Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sienna Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to designate an RN to serve as DON on a full-time basis and did not ensure a full-time or interim DON was employed for the cited period. The Corporate Nurse stated he served as the Interim DON but worked only 2 days per week, while the Administrator said he was the current DON and was unsure of his schedule. The Administrator also stated the facility had no policy for the DON requirement and followed state regulations.
Multiple nurses and medication aides were observed using personal laptops to access resident records and complete charting, medication administration, and order review. Staff confirmed the devices were their own and said they used them because facility equipment was limited, broken, or unavailable in their work areas. The facility’s handbook prohibited personal communication devices, including laptops, for work use, while leadership gave conflicting statements about whether personal computers were allowed and whether cybersecurity safeguards were in place.
Oxygen Therapy Not Properly Provided or Identified: The facility failed to ensure that residents ordered oxygen therapy actually received it and that oxygen-in-use signage was posted outside rooms with oxygen equipment. One resident was found with the O2 concentrator off for hours despite a continuous oxygen order, and two other residents had oxygen equipment in their rooms without the required doorway signage. Records showed COPD, emphysema, lung cancer, and respiratory failure diagnoses, along with orders for O2 at 2-4 LPM every shift.
A sample lunch tray included cold items that were measured above the required temperature when observed by surveyors, with a pudding dessert and tossed salad both out of range at the time of review. Staff gave differing statements about acceptable cold food temperatures, and the facility policy required cold foods to be less than 41 F and temperatures to be checked before every meal service.
Surveyors found multiple food storage and sanitation issues in the kitchen, including a moldy tomato stored with green onions, unlabeled bags of green onions, bologna sandwiches, and hardboiled eggs, and a box of chicken thighs leaking fluid and held at 45 F in the walk-in fridge. Dietary staff and supervisors stated items should be labeled, spoiled food discarded, and poultry kept at 41 F or below, but the observed foods were not being managed in accordance with those standards.
Unqualified Social Services Coordinator: The facility failed to employ a qualified full-time social worker for a 138-bed LTC facility. Surveyors found the Social Services Coordinator had a human services degree but no TX social work license or social work degree, while the Administrator and Regional HR Coordinator acknowledged the role did not meet the required qualifications. The Coordinator was performing care plans, BIMS, grievances, PHQ-9s, family contact, appointments, social assessments, and room changes.
Surveyors found a puddle of water under the walk-in fridge cooling system, with dietary staff reporting the leak had been ongoing for weeks to months and the Dietary Supervisor acknowledging difficulty keeping the unit below 40 degrees at times. Surveyors also observed multiple LPNs, RNs, and medication aides using personal laptops for charting, med admin, and order review because facility-issued computers were reportedly broken, scarce, or unavailable, while leadership gave conflicting statements about whether personal devices were permitted.
A resident with dementia and chronic bowel and bladder incontinence received perineal care during which a CNA cleaned urine and feces while wearing a single pair of gloves, then, without changing those contaminated gloves or performing hand hygiene, handled and applied a clean brief to the resident. The CNA later acknowledged she should have changed gloves, and the DON confirmed that facility policy and expectations require removal of soiled gloves, hand hygiene, and donning of clean gloves during personal/perineal care as part of the infection control program.
Failure to Notify Physician of Oxygen-Related Change in Condition: A resident with COPD, aphasia, severe cognitive impairment, and continuous O2 orders was found with the O2 concentrator off and the cannula in place. An LPN later stated the resident’s O2 sat was in the 80s, but she documented only a later 96% reading after O2 was restored and did not notify the physician, charge nurse, ADON, or family despite the change in condition.
Missing Grievance Documentation: The facility failed to maintain grievance records showing the results of all grievances for the required 3-year period. The grievance binder reviewed contained no documentation before February 2026, and interviews with Social Services, CNA E, LVN M, the ADON, and the Administrator showed inconsistent understanding of who tracked grievances before that time. The facility policy requires the grievance official to oversee, track, and retain grievance evidence for at least 3 years.
Failure to Trim a Resident’s Fingernails: A resident who was cognitively intact and needed setup or clean-up help for personal hygiene had fingernails more than 1 inch long and not trimmed as part of routine ADL care. She stated staff had not offered nail care on her shower day, and interviews with CNA and nursing staff confirmed that fingernail trimming was part of routine care and should be addressed when observed.
A resident with anxiety, DM2, schizophrenia, and significant cognitive and functional impairment was found on the floor with injuries to the forehead, chin, and both knees, but the CNA moved her back to bed before a nurse assessed her. The incident was not reported to the nurse until later that morning, despite facility expectations that CNAs notify nursing staff immediately and leave the resident in place for assessment first.
Daily nursing staffing information was not posted in a prominent place readily accessible to residents and visitors. The staffing schedule and census were only located behind the main Nurse's station desk and by the back wall, where staff stated residents and visitors could not easily see or access the information. Interviews with a CMA, RN, CNA, and the Administrator confirmed the posting was behind the desk and not in a location visible to residents, including those in wheelchairs or with visual impairments.
Failure to Post Resident Rights and State Advocacy Information: The facility did not post required Resident Rights information or the list of State agencies and advocacy groups in the secured male and female Memory Care Units. Surveyors observed no postings in either unit, and CNA T, RN U, and the Administrator all confirmed the information was not posted there. The facility policy required posting the State Survey Agency, Ombudsman, APS, and other advocacy contacts.
Survey Results Binder Not Readily Accessible: The facility failed to keep the annual survey results binder in a visible, readily accessible location for residents, families, legal reps, and the public. The binder was found inside a cabinet outside the Administrator's office with no signage, and the Administrator stated he was unsure whether it had to be out in the open. A CNA, an LVN, and the ADON stated the binder should be visible and accessible, while most residents interviewed did not know where it was or what it contained.
A resident with dementia, diabetes, and pre-existing protein-calorie malnutrition experienced an 11.47% weight loss over approximately three months while on a regular diet and requiring only setup assistance for eating. Although a weight-loss assessment identified significant weight loss and listed interventions such as a red cup program and high-calorie supplements, these were not entered as MD orders, the resident was not placed on the red cup list, and supplements were not ordered until mid-way through the second month. The RD’s admission recommendation for house supplements three times daily was not converted into active orders, the RD did not receive accurate weight-loss reporting, and the NP was not notified of the significant weight change. Observations showed poor meal intake and lack of consistent offering of alternatives or supplements, while staff interviews revealed unawareness of the resident’s weight loss and confusion over who monitored the red cup program. These failures to follow the facility’s weight policy, to monitor and communicate significant weight changes, and to implement ordered or recommended nutritional interventions resulted in the resident’s continued weight decline.
