequate Supervision and Faulty Alarms
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that adequate supervision was provided to prevent elopement for a resident. The resident, a male with severe cognitive impairment and a history of elopement, was admitted to the facility's secured unit due to his risk of wandering. Despite being on a secured unit, the resident managed to leave the facility premises, resulting in an unwitnessed fall and minor injuries. On the day of the incident, the resident was last seen by a nurse between 3 PM and 3:30 PM while vital signs were being taken. The nurse then left the secured unit to attend to other residents, during which time the resident eloped. The facility's Business Office Manager (BOM) was alerted by a neighbor that the resident was seen outside, prompting staff to search for and eventually find the resident down the road from the facility. The resident was assessed for injuries and sent to the emergency room for further evaluation. Interviews and observations revealed that the door alarms were not functioning properly, as the alarm on the back door was found to be off. Staff members, including the nurse and CNA on duty, did not hear any alarms during the incident. The facility's maintenance logs indicated that door checks were conducted regularly, but the malfunctioning alarm was not identified prior to the incident. The resident's care plan noted his risk for elopement, but the supervision and security measures in place were insufficient to prevent his escape.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an initial tour, surveyors observed an opened bag of potato chips that was not securely closed in the dry goods pantry, and a tin pan with stuffed green peppers in beef sauce in the freezer with the top cover lifted, exposing the food to potential contamination. Additionally, there were approximately seven baking sheet pans with thick black carbon buildup on the outside and rim, and two measuring cups were stored with the top openings facing up, which could collect dust. Interviews with kitchen staff revealed that they were aware of the proper procedures for food storage and handling but failed to consistently implement them. The staff also acknowledged the presence of pests in the past and the use of foil to line the baking sheet pans due to the carbon buildup that could not be removed despite scrubbing and using degreasers. The dietary manager admitted to not placing an order for new pans due to financial reasons and confirmed that the opened bag of potato chips was discarded because its open date was unknown. The stuffed bell peppers were inspected and served as an alternate meal despite the initial improper storage. The facility's policy on dietary services, dated 2007, emphasized the importance of preventing food contamination and foodborne illness by ensuring proper receipt and storage of food supplies and handling utensils in a way that avoids contact with surfaces that come into contact with food or drink. The assistant dietary manager and dietary manager both acknowledged the deficiencies and the potential risks to residents if food was not stored properly or if baking pans were not free of carbon buildup. The facility had been dealing with a pest issue, which had improved with weekly pest control services. However, the observed deficiencies in food storage and handling practices could place residents at risk of foodborne illness and food contamination.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that it was free of a medication error rate of 5 percent or greater, resulting in a medication error rate of 12.5%. This was based on 4 errors out of 32 opportunities, involving 4 of 6 residents reviewed for medication administration. The errors included administering medications at incorrect times and not following specific instructions related to food intake and timing before meals, which could affect the therapeutic benefits of the medications and the residents' health conditions. One resident, a [AGE] year-old female with diagnoses including gout and chronic pain, received Acetaminophen-codeine 300-30mg at 10:30 a.m. instead of the prescribed 8:00 a.m. Another resident, a [AGE] year-old male with a history of cerebral infarction, was given Aspirin 81mg at 9:31 a.m. instead of 8:00 a.m. and without food, contrary to the physician's orders. These deviations from the prescribed medication schedules could potentially compromise the effectiveness of the medications and the residents' health. Additionally, a [AGE] year-old male with gastro-esophageal reflux disease received Esomeprazole Magnesium 20mg at 9:23 a.m. instead of the ordered 7:00 a.m. Similarly, a [AGE] year-old female with severe cognitive impairment and gastro-esophageal reflux disease was administered Omeprazole 40mg at 9:56 a.m. instead of 7:00 a.m. and not 30-60 minutes prior to eating as required. These errors were observed during medication administration and confirmed through interviews with the staff, who acknowledged the importance of adhering to the specified times and instructions for medication administration.
Infection Control Failures
Penalty
Summary
The facility failed to ensure an effective infection prevention and control program, leading to multiple instances of cross-contamination and improper hygiene practices. One incident involved a CNA who did not change gloves or perform hand hygiene while providing incontinent care to a resident. The CNA touched various clean items and the resident's skin without changing gloves, despite knowing the correct procedures. This was confirmed by interviews with the CNA, LVN, and DON, who all acknowledged the risk of cross-contamination and increased infection risk due to these actions. Another incident involved two CNAs who did not follow Enhanced Barrier Precautions (EBP) while providing care to a resident with a colostomy and wound. Despite a sign indicating the need for gown and gloves, the CNAs did not don the required protective equipment. The CNA admitted to not understanding the full importance of EBP, even though they had recently received in-service training on the topic. This lapse was observed and confirmed by the WCN, ADON, and the CNA herself. Additionally, the facility failed to isolate a resident after urine cultures revealed the presence of ESBL, an antibiotic-resistant organism. The resident was not placed on contact isolation, and there were no physician orders or nursing notes indicating isolation status. Interviews with the DON and the resident confirmed that isolation protocols were not followed, increasing the risk of spreading the infection. The facility's infection control logs and policies were reviewed, revealing inconsistencies in the application of isolation precautions and EBP guidelines.
