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 Signature Pointe during CMS and state inspections, most recent first.
Missing Required State Agency and Complaint Postings: Surveyors found only a single posting on the 1st floor, with no HHSC complaint number or statement that residents may file a complaint with the State Survey Agency posted in other areas of the facility. Public areas, including the dining room, also lacked the abuse number. The SW said postings were updated with paper notices and the ADMIN stated it was important for the signage to be posted on each floor.
Incomplete Care Plans for Fall Prevention and Suction Use: The facility failed to include key interventions in care plans for several residents. Three residents were observed with beds in low position and fall mats in place, but their care plans did not reflect those fall-prevention interventions. Another resident with hemiplegia and dysphagia had a suction machine in use for secretion management, but the care plan did not address suctioning, and staff stated the resident had been using it for months.
Failure to Verify G-Tube Placement and Residuals Before Med Pass: An LVN administered crushed meds via a resident’s G-tube without verifying tube placement, another LVN flushed and gave meds without checking residuals, and an RN also failed to verify placement before using a G-tube. The residents had gastrostomy status, and the facility records and staff interviews confirmed orders and expectations to verify placement and, for one resident, check residuals before tube use.
Missing Physician Orders for Respiratory Care: Two residents received respiratory-related interventions without required physician orders. One resident with a tracheostomy was observed using an oxygen concentrator by nasal cannula, but the chart had no order or care plan for oxygen use. Another resident with hemiplegia and dysphagia had a suction machine at the bedside and staff reported using it for secretion removal for months, yet the record had no suction order and no care plan or MDS documentation reflecting its use.
Surveyors found medications and other biologicals left in residents’ rooms without self-administration assessments or, in some cases, without orders. A resident with memory problems had muscle cramp foam on a side table, a cognitively intact resident had a nasal spray and adaptogenic mushroom in the room, another resident had pain relieving gel on a side table, and a resident with chronic pain received Biofreeze from a therapist and kept it on her overbed table. Staff stated these items should not have been in the rooms and that only nurses should handle medications.
Food service sanitation and storage deficiencies were identified in the kitchen and substations. A staff member preparing food did not have her hair fully covered, a freezer item was not completely sealed, the main kitchen trashcan lacked a lid, and the 4th floor ice machine, ice scoop holder, and dining area bowls were dirty, with a German roach observed among clean bowls. Two microwaves had dried food stains, and a sanitizer bucket in a substation tested at 0 PPM.
Missing and nonfunctional privacy curtains left several residents in shared rooms without full visual privacy. A resident’s curtain was stuck in the track, other residents had no curtains at all or only partial coverage at the foot of the bed, and CNA care was observed with one resident’s room door open and the curtain only partially drawn. The DON and ADON acknowledged the missing curtains and stated more curtains had to be ordered.
Privacy During Care and AEM Consent Documentation: A CNA provided incontinent care to a resident while the room door was open and the privacy curtain was only partially drawn, with part of the curtain missing near the foot of the bed. The facility also did not have roommate consent documented in the active EHR for a resident living in a shared room with AEM, even though the room had an electronic monitoring sign and a camera was observed on one side of the room.
Resident-to-resident abuse was not prevented when one resident struck another during a roommate altercation. One resident with dementia and mood disorder, and another resident with impaired cognition and medical comorbidities, were involved in an incident where a plastic urinal/bottle was used to hit the other resident after an argument over wheelchair positioning and assistance. The injured resident reported being hit in the head and stomach, while staff noted neither resident had a prior aggression history and the facility’s resident rights and altercation policy required residents to be free from abuse and for altercations to be investigated and reported.
Missing AMA Documentation for Resident Discharge: A resident with joint replacement and seizures was documented as leaving the facility AMA, but the record did not contain a signed AMA form. The DON, Administrator, and RN stated the discharge nurse should have obtained the resident’s signature, but only progress notes were signed. The facility policy required transfer/discharge notice documentation with the reason, effective date, and destination.
MDS assessments for two residents did not accurately reflect their current devices and treatments. One resident’s MDS omitted an external catheter and suction use even though the care plan, physician order, and bedside observation showed both were in use; staff also stated the external catheter had been used for months. Another resident’s MDS omitted a nephrostomy despite the care plan, physician order, and resident interview confirming the nephrostomy tube and bag were present. The MDS Nurse acknowledged the coding omissions.
Failure to Complete Baseline Care Plan Within 48 Hours: A resident admitted with multiple serious diagnoses, including dysphagia, DM, HTN, acute kidney failure, aphasia, and gastrostomy status, did not have a baseline care plan that addressed immediate needs. The only documented focus was enhanced barrier precautions, while key issues such as swallowing needs, safety risks, supervision needs, and PASRR-related interventions were not included. The MDS nurse, ADON, DON, Administrator, and admitting LVN all acknowledged the baseline care plan was not completed as required.
Missing Physician Order for Scoop Mattress: A resident with severe cognitive impairment, muscle wasting, lack of coordination, and fall risk was observed lying on a scoop mattress even though no physician order was present for the equipment. The care plan did not include the scoop mattress, and the DON stated physician orders were required for such care.
Expired Insulin Left in Medication Cart: A resident with DM had an insulin KwikPen found in a nurse’s cart after its beyond-use date had passed. An LVN identified the pen as expired and discarded it, while the DON, ADON, and Administrator acknowledged that staff were responsible for checking expiration dates and keeping expired meds out of medication carts.
Hand hygiene and glove-use failures were observed with two residents. A CNA performed incontinent care for a resident with hemiplegia, hemiparesis, cognitive impairment, and bowel/bladder incontinence without washing hands before gloving, used wipes that had fallen on the bed, and did not change gloves before touching a clean brief. An RN preparing and administering medication via g-tube for a resident with a gastrostomy status also failed to perform hand hygiene before preparation and administration. Staff interviews confirmed the expected hand hygiene and clean-to-dirty technique were not followed.
A resident with depression, anxiety, and dementia, but assessed as cognitively intact, was moved from one floor to another Medicaid-designated room without the facility providing written notice or the reason for the move to the resident’s designated Resident Representative (RR), who held medical power of attorney. Staff had the resident sign a room change notification form, even though he was not his own Responsible Party, and he reported feeling coerced and not understanding why he was being moved. The RR stated she only learned of the move when the resident called her and that the facility did not notify her. The Administrator and CNO reported they believed informing the resident alone was sufficient if the resident was coherent and indicated they relied on the resident to notify the RR, despite facility policy stating that RR decisions are treated as the resident’s decisions.
A resident with dementia and depression, but assessed as cognitively intact, was prescribed PRN Tramadol for pain without notifying the designated Resident Representative (RR), despite admission documents showing the RR had consented to treatment and the facility’s policy defining the RR as a person to receive notifications. The RR later reported she had not been informed of the narcotic prescription and expressed concern due to the resident’s history as a recovering alcoholic. The Administrator and CNO stated they believed notification was unnecessary because the resident was coherent and able to make his own decisions, while the DON and ADON were unsure if RR consent was required but acknowledged they typically tried to keep the RR informed.