Multiple incidents occurred where residents with severe cognitive impairment and behavioral issues engaged in physical altercations, resulting in injuries such as head lacerations and skin tears. Despite being identified as needing 1:1 supervision, residents were not provided with dedicated staff, and existing CNAs were expected to cover both general care and 1:1 monitoring. Staff interviews and records confirmed that required supervision was not maintained, directly leading to resident-to-resident abuse and injuries.
Multiple incidents occurred where residents with severe cognitive impairment and behavioral issues engaged in physical altercations, resulting in injuries such as head lacerations and skin tears. Despite care plans and facility protocols requiring 1:1 monitoring, staffing records and staff interviews confirmed that no additional staff were assigned for this purpose, and existing CNAs were expected to rotate 1:1 monitoring duties while supervising the entire unit. This lack of adequate supervision led to repeated resident-to-resident altercations and injuries.
Multiple incidents occurred where residents with severe cognitive impairment and behavioral risks did not receive required 1:1 monitoring due to insufficient staffing. Existing CNAs were expected to supervise large numbers of residents and provide 1:1 monitoring simultaneously, leading to unsupervised periods and resulting in altercations and injuries. Staff interviews and records confirmed that no additional staff were assigned for 1:1 monitoring, and the facility lacked a formal staffing policy.
The DON worked as a charge nurse on multiple occasions when the facility census was 60 or more, contrary to regulatory requirements. The DON reported covering night shifts due to a staff vacancy and was unaware of the regulation prohibiting this practice. No policy for RN/DON coverage was provided when requested.
The facility did not update or revise care plans for three residents with severe cognitive impairment after multiple documented incidents of aggression and wandering, despite repeated behavioral episodes that required staff intervention and hospital transfers. Care plans had not been revised to include new interventions following these events, contrary to facility policy and standard practice.
Staff at the facility were observed using personal cell phones in the presence of residents, violating their rights to dignity and respect. Residents reported feeling disrespected and ignored, with staff using phones while providing care and passing medications. Despite facility policies prohibiting such behavior, the issue persisted, indicating a failure to enforce these rules effectively.
A facility failed to restrict access to its medication room, allowing unauthorized personnel, such as a Medical Records staff member and Central Supply staff, to enter and be alone in the room. This breach of protocol, observed during a survey, involved the use of a code to unlock the room, which contained various medications and medical supplies. The facility's policy mandates that only authorized personnel should have access to the medication supply.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures. CNAs did not use PPE during incontinent care and transfers for residents on EBP, and there was a lack of accessible PPE in resident rooms. Staff interviews revealed a breakdown in communication and understanding of EBP requirements, contributing to the risk of cross-contamination and infection spread.
A facility failed to label a Mid-line IV dressing with the date and initials, as required by policy, for a resident with chronic kidney disease and other conditions. The resident's dressing was intact but lacked labeling, which is necessary for monitoring changes and preventing infections. The DON confirmed the expectation for labeling to reduce infection risks.
A resident's shower log was inaccurately documented, showing multiple refusals of showers despite interviews indicating the resident never refused. Staff admitted to a possible documentation error, which could lead to inadequate care. The facility's policy requires accurate documentation, which was not followed in this instance.
A facility failed to accurately receive and store controlled medications for a resident, leading to the diversion of Alprazolam tablets. The resident, with multiple diagnoses including dementia and anxiety, was on hospice care. The medications were delivered by a hospice nurse without proper documentation or signature, and the DON was the last to have contact with them. Facility policies for securing and documenting controlled substances were not followed.
A resident's Tramadol was not secured in a double-locked area as required, leading to an investigation. The medication was delivered by a hospice nurse without obtaining a signature, and the DON, who was the last to see the medications, did not recall the specifics due to fatigue. The facility's policies for handling controlled substances were not followed, resulting in a breakdown in procedure adherence.
The facility failed to implement its QAPI plan, resulting in deficiencies in addressing adverse events for four residents. A resident repeatedly exhibited aggressive behaviors towards another, but the facility did not complete incident/accident reports, hindering behavior tracking. Additionally, two other residents demonstrated physical behaviors without proper documentation. Interviews revealed inconsistent tracking due to incomplete reports, impacting the facility's quality assurance processes.
The facility failed to follow professional standards for food service safety, resulting in improper food storage, cross-contamination risks, and inadequate use of hair restraints. Observations showed food stored beyond recommended periods, items on the floor, and improper thawing practices. Staff interviews confirmed these practices, and the facility's policies were not adhered to, posing potential risks to residents.
The facility failed to maintain essential kitchen equipment, including the oven, garbage disposal, and milk refrigerator, in safe operating condition. Observations revealed issues such as a rusted hinge and detached gasket on the refrigerator, a non-functional garbage disposal, and an oven that did not reach the required temperature. Staff acknowledged these problems, but no work orders were provided, and the Administrator was unaware of the issues.
A facility failed to update a care plan for a resident with a history of crawling behavior, leading to knee abrasions. Despite awareness of the behavior, the care plan lacked specific interventions, and video surveillance confirmed the resident's crawling and subsequent injuries. The resident was placed in a low bed with a floor mat, but no additional measures were taken to prevent injury.
A resident with a history of crawling behavior was not provided with adequate supervision or assistive devices, leading to injuries. Despite being aware of the behavior, the facility did not revise the care plan to include interventions. The resident sustained abrasions and reopened wounds on her knees, as documented in progress notes and observed in video surveillance. Staff interviews confirmed awareness of the behavior but not of specific incidents or injuries.
Failure to Maintain a Full-Time DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis and did not ensure that a full-time or interim DON was employed from 02/25/2026 through the exit date of 04/23/2026. During an interview on 04/23/2026 at 10:24 AM, the Corporate Nurse stated he was the Interim DON and worked 2 days per week in 8-hour shifts at the facility, and that he monitored nurses and residents online. During an interview on 04/23/2026 at 3:45 PM, the Administrator stated the Corporate Nurse was the current DON and said he was not aware of how many days or hours the DON worked at the facility. During an interview on 04/23/2026 at 10:00 AM, the Administrator stated the facility did not have a policy for the DON requirement and followed state regulations. Record review of Texas State Regulations stated that, except when waived, the facility must designate a registered nurse to serve as the director of nursing on a full-time basis.
Personal Laptops Used for Resident Charting
Penalty
Summary
The facility failed to ensure resident personal privacy and confidentiality of medical records when multiple staff members used personal laptops to access resident charts and document care without safeguards in place to protect confidential information. During observations, LVN C, LVN M, CMA N, CMA O, RN H, LVN P, RN Q, and RN G were each seen using their own personal computers while performing work-related tasks, including medication administration, charting, and review of orders. Each staff member verbally confirmed the computers were personal devices, and the devices varied in appearance and customization. The report states that resident medical records contained sensitive information, including social security numbers, dates of birth, addresses, phone numbers, insurance numbers, diagnoses, medications, orders, care plans, and labs. Staff interviews showed that several employees believed they needed their own laptops because facility-issued equipment was limited, broken, or not available in their work areas. Some staff stated they had been told by coworkers to bring personal computers, while others said they had used their own devices for months or years without direct authorization from leadership. Leadership interviews reflected conflicting understanding and oversight of device use. The Regional HR Coordinator stated staff should only use facility-owned computers, kiosks, and tablets/laptops for resident records and that personal devices were not to be used for charting or work tasks. The Administrator stated he believed staff could use personal computers based on his interpretation of the employee handbook and said he did not know whether cybersecurity monitoring was in place. The facility policy reviewed stated personal communication devices, including laptops, were not permitted for use at work unless specifically required by the job assignment, and that facility computers, internet, and email systems were for business use only.