Failure to Obtain Informed Consent for Medication Administration
Penalty
Summary
The facility failed to ensure that Resident #102 was fully informed and had given consent before administering Prozac, an antidepressant medication. Resident #102, who had severe cognitive impairment and a history of depression, was given Prozac without the consent of her responsible party (RP). The RP had explicitly stated that he did not feel comfortable giving verbal consent over the phone and wanted to see Resident #102 in person before making a decision. Despite this, the medication was administered on two occasions without the required consent. Interviews with the facility staff, including the Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN) F, revealed that the standard procedure was to obtain written consent for psychotropic medications either during admission or before starting a new medication. The ADON confirmed that the RP had not given consent and that the medication should not have been administered. LVN F admitted to administering the Prozac but was unsure if consent had been obtained. The Director of Nursing (DON) also acknowledged that the medication should not have been given without the RP's consent. The facility's policy on resident rights and a document from Texas Health and Human Services both emphasize the necessity of obtaining consent for psychiatric medications. Despite these guidelines, the facility failed to adhere to the protocol, resulting in the administration of Prozac to Resident #102 without proper consent. This failure could potentially place residents at risk of receiving medications without their knowledge or consent, leading to adverse reactions or other negative outcomes.
Failure to Ensure Resident Access to Call Light
Penalty
Summary
The facility failed to ensure that a resident had access to a call light, which is a critical component for requesting assistance. The resident, who was [AGE] years old and had diagnoses including high blood pressure, anxiety disorder, pain, and shortness of breath, was observed multiple times without access to their call light. The call light was found draped over the head of the mattress and between the mattress and the fitted sheet, making it inaccessible. The resident was unable to locate the call light and expressed concern about how to call for assistance. The care plan for the resident indicated that the call light should be kept within reach at all times, but this was not adhered to during the observations on multiple occasions over two days. Interviews with staff, including a CNA, RN, DON, and the Administrator, confirmed that the call light should have been within reach and that its inaccessibility could prevent the resident from voicing their needs or calling for help, potentially leading to falls or other injuries. The CNA responsible for the resident on the day in question did not notice the call light's position and assumed it was under the covers. The RN and DON both stated that call lights should not be between the mattress and the fitted sheet and should always be within the resident's reach. The Administrator emphasized that all staff members entering a resident's room are responsible for ensuring the call light is accessible. The facility's policy on answering call lights, dated October 2010, also indicated that call lights should be within easy reach of residents when they are in bed or confined to a chair.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote resident self-determination through support of resident choice for a resident who requested to be assisted out of bed. The resident, who had severe cognitive impairment and was dependent on staff for mobility, expressed a desire to go outside and be out of bed daily. Despite these requests, the resident was not assisted out of bed for at least two weeks. Staff interviews revealed that the resident's requests were ignored due to a misunderstanding about the resident's wound care needs, with some staff believing that the resident should remain in bed to allow a bedsore to heal. However, the wound care nurse clarified that there was no medical reason preventing the resident from being out of bed, other than the resident's non-compliance with wound care instructions. The Director of Nursing (DON) and other staff members acknowledged that the resident had the right to get out of bed and that his requests should have been honored. The DON admitted that the resident's prolonged bed rest could have psychosocial impacts. The facility's policy on resident rights, which includes the right to self-determination and support from the facility in exercising these rights, was not followed in this case. The failure to assist the resident out of bed as requested led to a deficiency in promoting and facilitating resident self-determination and choice.
Failure to Accurately Assess Resident's Tobacco Use
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident, specifically regarding tobacco use. Resident #36, who has diagnoses including post-traumatic stress disorder, unspecified mood disorder, and high blood pressure, was not identified as a tobacco user in his most recent MDS assessment. Despite being listed as a safe smoker on a separate list and observed waiting for a smoke break, his MDS and care plan did not reflect his smoking status. This discrepancy was confirmed through interviews with the MDS Nurse, DON, and Administrator, all of whom acknowledged the importance of accurate MDS assessments for proper care planning. The MDS Nurse admitted that tobacco use should have been marked on the MDS and that an inaccurate MDS could lead to an incorrect care plan, potentially affecting the resident's safety and care. The DON and Administrator also confirmed that the resident's smoking status should have been included in the MDS and care plan. The facility's policy on MDS assessment data accuracy, which aligns with federal regulations, was not followed in this instance, leading to the deficiency.
