Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Sandy Lake Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with ESRD and heart disease, who had an intact BIMS score and required total ADL assistance plus HD, was not included in her person-centered care planning process. Her last care plan conference was canceled and never rescheduled, and she stated she had not had a conference in quite some time despite wanting to participate. MDS nursing and the DON confirmed the missed conference and that it was overlooked.
Unclean Resident Rooms and Bathrooms: Multiple resident rooms had dirt, dust, stains, and debris in air vents, filters, night lights, toilets, bathroom floors, door frames, bed frames, bedside tables, soap dispensers, and mini fridges. Housekeeping staff and the Housekeeping Supervisor acknowledged the areas were their responsibility to clean, and the Administrator stated she expected resident rooms to be thoroughly cleaned.
A resident with cancer and sleep apnea had a container of germicidal wipes left on his bedside table near his CPAP mask. The resident said the wipes had been there for some time and staff used them to clean items in his room. The ADON, DON, and Administrator stated the wipes should have been secured in locked carts and not left in resident rooms because they contained chemicals.
A resident on continuous O2 had no Oxygen in Use sign outside the room, and two other residents had respiratory equipment left unbagged when not in use. One resident’s CPAP mask was found on a side table, and another resident’s nasal cannula was hanging on top of the O2 concentrator. Staff and leadership stated the sign and proper bagging were needed for cleanliness and to prevent cross contamination and infection.
An expired Duloxetine capsule was found in a resident’s med cart even though the resident had depression and was ordered the medication daily. Staff said the expired med should not have been in the cart, but it had been transferred with the resident and was not caught during cart checks. The DON and ADON stated expired meds should not be kept in carts, and facility policy required checking expiration dates and removing outdated meds.
A resident with dysphagia and a feeding tube received Venlafaxine 150 mg ER via g-tube, but an RN prepared the granules by adding water and stirring them when they would not pass through the syringe. The RN stated she sometimes crushed the medication to make it easier to administer, even though she knew ER meds should not be crushed or dissolved. The DON and ADON confirmed ER medications were not to be crushed or dissolved, and the facility policy required medications to be crushed only in accordance with policy.
Medicated creams and foam were found left accessible in resident rooms, including zinc oxide, triple antibiotics, and Theraworx on side tables, trays, and in cups at the bedside. Several affected residents had cognitive impairment, incontinence, or skin-related care plans, and observations showed the products were not secured or stored in locked compartments as required.
Improper Food Storage and Sanitation in Kitchen: Surveyors found unlabeled and undated food items in the walk-in cooler and freezer, frozen foods left uncovered, dirty storage bins in the dry storage area, and a bottle of sweet-and-sour sauce with visible mold around the lid and exterior. The DM and other dietary staff stated labeling, dating, covering food, and sanitizing containers were routine expectations, but these items had been overlooked.
Infection control failures were observed during resident care when staff did not follow EBP, hand hygiene, and device-care practices. A CNA changed linens for a resident with a catheter without a gown, an RN handled a PICC line without capping the end, an LVN performed wound care without sanitizing the table or scissors and without hand hygiene before gloves, an RN assisted a resident with a feeding tube without a gown, and staff did not perform hand hygiene during oxygen and incontinent care. The DON, ADONs, and Administrator acknowledged the expected practices and the facility policies cited required hand hygiene, EBP for residents with catheters and feeding tubes, and disinfectant caps on PICC lines.
Feeding Assistance Not Provided at Eye Level: A CNA was observed feeding a resident who had severe cognitive impairment, dysphagia, and required total assist for feeding while she was lying in bed and the CNA was standing over her instead of being at eye level. The RN and DON stated staff should feed residents at eye level and ensure the resident is sitting up for dignity and safety, but the CNA did not identify any concern with her approach.
Missed Quarterly MDS Assessment: A resident with dysphagia and a hx of CVA did not receive a required Quarterly MDS review within the 3-month timeframe after the prior completed assessment. The MDS nurse stated the assessment was overlooked and the DON confirmed it should have been completed by the MDS nurse; the facility policy requires quarterly review assessments at least once every 3 months between comprehensive assessments.
A facility failed to include key needs in two residents’ care plans. One resident with heart failure and severe cognitive impairment had a BiPAP order, but the care plan did not address BiPAP use. Another resident with severe protein-calorie malnutrition, dysphagia, and severe cognitive impairment required feeding assistance, but the care plan did not include assist feeding. The ADON, DON, and MDS nurse acknowledged both needs should have been care planned.
A resident with dysphagia and a g-tube was given multiple meds via the tube by an RN who crushed tablets and opened a venlafaxine capsule. When the granules did not pass easily through the syringe, the RN repeatedly added extra water beyond the ordered flush amounts to force the medication through. The DON and ADON stated the ordered flush volumes were important during g-tube med administration.
A nurse failed to accurately assess a resident with dementia and a history of multiple falls as a high fall risk, instead documenting them as low risk on two occasions. The resident required substantial assistance and had significant cognitive and physical impairments. The care plan included fall prevention interventions, but staff did not consistently implement them, and some were unaware of the resident's fall history. The nurse admitted to needing more training on the assessment tool, and leadership confirmed the assessments were inaccurate, resulting in insufficient fall prevention measures.