Two residents who were totally dependent for ADLs did not consistently receive required hygiene and grooming care. A male resident with hemiplegia and a contracted hand had excessively long, dirty fingernails for weeks despite repeated requests by him and his representative, and his grievance about nail care was not addressed in a timely manner. A female resident with hemiplegia, physical debility, and severe cognitive impairment, care planned as at risk for skin breakdown, reported that bed baths were not provided consistently and that she had not refused them, while her record initially contained only one uploaded shower form before additional bath records were later produced. Staff interviews showed that CNAs were expected to provide showers/bed baths and nail care and that charge nurses, the ADON, and the DON were responsible for ensuring completion and documentation of these ADL services in accordance with facility policy.
Three residents with severe cognitive impairment and significant physical limitations did not have their call lights within reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed that procedures to check and secure call lights were not consistently followed, resulting in residents being unable to request assistance when needed.
A nurse left a cart unattended in a hallway with a paper listing several residents' vital signs and an open laptop displaying their names, photos, and care levels. This information was visible to unauthorized staff and others passing by, violating facility policy on confidentiality and privacy of protected health information.
Multiple instances were observed where medicated ointments and wound cleansers were left unsecured in resident rooms, and a solution for a breathing treatment was left unattended on a nurse's cart. Staff interviews confirmed that these medications should have been stored in locked compartments and not accessible to residents, in accordance with facility policy.
Staff failed to follow infection control protocols during care for two residents, including not performing hand hygiene between glove changes during incontinent care and not wearing a gown as required under Enhanced Barrier Precautions when disconnecting an IV. These lapses occurred despite staff awareness of facility policies and posted reminders.
A resident with a gall bladder tube was found with her drainage bag uncovered and in public view, despite physician orders and facility policy requiring it to be covered for privacy and dignity. Multiple staff members, including an ADON, LVN, and DON, acknowledged the oversight and confirmed that the bag should have been concealed to maintain the resident's dignity.
Three residents with significant cognitive and physical impairments were found with their nurse call lights on the floor and out of reach while in bed, despite care plans and facility policy requiring call lights to be accessible. Staff confirmed the expectation that call lights should be within reach, but this was not maintained during the survey.
Two residents were found using bolster mattresses as physical restraints without required physician orders or proper care plan documentation. Staff confirmed that physician orders were necessary for these devices, but none were present in the records, contrary to facility policy.
A resident with acute respiratory failure who required regular nebulizer treatments was found to have her nebulizer mask left unbagged in her nightstand after use, in violation of facility policy and professional standards. The LVN responsible admitted to forgetting to bag the mask, and the DON confirmed the lapse in infection control practice.
A resident with severe cognitive impairment and bilateral hand contractures was not provided with an accessible call light system. The call light was out of reach, and staff had not assessed the resident's ability to use the standard or alternative call light options, as required by facility policy. This resulted in the resident lacking a suitable means to request assistance.
A resident with severe cognitive impairment and mobility issues was found in bed with bolster pads on all sides, preventing free exit. The use of these pads was not included in the care plan and lacked physician orders, despite facility policy requiring such authorization for restraints. Staff were unaware that orders were needed for this equipment.
A nurse left a piece of paper containing the names, vital signs, and blood sugar readings of five residents exposed and unattended on a nurse's cart in a hallway, making confidential medical information visible to unauthorized individuals. Facility leadership confirmed this was a violation of privacy and confidentiality policies.
Three residents requiring oxygen therapy had their nasal cannulas improperly stored when not in use, with devices left on beds, floors, or tables instead of being bagged as required. Staff and documentation confirmed that proper infection control procedures were not followed, despite physician orders and care plans specifying the need for continuous oxygen and safe storage of respiratory equipment.
A wound care cart containing medications and biologicals was found unlocked and unattended in a hallway near the rehabilitation department, with its drawers easily accessible to residents and staff. The DON, ADON, and Administrator confirmed the cart should have been locked when not in use, in accordance with facility policy.
The facility's kitchen failed to meet food safety standards, with staff not wearing proper hair coverings, improper food storage, and unclean equipment. Observations included uncovered trash cans, dirty storage bins, and expired food not discarded. The Dietary Manager and Executive Director were aware of these issues but had not yet addressed them.
A resident with rheumatoid arthritis and physical debility was found with an outdated wound dressing on her elbow, with no physician order documented. The wound care nurse, returning from leave, discovered the issue and contacted the doctor for proper orders. The use of agency nurses during the nurse's absence led to a lack of awareness about the dressing, risking infection due to non-compliance with the facility's wound care policy.
The facility failed to ensure proper infection control in respiratory care for two residents. A resident's CPAP hose was found on the floor, posing a contamination risk, while another resident's nasal cannula was left unbagged and balled up on the floor. Both instances were identified as infection control concerns by staff.
A resident with severe cognitive impairment was found with unsecured Mucinex tablets on her bedside table, which were brought by a family member without staff knowledge. The facility's ADON and DON confirmed that the medication should not have been in the room without a physician's order and assessment for self-administration, which were not present. Staff expressed concerns about potential overmedication due to unauthorized access.
A facility failed to maintain proper infection control when a CNA did not perform hand hygiene between glove changes during incontinence care for a resident with severe cognitive impairment. This action was against the facility's policy and could lead to cross-contamination. Staff interviews confirmed the importance of hand hygiene in preventing infections.
The facility failed to properly store and manage medications, with expired and discontinued drugs found in medication carts and refrigerators. Narcotic medications belonging to discharged residents were not documented or disposed of correctly, raising concerns about potential theft and medication errors. Staff interviews revealed non-compliance with facility policies on medication disposal and inventory management.
The facility failed to secure medication carts, leaving them unlocked and unattended, which could lead to unauthorized access by residents. The 3rd Floor Treatment Cart, 340 Hall Nurses Medication Cart, and 200 Hall Nurse Medication Cart were all found unlocked during a survey. Staff interviews revealed a lack of adherence to the facility's policy on securing medication carts, despite awareness of the requirement.
Missing Required State Agency and Complaint Postings
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, and failed to post the statement that residents may file a complaint with the State Survey Agency. Survey observations on 04/14/26 and 04/15/26 found only a single posting on the 1st floor, with no HHSC complaint number or complaint statement posted in other locations of the facility. The observations also noted that public areas, including the dining room, did not have the abuse number posted. During an interview on 04/16/26, the SW stated she updated the ombudsman and abuse coordinator information with paper postings and said the facility had an interim ombudsman because the current one had been promoted. She stated that, as a temporary fix, postings had been placed throughout the facility on all floors with contact information for the Ombudsman and ADMIN, but she did not have access to the glass cabinets displaying the postings. The ADMIN stated it was important to have the signage posted on each floor and said she did not know why the HHSC complaint number and statement that residents may file a complaint with the State Survey Agency were not posted in the facility.
