Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Seabreeze Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of stroke and glaucoma had personal bank card information used by a CNA through a payment application, resulting in unauthorized transfers and attempted transfers of funds to the CNA. The resident reported being awakened by the CNA, who requested his bank card under the pretense of putting money on it, and later learned from a family member overseeing his finances that multiple transactions linked to the CNA’s payment account had occurred without his authorization. The CNA admitted adding the resident’s card to her payment application for prior reimbursement and leaving it on file, despite having received abuse and misappropriation training, leading to the misappropriation of the resident’s funds.
Unclean food containers were observed in the main kitchen, including a full 1-gal container of ranch dressing and a full 1-gal container of soy sauce with visible residue and buildup on the exterior surfaces and lids. The DM acknowledged the containers appeared unclean and stated that kitchen staff were responsible for cleaning, labeling, dating, and storing food items. The facility policy required food to be stored to prevent deterioration or contamination.
A resident with diagnoses including CVA, carotid artery syndrome, Meniere’s disease, heart disease, Parkinsonism, and muscle wasting was discharged to another facility, but the required discharge summary/Recapitulation of Stay Summary was not completed. The record showed the resident’s discharge MDS, progress note, and transfer of belongings and meds, while the VP Clinical Services and ADON stated the summary was missing because of staffing changes and lack of available staff to complete it.
PASRR Screening and Form 1012 Not Completed Accurately: A resident with dementia, anxiety, depression, psychotic disorder, schizoaffective disorder, bipolar disorder, and schizophrenia had an inaccurate PASRR record and an incomplete Form 1012. The CCM said she was still in the process of sending the form, while leadership confirmed PASRR completion and updates were the CCM’s responsibility.
A resident admitted with lung cancer, adult failure to thrive, and an unstageable sacral pressure injury did not have a baseline care plan completed within 48 hours of admission. Record review showed no baseline care plan was developed, and the RN, DON, and ADON identified that the facility policy required completion within the required timeframe.
Care plan not updated for weight changes. A resident with encephalopathy and intact cognition had a care plan that still listed outdated weight gain and weight loss problems despite documented weight fluctuations and RD notes describing fluid-related changes and diuretic use. Interviews showed the CCM, ADON, and DON shared responsibility for care plan updates, but the resident’s plan was not revised to accurately reflect current weight status and related needs.
A staff member at the facility brought a pellet gun into the premises, which was discovered by a CNA during an overnight shift. The DON was informed and initially downplayed the severity, while the Administrator was investigating the incident. The facility's policy prohibits weapons, indicating a breach of protocol and a failure to ensure a safe environment.
A facility failed to properly store and secure medications, resulting in six missing hydrocodone pills for a resident with multiple health conditions. An LVN did not secure her keys or lock the medication room, leading to the discrepancy. Despite negative drug tests for staff, the missing medication was not accounted for, violating the facility's medication storage policy.
The facility failed to provide hot water for over a month, resulting in residents not receiving necessary showers or baths. This neglect affected several residents, leading to discomfort, distress, and potential health issues such as infections. Despite residents and families expressing concerns, the facility did not document refusals of showers, and maintenance issues with the hot water system were not promptly resolved.
The facility failed to provide necessary grooming and personal care services due to a lack of hot water for over a month, affecting several residents who did not receive showers or baths. This led to hygiene issues, with residents developing infections and expressing distress. The maintenance director acknowledged ongoing hot water issues, and the facility lacked documentation of alternative care provided to residents.
A resident with a history of diabetes and varicose veins did not receive prescribed compression therapy for edema management due to a lack of supplies and oversight. The care plan required compression wraps three times a week, but the therapy was not administered for 30 days, leading to increased swelling and discomfort. The DON noted signs of worsening edema and early skin breakdown, while the NP confirmed a change in the order to five times weekly.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, for 9 days out of 61 reviewed. The Administrator claimed coverage was provided through agency staffing but could not provide evidence for specific days. The facility's staffing policy did not reflect the required RN coverage, placing residents at risk of inadequate medical care.