Three residents with significant ADL needs and fall risks were found with their call lights out of reach, preventing them from obtaining assistance as required by their care plans and facility policy. Staff confirmed that call lights should have been accessible to residents at all times.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unassisted by exiting through the front door while staff were distracted, crossing a busy intersection before being found by a pedestrian and returned by staff. The resident had been identified as an elopement risk, but supervision and door security measures were not effectively implemented, resulting in the resident's elopement.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and a history of falls. The resident's bed was not consistently kept in the lowest position, and the bedside table was placed in a hazardous location, contrary to the facility's fall management policy. Staff acknowledged the potential fall risk, highlighting a deficiency in adhering to established safety protocols.
The facility failed to obtain physician orders for scoop mattresses used by two residents with severe cognitive impairments and total dependence on assistance. Observations revealed the use of these mattresses without proper medical justification, as confirmed by an LVN and the DON, who acknowledged the oversight.
A resident with COPD did not receive proper respiratory care as their nasal cannula was improperly stored on top of the oxygen concentrator without being bagged, contrary to facility policy. Staff interviews confirmed the expectation for nasal cannulas to be bagged to prevent infection, highlighting a lapse in adherence to respiratory equipment maintenance protocols.
A facility failed to maintain proper infection control when a resident's foley catheter bag was found touching the floor, contrary to policy. The resident, with a neurogenic bladder and at risk for UTIs, had their catheter bag improperly placed, which was acknowledged by an LVN and the ADON as an infection control issue.
A resident sustained a leg fracture after being transported in a wheelchair without footrests by the Director of Therapy, who failed to report the incident. The injury was not discovered until days later when the resident complained of pain, leading to a delay in medical intervention.
A resident sustained a leg fracture after the Director of Therapy failed to use the footrest during wheelchair transport, causing the resident's leg to get caught. The incident was not reported immediately, delaying treatment. The resident, who required moderate assistance, experienced pain and was diagnosed with a fracture days later. The DOT was terminated for neglecting safety protocols and failing to report the incident.
The facility failed to maintain a clean and homelike environment, with surveyors observing unclean conditions in 12 resident rooms and common areas. Handrails had dark stains, and rooms had dust and dirt on air conditioning units and vents. Bathrooms had dirt and stains, with some shower curtains stained. Housekeeping staff were not consistently following cleaning procedures, and the Administrator acknowledged the need for improvement.
The facility failed to maintain an effective Infection Prevention and Control Program, leading to deficiencies in hand hygiene and cross-contamination. A CNA did not change gloves or sanitize hands during incontinent care, an RN improperly brought test strips into a resident's room, and a medication aide neglected hand hygiene during medication administration. Additionally, an RN and CNA did not sanitize hands between glove changes during wound care, risking cross-contamination.
A resident with a neuromuscular bladder dysfunction was not provided a privacy bag for his catheter, despite a physician's order and facility policy requiring it. Observations and staff interviews confirmed the catheter bag was visible, potentially causing embarrassment. The facility's policy mandates privacy bags to maintain resident dignity.
Two residents with COPD in an LTC facility were found with improperly stored respiratory equipment, including a nebulizer mask and nasal cannula, which were not bagged when not in use. This failure to follow infection control practices was confirmed by an LVN and acknowledged by the DON and ADON, who stated that the facility's policy requires such equipment to be bagged to prevent contamination.
A resident with contractures in her hands was not provided with appropriate adaptive equipment for drinking, leading to a spill and scald injury. The resident was served hot coffee in a handle-free tumbler, which she could not grasp, resulting in the spill. The facility failed to provide a cup with handles as indicated in the care plan, and staff were unaware of any special equipment available for the resident.
Resident Not Included in Care Plan Conference Process
Penalty
Summary
The facility failed to ensure Resident #5 participated in the development and implementation of her person-centered plan of care, including the planning process, the right to identify individuals or roles to be included in the planning process, the right to request meetings, and the right to request revisions to the person-centered plan of care. Resident #5 was a female admitted to the facility with diagnoses of end stage renal disease and heart disease. Her quarterly MDS assessment reflected an intact cognitive response with a BIMS score of 15, and she required total assistance for ADL care and received hemodialysis. Record review showed the resident's last care plan conference occurred on 03/18/25, and the next conference scheduled for 06/18/25 was canceled and never rescheduled. During interview, Resident #5 stated she had not had a care plan conference in quite some time and wanted to be part of her care planning. MDS Nurse C stated the conference should have been scheduled, but she was unsure why it was canceled and not rescheduled. The DON stated the resident was in the hospital at the time and the care plan conference was never rescheduled, and that the social worker should have rescheduled it but it was overlooked.