Incomplete Care Plans for Fall Prevention and Suction Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for residents whose assessments identified specific needs. Review of the facility policy stated that each resident should have a comprehensive care plan that includes all services identified in the resident’s comprehensive assessment. The deficiency involved Residents #4, #9, #74, and #124, whose records and observations showed that needed interventions were not reflected in their care plans. Resident #4’s record showed diagnoses including lack of coordination and muscle weakness, and the resident was observed lying in bed with the bed in its lowest position and a fall mat on the left side of the bed. However, the comprehensive care plan for fall prevention did not include interventions for the bed to be in the lowest position or for fall mats to be placed on both sides of the bed. Resident #9’s record showed diagnoses including lack of coordination, muscle weakness, and seizure disorder, and the resident was observed in bed with the bed in a low position and fall mats on both sides. The care plan did not include a fall prevention plan or those interventions. During interview, RN M stated the resident required the bed to be in a low position and fall mats on both sides to reduce the chance of injury if she fell out of bed. Resident #124’s record showed a diagnosis of Alzheimer’s disease, and the resident was observed in bed with the bed in a low position and fall mats on both sides. The care plan did not include fall prevention or those interventions. Staff stated the resident should be care planned because she was a fall risk and the care plan was needed to inform staff of the plan of care. Resident #74’s record showed diagnoses of hemiplegia and dysphagia. The resident had a suction machine present, and staff stated she had been using it for more than four months because she was unable to expel secretions. The comprehensive care plan dated 02/05/2026 did not include suction use, and the physician’s order reviewed did not show an order for suctioning. MDS Nurse G stated that if the resident was using a suction machine, there should be a care plan in place for suctioning so staff would know the interventions and goals related to suction use.
Failure to Verify G-Tube Placement and Residuals Before Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for three residents with gastrostomy tubes. Resident #8 had a diagnosis of gastrostomy, a care plan intervention to check tube placement, and a physician order to check G-tube placement before administering water, formula, or medications through the tube. During observation, an LVN prepared and administered crushed medications through the G-tube after checking residual and flushing the tube, but did not check G-tube placement before flushing and giving the medications. In interview, the LVN stated he had assessed the abdomen for bowel sounds and acknowledged that tube placement should have been checked to ensure the tube was not dislodged. Resident #74 also had gastrostomy status, memory problems, and a care plan intervention to monitor aspiration. The physician order directed staff to check residual before medication administration and to hold medications and formula if residual was greater than 100 cc. During observation, an LVN checked G-tube placement by auscultation, then flushed the tube and administered medications, but did not check the residual before flushing and medication administration. In interview, the LVN stated she missed the order to check residual and said residuals should be checked to make sure the stomach was functioning properly and not too full. Resident #125 had gastrostomy status, and the baseline care plan did not include tube feeding. During observation, an RN prepared crushed medications, disconnected the G-tube from formula, checked residual, flushed the tube, and administered the medications, but did not check G-tube placement before flushing and medication administration. In interview, the RN stated that placement should be checked every time the G-tube is used to ensure the formula and medication go to the stomach and that the tube is not displaced. The DON and Administrator both stated that staff were expected to check G-tube placement and residual content as ordered, and the facility policy required verification of feeding tube placement and aspiration-related residual checks.
Missing Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents by not having physician orders in place for respiratory-related interventions that were being provided. Resident #9, an older female with a tracheostomy, was observed lying in bed using an oxygen concentrator through a nasal cannula, but her record showed no physician order for oxygen use and no care plan addressing oxygen use. Staff confirmed that the resident did not have the required order and stated that physician orders were needed for the device and for the resident’s safety. Resident #74, a female with hemiplegia and dysphagia, had a suction machine on her side table and staff reported that it had been used for more than four months to clear secretions from her mouth. Her quarterly MDS did not indicate suction machine use, her care plan did not reflect suction use, and her physician orders did not include suctioning. During interview, an LVN verified that no suction order was present and stated that there should be an order for all treatments being done for the resident. Facility leadership acknowledged that physician orders should be present for these respiratory interventions. The ADON stated that suctioning should have an order reflecting the procedure, frequency, and rationale, and identified the missing order as an oversight by charge nurses and herself. The DON and Administrator also stated that physician orders were required for suction use and for treatments such as oxygen, and the facility policy stated that medications and treatments must be administered only upon written order.
Unsecured medications found in resident rooms without self-administration assessments
Penalty
Summary
The facility failed to keep all drugs and biologicals stored in locked compartments and under proper control when medications and other products were found inside residents’ rooms without a self-administration assessment or an order. Surveyors observed a muscle cramp foam on Resident #52’s side table, a nasal spray and a bottle of adaptogenic mushroom on Resident #67’s drawer, a pain relieving gel on Resident #79’s side table, and a cup of green ointment identified as Biofreeze on Resident #19’s overbed table. In each instance, the item was in plain view in the resident’s room and was removed by staff after the observation. Resident #52 was a female with diagnoses including muscle spasm and chronic pain. Her records showed she was unable to complete the BIMS interview, had memory problems, had chronic pain in her care plan, and had no assessment for self-administration of medications and no physician order for the muscle cramp foam. During the observation, she stated the foam was hers but that she was not using it. RN B stated that if a resident did not have an assessment for safe self-administration, no medications should be inside the room. Resident #67 was a cognitively intact male with impaired visual function and no assessment for self-administration of medications. His record did not include an order for the nasal spray or adaptogenic mushroom. He told staff the items were his medications and that he took the adaptogenic mushroom to increase his strength. ADON A stated residents should not have medications inside their rooms because staff would not be able to monitor effectiveness or how often they were being used. Resident #79 had dementia and osteoarthritis, was documented as cognitively intact on the MDS, and had pain in the last seven days. Her record showed no assessment for self-administration and no physician order for the pain relieving gel. She said the gel had always been in her side table. The WCN stated there should be no medications inside the room because residents might use them inappropriately. Resident #19 had fibromyalgia, was cognitively intact, had chronic pain in her care plan, and had an order for Biofreeze PRN, but no assessment for self-administration. She said a therapist handed her the Biofreeze when she asked for it. The DON and Administrator stated that therapists were not authorized to dispense medications and that medications should not be inside residents’ rooms unless the resident had been assessed as safe to self-administer.
Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Food service safety standards were not followed in the facility’s main kitchen and two substations during observations and record review. In the kitchen, a staff member preparing food wore a ball cap with a large ponytail protruding from underneath and not fully covered. A large sheet cake in the freezer was not completely sealed and was exposed to air, a large trashcan in the main kitchen did not have a lid, and the ice machine and ice scoop holder in the 4th floor substation showed white and dark stains, with water pooled in the scoop holder. Two microwaves in the 3rd and 4th floor dining areas had dried food stains on the inside panel walls. In the 4th floor dining area, a tray of six clean small serving bowls had a German roach crawling between the bowls. In the 3rd floor substation, the sanitizer bucket was checked during food plating and registered 0 PPM, indicating no sanitizer solution in the mixture. The Dietary Manager stated the bucket needed the proper amount of sanitizer solution to clean spills while serving food to residents. Facility policies required food to be stored in clean, dry, contaminant-free areas, employees to wear hair restraints, and dining and food service areas to be maintained through a written cleaning schedule.