The facility failed to maintain its hot water system, leaving residents without hot water for two to three weeks. Residents and staff reported the issue, which affected the ability to provide showers and proper hygiene care. The Maintenance Director and Administrator were aware of the problem, but repairs were delayed, resulting in lukewarm water temperatures in the facility.
A facility failed to create a baseline care plan within 48 hours for a newly admitted resident with multiple health conditions, including a broken leg and heart failure. Despite the resident's cognitive intactness and need for assistance, no baseline care plan was documented, as confirmed by staff interviews. This oversight was attributed to the admitting nurse's responsibility, resulting in a lack of resident-specific care.
A facility failed to ensure accurate documentation and counting of controlled medications for a resident with chronic pain. An LVN did not properly document the administration of Percocet, leading to a discrepancy in the narcotic count. Interviews revealed that the narcotic count was not accurately performed, raising concerns about potential drug diversion and medication errors.
A facility failed to document a resident's PASRR evaluation results in their medical record, which is essential for maintaining an accurate medical history. The resident, with multiple diagnoses including dementia and intracranial injury, was observed to be alert only to person and using an enteral feeding tube. Interviews revealed that the PASRR denial letter was not included in the record, highlighting a lapse in maintaining accurate clinical documentation.
The facility failed to regularly inspect and maintain bed frames, mattresses, and bed rails, leading to potential hazards for a resident with cognitive impairment and mobility issues. Despite requests from family and staff, the resident's torn and stained mattress was not replaced. The facility lacked a policy or schedule for bed inspections, and communication between staff and maintenance was insufficient.
A resident with a complex medical history was re-hospitalized due to the facility's failure to obtain ordered laboratory services. Despite having orders for weekly lab tests, these were not documented or conducted, leading to a worsening of the resident's condition. Interviews revealed lapses in communication and documentation by the facility staff.
Misappropriation of Resident Funds via Staff Payment Application
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of funds and exploitation by a CNA. The resident was an adult male with a history of cerebral infarction and unspecified glaucoma, and his quarterly MDS showed a BIMS score of 11, indicating moderate cognitive impairment. Bank records for the resident showed a funds transfer to the CNA via a payment application, as well as later attempted and completed transactions to the same CNA that the resident and his family reported as unauthorized. According to the resident’s account, he was asleep when the CNA entered his room and asked for his bank card, stating she was going to put money on it. The resident, who reported that he did not fully understand the situation and was half asleep, gave the CNA his card. He stated that the CNA returned the card within a few minutes and told him she did not put any money on it. The resident later spoke with his family member, who managed his finances, and was informed that money had been withdrawn from his account and that there had been additional attempted transactions that were not completed. The resident denied ever authorizing the CNA to make purchases on his behalf or asking her to go to the store for him. Bank statements and email correspondence from the bank confirmed multiple payment application transactions and attempted transactions associated with the CNA’s name and account. The CNA acknowledged that she had previously added the resident’s bank card to her payment application, stating that she did so to reimburse herself after going to the store for the resident and that she forgot to remove his card from her account. She claimed that any subsequent transfers using the resident’s card were accidental and that she did not intend to take money from the resident. Despite having signed orientation and policy documents acknowledging the facility’s abuse, neglect, and misappropriation policies, the CNA’s actions resulted in the resident’s personal bank card information being stored on her payment application and used for transfers to her, which constituted misappropriation of resident funds and exploitation.
Unclean Food Containers Stored in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. During observation, one 1-gallon full container of ranch dressing was found with visible food residue and buildup on the exterior surfaces, including the lid and surrounding container. A second 1-gallon full container of soy sauce was also observed with buildup on the exterior surfaces and surrounding container. The Dietary Manager stated it was important to wipe each container completely after use so the date would be clearly visible and acknowledged that it was her responsibility to ensure food items were cleaned, dated, and labeled, and that all kitchen staff were responsible for labeling, dating, storing, and cleaning items. She also acknowledged the containers appeared unclean. The President of Clinical Services stated that the food server supervisor, dietician, and administrator do rounds in the kitchen and also acknowledged that the condition of the containers could place residents at risk of potential illness. The facility's Food Safety Requirements stated that food must be stored in a manner that prevents deterioration or contamination.