Unclean Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for 15 of 20 resident rooms on the 300 and 400 halls. During observations, multiple resident rooms were found with dirt, dust, stains, and debris in areas including air conditioning vents and filters, night lights, toilet bowls and bases, bathroom floors, door frames, bed frames, bedside tables, soap dispensers, and mini fridges. Several bathrooms had brownish or dark gray stains around toilets and on floors, and some rooms had food residue or other stains inside refrigerators and on room surfaces. Housekeeper E stated she had been assigned to clean the 300 hall and said housekeeping was responsible for cleaning everything in the resident rooms, including the bathrooms and shower stalls. She also stated the floor techs were to clean the air conditioning filters. After being shown the observed conditions in the affected rooms, she stated housekeeping was responsible for cleaning the areas mentioned and that not cleaning them could impact residents' breathing. The Housekeeping Supervisor stated housekeeping staff used a checklist to clean resident rooms, that he spot checked rooms, and that floor techs cleaned air filters once a week. He also stated they completed deep cleans daily and acknowledged that not thoroughly cleaning resident rooms could impact residents' breathing. The Administrator was shown pictures of the observed concerns in the affected rooms and stated she expected resident rooms to be thoroughly cleaned. She stated not thoroughly cleaning the resident rooms could cause infections. The facility policy on Safe/Comfortable/Homelike Environment stated housekeeping and maintenance services include the cleaning, sanitization, and care for rooms and common areas to ensure the facility is safe for all who reside, work, and visit.
Germicidal Wipes Left Accessible in Resident Room
Penalty
Summary
The facility failed to ensure that Resident #28’s environment remained free of hazards when a container of germicidal wipes was left inside the resident’s room on 08/17/2025. Resident #28 was a cognitively intact male admitted to the facility with diagnoses including neoplasm of the kidney and bone, stage 4 carcinoma, and sleep apnea. His comprehensive MDS assessment dated 07/17/2025 reflected a BIMS score of 15, and his care plan also identified cancer and sleep apnea. During observation at 9:59 AM, Resident #28 was in bed awake, and a container of germicidal wipes was seen on his bedside table near the CPAP mask that was also on the table. The resident stated the wipes had been sitting there for some time and that staff used them to clean items in his room. The ADON later stated the wipes should not have been inside the resident’s room or near items used by the resident, including the CPAP mask, and said they should be kept inside locked carts. She also stated the wipes contained chemicals that could cause skin irritation, eye irritation, and respiratory issues. A CNA stated he did not know who left the wipes in the room and said he had not noticed them during his morning round. The Administrator and DON both stated the wipes should not be left in residents’ rooms and should be secured in locked carts because they contained chemicals and could be harmful if accessed by residents. The facility policy on medication storage stated potentially harmful substances such as cleaning supplies and disinfectants are to be clearly identified and stored away.
Respiratory equipment not properly stored and oxygen signage missing
Penalty
Summary
The facility failed to ensure an Oxygen in Use sign was placed outside the room of a resident receiving continuous oxygen therapy. Resident #2 had shortness of breath, moderate cognitive impairment, and an order for oxygen at 2 liters per minute via nasal cannula. During observation, the resident was in bed on oxygen, but no Oxygen in Use sign was posted outside the room. An LVN stated the sign should be outside the door whenever oxygen is being used and then retrieved one from storage and placed it outside the room. The facility also failed to ensure respiratory equipment was properly stored when not in use for two other residents. Resident #28 had sleep apnea, was cognitively intact, and had an order for CPAP during sleep and naps. During observation, the resident was in bed awake and the CPAP mask was found on the side table unbagged. The resident stated staff put it on at night and removed it, and the ADON stated CPAP masks should be in a plastic bag when not in use to prevent cross contamination and respiratory infection. Resident #71 had COPD, moderate cognitive impairment, and an order for oxygen via nasal cannula every shift as needed. During observation, the resident was in bed with an oxygen concentrator at bedside and the nasal cannula hanging on top of the concentrator, not bagged. The LVN stated the cannula should be bagged when not in use to prevent transfer of microorganisms and said she would get a new one and place it in a bag. Facility leadership, including the DON and Administrator, acknowledged that nasal cannulas and CPAP masks should be kept clean and bagged when not in use, and that an Oxygen in Use sign should be posted outside rooms where oxygen is being used.
Expired antidepressant found in medication cart
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when an expired Duloxetine capsule for one resident was found inside the medication cart. The resident was a cognitively intact female with a diagnosis of depression, and her care plan reflected treatment with antidepressant medication to manage symptoms. Her physician’s order included Duloxetine HCl 30 mg by mouth daily. During observation, surveyors found the expired Duloxetine container in the cart, with a date of 11/17/2024. The medication aide stated she had just transferred to the hall and used the resident’s blister pack for administration, but said the expired container should not have been in the cart and that staff administering medications could mistakenly use it. The ADON also observed the expired medication and stated it should not have been in the cart, that it may have been brought from the hospital when the resident was admitted, and that it had been placed in the cart without checking the date. Additional interviews showed staff members were responsible for auditing the carts and checking for expired medications, but the expired medication remained in the cart after the resident’s transfer between halls. The DON and Administrator stated expired medications should not be kept in carts, and the facility policy required checking expiration dates and immediately removing and disposing of outdated medications. The expired Duloxetine was removed from the cart during the survey.