Missing and Nonfunctional Privacy Curtains
Penalty
Summary
The facility failed to ensure that ceiling-suspended privacy curtains were in place and functional to provide total visual privacy for seven residents in shared rooms, including Residents #4, #48, #50, #64, #73, #95, and #100. During observations, Resident #100’s privacy curtain was stuck in the track and could not close. Resident #50 had no privacy curtain in a shared room, Resident #4 had no privacy curtains, Resident #64 had no privacy curtains for the foot of the bed, and Residents #95 and #73 also had no privacy curtains for the foot of the bed in shared rooms. During interview, the DON stated he and the Administrator went to the 4th floor and identified rooms that did not have complete privacy curtains, and that some rooms were corrected while more curtains had to be ordered. The DON was also informed that CNA S was providing incontinent care to Resident #48 while the room door was open and the privacy curtain was only partially drawn; he stated the door should have been closed and the curtains drawn for the resident’s dignity. The ADON S was similarly informed of the missing curtains and stated housekeeping had ordered curtains for the residents. The facility policy on Resident Rights stated employees shall treat all residents with kindness, respect, and dignity, and that residents have the right to a dignified existence and to be treated with respect, kindness, and dignity.
Privacy During Care and AEM Consent Documentation
Penalty
Summary
The facility failed to ensure Resident #48’s personal privacy during incontinent care. Resident #48 was an [AGE]-year-old male admitted to the facility with diagnoses of muscle wasting and lack of coordination, and his MDS assessment dated 03/19/2026 reflected an intact cognitive response with a BIMS score of 15. During an observation on 04/14/2026 at 11:29 a.m., a CNA was providing incontinent care while the resident’s room door was open and the privacy curtain was only partially drawn. The resident was also missing part of the privacy curtain near the foot of the bed. During interview, the CNA stated she was providing incontinent care and was not aware the roommate had left the room. She stated she was focused on the resident and did not notice the room door had opened. She also stated she pulled the privacy curtain alongside the resident’s bed but the resident did not have a privacy curtain near the foot of the bed to completely provide privacy. An LVN was later informed of the observation and stated the CNA should have closed the door for the resident’s privacy and dignity. The facility also failed to ensure that roommate consent for electronic audio/visual monitoring was maintained in the active section of the EHR for Resident #84. Resident #84 was admitted on 01/07/2026 with diagnoses including chronic systolic heart failure, COPD, unspecified dementia, and anxiety disorder, and a quarterly MDS reflected a BIMS score of 12. The resident’s care plan, last updated 03/30/2026, did not indicate the resident was in a room with ongoing AEM. Observation on 04/14/2026 and again on 04/15/2026 showed a sign stating the room was electronically monitored and a camera placed on Resident #107’s side of the shared room. Record review for Resident #107 showed a signed consent dated 02/05/2021 for being moved into a room with ongoing AEM as a roommate, but the report identified no signed consent in the active EHR section for Resident #84 or the resident’s RP acknowledging the AEM in the shared room.
Resident-to-Resident Abuse Not Prevented
Penalty
Summary
The facility failed to ensure two residents were free from abuse when one resident struck another resident during a roommate altercation. Resident #92 had diagnoses including unspecified dementia and an unspecified mood disorder, and a quarterly MDS showed moderately impaired cognition with a BIMS score of 11. Resident #10 also had moderately impaired cognition with a BIMS score of 12 and diagnoses including acute respiratory failure and type 2 diabetes mellitus with hyperglycemia. The incident was documented in both residents’ care plans as a resident-to-resident event in which Resident #10 was struck on the side of the face. Resident #10 stated that while his roommate was trying to get into his wheelchair, he told him to call the nurse for help. He said the roommate became upset, came to the side of his bed, and attempted to hit him in the head with his fist. Resident #10 stated he responded by threatening to knock the other resident out, and then the roommate picked up a plastic urinal from the bedside table and hit him in the stomach and head. Resident #10 said he yelled for the nurse, who came in with a CNA and completed an assessment. He stated he did not have to go to the emergency room and that he told the ADMIN and DON he did not want to press charges. The social worker stated nursing staff reported the residents were arguing and that Resident #92 said his wheelchair got stuck on Resident #10’s wheelchair and that Resident #10 made comments to him. The social worker stated Resident #92 said he grabbed the plastic bottle off the table and lightly tapped Resident #10 with it, and that Resident #92 understood physical behavior was not tolerated. Staff interviews indicated neither resident had a documented history of aggression toward the other or toward other residents. The facility’s resident rights statement said residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and the resident-to-resident altercations policy required investigation and reporting of altercations that may represent resident-to-resident abuse.
Missing AMA Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that Resident #121’s transfer or discharge was documented in the resident’s medical record. Resident #121 was a [AGE]-year-old female admitted to the facility with diagnoses of joint replacement and seizures. Review of her MDS assessment dated 02/23/26 reflected those active diagnoses, and the record review on 04/16/26 at 9:40 a.m. showed progress notes indicating that she had discharged from the facility against medical advice. However, the facility’s system of records did not contain a signed AMA form for the discharge. During interviews on 04/16/26, the DON and the Administrator stated that the discharge nurse on duty should ensure that the resident or resident representative signed the AMA form upon discharge. RN M stated that he completed the discharge for Resident #121, knew the resident had to sign an AMA form, but forgot and only had her sign the progress notes forms. He stated the AMA form was needed because it informed the resident of the risk of leaving the facility. The facility’s undated Transfer and Discharge policy stated that the transfer/discharge notice would be provided to the resident and representative in a language and manner they could understand and would include the specific reason and basis for transfer or discharge, the effective date, and the specific location to which the resident was to be transferred or discharged.
MDS assessments did not reflect external catheter, suction, or nephrostomy use
Penalty
Summary
The facility failed to ensure that the Quarterly MDS assessments accurately reflected the status of two residents. For one resident, the Quarterly MDS dated 03/19/2026 did not indicate use of an external catheter or a suction machine, even though the resident’s care plan identified use of an external catheter and included an intervention to ensure suction tubing was connected securely and functioning properly. The resident’s physician order dated 10/30/2025 directed insertion of a PureWick female catheter and maintenance of the catheter device to low continuous suction per protocol every shift. During observation on 04/15/2026, a suction machine was seen on top of the resident’s side table, and an LVN identified it as a suction machine. The LVN stated the resident had an external catheter and had been using both for more than four months, but the external catheter was not suctioning well and the family member had taken it home. The MDS Nurse later stated the resident was not coded for the external catheter and suction use, and said the suction use was not captured because there was no order or documentation for it. She also stated that if residents were using an external catheter, suction machine, or nephrostomy, they should be coded accordingly. For the second resident, the Comprehensive MDS dated 02/10/2026 did not indicate the presence of a nephrostomy, although the resident’s care plan identified a nephrostomy tube and included nephrostomy care every shift. The resident’s physician order dated 10/30/2025 referenced dressing changes related to displacement of the nephrostomy catheter. During observation on 04/14/2026, the resident stated he had a nephrostomy tube on the left side of his body for approximately a year and exposed the nephrostomy bag. The MDS Nurse later confirmed the resident was not coded for the nephrostomy and stated this was an oversight.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #125. The resident was admitted with multiple diagnoses, including malignant neoplasm of the mandible, diabetes mellitus, hypertension, gastro-esophageal reflux, acute kidney failure, dysphagia, aphasia, and gastrostomy status. Record review showed the resident’s comprehensive MDS assessment had an ARD of 04/23/2026, and a review of the baseline care plan on 04/14/2026 showed it addressed only enhanced barrier precautions. The baseline care plan did not include the minimum healthcare information needed to care for the resident immediately upon admission and did not address the resident’s dysphagia, diabetes, neoplasm, kidney failure, aphasia, gastrostomy, elopement risk, fall risk, supervision needs for transfer, shower, and dressing, or any PASRR-related behavioral intervention. During interviews, the MDS Nurse, ADON, DON, Administrator, and admitting LVN acknowledged that the baseline care plan was not completed as required and that it should have been initiated by the admitting nurse or next shift, but it had not been done for this resident.
