Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Silver Tree Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to ensure MDS assessments accurately reflected resident status for several residents. One resident’s admission MDS listed insulin injections even though she received liraglutide, while two other residents’ MDSs omitted antidepressant, opioid, and scheduled pain medication use despite active orders and MAR documentation. Another resident’s quarterly MDS failed to include respiratory failure as an active dx even though the record, orders, and resident interview confirmed the condition and oxygen use.
Incomplete Care Plans for Hospice, Sensor Pad, and Oxygen Use: The facility failed to ensure care plans reflected key resident needs and behaviors for three residents. One resident’s plan did not include hospice services despite active hospice care and hospice aide visits. Another resident’s plan did not include use of a sensor pad even though he relied on it to call for help. A third resident’s plan did not reflect that he removed and reapplied his O2 cannula, although he stated he managed his O2 himself and an RN confirmed it.
The facility failed to ensure accurate pharmaceutical services for two residents and related medication storage and recordkeeping. An LPN administered a resident’s insulin glargine pen without priming it first, and a controlled medication log for another resident’s hydrocodone-acetaminophen did not match the blister pack count. In addition, a controlled substance reconciliation log for a medication aide cart had been signed before shift change, and an expired IV tubing supply was found in the LTC medication room.
Medication labeling and storage deficiencies were observed during med pass and cart/room checks. An LPN prepared hydrocodone-acetaminophen for a resident from blister packs whose labels did not match the EMR orders, another cart contained a loose pill in an unlabeled state, and a rehab unit med room had a controlled-medication lock box that was not affixed to the refrigerator. The DON and Administrator stated labels should match orders, carts should not contain loose pills, and controlled meds should be securely locked.
The facility failed to keep complete and accurately documented clinical records for two residents. One resident had conflicting MD/NP notification orders for elevated blood glucose, with one order to notify for BS >250 and another sliding-scale insulin order directing a call if BS was >400. Another resident’s facesheet omitted insomnia and anxiety diagnoses even though the care plan and psych services note documented those conditions; the DON confirmed outside-provider diagnoses should have been included in the record and facesheet.
Call Sensor Pad Not Within Reach: A resident with Parkinsonism, muscle spasms, seizures, and moderately impaired cognition was observed sitting in a wheelchair with his sensor pad left on his bed and out of reach. He stated he could not reach it and would have to yell for help, and CNA, RN, DON, and ADM interviews confirmed the device was not within reach and should have been accessible.
Failure to Complete and Transmit Discharge MDS: A resident admitted with fractures and other diagnoses was discharged the same day as admission, but the facility completed only an entry MDS and did not complete, encode, or transmit a discharge MDS. The DON and MDS Coordinator both stated a discharge MDS should have been completed, and the MDS Coordinator said the omission was an oversight.
PASRR screening was not completed correctly for a resident with schizophrenia, encephalopathy, severe cognitive impairment, and antipsychotic medication needs. The admission MDS and hospital discharge paperwork documented serious mental health history and impaired communication, but the PASRR level 1 was marked no for serious mental illness and no corrected PL1 was found. MDS staff were unsure who reviewed the form, and the DON and MDS Nurse stated the form should have been completed to trigger a PASRR level 2 evaluation.
Care plan omissions were identified for two residents. One resident’s care plan did not include multiple documented diagnoses, including UTI, bleeding hemorrhoids, TBI, pneumonia, CKD, and diverticulitis, despite severe cognitive impairment. Another resident’s care plan did not include a physician order for biannual valproic acid level testing and monitoring for side effects, and the DON and MDS Coordinator stated these items should have been included.
The facility failed to maintain infection control for two residents. An RN did not sanitize hands between glove changes while administering medication via a resident’s PEG tube, despite the resident being on EBP and having a care plan for tube feeding and meds via PEG. In another instance, a resident with respiratory failure had oxygen tubing left unbagged when not in use, even though staff stated it should be bagged to prevent contamination.