Medication Error With Extended-Release Venlafaxine via G-Tube
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when RN C prepared Venlafaxine 150 mg ER for administration via g-tube and poured water on the medication granules, stirring them one by one with a plastic spoon. The resident was a cognitively intact female with dysphagia and a feeding tube, and her orders included enteral feeding instructions to flush the tube before and after medication administration and between each medication. Her physician order also reflected Venlafaxine 150 mg ER via gastric tube two times a day. During observation, RN C stated she had difficulty with the medication because the granules would not pass through the syringe and said she tried to dissolve it but it would not dissolve completely. She also stated she would sometimes crush the medication so it would pass through the tube easier, and acknowledged that extended-release medications should not be crushed or dissolved because they are designed to be released over an extended period of time. The DON and ADON stated extended-release medications were not to be crushed or dissolved because doing so could affect how the medication is released and absorbed, and the facility policy required oral medications to be crushed in accordance with facility policy.
Medications Left Accessible in Resident Rooms
Penalty
Summary
The facility failed to ensure multiple medications and biologicals were stored in locked or otherwise secured locations with limited access. During observations, zinc oxide, triple antibiotics, and Theraworx foam were found left in resident rooms or on bedside tables, including on top of side tables, on trays with snacks, and in cups at the bedside. The report identified this issue for eight residents: two residents had zinc oxide left on their side tables, one resident had triple antibiotics left in the room, one resident had Theraworx foam left on the side table, and two residents had zinc oxide in cups left at the bedside. Resident #2 had moderate cognitive impairment with a BIMS score of 10, was incontinent of bladder, and had a care plan noting risk for pressure ulcer with use of skin barrier cream. On observation, a container of zinc oxide was on top of the resident’s side table while the resident was in bed with eyes closed. Resident #3 was cognitively intact with a BIMS score of 15, was incontinent of bladder and bowel, and also had a care plan calling for skin barrier cream; a container of zinc oxide was observed on top of the resident’s side table while the resident was in bed with eyes closed. Resident #5 was cognitively intact with a BIMS score of 15, had moisture associated skin damage, and had an order to apply barrier cream as needed; a tube of zinc oxide was observed on the overbed table and on a tray with snacks, and the resident stated it had been on the tray for quite some time. Resident #7 had severe cognitive impairment with a BIMS score of 03 and a care plan for nerve pain; a Theraworx foam spray was observed on the side table while the resident was not in the room, and it remained there on a later observation. Resident #49 had moderate cognitive impairment with a BIMS score of 11, was incontinent of bladder and bowel, and had a wound treatment order for the right buttock; a tube of triple antibiotics was observed on top of the resident’s side table while the resident was not in the room. Resident #60 had severe cognitive impairment with a BIMS score of 07 and a care plan for pressure ulcer risk; some cream in a cup was observed at the bedside table while the resident was not in the room. Resident #68 had severe cognitive impairment with a BIMS score of 07, was incontinent of bladder and bowel, and had an order for barrier cream after each incontinent episode; some cream in a cup was observed at the bedside table while the resident was not in the room. Resident #77 had moderate cognitive impairment with a BIMS score of 12 and a care plan for pressure ulcer risk; a container of zinc oxide was observed on top of the resident’s side table while the resident was in bed with eyes closed.
Improper Food Storage and Sanitation in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. During observation of the kitchen, surveyors found one zip lock bag of fish filets in the walk-in cooler that was not labeled with the date stored, one large container of thick substance in the walk-in cooler that was not labeled and dated, and one large bag of diced bell peppers in the walk-in cooler that was not labeled with the date stored. In the freezer, one large box of frozen lima beans and one large box of frozen biscuits were not concealed from airborne contaminants, and one bag of hash browns was not labeled with the date stored. In the dry storage area, two storage bins containing sugar and flour had dirt stains on the outside and near the opening, one large storage bin of corn meal had a brown stain along the inside walls, and one large storage bin of salt had a brown patch in the salt described as dried up water mixed into the salt. Surveyors also observed one large plastic bottle of sweet-and-sour sauce with visible mold growth around the lid and exterior of the bottle. In interviews, the Dietary Manager stated staff were responsible for labeling and dating food in the freezer, walk-in cooler, and dry storage area, and said she normally inspected the area each morning but had not done so that morning. She stated the freezer foods should have been covered to avoid freezer burn and that the containers were cleaned at least weekly, but this had been overlooked. Other dietary staff stated bottles and containers were expected to be sanitized regularly, any sign of mold or buildup required immediate disposal, and the molded bottle should have been thrown away. The Administrator stated kitchen staff were expected to follow policy on proper food storage and kitchen sanitation, including labeling, dating, and handling of kitchen containers.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for five residents reviewed for infection control. During observation, CNA J was seen fixing Resident #23’s bed linens while the resident had an indwelling catheter and was on enhanced barrier precautions, but CNA J was not wearing a gown. CNA J later stated she should have worn a gown and gloves because the resident was on EBP and the signage outside the room clearly stated to use EBP when changing linens. Resident #28 had a PICC line for IV cefepime for a skin infection. During observation, RN C was preparing to administer the antibiotic through the PICC line, and the end of the line was not capped and was touching the resident’s hospital gown. RN C stated she usually placed a green cap on the PICC line to prevent cross contamination, but did not see one available. She also stated the line should be capped after medication administration to prevent cross contamination and infection. Resident #48 required daily wound care for a skin tear on the right knee. During observation, LVN E placed wound care supplies on the resident’s overbed table without sanitizing the table, did not perform hand hygiene before donning gloves, and used scissors taken from her pocket without sanitizing them before cutting xeroform. Resident #70 had a feeding tube and was on enhanced barrier precautions, but RN C assisted with dressing the resident without wearing a gown. Resident #71 was observed during oxygen care and incontinent care, and LVN E and CNA I did not perform hand hygiene before glove use or between glove changes during care. The facility’s DON, ADONs, and Administrator all acknowledged that hand hygiene, capping the PICC line, sanitizing equipment and surfaces, and wearing PPE for EBP were expected, and the report cited facility policies requiring hand hygiene, hand hygiene after glove removal, hand hygiene during incontinence care, EBP for residents with catheters and feeding tubes during dressing and linen changes, and disinfectant end caps on PICC lines.