Oxygen Therapy Not Properly Provided or Identified
Penalty
Summary
The facility failed to ensure that residents who were ordered oxygen therapy received respiratory care consistent with their care plans and physician orders. Resident #68 had an order for oxygen administration at 2-4 LPM every shift and was identified in the care plan as needing continuous oxygen therapy. On 04/21/2026, the resident was observed in bed with the nasal cannula in place, but the oxygen concentrator was not turned on. The resident remained in that condition during follow-up observations until later in the day, when the oxygen was found to be on. Record review showed an oxygen saturation of 96% documented at approximately 1:30 PM, and staff interviews described that the resident had initially been found with oxygen saturation in the 80s before oxygen was turned on. Resident #58 also had a physician order for oxygen administration at 2-4 LPM every shift and a care plan intervention to give oxygen therapy as ordered for COPD. During observation, an oxygen concentrator was present in the room, but there was no oxygen-in-use sign posted on the doorway. Resident #58 was later observed ambulating without portable oxygen and without signs of respiratory distress, labored breathing, skin discoloration, or faintness. The record also identified COPD and lung cancer in the resident’s history. Resident #77 had an order for oxygen administration at 2-4 LPM every shift and a care plan for emphysema with an intervention to ensure the resident remained free of signs and symptoms of respiratory insufficiency. During observation, an oxygen concentrator was present in the room, but there was no oxygen-in-use sign posted on the doorway. The resident stated she had the concentrator but was not using it because she was getting better and did not need it, and she denied difficulty breathing, faintness, or skin discoloration at that time. The report also states that the facility failed to ensure oxygen-in-use signage was posted on the doorway entries for Residents #58, #68, and #77.
Cold Food Served Above Required Temperature
Penalty
Summary
The facility failed to ensure that cold food items were served at a safe and appetizing temperature on a sample lunch tray. During an observation, a regular diet sample tray was provided to the survey team, and the cold items on the tray were measured by the Dietary Manager at 53.2 F for a pudding dessert and 69.4 F for a tossed salad. The tray had arrived in the conference room 11 minutes after leaving the kitchen steam table. A Dietary Supervisor stated that cold items should be held at 41 F or below, that the salad had been in an ice bath and the pudding had been in the refrigerator before meal service, and that cold items not held below 41 F could develop bacteria during the resting time. Record review showed the facility's lunch temperature log for that same meal documented the tossed salad at 40.8 F and the pudding dessert at 40.1 F before meal service began. Staff interviews reflected differing temperature standards, with one Dietary Supervisor stating cold foods should be 31 F to 41 F and another stating cold foods should be 45 F and below. The facility policy titled Daily Food Temperature Control stated that temperatures of all hot and cold food shall be taken prior to every meal service and that cold foods shall be less than 41 F.
Food Storage and Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to distribute and serve food in accordance with professional standards in the kitchen after surveyors observed multiple food storage and sanitation problems during the initial tour. A moldy tomato was found in an unlabeled bag stored with green onions, and other produce in the walk-in refrigerator showed signs of spoilage. A bag of green onions, a bag of bologna sandwiches, and hardboiled eggs were also found without labels. The observations were made during the kitchen tour with the Dietary Supervisor present. Surveyors also found a box of chicken thighs in the walk-in refrigerator that was leaking fluid, unlabeled, and not maintained at a safe temperature. The Dietary Supervisor stated the chicken thighs had been transferred from the freezer to the walk-in refrigerator several days earlier to thaw and had been intended for cooking before the survey. Two chicken thighs were tested and measured at 45 F while the Dietary Supervisor and another Dietary Supervisor were present and acknowledged the result. The chicken thighs were later removed from the refrigerator, and staff stated the fluid buildup was a sanitary concern and a cross-contamination issue. Interviews with dietary staff and supervisors showed that staff were responsible for checking refrigerator contents, labeling items, discarding spoiled food, and monitoring temperatures, but the observed items had not been properly managed. Staff stated that unlabeled, spoiled, or mixed items should not be in the walk-in refrigerator and that poultry should be stored at 41 F or below. The facility policy on food storage and supplies stated that open packages should be stored in closed containers or sealed bags, dated, and discarded if spoiled or past expiration, and that thawed frozen items should be refrigerated and dated when removed from the freezer.
Unqualified Social Services Coordinator
Penalty
Summary
The facility failed to employ a qualified full-time social worker in a building with 138 total capacity. During record review of personnel files on 04/23/2026, surveyors found that the Social Services Coordinator had not completed a bachelor's degree in social work and did not hold licensure from the Texas State Board of Social Worker Examiners. The report states the facility had gone 8 months without a Social Services department after the previous social worker died in May 2025, and the Regional HR Coordinator acknowledged the facility did not have a policy on social services qualifications but followed the regulation for social worker qualifications. Interviews showed the Social Services Coordinator held a bachelor's degree in human services, had no social work license, and had never worked in a nursing facility before. She described duties including care plans, BIMS, grievances, PHQ-9s, family contact, appointments for eye, dental, and podiatry services, social assessments, and room changes. The Administrator stated he knew the Social Services Coordinator did not meet the qualifications for a licensed social worker and still proceeded with the employment offer, and he was aware the facility was not in compliance with the requirement for a qualified full-time social worker for a facility with 138-bed capacity.