Missing Physician Order for Scoop Mattress
Penalty
Summary
The facility failed to ensure Resident #73’s environment remained free of hazards when the resident was observed lying in bed on a scoop mattress without a physician’s order for that equipment. Resident #73 was a [AGE]-year-old male admitted to the facility with diagnoses including muscle wasting and lack of coordination, and his Initial MDS reflected severe cognitive impairment with a BIMS score of 3, along with active diagnoses of age-related physical debility and lack of coordination. His comprehensive care plan identified him as a fall risk, but it did not include the use of a scoop mattress as an intervention. During record review, the resident’s physician orders did not include an order for a scoop mattress. In interviews, the ADON stated she had been informed that the resident was on a scoop mattress without a physician’s order and said the resident had been assessed and the mattress was replaced with an air mattress. The DON stated physician orders were required for the equipment, that the admitting nurse should ensure orders were in place for particular care, and that if the resident did not have orders, care may not be carried out.
Expired Insulin Left in Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with diabetes mellitus by not disposing of an expired insulin KwikPen. Resident #98 was a cognitively intact female with diabetes mellitus, and her care plan directed staff to administer insulin as ordered. The physician order required GLARGIN YFGN injection 10 units subcutaneously at bedtime for diabetes mellitus due to underlying condition with diabetic nephropathy. During observation, the resident’s insulin KwikPen was found inside a nurse’s cart with a date opened of 03/14/2026 and instructions to discard after 28 days. The LVN who observed the pen calculated that it should have been discarded on 04/11/2026 and stated it was expired for four days before discarding it. The DON, ADON, and Administrator all acknowledged that expired medications should not remain in carts and that staff were responsible for checking medication expiration dates. The facility policy stated that medications are administered in a safe and timely manner, the expiration or beyond-use date is checked before administration, and the date opened is recorded on multi-dose containers.
Hand Hygiene and Glove Use Failures During Incontinent Care and G-Tube Medication Administration
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents. One resident had hemiplegia, hemiparesis, moderate cognitive impairment with a BIMS score of 12, and bowel and bladder incontinence. Her care plan directed staff to clean the peri-area with each incontinent episode. During observation of incontinent care, a CNA put on gloves without performing hand hygiene, used wipes that had fallen on the bed, cleaned the resident’s perineal area, and then cleaned the resident’s bottom without changing gloves before touching a new brief. The CNA later removed her gloves, looked for barrier cream, and put on a new pair of gloves without doing hand hygiene first. A second resident had a gastrostomy status and was observed during medication administration via g-tube. An RN put on gloves and began preparing the resident’s medication without performing hand hygiene before preparation. He then entered the room, wore a gown and gloves, and administered the medication without performing hand hygiene before administration. The resident’s baseline care plan did not include tube feeding at the time of review. During interviews, the CNA stated she should have changed gloves after cleaning the resident’s bottom before touching the new brief and said she should have washed or sanitized her hands before care, including when no sanitizer was available in the room. She also stated the wipes that fell on the bed should have been discarded. The RN stated he did not know why he forgot to wash or sanitize his hands before preparing medication and before putting on PPE, and acknowledged hand hygiene was important during medication preparation and administration. The ADON, DON, and Administrator stated hand hygiene should be done before, during, and after care and treatment, and that gloves should be changed after contact with soiled areas.
Failure to Notify Resident Representative Prior to Room Change
Penalty
Summary
The facility failed to provide required written notice, including the reason for a room change, to a resident and the resident’s Resident Representative (RR) before moving the resident from one room and floor to another. The resident, a male with diagnoses of depression, anxiety, and dementia but assessed as cognitively intact on a recent Quarterly MDS, was not his own Responsible Party. The room change notification form was signed by the resident, not the RR, and indicated he was being moved from the third floor to a Medicaid room on the fourth floor. Admission documents showed the RR had previously signed as the party consenting to treatment and held medical power of attorney for the resident’s care decisions. The RR reported she was not informed by the facility of the room change and only learned of it when the resident called her, and she stated she should have been notified of any changes involving the resident. The resident stated staff “shoved” a form in his face telling him he was going to be moved to the fourth floor, that he felt coerced into signing because it was presented as if he had no choice, and that he was unsure why he was being moved. In interviews, the Administrator stated she had been trained that if a resident was of sound mind, staff could inform the resident and the resident could inform the RR, and that the RR would only be notified if the resident was not coherent. The Administrator and Chief Nursing Operator (CNO) stated the resident had the right to make decisions regarding his care, and the Administrator acknowledged that staff notified the resident of the room change and relied on him to notify the RR. The CNO stated they would change the RR designation to the resident to avoid contacting the current RR for care decisions, despite the facility’s policy stating that the facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated or required by law.
Failure to Notify Resident Representative of New Narcotic Pain Medication Order
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to notify a resident’s designated Resident Representative (RR) of a significant change in treatment. A male resident with dementia and depression, admitted in mid-2025 and assessed as having intact cognition on a quarterly MDS, had an order for Tramadol HCl 50 mg by mouth every 8 hours as needed for pain, prescribed in late 2025. The resident’s admission forms, signed earlier in 2025, showed that the RR had consented to the resident receiving treatment at the facility. However, record review and interviews revealed that the RR was not notified when Tramadol, a narcotic pain medication, was prescribed. The RR reported she was unaware the resident was receiving Tramadol and believed she should have been informed of the physician’s orders, particularly because the resident was a recovering alcoholic. During interviews, the RR stated she had spoken with the Administrator, who told her the facility did not have to contact the RR because the resident was of sound mind. The Administrator and Chief Nursing Operator confirmed they believed that, since the resident was coherent and able to make his own decisions, the RR did not need to be notified of the new medication order and that the RR would only be contacted if the resident was not coherent. The DON and ADON stated they were unsure whether consent from the RR was required when a resident was of sound mind, but indicated they generally tried to keep the RR informed because she was frequently in communication with nursing staff. Review of the facility’s Resident Representative policy defined the RR as an individual chosen by the resident to act on the resident’s behalf in decision-making and to receive notifications, but the RR was not notified of the Tramadol order as required.