Feeding Assistance Not Provided at Eye Level
Penalty
Summary
The facility failed to treat a resident with respect and dignity during lunch feeding for 1 of 8 residents reviewed for dignity. Resident #50 was an [AGE] year-old female with diagnoses including severe protein-calorie malnutrition and dysphagia, and her quarterly MDS reflected severe cognitive impairment with a BIMS score of 3 and total assistance needed for feeding. Her physician order reflected eating with assist of 1 person, but her comprehensive care plan did not reflect a care plan for feeding assistance. During an observation and interview, a CNA was seen feeding the resident while she was lying in bed and standing over her rather than being at eye level. When asked about the feeding position, the CNA stated the resident should be sitting up at a 45-degree angle and said she could see the resident's eyes, finding no concern with standing over her while feeding her. An RN stated staff should ensure the resident was sitting up and staff should be at eye level for choking prevention and dignity, and the DON stated staff was to be at eye level while feeding residents because it was for dignity.
Missed Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident #54 received a Quarterly Review assessment within 3 months of the prior completed assessment. Record review showed the resident was a [AGE]-year-old female admitted to the facility with diagnoses of dysphagia and cerebral infarction, and her 04/18/25 Quarterly MDS reflected an intact cognitive response with a BIMS score of 14, total assistance for ADLs, and a diagnosis of muscle weakness. That assessment listed a due date of 07/19/25, but the Quarterly Review assessment was not completed by that date. During an interview on 08/19/25 at 9:50 AM, the MDS nurse stated the Quarterly MDS Assessment was not completed for Resident #54 and said she did not know how it was overlooked. She stated it was the MDS nurse’s responsibility to complete the assessment and that not completing it could impact the resident’s overall care. In a later interview, the DON stated the assessment should have been completed by the MDS nurse and noted the nurse was new and trying to get caught up. The facility policy stated that a quarterly review assessment is completed using the standardized Quarterly review assessment tool no less than once every 3 months between comprehensive assessments.
Failure to Care Plan BiPAP Use and Feeding Assistance
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents whose assessments and physician orders identified specific care needs. Resident #1, an older female with atrial fibrillation, heart failure, and severe cognitive impairment with a BIMS score of 3, had a physician order for noninvasive ventilation via BiPAP ST at bedtime and during naps, but her quarterly care plan did not include the BiPAP machine. During interviews, the ADON, DON, and MDS nurse stated the resident should have been care planned for the BiPAP use and acknowledged that it was their responsibility to ensure it was included. Resident #50, an older female with severe protein-calorie malnutrition, dysphagia, and severe cognitive impairment with a BIMS score of 3, had a physician order for eating with assist of one person and the quarterly MDS reflected total assistance for feeding. Her comprehensive care plan did not include feeding assistance. In interviews, the MDS nurse, ADON, and DON stated the resident should have been care planned for assist feeding and that the care plan should reflect all care pertaining to the resident.
Excessive Water Used During G-Tube Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one resident with a feeding tube. Resident #70 was a cognitively intact female with dysphagia and a gastrostomy tube, and her care plan identified her as at risk for aspiration due to the presence of the feeding tube. Her physician orders directed that the tube be flushed with 60 cc of warm water before and after medication administration and 10 to 15 cc between each medication. During observation, RN C prepared four medications for administration through the resident’s g-tube. She crushed three medications and opened a venlafaxine capsule, placing the granules in a cup. She prepared two large cups of water and stated she would use the water to flush the tube and dissolve the medications. While administering the medications, the granules from the venlafaxine did not dissolve easily and became stuck where the syringe connected to the g-tube. RN C repeatedly added water in amounts of about 30 ml and then about 15 ml several times until the granules passed through the syringe. RN C later stated she had used too much water because she had to make sure the granules would go through, and she knew she was only supposed to flush 60 ml before and after medications and 15 ml between medications. The ADON and DON stated that the ordered amount of water was important during medication administration via g-tube and that more than the ordered amount could affect the resident, including causing fluid overload, vomiting, and aspiration. The facility policy stated that gastrostomy tubes are used to maintain nutrition and electrolyte balance and to provide sufficient fluids to maintain proper hydration and prevent complications of enteral feeding.