Incomplete discharge summary for a resident transferred to another facility
Penalty
Summary
The facility failed to ensure that a discharge summary was completed when discharge was anticipated for one resident. The resident’s face sheet showed an admission date of 7/15/25 and diagnoses including cerebral infarction, carotid artery syndrome, Meniere’s disease, heart disease, Parkinsonism, and muscle wasting and atrophy. The discharge MDS showed the discharge was not anticipated to return, with a planned discharge to a nursing home, BIMS 15, and functional status at discharge including independent eating, set-up oral hygiene and upper body dressing, and maximum assistance for toileting hygiene, showering/bathing, lower body dressing, and personal hygiene; the resident also had a catheter due to neurogenic bladder and was occasionally incontinent of bowel. The resident’s progress note stated the resident was discharged to another facility and that all belongings, medications, and the face sheet were sent with the resident, and the Ombudsman was emailed about the discharge. In interview, the VP Clinical Services stated the company policy requires a Recapitulation of Stay Summary form for all discharges, including final diagnosis, brief history, pertinent physical and laboratory findings, course of treatment, condition on discharge, rehabilitation potential, and follow-up and discharge medication instructions, but the discharge summary for this resident was not completed due to changes in administrative staff and lack of available staff. The ADON and MDS nurse also stated the discharge summary was not completed, and the facility policy stated a discharge summary is provided upon discharge and addresses each resident’s discharge goals and needs, including caregiver support and referrals to local contact agencies.
PASRR Screening and Form 1012 Not Completed Accurately
Penalty
Summary
The facility failed to ensure that a resident with multiple mental health diagnoses received an accurate PASRR screening and that Form 1012 was completed and submitted in a timely manner. Resident #44 was admitted with diagnoses including unspecified dementia with mood disturbance, and the record also showed active diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, and other schizoaffective disorders. The resident’s history and physical also listed bipolar disorder and schizophrenia, and the care plan included problems related to antipsychotic use for depression and schizoaffective disorder, cognitive loss/dementia, and schizoaffective disorder with use of Amitriptyline and Ritalin. The resident’s PASRR Level 1 Screening dated 3/30/2024 showed no evidence that dementia was the primary diagnosis and no evidence of mental illness. However, the resident’s Form 1012 also reflected a PASRR level 1 assessment date of 3/30/2024 with schizoaffective disorder marked yes under mental illness indication, and the form did not include a date in the section indicating a new positive PL1 was submitted or a signature date for the staff completing the form. The Clinical Care Manager stated that she was in the process of sending the Form 1012 for the resident and that the resident would be reevaluated when the referral was received. During interviews, the Clinical Care Manager said she was responsible for PASRR reviews and that if PASRR was not completed correctly, residents could miss out on PASRR services. The ADON stated that the Clinical Care Manager was responsible for ensuring PASRR was correct and completed if needed. The President of Clinical Services stated that the Clinical Care Manager was responsible for PASRRs and sending updated forms, and that residents could possibly not get the services they were entitled to through PASRR if PASRRs were not completed correctly. The facility policy stated that the CCM must ensure the 1012 form is completed and uploaded into the resident's electronic medical record.
Failure to Complete Baseline Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for Resident #57. Record review showed the resident was admitted on [DATE] with diagnoses including malignant neoplasm of the right main bronchus, adult failure to thrive, and a pressure ulcer of the sacral region that was unstageable. Review of the electronic admission record revealed no baseline care plan was developed upon admission. The resident’s primary physician record dated 12/19/2025 showed she was admitted to a hospice agency with a diagnosis of lung cancer and a DNR code status. During interviews on 01/08/2026, the Regional Nurse stated facility policy required baseline care plan completion within 48 hours and identified the DON and ADON as responsible for completion. The ADON stated she could not explain why the baseline care plan was not completed within 48 hours and confirmed that it had not been completed.