Walk-in fridge leak and staff use of personal computers
Penalty
Summary
The facility failed to maintain the walk-in fridge cooling system in safe operating condition when surveyors observed a small puddle of water developing on the floor directly underneath the cooling system during the initial kitchen tour. Dietary staff reported that the unit had been leaking for weeks to months, with one dietary aide stating she had notified management in March 2026 after seeing water pooling under it. The Dietary Supervisor stated she had been aware of the leak for about 3 months and that a previous maintenance worker had applied foil tape to minimize it, while the Administrator later stated the water was only condensation from the copper pipe and denied that there was a leak in the cooling system. During interviews, staff gave differing accounts of the condition of the walk-in fridge and the effect on food storage. One dietary aide stated the leak sometimes stopped and sometimes continued, and that if equipment stopped working the temperatures could be off and residents could be served spoiled food. The Dietary Supervisor stated it had been difficult to keep the fridge temperature below 40 degrees and that it had risen to 41 or 42 at times, although temperature logs reviewed by surveyors did not show variation above 40 degrees for the prior 2 weeks. The supervisor also stated the door needed to be pressed hard to close properly because of the handle mechanism and that staff were responsible for reporting equipment issues immediately. The facility also failed to ensure nursing staff had access to working facility-issued laptops and desktops. Surveyors observed multiple nurses and medication aides using their personal computers while completing medication administration, charting, and other work tasks. Staff members stated that facility laptops were not turning on, not charging properly, or were otherwise not functional, and several said they had been using their own devices for months or years because facility equipment was unavailable or broken. The Regional HR Coordinator stated staff should only use facility-owned devices for work and should not use personal devices for charting or accessing the medical record, while the Administrator stated he believed personal computers were acceptable under his interpretation of the handbook and could not confirm whether staff were using personal laptops.
Failure to Change Contaminated Gloves During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during incontinent care for one resident. The resident, an older adult with dementia and constipation, was care planned and assessed as always incontinent of bowel and bladder, with instructions to check frequently, assist with toileting, and provide pericare after each incontinent episode. During an observation, a CNA donned clean gloves, opened the resident’s brief, and used wet wipes to clean the resident’s scrotum and penis. The CNA then turned the resident to his side and continued perineal care, wiping the rectal area and removing bowel movement from the resident’s bottom while still wearing the same pair of gloves. After completing the cleaning, the CNA removed the soiled brief and, without changing the contaminated gloves, took a clean brief and fastened it on the resident, then assisted him back onto his back, completing the care. In a subsequent interview, the CNA acknowledged she should have changed her gloves before handling the clean brief and stated she had been nervous during the care. The DON stated that facility expectations were for CNAs to remove gloves once contaminated, perform hand hygiene, and then don new gloves, and acknowledged that failure to change gloves could result in spread of fecal matter and germs. Facility policies on personal/perineal care and infection control required glove removal when visibly soiled, hand hygiene before and after glove use, and maintenance of an infection control program to prevent the development and transmission of disease and infection.
Failure to Notify Physician of Oxygen-Related Change in Condition
Penalty
Summary
The facility failed to immediately inform the resident’s physician and representative when Resident #68 had a significant change in condition related to oxygen therapy. Resident #68 was admitted with chronic obstructive pulmonary disease and aphasia following a cerebral infarction, had severe cognitive impairment, was dependent on staff for all bed mobility and transfers, and was ordered to receive continuous oxygen therapy at 2-4 liters per minute. The care plan included monitoring for respiratory distress and notifying nursing staff if the oxygen was off. On 04/21/2026, Resident #68 was observed asleep in bed with the nasal cannula in place, but the oxygen concentrator was not on. The resident was not showing visible signs of respiratory distress or skin discoloration during the observations, and later the oxygen was found to be on with the cannula properly applied. LVN C stated that when she first checked the resident’s oxygen saturation it was in the 80s, and COTA F stated it was 86% when initially measured. LVN C also stated she did not know why she did not document the low oxygen saturation and documented only the later 96% reading after oxygen was administered. LVN C stated she did not report the event to the charge nurse, physician, or ADON because the oxygen level returned to normal and her assessment showed no findings. The record review showed no respiratory assessment or physician notification documented for that event. Facility staff interviewed later stated that oxygen being disconnected for an unknown length of time with an oxygen saturation of 86% was a change in condition and that the physician, ADON, resident’s nurse, and family should have been notified.
Missing Grievance Documentation
Penalty
Summary
The facility failed to maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision. During observation on 04/21/2026 at approximately 1:30 PM, the grievance binder provided did not contain any documentation of grievances prior to 2/13/2026. The report states this was 1 of 1 grievance binders reviewed, and the missing documentation meant there was no evidence available for grievances handled before that date. During interviews on 04/23/2026, the Social Services staff member stated she began working at the facility in February 2026 and found no grievance documentation when she took office. She stated she began taking grievances in February 2026 and using a tracking binder, but did not know how grievances were tracked before then. CNA E, LVN M, the ADON, and the Administrator each described different understandings of who had been responsible for grievance tracking before February 2026, including the previous Social Worker, interim administrators, the DON, and the Administrator. The Administrator stated the only grievance documentation in place was what was provided on 04/21/2026 and that no earlier binder was located. The facility policy titled Grievances, dated 11/2/2016, states the grievance official is the administrator or designee, will oversee the grievance process, receive and track grievances to conclusion, and maintain evidence demonstrating the results of all grievances for at least 3 years from the grievance decision.
Failure to Trim Resident’s Fingernails
Penalty
Summary
The facility failed to ensure Resident #12 received needed ADL assistance to maintain grooming and personal hygiene when her fingernails were not trimmed. Resident #12 was an older female with an original admission date of 06/18/2020 and a readmission date of 02/26/2021. Her MDS showed a BIMS score of 15, indicating she was cognitively intact, and she required setup or clean-up assistance for personal hygiene. Her care plan included assisting with personal hygiene as needed and checking nail length during bathing, with trimming on bath day or as necessary. Her medical record also noted neuropathy and joint pain reported to the physician during a visit. During an observation and interview, Resident #12 stated her nails were long, that she usually asked therapy to cut them because she was not diabetic, and that staff had not offered to trim them on her most recent shower day. She wanted her nails cut because they were getting long and could not recall when they were last trimmed. At the time of observation, her fingernails were more than 1 inch long and not her preference. Staff interviews indicated CNAs and nurses could trim fingernails, that nail length should be reviewed during routine care, and that lengthy nails should be addressed when observed. The facility’s nail care policy stated nail care should be performed regularly and safely, and the most recent nail care/refusal sheet did not list Resident #12 as having received nail care.
Failure to Assess Resident Immediately After a Fall
Penalty
Summary
The facility failed to ensure Resident #6 was assessed by a nurse immediately after a fall on 03/13/2026. Resident #6 was a female with a history of anxiety, type 2 diabetes mellitus, and schizophrenia, and her quarterly MDS indicated she was never or rarely understood and was completely dependent for ADLs and mobility. Her care plan identified her as at risk for falls related to dementia, wandering, anti-anxiety/antidepressant medication use, and poor safety awareness. According to the event nurses' note, during morning rounds Resident #6 was found with redness to both knees, a knot to the right side of her forehead, and a red swollen chin. The note also stated that during report the nurse did not receive any report of an incident. The ADON was notified and contacted the night CNA, who stated he had found the resident on the floor, picked her up from the floor, and placed her back in bed after forgetting to report the fall to the PM nurse. Vital signs were taken, and the physician and responsible party were notified. Record review showed x-rays were ordered for the chin and both knees, with no acute findings on the mandible and bilateral knee reports. The neurological assessment documented monitoring over the following hours with no acute findings. In interviews, the CNA stated he found the resident on the floor around 4:45 AM to 5:00 AM, moved her back to bed because he could not locate the assigned nurse, and did not report the fall until later that morning. The Corporate Nurse, ADON, and Administrator all stated the expectation was for CNAs to leave residents in place and notify a nurse immediately so the resident could be assessed before being moved.