Failure to Ensure Accurate PASRR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that Resident #27, who had a diagnosis of schizophrenia, was provided an accurate Preadmission Screening and Resident Review (PASRR) Level 1 assessment. The PASRR Level 1 assessment for Resident #27 did not reflect his mental illness, specifically schizophrenia, which was documented in his medical records and care plan. The MDS Nurse, who was responsible for reviewing PASRR Level 1 assessments for accuracy, did not review Resident #27's assessment because he was already PASRR positive. The MDS Nurse admitted that she had not reviewed PASRR positive residents' assessments since her employment began, focusing only on PASRR negative residents. The Director of Nursing (DON) and the Administrator also acknowledged that the MDS Nurse was responsible for ensuring the accuracy of PASRR Level 1 assessments, but the process failed to verify the information accurately for Resident #27. The deficiency was identified during a review of Resident #27's records, which showed inconsistencies between the PASRR Level 1 assessment and other medical documentation. The PASRR Level 1 assessment dated 04/19/18 indicated no evidence of mental illness, despite Resident #27 having an active diagnosis of schizophrenia. Interviews with the MDS Nurse, DON, and Administrator revealed a lack of thorough review and verification of PASRR Level 1 assessments, leading to the oversight. The facility's policy on PASRR did not address the accuracy of these assessments, contributing to the failure to provide Resident #27 with the necessary specialized services for his mental health condition.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. For one resident, the facility did not include smoking in the care plan despite the resident being a known smoker. This oversight was due to the resident not being marked as a tobacco user on the MDS, which the MDS Nurse acknowledged as a safety issue. The resident was observed waiting for a smoke break, and both the MDS Nurse and the DON confirmed that the care plan should have included smoking to ensure proper care and safety measures were in place. For another resident receiving hospice services, the facility failed to notify the hospice agency of significant behavioral changes and the resident's move to a secured unit. The resident exhibited severe cognitive impairment and behavioral issues, including sexual inappropriateness and exit-seeking behavior. Despite these changes, the LVN did not inform the hospice agency, which could have provided additional support and interventions. The hospice representative and the resident's RP both expressed concerns about the lack of communication, and the DON confirmed that the hospice agency should have been notified according to the care plan. These failures highlight the facility's inability to maintain accurate and comprehensive care plans, which are essential for coordinating care and ensuring residents' needs are met. The lack of proper documentation and communication with relevant parties, such as the hospice agency, resulted in missed opportunities for timely interventions and appropriate care for the residents involved.
Improper Mechanical Lift Transfer Procedure
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided adequate supervision to prevent avoidable accidents. Specifically, CNA A did not perform a safe mechanical lift transfer for Resident #13. During an observation, CNA A operated the mechanical lift with the base legs closed while lowering Resident #13 into her bed, contrary to the correct procedure of keeping the base legs open for stability. This incorrect procedure was confirmed by multiple staff members, including LVN F, the DON, and the CNA Coordinator, who all stated that the base legs should be open to prevent the lift from tipping and potentially injuring the resident. Resident #13, a [AGE] year-old female with severe cognitive impairment, dementia, stroke, hemiplegia, and osteoporosis, was dependent on staff for transfers and required the use of a mechanical lift with two staff members. The care plan for Resident #13 indicated that she should be transferred using a mechanical lift with the base legs open for stability. However, during the observed transfer, CNA A closed the base legs while lowering the resident, which could have led to the lift tipping and causing injury. Interviews with staff revealed that CNA A had been taught at another facility to close the base legs when lowering a resident, which contradicted the facility's training and best practices. The DON and CNA Coordinator emphasized the importance of keeping the base legs open for stability during transfers. The facility's records showed that CNA A had completed a departmental orientation checklist, including transferring patients with a mechanical lift, but the incorrect procedure was still followed during the observed transfer. The operation guide and best practices for using patient lifts also indicated that the base legs should be open for optimum stability and safety.
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 49 citations issued within 25 miles in the last 12 months — including the 1 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 Atlanta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Villa | 0.2 mi | ★★★★★ | 8 | 0 |
| Focused Care At Linden | 13.9 mi | ★★★★★ | 10 | 1 |
| Vivian Healthcare Center | 19.8 mi | ★★★★★ | 0 | 0 |
| Avir At Citizens Trail | 22.7 mi | ★★★★★ | 28 | 0 |
| The Springs Of Texarkana | 23.2 mi | ★★★★★ | 3 | 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.