Failure to Accurately Assess and Address Fall Risk
Penalty
Summary
Nurses at the facility failed to demonstrate competency in assessing fall risk for a resident with a complex medical history, including dementia, multiple falls, and a recent hip fracture. The resident was admitted for hospice care and had diagnoses such as narcotic poisoning, vascular dementia, contractures, and chronic pain. Despite a documented history of multiple falls and significant physical and cognitive impairments, the resident was repeatedly assessed as a low fall risk by an LVN using the Morse Fall Scale on two separate occasions. These assessments did not accurately reflect the resident's condition or history, as the resident required substantial assistance with mobility and activities of daily living and was not aware of his own abilities. The care plan for the resident identified him as being at risk for falls due to medication use, cognitive impairment, vision issues, weakness, and a history of falls. Interventions included close monitoring, keeping the bed in the lowest position, ensuring the call light and personal items were within reach, and providing a clutter-free environment. However, observations revealed that the resident's bed was not always kept in the lowest position, and staff were not consistently aware of the resident's fall history. Additionally, the LVN responsible for the fall risk assessments admitted to needing more training on the assessment tool and acknowledged that the assessments were inaccurate. Interviews with facility staff, including the DON and the administrator, confirmed that the assessments were not completed accurately and that the resident should have been identified as a high fall risk. The facility's policies required accurate identification of fall risk and individualized care planning, but these were not followed in this case. The failure to accurately assess and document the resident's fall risk led to insufficient interventions being implemented for the resident's safety.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of three residents were accessible, as required by their care plans and facility policy. Observations revealed that one resident's call light was on the floor and out of reach while he was lying in bed, despite his need for extensive assistance and his status as a fall risk. Another resident, who also required extensive assistance and had a history of falls, was found with his call light pad under the bed and out of reach. This resident reported being unable to contact staff for help when he was wet earlier in the morning. A third resident, who required supervision or touching assistance and was a fall risk, was heard calling for help from his room; his call light was found hanging on the wall, wrapped around an air freshener, and not accessible to him. Staff interviews confirmed that the call lights should have been placed within reach of the residents, in accordance with their care plans and the facility's policy. Staff acknowledged that the improper placement of call lights could prevent residents from alerting staff when assistance was needed. The facility's policy specifically required that call lights be placed within reach of residents when staff leave the room.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of wandering was able to elope from the facility. The resident, who had diagnoses including Alzheimer's disease, dementia, and senile degeneration of the brain, was assessed as an elopement risk and had demonstrated exit-seeking behaviors. On the day of the incident, the resident independently propelled himself in a wheelchair out of the facility's front entrance and crossed a busy intersection with multiple lanes of traffic before being found by a pedestrian and returned to the facility by staff. At the time of the event, the lobby area was busy with residents and staff, and a vendor had entered the building with another resident. The receptionist was engaged in conversation with the vendor and did not notice the resident approaching or exiting through the door. The resident was able to leave the building unassisted because the door was not properly secured after the vendor's entry, and staff did not observe the resident's departure. The facility had identified the resident as an elopement risk, with care plans and assessments noting his cognitive deficits, history of wandering, and need for supervision, but these measures were not effectively implemented to prevent the elopement. Interviews with staff and review of facility policies revealed that procedures were in place for monitoring elopement risk residents, including the use of elopement binders, regular rounding, and staff education on elopement prevention. However, on the day of the incident, these procedures were not adequately followed, as the resident was able to exit the facility without detection. The failure to provide adequate supervision and ensure the security of exit doors directly led to the resident's elopement.
Failure to Implement Comprehensive Care Plan for Fall Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. The resident, a male with severe cognitive impairment, unsteadiness on feet, dementia, and muscle weakness, was totally dependent on assistance for activities of daily living such as transfers, toileting, and bathing. Despite having a history of falls, the care plan did not adequately address fall prevention measures, as evidenced by the resident's bed not being in the lowest position and the bedside table being placed in a potentially hazardous location. Observations and interviews revealed that the resident's bed was not consistently maintained in the lowest position, which was a preference expressed by the resident's family member to prevent falls. The facility's policy on fall management emphasized maintaining an environment free of accident hazards, yet the resident's living area was not arranged to minimize fall risks. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged the potential fall risk posed by the bed and bedside table arrangement, indicating a failure to adhere to the facility's fall management policy.
Failure to Obtain Physician Orders for Scoop Mattresses
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints without proper medical justification. Specifically, the facility did not obtain physician orders or conduct a physician assessment for the use of scoop mattresses for two residents, both of whom had severe cognitive impairments and were totally dependent on assistance for activities of daily living. These residents were observed to have scoop mattresses on their beds without the necessary physician orders, which is a requirement for such interventions. The deficiency was identified through observations, interviews, and record reviews. An LVN confirmed that both residents had been using scoop mattresses during her tenure at the facility, but no physician orders were found in their records. The DON acknowledged the oversight and confirmed that physician orders were needed to prevent potential injuries from falls. The facility's policy on fall management emphasizes the need for appropriate assessments and interventions to prevent falls, which was not adhered to in this case.