Daily Nursing Staffing Information Not Posted in a Readily Accessible Location
Penalty
Summary
The facility failed to ensure that daily nursing staffing information was posted in a prominent place readily accessible to residents and visitors for 3 of 3 days. During an observation on 04/22/2026 at 11:25 AM, the staffing schedule and census were posted in the main Nurse's station behind the desk and by the back wall, where they were not accessible to residents in wheelchairs or residents with visual impairments. The Nurse's station had two open walkways on each side of the desk, and only facility staff were observed walking through and behind the desk area. During interviews, CMA N stated on 04/22/2026 at 11:29 AM that the staffing schedule information was only located in the main Nurse's station behind the desk and that there was no staffing schedule in either memory care unit. RN S stated on 04/23/2026 at 10:00 AM that the staffing schedule was only located behind the main Nurse's station and that residents likely could not observe it because it was on the wall behind the desk. CNA T stated on 04/23/2026 at 10:19 AM that the staffing schedule and census information were located behind the desk at the main Nurse's station and were not readable or observable by residents or visitors. The Administrator stated on 04/23/2026 at 3:39 PM that ADONs assisted with posting the daily census and staffing schedule and that the purpose of the posting was for everyone to be aware of the resident census and staffing census. On 04/23/2026 at 9:00 AM, the Administrator stated the facility did not have a policy for scheduled staffing and followed state regulations.
Failure to Post Resident Rights and State Advocacy Information
Penalty
Summary
The facility failed to post, in a form and manner accessible and understandable to residents and resident representatives, a list of names, addresses, and telephone numbers of pertinent State agencies and advocacy groups, including the State Survey Agency, licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit. This deficiency was identified for 2 of 5 halls reviewed: the 400-hall/Male Memory Care Unit and the 500-hall/Female Memory Care Unit. During observations on 04/22/2026, surveyors found no postings regarding Resident Rights or state client advocacy groups in either the secured female Memory Care Unit at 12:00 PM or the secured male Memory Care Unit at 12:10 PM. In interviews on 04/23/2026, CNA T stated there were no postings in the Memory Care Units and that residents could contact the Administrator, whose information was posted in residents' rooms, but there was no information for the State Agency or Ombudsman. RN U stated the postings were intended to allow residents or families to contact another party if concerns were not resolved by the facility, and the Administrator stated there were no written postings regarding resident rights, the State Agency, or the Ombudsman in the memory care units. Record review of the facility's Resident Rights policy stated the facility must post the required list of state agencies and advocacy groups.
Survey Results Binder Not Readily Accessible
Penalty
Summary
The facility failed to ensure residents had the right to examine the results of the most recent survey and failed to post the survey results in a place readily accessible to residents, family members, legal representatives, and the public. During an observation on 04/22/2026 at 11:30 AM, the annual survey results binder could not be located in an easily accessible area near the entrance or nurse's station. The Administrator then obtained the binder from a cabinet located outside his office doorway, and there was no sign or notice indicating the binder was inside the cabinet. During interviews, the Administrator stated the binder was kept inside the cabinet by the front entrance and acknowledged there was no signage or notice for it. He stated residents had previously taken the binder to their rooms and used it as a coloring book, and he did not know whether it had to be out in the open or if placement inside the cabinet was acceptable. A CNA, an LVN, and the ADON stated the binder should be visible and accessible to residents, families, and visitors, and that keeping it tucked away in the cabinet without signage was not acceptable. In a confidential group interview, 8 of 10 residents did not know where the binder was located or what it contained. Record review showed the facility's Resident Rights policy required residents to be able to examine the most recent survey results and required the facility to post the results in a readily accessible place and post notice of their availability in prominent public areas.
Failure to Implement and Coordinate Nutritional Interventions for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident maintained acceptable parameters of nutritional status, as evidenced by an 11.47% weight loss over 80 days without timely and fully implemented interventions. The resident was an elderly female admitted with diagnoses including protein-calorie malnutrition, diabetes mellitus, dementia, and anxiety disorder. Her admission MDS showed severe cognitive impairment (BIMS score of 2), a regular diet, and no documented weight loss or physician-ordered weight-loss program. Her care plan, revised in early December, identified her as at risk for malnutrition with interventions such as determining food preferences, monitoring and documenting intake, monitoring weight per facility protocol, serving the ordered diet, and notifying the physician of negative findings. Weight records showed an active decline from early December through mid-February, with the resident’s weight decreasing from 191.8 pounds to 169.8 pounds. A nutrition assessment by the RD in mid-December documented a weight of 185.6 pounds, a regular diet and texture, and food intake ranging from 25–100%. A weight watchers’ assessment in mid-January identified a 14.4‑pound weight loss and listed interventions of a red glass and a 2‑calorie supplement with each med pass. However, the resident did not appear on the facility’s red cup program list, and there were no corresponding physician orders in January for supplements or the red glass program. In February, no supplement order was present until mid-month, when Boost twice daily was ordered; there was still no physician order for the red glass program. Observations and interviews further demonstrated that the identified interventions were not consistently implemented or communicated. During lunch observations on consecutive days in February, the resident took only a few bites of food, repeatedly left the table, and on one day accepted a supplement, while on another day no alternative or supplement was observed being offered. The Dietary Manager stated she was responsible for the red glass program notifications but was unaware of the resident’s weight loss and confirmed the resident was not on the snack list. The new DON reported she had only recently become aware of the weight loss, implemented a supplement order mid-February, and believed the resident should have had weekly weights, supplements, and placement on the red glass program. The ADON acknowledged completing a weight watcher assessment in mid-January and intending to initiate the red glass program and 2‑calorie supplements with each med pass but admitted she forgot to enter these as physician orders. The RD stated she had recommended house supplements three times daily on admission and that these should have been entered as physician orders, but the resident did not appear on the January weight loss report. The NP reported she was unaware of the extent of the weight loss and had not been notified. These actions and inactions occurred despite a facility policy requiring review of significant weight changes, documentation on weight watcher forms with interventions, physician and family notification, initiation of an acute care plan for weight loss, and RD assessment and recommendations for significant weight loss. The facility’s own policy defined significant weight loss thresholds and required that such changes be recorded on a weight watchers’ form with interventions and follow-up, that the physician and family be notified, and that an acute care plan for weight loss be initiated. It also required referral of all significant weight changes to the Regional Dietitian for assessment and review of interventions. In this case, although a weight watchers’ assessment was completed and interventions were listed, they were not converted into active physician orders, the resident was not placed on the red glass program list, and the RD did not receive accurate weight loss reporting in January. Staff interviews showed inconsistent awareness of the resident’s weight loss and program status, and the NP was not informed of the significant weight change. These documented failures to follow policy and to implement and coordinate ordered or recommended nutritional interventions contributed directly to the resident’s continued weight decline. Throughout this period, meal intake documentation for January and February continued to show 25–100% consumption, while direct observations showed poor intake and difficulty remaining at the table. CNAs and nursing staff reported offering alternatives and snacks generally, but the assigned CNA confirmed the resident was not on the red cup program, which was supposed to trigger extra attention to intake. The DON, ADON, RD, and NP each described gaps in communication and follow-through regarding weight monitoring, program placement, and supplement orders. Collectively, these documented lapses in monitoring, communication, and implementation of nutritional interventions led to the resident’s significant, ongoing weight loss and constituted the cited deficiency in maintaining acceptable nutritional status.