Care Plan Not Updated for Weight Changes
Penalty
Summary
The facility failed to ensure that Resident #61’s comprehensive care plan was reviewed and revised by an interdisciplinary team to reflect her weight changes. The resident was an [AGE]-year-old female admitted with diagnoses including other encephalopathy. Her quarterly MDS showed a BIMS score of 13, indicating intact cognition, and did not document weight loss or gain of 5% or more in the last month or 10% or more in the last 6 months. However, the care plan in place on 1/7/26 still included a problem statement for weight gain tied to a 5/7/24 weight of 232 lbs with gain percentages listed, and another problem statement that the resident had experienced a significant weight loss within the past 30 days and was at risk for significant weight loss, with a last reviewed/revised date of 1/6/26. Record review showed the resident had weight fluctuations documented by the RD, including a 9/9/25 note stating a 1.4% weight loss in 30 days, 4.2% weight gain in 90 days, and 14.5% weight gain in 180 days, with possible shifts related to diuretic treatment and recent adjustment. Weights in the record included 312.5 lbs on 7/8/25, 310.6 lbs on 10/7/26, and 297.2 lbs on 1/6/26. During interviews, the CCM stated nursing would update care plans for acute issues and the ADON handled weight-related care plan changes; the ADON stated she would be responsible for weight-related changes, noted the resident had fluid-related weight changes and had been hospitalized for diuresis, and said the weight loss statement should simply indicate the resident is at risk for weight loss. The President of Clinical Services stated the DON, ADON, and CCM were responsible for updating care plans and that the DON or ADON handled acute care plans, while the facility policy stated the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Staff Member Brings Weapon into Facility, Breaching Safety Protocols
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, as evidenced by an incident involving a staff member bringing a weapon into the facility. Specifically, LVN-B brought a pellet gun into the facility, which was discovered by CNA-A during an overnight shift. CNA-A observed LVN-B placing an object in her pocket and upon inquiry, LVN-B revealed it was a gun. This incident highlights a lapse in maintaining a secure environment for residents and staff. The Director of Nursing (DON) and the Administrator were made aware of the situation, with the DON initially downplaying the severity by stating that the gun was not lethal. The facility's policy on professional behavior explicitly prohibits the possession of firearms or other weapons on the property, indicating a breach of protocol. Additionally, the facility failed to ensure that staff were adequately trained to maintain an environment free of accident hazards, as evidenced by this incident.
Medication Storage Deficiency Leads to Missing Narcotics
Penalty
Summary
The facility failed to ensure that medications for a resident were properly stored and secured, leading to the unaccounted disappearance of six hydrocodone pills. The incident involved a Licensed Vocational Nurse (LVN-A) who did not secure her keys nor ensure that the medication room was locked. As a result, the Norco drugs were found missing from the resident's narcotic blister pack. The resident, a male with a history of major depressive disorder, bipolar disorder, dementia, shortness of breath, and congestive heart failure, was prescribed hydrocodone to be administered as needed. The deficiency was discovered when the Director of Nursing (DON) was informed by LVN-A about the missing medication. Upon investigation, it was found that LVN-A had left the keys to the medication cart unsecured in the medication room, which was not locked. The DON and staffing coordinator conducted a medication count and confirmed the discrepancy in LVN-A's cart. Despite drug testing all staff, which returned negative results, the missing medication remained unaccounted for. The facility's medication policy mandates that all medication storage areas be locked at all times unless in use and under direct observation, which was not adhered to in this case.