Failure to Provide Required ADL Hygiene and Grooming Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance, including grooming and hygiene, to dependent residents. One male resident with hemiplegia affecting the left dominant side and a contracture of the left hand was totally dependent on staff for ADLs per his MDS and care plan. He filed a grievance on 12/17/25 about his fingernails not being trimmed. Photographs dated 01/05/26 provided by his responsible representative showed fingernails on both hands at least a half-inch long with thick black substance under some nails. The resident reported he had been requesting nail trimming for weeks from CNAs, a male nurse, and another staff member checking on residents, and that his long nails were digging into the palm of his contracted left hand. His responsible representative stated she had also been attempting for weeks to get his nails trimmed and had been assured by nursing staff and the Administrator that it would be done, but the nails were not trimmed until early January. A female resident with hemiplegia affecting the left dominant side, physical debility, severe cognitive impairment, and total dependence for ADLs was care planned as being at risk for skin breakdown and totally dependent on staff for ADL care. Review of her clinical record on 01/14/26 initially showed only one shower form dated 10/17/25 uploaded in the system. After this was brought to the attention of the ADON and DON, the facility produced additional shower/bed bath forms for December 2025 and January 2026, documenting bed baths on 12/05/25, 12/11/25, 12/16/25 (refused due to cold water), 12/20/25, 01/02/26, and 01/10/26. The resident stated she liked getting bed baths but had not been receiving them consistently, reporting that she had only received one bed bath in the prior week, needed her hair washed, and had not refused any bed baths. Staff interviews confirmed expectations and responsibilities related to ADL care that were not met. The LVN charge nurse for the hall stated she was unaware of the male resident’s untrimmed nails and indicated CNAs on the 2 PM–10 PM shift should check and trim nails during showers. She also stated that evening CNAs were responsible for the female resident’s showers and bed baths, that the resident was scheduled for showers three times weekly, and that it was her and the ADON’s responsibility to ensure residents received showers or bed baths. The ADON stated charge nurses were responsible for ensuring showers/bed baths and nail care were completed, that CNAs must complete showers/bed baths as scheduled, and that shower forms must be signed by nurses and uploaded to the record. He acknowledged being informed by the surveyor that only one shower sheet was uploaded for the female resident and said he would research the missing forms. The DON stated CNAs complete shower sheets, nurses sign them, and they are then scanned into the record, and that ADONs should be checking to ensure residents receive showers or bed baths. The facility’s ADL policy stated that appropriate care and services will be provided for residents unable to carry out ADLs independently, including assistance with hygiene such as bathing, dressing, grooming, and oral care.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents had access to their call light systems, which are necessary for requesting staff assistance, as required by their care plans and facility policy. During observations and interviews, it was found that three residents with severe cognitive impairment and significant physical limitations did not have their call lights within reach. In each case, the call light was observed on the floor, out of the resident's reach, and the residents were unaware of the location of their call lights when asked. Record reviews indicated that these residents were dependent on staff for all or substantial assistance with activities of daily living and were identified as fall risks. Their care plans specifically included interventions to ensure call lights were accessible. Despite this, staff interviews revealed that although there were procedures in place to check and clip call lights within reach during rounds, these procedures were not consistently followed, resulting in the call lights being inaccessible at the time of surveyor observation. Multiple staff members, including CNAs, LVNs, the DON, ADON, and the Administrator, acknowledged awareness of the importance of keeping call lights within reach and described ongoing efforts to remind staff of this requirement. However, the deficiency persisted, as evidenced by direct observation and staff admissions that call lights were not always secured or checked as required. The facility's own policy emphasized the necessity of ensuring call lights are accessible to residents when in bed, but this standard was not met for the three residents reviewed.
Failure to Secure Resident Medical Information and Maintain Confidentiality
Penalty
Summary
The facility failed to ensure the confidentiality of personal and medical records for eight residents. On the specified date, an untitled piece of paper containing the blood pressure, pulse rate, and oxygen saturation of these residents was left on top of a nurse's cart parked in the hallway. Additionally, a laptop on the same cart was left open and unattended, displaying the residents' pictures and indicating their skilled nursing status. The cart was positioned facing the hallway, where several staff members were observed walking back and forth, making the information accessible to unauthorized individuals. Interviews with staff confirmed that the nurse had left the cart to assist a resident and did not secure the paper or close the laptop before leaving. The nurse acknowledged that best practice would have been to secure all resident information before leaving the cart unattended. The Director of Nursing (DON), Administrator, and Assistant Director of Nursing (ADON) all stated that personal and medical information should be protected and not visible to unauthorized individuals, including staff not involved in the residents' care, visitors, and vendors. They confirmed that the information left exposed included vital signs, names, pictures, and care levels, all of which are considered protected health information. A review of the facility's policy on confidentiality and personal privacy indicated that the facility is required to safeguard the personal privacy and confidentiality of all resident personal and medical records. The observed actions were inconsistent with this policy, as sensitive information was left exposed and unattended in a public area, accessible to individuals without authorization.
Failure to Secure Medications and Biologicals
Penalty
Summary
Surveyors identified that the facility failed to store drugs and biologicals in accordance with state and federal regulations, resulting in multiple instances where medications were left unsecured and accessible to residents. Specifically, tubes of zinc oxide, a medicated barrier cream, were found left in the rooms of three different residents. In each case, the zinc oxide was observed on top of dressers or side tables, within easy reach of the residents. For one resident, who was cognitively intact and always incontinent, the zinc oxide was left on his dresser and used by staff after each episode of incontinence. There was no assessment for self-administration or documentation that the resident was competent to manage his own medications. For two other residents, both with severe cognitive impairment and incontinence, tubes of zinc oxide and a container of wound cleanser were also found in their rooms, with no clear explanation as to why these items were not secured in the treatment cart as required. Additionally, surveyors observed a vial of solution for a breathing treatment left unattended on top of a nurse's cart in a hallway. The cart was facing the hallway and was not attended by staff, while residents and staff passed by. The nurse responsible for the cart acknowledged that she had left the medication unattended when called away, and recognized the risk that residents could access the medication. Facility staff, including CNAs, wound care nurses, the DON, and the ADON, all confirmed during interviews that medications, including medicated ointments and wound cleansers, should not be left in resident rooms or unattended on carts, as this could lead to improper use or ingestion by residents. Record reviews confirmed that facility policy required all medications and biologicals to be stored in locked compartments and not left unattended or accessible to residents. The policies also specified that only authorized personnel should have access to medications and that medications should not be kept on top of carts. Despite these policies, the observed actions and inactions of staff led to multiple instances where medications were not properly secured, resulting in a deficiency related to medication storage and access.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving staff not following established protocols. In the first incident, a certified nursing assistant (CNA) provided incontinent care to a female resident with kidney failure and incontinence. During the care, the CNA changed gloves multiple times without sanitizing her hands between glove changes, despite being aware that hand hygiene was required to prevent cross-contamination. The resident's care plan specifically required pericare after each episode of incontinence, and the facility's policy mandated hand hygiene after removing gloves. In the second incident, a licensed vocational nurse (LVN) disconnected an intravenous (IV) line from a male resident who had an infection related to a right knee prosthesis and was receiving antibiotics via a PICC line. The resident was under Enhanced Barrier Precautions (EBP), which required staff to wear both gloves and a gown during high-contact care activities, including device care. Despite signage outside the resident's room and physician orders indicating the need for a gown, the LVN only wore gloves and did not don a gown while disconnecting the IV. Interviews with staff, including the CNA, LVN, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator, confirmed awareness of the required infection control procedures. Staff acknowledged the lapses and recognized the importance of hand hygiene and gown use in preventing the spread of infection, as outlined in the facility's policies. However, these protocols were not followed during the observed care activities, resulting in deficiencies in infection prevention and control.