Failure to Provide Sufficient Staffing and 1:1 Monitoring Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically by not providing sufficient staffing and failing to implement required 1:1 monitoring for residents with known behavioral risks. Multiple incidents occurred in both male and female secured locked units, where residents with severe cognitive impairment and behavioral diagnoses engaged in physical altercations resulting in injuries such as head lacerations, skin tears, and hospitalizations. In several cases, residents who were supposed to be under 1:1 supervision were not provided with a dedicated staff member, as required by the facility's own in-service training and policy. On multiple occasions, staff assignments did not include additional personnel for 1:1 monitoring, despite residents being identified as needing such supervision due to aggressive or violent behaviors. For example, one male resident with a history of explosive disorder and severe cognitive impairment physically assaulted another resident, causing a head injury that required emergency room treatment and staples. Another incident involved a resident slapping and injuring a peer while supposed to be under 1:1 monitoring, but no extra staff was assigned, and the monitoring was performed by staff already responsible for the entire unit. Similar failures occurred in the female secured unit, where a resident with traumatic brain injury and dementia physically assaulted two other residents, causing skin tears and facial injuries, again without the required 1:1 supervision being provided. Interviews with staff and review of staffing schedules confirmed that the facility routinely failed to assign additional staff for 1:1 monitoring, instead expecting existing CNAs to rotate or cover both general care and 1:1 supervision, even during night shifts when staffing was further reduced. Staff reported being unable to maintain arm's-length supervision as required, and monitoring sheets were often signed by staff who were simultaneously responsible for multiple units or entire halls. These actions and inactions directly led to resident-to-resident altercations and injuries, as documented in progress notes, investigation reports, and staff interviews.
Failure to Provide Adequate Supervision and 1:1 Monitoring Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, specifically in relation to resident-to-resident altercations on two secured units. Multiple incidents occurred where residents with known behavioral issues and severe cognitive impairment engaged in physical altercations, resulting in injuries such as head lacerations, skin tears, and hospitalizations. In several cases, residents who were supposed to be on 1:1 monitoring did not have a designated staff member assigned to them, as required by the facility's own in-service training and staffing protocols. Instead, existing staff were expected to rotate or cover 1:1 monitoring in addition to their regular duties, leading to lapses in supervision. On the male secured locked unit, one resident with a history of explosive disorder and severe cognitive impairment physically assaulted another resident who had wandered into his room, causing a head injury that required emergency room treatment and staples. The same resident later assaulted a different resident, resulting in a fall and a skin tear. Despite care plans indicating the need for 1:1 supervision, staffing records and interviews confirmed that no additional staff were assigned for this purpose, and the two CNAs on duty were responsible for supervising all residents on the unit as well as providing 1:1 monitoring. Staff interviews corroborated that it was common practice for no extra staff to be provided for 1:1 monitoring, even when required. Similar deficiencies were observed on the female secured unit, where a resident with traumatic brain injury and severe cognitive impairment physically assaulted two other residents, causing skin tears and facial injuries. Again, although 1:1 monitoring was indicated after the first incident, staffing records showed that only one CNA was present for the entire unit, and no additional staff were assigned for 1:1 monitoring. Staff interviews revealed that it was rare for a third CNA to be sent for 1:1 monitoring, and that CNAs often had to rotate the responsibility among themselves while still supervising the rest of the unit. The lack of adequate supervision and failure to follow established protocols for 1:1 monitoring directly contributed to repeated resident-to-resident altercations and injuries.
Failure to Provide Sufficient Staffing and 1:1 Monitoring in Secure Units
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly in the secure male and female units, resulting in multiple resident-to-resident altercations and injuries. On several occasions, residents who required 1:1 monitoring due to behavioral risks did not have a designated staff member assigned to them, as required by the facility's own in-service training and stated procedures. Instead, existing CNAs were expected to rotate or attempt to monitor these residents in addition to their regular duties, despite being responsible for large numbers of residents with known behavioral issues. This lack of dedicated staffing led to incidents where residents were left unsupervised, resulting in physical altercations, falls, and injuries such as skin tears and lacerations. Specific incidents included a male resident with severe cognitive impairment and a history of physical aggression who was placed on 1:1 monitoring after an altercation, but no additional staff was assigned. This resident subsequently assaulted another resident, causing a fall and injury, while unsupervised in the dining room. Similarly, in the female secure unit, a resident with a traumatic brain injury and severe cognitive impairment was involved in multiple altercations, including grabbing and slapping other residents, while supposed to be on 1:1 monitoring. Staffing records and interviews confirmed that no extra staff were provided for 1:1 monitoring during these times, and CNAs reported being unable to maintain required supervision due to being the only staff on the unit or having to cover both secure units simultaneously. Interviews with staff, including CNAs and nurses, revealed that it was common practice for the facility to operate with fewer staff than required, especially during night shifts, and to rely on existing staff to provide 1:1 monitoring without relief. The Director of Nursing and Assistant Director of Nursing acknowledged that additional staff should be assigned for 1:1 monitoring but were unaware of instances where this did not occur. The facility did not have a formal staffing policy, and documentation showed that 1:1 monitoring sheets were often signed by staff already assigned to the unit, rather than by a dedicated monitor. These failures were confirmed through observation, record review, and staff interviews.
DON Served as Charge Nurse During High Census
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse when the average daily occupancy was 60 or more residents, as required by regulation. Review of the daily staffing schedule showed that the DON worked as a charge nurse on nine separate days during the review period. During an interview, the DON confirmed she had been working night shifts as the charge nurse due to a recent staff resignation and stated that no one else had been designated to perform her DON duties during these times. The DON also indicated she was unaware of the regulation prohibiting her from working the floor in this capacity. Additionally, when requested, the facility was unable to provide a policy for RN/DON coverage. The job description for the DON emphasized the need for knowledge of nursing home regulations and accountability for compliance, but also included a provision to augment floor staffing if needed. There were no details provided about specific residents or their conditions related to this deficiency.