Facility Neglects Resident Hygiene Due to Lack of Hot Water
Penalty
Summary
The facility failed to ensure residents were free from abuse, neglect, exploitation, or mistreatment, affecting five residents specifically and placing an additional 68 residents at risk. The deficiency involved the facility's inability to provide hot water for over a month, resulting in residents not receiving showers or baths, which are essential for maintaining cleanliness and access to activities of daily living. This neglect led to residents experiencing discomfort, distress, and potential health issues such as skin breakdowns and infections. Resident #8, who was cognitively intact and required assistance for personal care, had a urinary tract infection and had not received a bath or shower in weeks. Despite her family expressing concerns, the facility failed to document any refusals of showers. Resident #12, also cognitively intact, had not received a shower in over three weeks, leading to feelings of distress and uncleanliness. She had pressure sores and fragile skin, which required regular hygiene care. Resident #18, who had a skin rash and other health issues, had not received a bath in several weeks, resulting in a noticeable odor and unsanitary living conditions. Resident #20, who had recurring urinary tract infections, had not been given a shower or bed bath for almost a month, exacerbating her health issues and leading to hospitalization. Resident #30, who was dependent on assistance for personal care, had not received showers due to the lack of hot water, which he reported to his family. The facility's maintenance director acknowledged the ongoing issues with the hot water system, which had been problematic for nearly two months, but failed to resolve the issue promptly, leading to the neglect of residents' hygiene needs.
Removal Plan
- All residents were offered a shower. All residents who were nonverbal/non-interviewable were offered and given showers with no refusals.
- All interviewable residents were interviewed to address who did not receive showers on their scheduled shower days, and nonverbal residents were assessed for hygiene and cleanliness.
- All active infections were reviewed by the Director of Nursing.
- Plumber Vendor serviced the boiler system. The new hot water system was ordered and installed.
- All facility laundry was done in-house using a laundry sanitation system effective in cold water.
- The facility policy/procedure was reviewed for ADL Care and Monitoring.
- Education provided to Nurses & CNAs regarding the policy for ADLs, identifying residents that appear unkempt, and actions to take if they note any issues.
- Shower/bath assignment sheet is being completed by the CNA and nurses to sign off that showers/baths have been completed.
- Water temperature log continued to monitor water temperature.
- Ad hoc QAPI performed with Medical Director during survey to inform of the water issue, the immediate jeopardy template, and the facility's plan to remove the immediacy.
Facility Fails to Provide Adequate Hygiene Care Due to Lack of Hot Water
Penalty
Summary
The facility failed to provide necessary services to maintain grooming and personal care for several residents, as there was no hot water available for over a month. This resulted in residents not receiving showers or baths, which are essential for maintaining cleanliness and access to activities of daily living. The lack of hot water led to residents going without showers for weeks, and there was no documentation to show that residents had received bed baths or showers for the entire month of September. Several residents were directly affected by this deficiency. One resident expressed discomfort and distress due to not having a bed bath or shower in weeks, while another resident, who required assistance with personal care, developed a urinary tract infection and had not bathed in a month. Another resident, diagnosed with a skin rash, had not bathed in weeks and was noted to have a strong odor. Additionally, a resident developed complications with possible bacteria in her urine during the period without baths and was hospitalized for a urinary tract infection. Another resident reported his concerns to his family after not having a shower for a month. The facility's maintenance director acknowledged that the hot water issues had been ongoing for almost two months, with the water getting hot randomly on one side of the building until it finally stopped working. The facility administrator and DON were aware of the problem but did not have documentation showing that residents were receiving alternative care, such as bed baths. The lack of proper hygiene care placed residents at risk of infections, skin breakdowns, and other health issues.
Removal Plan
- All residents were offered a shower. All residents who were nonverbal/non-interviewable were offered and given showers with no refusals.
- All interviewable residents were interviewed to address who did not receive showers on their scheduled shower days, and all residents that were nonverbal or non-interviewable were assessed for hygiene and cleanliness and received a shower.
- All active infections were reviewed by the Director of Nursing.
- Plumber Vendor serviced the boiler system. The boiler was temporarily rerouted, and a new hot water system was ordered and installed.
- All facility laundry was done in-house using a laundry sanitation system effective in cold water.
- The facility policy/procedure was reviewed for ADL Care and Monitoring, and no needed changes were identified.
- Education provided to Nurses & CNAs regarding the policy for ADLs, identifying residents that appear unkempt, actions to take if they note any issues, peri-care, hand hygiene, communication/reporting on maintenance issues, showers/baths & documentation, and abuse & neglect.
- Shower/bath assignment sheet is being completed by the CNA and nurses to sign off that showers/baths have indeed been completed.
- Water temperature log continued to monitor water temperature.