Failure to Maintain Resident Dignity by Not Covering Gall Bladder Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of acute cholecystitis and a gall bladder tube (C-tube) was observed with her gall bladder drainage bag uncovered and in public view. The resident's physician order specifically required that the bag be covered with a pillowcase for privacy and dignity. During the survey, the Assistant Director of Nursing (ADON) and the surveyor observed the uncovered bag on the resident's bed. The ADON acknowledged that the bag should have been covered for dignity reasons and was unsure why it was not. Further interviews with nursing staff, including an LVN and another ADON, confirmed that the bag was not covered during their rounds and that it should have been concealed for privacy, infection control, and dignity. The Director of Nursing (DON) also confirmed that the resident should have had a privacy bag or pillowcase to cover the gall bladder bag, as required by facility policy and physician orders. The facility's policy on dignity emphasized the importance of caring for residents in a manner that promotes their well-being and self-esteem.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that the nurse call system was accessible for three residents who required varying levels of assistance with activities of daily living (ADLs) and had significant medical conditions. Observations revealed that the call lights for these residents were found on the floor and out of reach while the residents were in bed. One resident, with severe cognitive impairment and muscle weakness, had her call light on the floor near the bedside table. Another resident, also with severe cognitive impairment and total dependence for ADLs, was unable to locate his call light and expressed a need for assistance to urinate. The third resident, who was a fall risk and required substantial assistance, had her call light under the nightstand and out of reach. Record reviews indicated that care plans for at least two of these residents specifically required that call lights be kept within reach and that residents be encouraged to use them. Staff interviews confirmed that call lights should be accessible to residents and acknowledged that the devices may have been knocked down during movement in bed. The facility's policy also required that call lights be accessible to residents when in bed, but this was not followed at the time of the observations.
Failure to Obtain Physician Orders for Bolster Mattresses Used as Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints not required to treat medical symptoms, specifically regarding the use of bolster mattresses. For one resident with muscle weakness and unsteadiness, the care plan identified her as a fall risk and included the use of a bolster mattress as an intervention. However, there was no physician order for the device, and the resident was observed lying on the bolster mattress. Facility staff confirmed that a physician order was required but not present in the records. Similarly, another resident with repeated falls and muscle weakness was observed using a bolster mattress, but there was no care plan or physician order for the device. Staff interviews confirmed the absence of required physician orders for both residents. The facility's policy required an interdisciplinary assessment and physician orders for such devices, but these steps were not followed, resulting in the deficiency.
Failure to Properly Store Nebulizer Mask for Resident Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required nebulizer treatments for acute and chronic respiratory failure. On the date of observation, the resident's nebulizer mask was found unbagged in her nightstand after use, contrary to professional standards of practice and the facility's own policy, which requires the mask to be bagged when not in use to prevent infection. The LVN responsible for the resident's care acknowledged that she had overlooked bagging the mask after the morning treatment. The resident in question was an elderly female with a diagnosis of acute respiratory failure, requiring extensive assistance with activities of daily living and regular nebulizer treatments as ordered by her physician. The deficiency was identified through observations, interviews with staff, and review of the resident's medical records and care plan, all of which confirmed that the required infection control practice of bagging the nebulizer mask was not followed.
Failure to Provide Accessible Call Light System for Resident with Physical Limitations
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and bilateral hand contractures had access to a call light system that accommodated her physical limitations. On observation, the resident was found lying in bed with her call light not within reach, as it was hanging on the back wall behind the bed. The resident's hands appeared contracted, and she was unable to communicate coherently. Staff interviews revealed uncertainty about whether the resident could use the standard call light button or a touch pad, and it was confirmed that no assessment had been completed upon admission to determine the resident's ability to use the call light system. The Director of Nursing (DON) and other staff acknowledged that the resident required total care and was a full code, but admitted that the admitting nurse had not assessed the resident's ability to use the call light or touch pad. The facility's policy required that residents with disabilities preventing use of the standard call system be provided with an alternative means of communication, documented in the care plan. However, this was not done for the resident in question, resulting in the resident not having a call light system accessible or suitable for her needs at the time of the survey.
Failure to Obtain Physician Orders for Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. A female resident with muscle weakness, lack of coordination, and severe cognitive impairment was observed in bed with bolster pads attached to all sides of her mattress, which prevented her from freely exiting the bed. Review of her care plan and physician orders revealed no documentation or orders for the use of these bolster pads as a restraint or safety device. The resident's care plan did not include the use of bolster pads as an intervention, and there were no physician orders authorizing their use. Interviews with the DON, ADON, and Administrator confirmed that the resident had arrived at the facility with the bolster pads, which had been provided by hospice, but staff were unaware of the need for physician orders for this equipment. The facility's policy defined physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident. The lack of physician orders and care plan documentation for the bolster pads constituted a failure to ensure the resident's environment was free from unauthorized restraints.
Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of personal and medical records for five residents, as required by policy. On the specified date, a piece of paper containing the names, vital signs, and blood sugar readings of five residents was left exposed and unattended on top of a nurse's cart in a hallway. The cart was unattended and located in an area with frequent staff traffic, making the information visible to unauthorized individuals. The residents involved had various medical conditions, including diabetes mellitus and hypertension, and their medical information was documented on the exposed paper. The information included sensitive data such as blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and blood sugar levels. The exposure occurred when an LVN left the cart to administer treatment to a resident, leaving the paper unsecured. Facility staff, including the ADON, Administrator, and DON, acknowledged that the residents' information was confidential and should not have been left exposed. They confirmed that the expectation was for all staff to protect residents' personal and medical information at all times, and that leaving such information unattended constituted a violation of privacy and confidentiality policies.
Failure to Properly Store Nasal Cannulas for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that nasal cannulas used for oxygen therapy were properly stored when not in use for three residents. Observations revealed that one resident's nasal cannula was left spread out on top of the bed, another resident's nasal cannula was found on the floor, and a third resident's nasal cannula was placed on a side table with the prongs touching the surface. In each case, the nasal cannulas were not bagged as required by facility policy and professional standards of practice. The residents involved had significant medical needs requiring oxygen therapy, including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and conditions such as intracranial hemorrhage and seizures. Documentation confirmed that these residents had physician orders for continuous oxygen therapy and care plans reflecting their respiratory needs. Despite these documented requirements, staff did not consistently follow procedures to prevent contamination of respiratory equipment. Interviews with staff and residents confirmed that the nasal cannulas were not stored in plastic bags when not in use, and staff acknowledged that this practice was necessary to prevent infection. The facility's own policy specified that oxygen cannulas and tubing should be kept in a plastic bag when not in use, but this was not followed, resulting in a failure to meet professional standards and the residents' care plans.