Failure to Update Care Plans After Behavioral Incidents and Assessments
Penalty
Summary
The facility failed to review and revise comprehensive care plans by the interdisciplinary team after each assessment for three residents. Specifically, the care plans were not updated to reflect new or ongoing behavioral issues, such as aggressive and physical behaviors towards other residents and wandering, despite documented incidents in the residents' progress notes. The care plans for these residents had not been updated with new interventions since their last revisions, even though there were multiple documented episodes of aggression and wandering that required staff intervention and, in some cases, resulted in hospital transfers. One male resident with severe cognitive impairment and a history of explosive disorder exhibited repeated aggressive behaviors, including hitting and shoving other residents, which led to another resident being sent to the emergency room. Despite these incidents, his care plan had not been updated with new interventions since the previous year. Another female resident with traumatic brain injury and dementia also demonstrated physical aggression, such as grabbing and slapping other residents, but her care plan interventions had not been revised since the previous year, even after multiple aggressive episodes were documented. A third male resident, also with severe cognitive impairment and a history of explosive disorder, was involved in a resident-to-resident altercation after wandering into another resident's room, resulting in a fall and injury. His care plan, which addressed wandering, had not been updated with new interventions since his admission, despite these incidents. The Director of Nursing confirmed that care plans should be updated after such events but was unable to explain why this had not occurred. Facility policy requires care plans to be reviewed and revised after each assessment and in response to changes in the resident's condition or interventions.
Staff Cell Phone Use Violates Resident Dignity
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by staff members using personal cell phones in the presence of residents. This behavior was observed during a confidential group interview with 11 residents, who reported feeling disrespected and ignored. The residents expressed concerns that staff were frequently on their phones, even while providing care, passing medications, and ignoring call lights. This led to feelings of discomfort and the perception that staff did not care about them. The issue was reported multiple times in Resident Council Meetings, with residents noting that staff conversations were often personal and inappropriate. The facility's policy prohibits the use of personal communication devices during work hours, except during breaks, and explicitly forbids the use of cell phones in residents' presence. Despite this policy, the Activity Director was observed using a cell phone in the main dining room, and residents reported that staff were on their phones while providing care. Interviews with the ADON, DON, and RN Consultant revealed that they were unaware of the extent of the issue, although they acknowledged the policy and the potential for privacy violations. The facility had conducted in-services on phone use, but the problem persisted, indicating a failure to enforce the policy effectively.
Unauthorized Access to Medication Room
Penalty
Summary
The facility failed to ensure that only authorized personnel had access to the medication room, which was reviewed for drug storage. During an observation, it was noted that a Medical Records staff member, who was unauthorized to be in the medication room unattended, had access to the room. The staff member unlocked the medication room using a code and was present in the room without any nursing staff. The room contained various medications, including over-the-counter and prescribed drugs, as well as insulin and other medical supplies. Interviews revealed that the Medical Records staff member often stocked the medication room with over-the-counter medications and was sometimes left alone in the room when the nurse stepped out. Additionally, the Central Supply staff member also had access to the medication room and had been in the room alone to stock it. The facility's policy indicated that only licensed nursing personnel, pharmacy personnel, or staff members authorized to administer medications should have access to the medication supply. This breach in protocol could potentially lead to drug diversion.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Specifically, CNAs A, B, E, and D did not use personal protective equipment (PPE) during incontinent care for residents on EBP, such as Residents #17 and #60. CNA B, in particular, did not change her gloves after they became contaminated during care for Resident #17, and neither CNA A nor B wore gowns during the procedure. Additionally, CNAs C, D, E, and F did not use PPE during transfers for EBP residents, including Residents #49, #60, and #67. For instance, CNA C and CNA D assisted Resident #49 with a transfer without wearing gowns, despite the resident being on EBP due to a past diagnosis of an antibiotic-resistant infection. Similarly, CNA E and CNA D performed incontinent care and a transfer for Resident #60 without gowns, even though there was a sign indicating EBP was required. The facility's failure to ensure proper use of PPE and adherence to EBP protocols was further highlighted by the lack of accessible PPE in resident rooms and the staff's lack of awareness regarding which residents were on EBP. Interviews with staff, including the ADON, revealed a breakdown in communication and understanding of EBP requirements, contributing to the risk of cross-contamination and infection spread among residents.
Failure to Label IV Dressing
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids for a resident, specifically by not adhering to professional standards regarding the labeling of a Mid-line intravenous line dressing. The resident, a female with chronic kidney disease, type 2 diabetes, and pressure ulcers, was admitted to the facility with a Mid-line IV for administering fluids and medications. The dressing on the resident's Mid-line IV was observed to be intact but lacked the required date and initials, which are essential for monitoring dressing changes and preventing infections. The resident was unable to recall when the Mid-line was inserted or when the dressing was last changed. The Director of Nursing (DON) confirmed that the facility's policy mandates that IV dressings be labeled with the date, time, and initials to track dressing changes and minimize infection risks. The facility's policy on dressing changes explicitly requires this labeling, yet the observation and record review revealed non-compliance with this standard. The absence of labeling on the dressing could potentially place residents at risk for infections, although no signs of infection were noted at the time of observation.
Inaccurate Documentation of Resident's Shower Log
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for a resident whose assessments were reviewed. Specifically, the shower log for the resident inaccurately documented that the resident refused showers on multiple occasions, despite interviews indicating that the resident never refused showers. The resident, a male with diagnoses including Dementia, Malnutrition, and obstructive pulmonary disease, was supposed to receive showers on specific days, but the log incorrectly noted refusals. Interviews with staff and another resident revealed that the resident consistently received showers and never refused them. A staff member admitted to possibly mis-clicking on the documentation, leading to the incorrect recording of shower refusals. The Assistant Director of Nursing confirmed that this was a documentation error, which could potentially lead to inadequate care due to inaccurate records. The facility's policy requires complete and accurate documentation for each resident, which was not adhered to in this case.
Failure to Secure and Document Controlled Medications
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 accurately receive and store 45 tablets of Alprazolam, an anti-anxiety medication, and 60 tablets of Tramadol, a pain medication, both classified as Schedule IV narcotics. This failure resulted in the diversion of the Alprazolam tablets. The resident involved was an elderly male with multiple diagnoses, including dementia with behavioral disturbance, hypertension, depression, anxiety, and a psychotic disorder with delusions. He was living in a secured unit and receiving hospice services. The resident's care plan included the use of anti-anxiety medications to manage his symptoms, and he had a prescription for Alprazolam to be administered twice daily and as needed. The deficiency was identified when a Licensed Vocational Nurse (LVN) discovered that the Alprazolam medication card was missing from the medication cart. The facility's investigation revealed that the medications were delivered by a hospice nurse, but there was no signature or confirmation of receipt. The Director of Nursing (DON) was reportedly the last person to have contact with the medications, but she did not recall handling them. The facility's policies required controlled substances to be stored under double lock and documented with a narcotic count sheet, which was not followed in this instance.