Improper Storage of Nasal Cannula for Resident with COPD
Penalty
Summary
The facility failed to provide proper respiratory care for a resident diagnosed with chronic obstructive pulmonary disease (COPD), who required oxygen therapy. The deficiency was identified when the resident's nasal cannula was observed to be improperly stored on top of the oxygen concentrator and not bagged when not in use. This improper storage was confirmed during an observation when the resident was not in her room, and the nasal cannula was found hanging on the oxygen concentrator without a protective bag. Interviews with staff, including a CNA and an RN, revealed that the nasal cannula should have been placed in a plastic bag to maintain cleanliness and prevent respiratory infections. The CNA admitted to placing the nasal cannula on top of the bed while searching for a plastic bag, and the RN confirmed the need for bagging the nasal cannula to prevent infection. The Director of Nursing (DON) and the Administrator both acknowledged the expectation for staff to ensure nasal cannulas are bagged when not in use, as per the facility's policy on respiratory equipment maintenance.
Infection Control Deficiency: Foley Catheter Bag Handling
Penalty
Summary
The facility failed to maintain an infection control program, as evidenced by the improper handling of a foley catheter bag for a resident with neuromuscular dysfunction of the bladder. On the date of observation, the resident's foley catheter bag was found touching the floor, which is against the facility's policy designed to prevent contamination and infection. The resident, who had been admitted with a neurogenic bladder and was at risk for urinary tract infections, mentioned that the catheter was usually hung on the side of the bed. During the observation, a Licensed Vocational Nurse (LVN) acknowledged the error and adjusted the bed height to prevent the catheter bag from touching the floor. The Assistant Director of Nursing (ADON) also confirmed that the catheter bag should not have been on the floor, recognizing it as an infection control issue. The facility's policy explicitly states that the drainage bag should not be placed on the floor to reduce the risk of contamination and subsequent catheter-associated urinary tract infections.
Failure to Notify Physician of Resident Injury
Penalty
Summary
The facility failed to notify the physician of an accident that resulted in an injury requiring medical intervention for a resident. The incident involved the Director of Therapy (DOT) transporting the resident in a wheelchair without footrests, leading to the resident's left leg getting caught and resulting in a fracture. The injury was not discovered until several days later when the resident complained of pain, and an x-ray confirmed the fracture. The resident, who was cognitively intact and required moderate assistance for activities of daily living, did not report pain immediately following the incident. Progress notes indicated no complaints of pain until the resident informed a nurse practitioner, who then ordered an x-ray. The delay in reporting the incident and the injury resulted in the resident not receiving immediate medical attention, which could have led to further damage. Interviews with staff revealed that the DOT did not report the incident until several days later, and the resident's complaints of pain were not adequately addressed until the weekend following the incident. The facility's policy required timely notification of changes in a resident's condition, which was not adhered to in this case, leading to the deficiency.
Failure to Use Wheelchair Footrest Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices, leading to an accident involving a resident. The incident occurred when the Director of Therapy (DOT) transported the resident without utilizing the footrest on her wheelchair. As a result, the resident's sneakers gripped the floor, causing her left leg to get caught under the wheelchair, leading to a fracture in her left leg. The resident, who was cognitively intact and required moderate assistance for activities of daily living, experienced pain and was later diagnosed with a fracture after an x-ray was conducted. Interviews revealed that the DOT did not report the incident immediately, and the resident's complaints of pain were not addressed until several days later. The resident expressed that she was in pain following the accident and had to remain in bed for eight weeks due to the injury. The facility staff, including the Physical Therapist and Regional Director of Operations, confirmed that the DOT failed to report the incident promptly, which delayed the resident's treatment. The facility's staff, including the Administrator and Nurse Practitioner, acknowledged the delay in reporting the incident and the subsequent injury. The Administrator noted that the DOT was suspended and later terminated for neglecting to use the footrest and failing to report the incident. The Nurse Practitioner confirmed that the resident was sent for an x-ray after complaints of pain, which revealed the fracture. The incident highlighted a lapse in communication and adherence to safety protocols within the facility.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by observations of unclean and unsanitary conditions in 12 resident rooms and common areas. The surveyors observed long streaks of dark brownish stains on the handrails in the hallways, and multiple resident rooms had dust and dirt on air conditioning units, air filters, and vents. Additionally, the bathrooms in these rooms had dirt particles, built-up dirt stains, and dark stains in the shower areas, with some rooms having stained shower curtains and rusted handrails. Interviews with housekeeping staff revealed that the cleaning procedures were not being followed consistently. A housekeeper, who had been at the facility for two weeks, stated that she was trained by shadowing another housekeeper and was unsure who was responsible for cleaning the handrails. She mentioned that deep cleaning was done for 2 to 3 rooms a day, but there was no clear schedule for cleaning air filters or handrails. The Housekeeping Supervisor confirmed that the rooms, handrails, and showers were supposed to be cleaned daily and acknowledged the lack of a schedule for cleaning shower curtains. The facility's Administrator admitted that the cleanliness and physical appearance of the facility needed improvement and that key leadership was not consistently conducting Angel rounds to ensure resident well-being. The facility's policy on maintaining a safe and homelike environment emphasized the importance of cleaning and sanitization, but the observed deficiencies indicated a failure to adhere to these standards, potentially leading to contamination.