Unsecured Wound Care Cart with Medications and Biologicals Left Unattended
Penalty
Summary
A wound care cart was observed parked in a hallway near the rehabilitation department with its lock protruding, indicating it was not secured. The cart and its drawers, which contained wound care supplies such as normal saline, triple antibiotics, and wound cleanser solutions, were easily accessible and could be opened by anyone passing by, including residents and staff. The cart was left unattended and unlocked in an area with frequent resident and staff traffic, and the contents could be easily taken. Interviews with the DON, ADON, and Administrator confirmed that the cart should have been locked when not in use and that the expectation was for staff to secure all medication and wound care carts when unattended. The facility's policy also required all medications and biologicals to be stored in locked compartments when not in use. The DON was unaware of how long the cart had been left unlocked and believed it may have been last used by night nurses.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its main kitchen, leading to several deficiencies. Observations revealed that kitchen staff did not wear appropriate beard and hair coverings, with one staff member having a beard without a covering and others with ponytails protruding from their caps. Additionally, food storage practices were inadequate, with items in the refrigerator not properly sealed, and expired food not discarded. The ice machine and its scoop holder were not maintained properly, exposing them to airborne contaminants. Furthermore, a large trash can in the kitchen was left uncovered, and food storage bins in the dry storage area were found to be dirty. The facility's policies on food receiving, storage, and sanitation were not followed, as evidenced by the presence of dirt and rust in the ice machine, uncovered food items, and improper labeling and dating of refrigerated foods. The Dietary Manager acknowledged the issues but had not yet addressed them with the Executive Director. The Executive Director was aware of the potential for food contamination and illness among residents due to these lapses but had not yet taken corrective action. The facility's failure to comply with local, state, and federal standards for food safety and sanitation was evident in the observed deficiencies.
Failure to Ensure Proper Wound Care Documentation and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, based on the comprehensive assessment and professional standards of practice. A resident, who was cognitively intact and had a history of rheumatoid arthritis and age-related physical debility, was observed with a wound bandage on her right elbow that was dated 10 days prior to the observation. The resident's care plan indicated a high risk for skin-related injury, and the wound care was to be provided per the physician's orders. However, there was no physician order for a dressing on the resident's right elbow, and the wound care nurse, upon returning from leave, discovered the outdated dressing and no corresponding order in the resident's chart. The wound care nurse, upon discovering the issue, removed the old dressing and noted dried blood and scant serosanguinous drainage. The nurse then contacted the resident's doctor to report the skin tear and received an order for wound care. The facility had been using agency nurses during the wound care nurse's absence, and it was noted that the lack of a documented order could lead to nurses being unaware of the need to change the dressing, potentially causing infection. The facility's policy on wound care emphasized the importance of following provider's orders to promote healing, which was not adhered to in this instance.
Infection Control Concerns in Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, leading to potential infection control concerns. Resident #10, a male with severe cognitive impairment and diagnosed with sleep apnea, had his CPAP hose placed on the floor, disconnected from the mask. This placement was identified as a contamination risk by an LVN, as the floor is not a sanitary area for medical equipment. The resident's care plan required the use of a CPAP machine, and the improper storage of the hose was inconsistent with professional standards of practice. Similarly, Resident #80, a female with intact cognitive response and requiring continuous oxygen therapy, had her nasal cannula hanging unbagged on her headboard while she was not in the room. The tubing was also observed balled up on the floor, which was noted as a contamination risk by an LVN. The facility's policy required that oxygen cannulas and tubing be stored in a plastic bag when not in use to prevent infection. Both instances were acknowledged by the DON and the Executive Director as infection control concerns.
Unsecured Medication Found in Resident's Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and allowed unauthorized access to medication for one resident. Specifically, a box of Mucinex tablets was found unattended and unsecured on the bedside table of a resident with severe cognitive impairment. The resident, who had been diagnosed with Covid-19 and acute respiratory failure, stated that a family member had brought the medication to her a long time ago, but she had not taken any of it. The facility's Assistant Director of Nursing (ADON) confirmed that the medication should not have been in the resident's room without an assessment and physician's order for self-administration, which was not present in the resident's chart. Interviews with facility staff, including the ADON, a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), revealed that the medication was not authorized for self-administration and should have been removed from the resident's room. The staff expressed concerns that the resident could have taken the medication without supervision, potentially leading to overmedication. The DON acknowledged that family members sometimes brought items to residents without staff knowledge and confirmed that the facility's policy required medications found at the bedside without authorization to be turned over to the nurse in charge.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA B during incontinence care for Resident #32. Resident #32, a female with severe cognitive impairment and incontinence, was observed receiving care where CNA B did not perform hand hygiene between glove changes. Specifically, CNA B changed gloves multiple times without using hand sanitizer or washing hands, which is contrary to the facility's policy and standard infection control practices. The deficiency was highlighted during an observation where CNA B provided incontinence care without adhering to proper hand hygiene protocols, potentially risking cross-contamination. Interviews with staff, including LVN A, the ADON, and the DON, confirmed the importance of hand hygiene in preventing the spread of infections. The facility's policy requires hand sanitization or washing between glove changes, which was not followed in this instance, leading to the identified deficiency.
Improper Storage and Management of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed in two medication carts and two medication refrigerators. On the 2nd floor, the medication refrigerator contained narcotic medications belonging to discharged residents without the necessary narcotic sheet records. Similarly, the 3rd floor medication cart and refrigerator contained expired and discontinued medications that were not removed after residents were discharged. These lapses in medication management could lead to residents being exposed to medications not intended for them or receiving expired medications with reduced potency. The report highlights specific instances where medications were not managed according to professional principles. For example, insulin pens and bottles of Lorazepam were found in the medication room and carts, belonging to residents who had been discharged. The facility's staff, including LVNs and RNs, acknowledged that medications of discharged residents should be handed over to the ADON for disposal, but this process was not followed. Additionally, there were no narcotic sheets for certain medications, raising concerns about potential theft or mismanagement. Interviews with staff revealed a lack of adherence to the facility's policies regarding medication disposal and inventory management. The DON and ADON confirmed that expired medications should be disposed of in a locked trash bin, and narcotic medications should be accounted for to prevent theft. However, the absence of proper documentation and disposal practices led to the presence of expired and discontinued medications in the facility, posing a risk of medication errors and adverse reactions among residents.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. Specifically, the 3rd Floor Treatment Cart was observed unlocked and unattended, containing medications such as Mupirocin and Bacitracin ointments. Additionally, the 340 Hall Nurses Medication Cart was found unlocked with no staff present, and the 200 Hall Nurse Medication Cart was left unlocked in the dining room of the secured unit. These lapses in securing medication carts were observed during a survey, with staff and residents passing by the unsecured carts. Interviews with staff revealed a lack of adherence to the facility's policy on securing medication carts. RN A and MA B, who shared responsibility for the 340 Hall Nurses Medication Cart, both acknowledged the importance of locking the carts but failed to do so. LVN C admitted to being distracted and forgetting to lock the 200 Hall Nurse Medication Cart. The ADON and DON both stated that staff were aware of the policy requiring carts to be locked when not in use, and the Administrator emphasized the expectation for staff to secure medication carts to prevent unauthorized access by residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,362 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Treemont Healthcare And Rehabilitation Center | 1.9 mi | ★★★★★ | 5 | 2 |
| The Madison On Marsh | 3.4 mi | ★★★★★ | 10 | 0 |
| Cottonwood Creek Healthcare Community | 3.4 mi | — | 0 | 0 |
| Richardson Nursing And Rehabilitation | 4 mi | ★★★★★ | 31 | 0 |
| Presbyterian Village North Special Care Ctr | 4.1 mi | ★★★★★ | 0 | 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.