Medication Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to medications, specifically for one of the four medication carts reviewed. This deficiency was highlighted by the case of a resident whose 60 tablets of Tramadol were not secured in a double-locked area, as required for controlled substances. The Tramadol was delivered by a hospice nurse and was later found missing, leading to an investigation by the facility. The investigation revealed that the Tramadol was delivered by a hospice nurse who did not obtain a signature upon delivery, and the medication was allegedly left in the medication room instead of being secured in the medication cart's locked drawer. The Director of Nursing (DON) was identified as the last person to have seen the medications, but due to working multiple shifts and being tired, the DON did not recall the specifics of the delivery or handling of the medications. The Assistant Director of Nursing (ADON) and other staff members expressed concerns about the lack of proper procedures followed during the delivery and storage of the medications. Interviews with various staff members, including the Administrator, ADON, and MDS Coordinator, indicated a breakdown in communication and procedure adherence. The hospice nurse admitted to not having the DON sign for the medications and mentioned the chaotic environment on the day of delivery. The facility's policies and procedures for handling controlled substances were not followed, as the Tramadol was not placed in the narcotic box with a count sheet, and the delivery process lacked proper documentation and accountability.
Failure to Implement QAPI Plan and Document Incidents
Penalty
Summary
The facility failed to implement its Quality Assessment and Performance Improvement (QAPI) plan, which led to deficiencies in addressing adverse events related to potential deficient practices for four residents. The facility did not identify a pattern of behaviors between two residents, where one resident repeatedly exhibited aggressive behaviors towards another over a six-month period. Despite multiple incidents, including hair-pulling and physical aggression, the facility did not complete incident/accident reports, which hindered the ability to track and trend these behaviors effectively. Additionally, the facility failed to complete incident/accident reports for two other residents who demonstrated physical behaviors. One resident exhibited aggressive behaviors such as attempting to hit others and making false accusations, while another resident engaged in behaviors that could lead to altercations, such as shaking other residents' wheelchairs. The lack of documentation and reporting of these incidents prevented the facility from identifying patterns and implementing appropriate interventions. Interviews with facility staff revealed a lack of consistent tracking and trending of behaviors due to incomplete incident/accident reports. The facility relied on morning meetings to discuss behaviors, but without proper documentation, it was challenging to identify patterns or trends. The facility's policy required incident/accident reports for behaviors affecting others, but this was not consistently followed, leading to deficiencies in the facility's quality assurance processes.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, leading to several deficiencies. Observations revealed that food was not stored properly, with items such as pudding, garbanzo beans, and black olives being kept beyond the recommended seven-day period. Additionally, pasteurized eggs, tea, and water were stored on the floor of the walk-in refrigerator, which is against food safety protocols. A tube of ground beef was found thawing without a pan, resulting in a puddle of blood on the floor, indicating improper thawing practices. The facility also failed to prevent cross-contamination during food preparation. Cook A was observed changing gloves multiple times without washing or sanitizing her hands after touching the trash can lid, which could lead to contamination. Furthermore, dietary aides were not using effective hair restraints, with one aide's beard partially uncovered and another aide's hair partially exposed. The pots and dishes were stored face up and uncovered, leaving them susceptible to airborne contamination. Interviews with the Dietary Manager (DM) and staff confirmed these practices, with the DM acknowledging the improper storage and handling of food items. The DM also admitted that the hairnets used were ineffective and that there was no explanation for the eggs being stored on the floor. The facility's policies and procedures, dated 2012, were reviewed and found to be in place to prevent such deficiencies, but they were not being followed, leading to potential risks of foodborne illness and cross-contamination for residents receiving meals from the kitchen.
Facility Fails to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, which included the oven, garbage disposal, and milk refrigerator. Observations revealed that the milk refrigerator had a rusted hinge and a detached, black gasket, which compromised its sealing ability. The garbage disposal was non-functional, and the oven failed to reach the required temperature during meal preparation. These issues were observed over several days, with staff acknowledging the problems but no immediate corrective actions were evident. Interviews with the Dietary Manager (DM) indicated that the garbage disposal had been non-functional for two weeks, and the refrigerator issues had persisted for over a year. The DM had informed the maintenance director about these issues, but no work orders were provided to substantiate these claims. The DM also mentioned that the oven's temperature gauge had been replaced, but it still failed to reach the correct temperature intermittently. The Administrator and Regional Compliance Officer were unaware of these issues, indicating a communication breakdown within the facility.
Failure to Revise Care Plan for Crawling Behavior
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident who exhibited crawling behavior, which was not addressed in her care plan. The resident, a female with multiple diagnoses including seizures, developmental disorder of speech and language, and schizophrenia, was admitted with a history of crawling behavior. Despite this, the care plan did not include interventions for this behavior, even though it was documented in progress notes multiple times over the course of a year. The resident was placed in a low bed with a floor mat due to poor safety awareness, but no specific interventions were in place to address the crawling behavior. The deficiency was highlighted when the resident sustained abrasions to her knees from crawling, which were documented in progress notes. Interviews with the resident's responsible party and facility staff revealed that the facility was aware of the behavior but had not implemented additional interventions to prevent injury. Video surveillance confirmed the resident's crawling behavior and subsequent injuries. The facility's failure to update the care plan to include interventions for the resident's crawling behavior placed her at risk of injury.
Failure to Prevent Injuries from Crawling Behavior
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for a resident with a known crawling behavior. The resident, a female with multiple diagnoses including seizures and schizophrenia, was admitted with a history of crawling behavior. Despite this, her comprehensive care plan did not include interventions for this behavior. The resident was placed in a low bed with a floor mat due to poor safety awareness, but no additional measures were implemented to address her crawling. The resident's progress notes documented her crawling behavior on multiple occasions, leading to abrasions and reopened wounds on her knees. Staff interviews revealed that the facility was aware of the behavior but not of specific incidents or injuries. Video surveillance showed the resident crawling and walking in the hallway, refusing staff assistance, and becoming aggressive. The facility's lack of intervention and supervision resulted in the resident sustaining injuries, highlighting a deficiency in ensuring a safe environment.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Odessa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Odessa | 0.6 mi | ★★★★★ | 12 | 0 |
| Buena Vida Nursing & Rehab Odessa | 4.5 mi | ★★★★★ | 4 | 0 |
| Deerings Nursing And Rehabilitation | 5.4 mi | ★★★★★ | 2 | 0 |
| Madison Medical Resort | 5.5 mi | ★★★★★ | 2 | 0 |
| Parks Health Center | 8.1 mi | ★★★★★ | 10 | 0 |
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