- Ad hoc QAPI performed with Medical Director to inform of the water issue, the immediate jeopardy template, and the facility's plan to remove the immediacy.
Failure to Administer Compression Therapy
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to increased swelling and discomfort in her lower extremities. The resident, who was admitted with diagnoses including Type 2 diabetes mellitus with diabetic neuropathy and varicose veins, required compression wraps to manage edema as per her care plan. The care plan specified that the compression wraps should be applied three times a week and monitored for effectiveness and skin integrity. However, the facility did not apply the compression wraps as ordered, and the resident reported that her legs had not been wrapped for several weeks due to the facility's inability to provide transportation to a clinic. Interviews with the nursing staff revealed that the compression therapy had not been administered for the past 30 days due to a lack of supplies and oversight. The MDS nurse was unaware of any changes to the order, and the DON noted signs of worsening edema and early stages of skin breakdown, indicating a risk for infection and further complications. The NP later stated that the order had been changed to have the resident's legs wrapped five times weekly or as needed, but the original order was for three times weekly. This oversight placed the resident at risk for further injury or harm.
Deficiency in RN Staffing Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified for 9 out of 61 days reviewed for RN staffing coverage. Specifically, there was no documented proof of RN coverage on the days of 05/17/24, 05/18/24, 05/20/24, 05/21/24, 05/22/24, 05/23/24, 05/24/24, 05/31/24, and 06/01/24. The facility's Administrator claimed that the PBJ report was incorrect and that RN coverage was provided through agency staffing, referred to as 'shift key,' but could not provide evidence for the specified days in May and June. The facility's staffing policy, last revised in July 2001, did not reflect the requirement for RN coverage for 8 hours in a 24-hour period. This lack of RN coverage placed all residents at risk of not receiving adequate medical care and supervision.
Facility Fails to Maintain Hot Water System, Affecting Resident Care
Penalty
Summary
The facility failed to maintain its hot water system, resulting in a lack of hot water for residents' use for approximately two to three weeks. This deficiency was observed during a survey, where residents and staff reported the absence of hot water, affecting the ability to provide showers and proper hygiene care. Residents expressed discomfort with taking showers in cold water, and staff confirmed that they had been providing bed baths instead. The water temperature in the facility's shower rooms was recorded at lukewarm levels, ranging from 84 to 86 degrees Fahrenheit. Interviews with the facility's staff, including the Maintenance Director and Administrator, revealed that the hot water issue had been ongoing, with the system being on and off in different parts of the building. The Maintenance Director attempted to address the problem by adjusting the thermostat, but the issue persisted. The Administrator was informed of the problem on September 16, 2024, and a local plumbing company was contacted to resolve the issue. However, the repair was delayed due to the need for approval and scheduling, leaving residents without consistent access to hot water for an extended period.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours, as required by CMS policy. This deficiency was identified for a resident who was admitted with multiple serious health conditions, including an unspecified fracture to the left femur, diabetes mellitus, end-stage renal disease, and unspecified systolic congestive heart failure. Despite the resident being cognitively intact and requiring varying levels of assistance for personal hygiene and mobility, no baseline care plan was created in the facility's electronic health record system. Interviews with facility staff, including the MDS Coordinator, ADON, DON, and Administrator, revealed that the responsibility for creating the baseline care plan lay with the admitting nurse. However, this was not completed, and only a comprehensive care plan was present in the records. The absence of a baseline care plan was acknowledged by the staff as a failure to provide resident-specific and person-centered care, which is crucial for ensuring continuity of care and meeting the resident's immediate needs upon admission.