Infection Control Deficiencies in Hand Hygiene and Cross-Contamination
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in several deficiencies related to hand hygiene and cross-contamination. One incident involved a CNA who did not change gloves or perform hand hygiene after providing incontinent care to a resident, potentially transferring contaminants from soiled to clean areas. The CNA acknowledged the oversight and recognized the risk of cross-contamination and infection. Another deficiency was observed when an RN brought a container of test strips into a resident's room while checking blood sugar levels. The RN admitted that the container should have remained on the cart, as it was used for multiple residents, and bringing it into the room could lead to cross-contamination. The RN understood that the best practice was to avoid bringing shared items into individual resident rooms. Additionally, a medication aide failed to perform hand hygiene before and after administering medications to multiple residents. This lapse in protocol was acknowledged by the aide, who noted the importance of hand hygiene in preventing contamination. Furthermore, during wound care for a resident with a pressure ulcer, an RN and a CNA did not sanitize their hands between glove changes, despite handling soiled items. Both staff members recognized the importance of hand hygiene in preventing the spread of germs and cross-contamination.
Failure to Provide Privacy Bag for Catheter
Penalty
Summary
The facility failed to maintain the dignity of Resident #53, a cognitively intact male with a neuromuscular dysfunction of the bladder, by not providing a privacy bag for his catheter bag. Despite having a physician's order for a privacy bag to be used every shift, observations revealed that the catheter bag was visible without a privacy cover, which was confirmed by both the resident and staff members. The resident was unaware of the exposure, and staff interviews indicated that the lack of a privacy bag could lead to embarrassment or discomfort for the resident. Interviews with the LVN, CNA, DON, ADON, and the Administrator confirmed the expectation that catheter bags should be covered with privacy bags to maintain resident dignity. The facility's policy on catheter care also stipulated the use of privacy bags to promote hygiene, comfort, and dignity. The failure to adhere to these policies and procedures resulted in a deficiency in treating the resident with respect and dignity, as required by the facility's standards and resident rights policies.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the storage of respiratory equipment. Resident #20, a female with chronic obstructive pulmonary disease (COPD) and shortness of breath, was observed with her nebulizer mask improperly stored on top of the nebulizer machine without being bagged. This part of the mask, which touches the face during use, was in contact with the machine's surface. The resident reported that the nurse would sometimes leave the mask on the table after treatment, and she had never seen a bag for her nebulizer mask. Similarly, Resident #45, also diagnosed with COPD and shortness of breath, was found with her nasal cannula hanging on the oxygen concentrator without being bagged. The nasal cannula was not stored in a plastic bag, which is necessary to prevent contamination. An LVN confirmed the improper storage of both the nebulizer mask and the nasal cannula, acknowledging that they should not be exposed or touching surfaces to avoid cross-contamination and infection. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the facility's policy requires respiratory equipment to be bagged when not in use to prevent infection. The DON and ADON both stated that the staff is responsible for ensuring proper storage of respiratory equipment, and the expectation is for these items to be bagged when not in use. The facility's policy on respiratory treatment and care emphasizes the importance of following infection control practices, including the proper handling and storage of equipment.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide appropriate assistive devices to a resident who needed them to maintain or improve their ability to eat or drink independently. The resident, a cognitively intact female with multiple diagnoses including lack of coordination, was served hot coffee in a handle-free tumbler, which she could not grasp due to contractures in her hands. This resulted in the coffee spilling and scalding her right upper chest. The resident's care plan indicated the need for a cup with handles, but this was not provided. Instead, the resident was using a personal handle-free tumbler, which was not safe for her condition. The resident had previously insisted on using her personal cup, but there was no documentation of the facility providing or suggesting safer alternatives. The incident occurred when a CNA used the resident's personal tumbler to serve coffee, leading to the spill and subsequent injury. Interviews and observations revealed that the staff was unaware of any special equipment available for the resident to assist with eating or drinking. The resident's care plan and progress notes did not reflect recommendations for adaptive eating equipment, and the facility's policy on assistance with meals was not followed. The incident highlighted a lack of appropriate adaptive equipment and staff awareness, which contributed to the resident's injury.
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 1,391 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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 Coppell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Ridge Nursing & Rehabilitation Center | 2.5 mi | ★★★★★ | 14 | 0 |
| Heritage Gardens Rehabilitation And Healthcare | 2.6 mi | ★★★★★ | 10 | 0 |
| Carrollton Health And Rehabilitation Center | 3.3 mi | ★★★★★ | 27 | 0 |
| The Madison On Marsh | 5.5 mi | ★★★★★ | 10 | 0 |
| Brookhaven Nursing And Rehabilitation Center | 5.8 mi | ★★★★★ | 4 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.