Inaccurate Narcotic Count and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of controlled medications for a resident. Specifically, the facility did not ensure that a Licensed Vocational Nurse (LVN) accurately documented on the narcotic count sheet for the resident's scheduled pain medication administration of Percocet 5/325 mg. This discrepancy was identified during a controlled medication count of the medication cart, which revealed an incorrect count of the resident's Percocet tablets. The resident involved was an elderly female with a history of dementia, atherosclerotic heart disease, hypertension, schizoaffective disorder, and chronic pain. She was on a physician-ordered regimen of Percocet for chronic pain management. The narcotic count sheet indicated that a tablet was signed out by an LVN, but the medication administration record (MAR) showed that the medication was not administered at the documented time. This inconsistency in documentation raised concerns about potential drug diversion and the risk of the resident not receiving her medication as intended. Interviews with facility staff, including the LVN involved, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that the narcotic count was not accurately performed, and the documentation was not completed as required. The facility's policy mandates that controlled substances be reconciled at the end of each shift, and any discrepancies should be reported immediately. However, the failure to adhere to these procedures resulted in an inaccurate narcotic count, which could lead to serious consequences such as drug diversion or medication errors.
Failure to Document PASRR Evaluation in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of the PASRR evaluation results. The resident, who was admitted with multiple diagnoses including intracranial injury, aneurysm, muscle wasting, dysphagia, cognitive communication deficit, encephalopathy, and dementia, did not have the PASRR Level II evaluation results documented in their clinical record. The evaluation had determined that the resident did not have a serious mental illness or developmental disorder, and this information was crucial for maintaining an accurate medical history. During the survey, it was observed that the resident was in bed, alert only to person, and not responding to questions, with an enteral feeding tube in use. Interviews with the MDS nurse and the DON revealed that the PASRR denial letter, which was received after surveyor intervention, should have been included in the resident's medical record. The absence of this documentation was acknowledged as a failure to maintain accurate records, which is essential for staff knowledge of the resident's medical history. The facility's policy on clinical records was not available at the time of the survey exit.
Failure to Inspect and Maintain Bed Safety
Penalty
Summary
The facility failed to conduct regular inspections and maintenance of resident bed frames, mattresses, and bed rails, leading to potential entrapment hazards for a resident. The resident's bed had a significant gap between the mattress and bed frame, and the mattress was torn with foam coming away from the cover, covered with stains and rips. The resident, who had Parkinson's, osteomyelitis, and dementia, required substantial assistance for bed mobility and had a cognitive impairment. Observations revealed several beds with loose bed rails and gaps between the mattress and bed frame, along with torn and stained mattresses. Interviews with staff and family members highlighted a lack of communication and responsibility regarding mattress replacement. The family member of the resident had requested a new mattress due to its worn-out condition, but it was not replaced. The Administrator stated that residents or staff should request new mattresses, but there was no policy or schedule for bed inspections. The maintenance director was unaware of any policies and relied on nursing staff to report issues. The DON stated that nurses were required to inspect mattresses, but CNAs reported that their concerns about torn mattresses were not addressed. The charge nurse confirmed that aides reported bed issues, but no action was taken.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services as ordered by a physician for a resident, leading to a deficiency. The resident, who was discharged from an acute care hospital, had orders for weekly laboratory tests including CMP, CBC, and CPK, which were not documented or obtained by LVN A. This oversight resulted in the resident being re-hospitalized with elevated WBC values, indicating an infection. Additionally, LVN A did not document or obtain weekly laboratory services as ordered by the resident's NP during medication reconciliation. The resident was diagnosed with polymicrobial skin and soft tissue infections and multifocal osteomyelitis of the pelvis, conditions that required close monitoring through laboratory tests. The failure to conduct these tests contributed to the resident's re-hospitalization. The resident had a complex medical history, including metabolic encephalopathy, quadriplegia, acute kidney failure, and multiple infections. Despite being prescribed antibiotics and having a care plan in place, the resident's condition worsened due to the lack of timely laboratory monitoring. Interviews with facility staff revealed lapses in communication and documentation, which were critical in ensuring the resident's health needs were met.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Texas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Shoal | 0.4 mi | ★★★★★ | 5 | 0 |
| The Lakes At Texas City | 1.3 mi | ★★★★★ | 15 | 1 |
| Bayou Pines Care Center | 1.9 mi | ★★★★★ | 4 | 1 |
| Harbor Point Skilled Nursing | 3.3 mi | ★★★★★ | 9 | 0 |
| The Phoenix Post-acute | 5.1 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.