Surveyors found that MDS assessments were inaccurate and not properly validated when one resident’s quarterly MDS omitted active, treated diagnoses of GERD and hypothyroidism and the care plan incorrectly listed hyperthyroidism, while another resident’s assessment lacked required RN review. In both cases, the LVN MDS Coordinator signed in the section designated for the RN Assessment Coordinator without an RN signature, despite facility policy requiring that assessments accurately reflect resident status and be conducted or coordinated by an RN.
A resident with documented hypothyroidism had a care plan that incorrectly listed hyperthyroidism and included interventions appropriate for hyperthyroidism rather than the resident’s actual condition. The MDS assessment did not list either thyroid diagnosis, and the resident had moderate cognitive impairment and required moderate ADL assistance. The MDS nurse and other team members were responsible for developing and reviewing care plans, but the incorrect diagnosis and related interventions, originally entered by an LVN who had left the facility, were not corrected during routine reviews. The DON reported that she did not review this resident’s MDS assessment, even though she stated that accurate care plans are important for accurate care.
The facility failed to maintain complete clinical records when physician progress notes for a resident with acute kidney failure, HTN, and rheumatoid arthritis were not obtained and uploaded into the EMR, despite existing paper notes. The DON confirmed that no physician notes were in the EMR and that the facility was behind on uploads. The Medical Records staff reported he was not on the physicians’ email group, only requested and uploaded documents when specifically asked, and had no defined timeframe or routine process. The DON and Administrator both acknowledged that physician offices were behind in sending documentation and that there was no established system or regular schedule for requesting and uploading physician progress notes, contrary to facility policy requiring notification of physicians when notes are due and use of routine chart audits.
A resident with significant medical and cognitive needs was transferred using a mechanical lift by a single CNA, despite the care plan and facility policy requiring two staff for such transfers. The CNA, new to the facility and not yet trained on the lift, acted alone because other staff were unavailable, and did not request help. No injury occurred, but the event was confirmed through observation, interviews, and record review, showing a failure to implement the resident's comprehensive care plan.
A resident with dementia and a history of falls, identified as an elopement risk, exited the facility unsupervised due to lack of care plan interventions and insufficient alarm volume. Staff did not recognize the resident as exit-seeking prior to the incident, resulting in the resident being found outside with injuries.
The facility did not ensure that care plans for two residents reflected their specific needs and behaviors, including one resident's repeated refusal of wound care and another resident's ongoing behavioral issues involving allegations against staff. Staff interviews and records confirmed these issues were known and addressed in practice, but the care plans were not updated to include measurable objectives, timeframes, or interventions as required.
A resident with severe cognitive impairment and a history of wound care refusal did not have wound treatment or refusals documented in the medical record for several days, despite daily wound care orders. Nursing staff confirmed the resident often refused care and that these refusals were not recorded as required by facility policy.
A nurse failed to immediately notify a physician and a resident's representative after a resident was found injured and confused on the floor, resulting in delayed medical intervention. The resident, who had a complex medical history and recent changes in mental status, was later hospitalized with multiple injuries. The nurse did not recognize the incident as a fall and did not follow required notification protocols.
A resident with multiple complex medical conditions experienced an unwitnessed fall with injuries. Two CNAs repositioned the resident without a nurse's assessment, and the LPN on duty failed to initiate required neuro checks or promptly notify the physician and the resident's representative. Documentation was inaccurate regarding notifications, and the resident was later found to have additional injuries and confusion, leading to hospital transfer. The facility's protocols for post-fall assessment and notification were not followed, resulting in a deficiency.
Surveyors found that the medication room was left unlocked and unattended, with medications accessible, and a syringe of normal saline for flushing a resident's PICC line was left unattended on the resident's nightstand. Both the DON and an LVN confirmed these items should have been secured in locked storage or a nursing cart, as required by facility policy.
Surveyors identified that dietary staff failed to use facial hair restraints properly, did not follow correct hand hygiene, and handled food contact surfaces inappropriately during meal preparation and service. The Dietary Manager and another staff member were observed not adhering to facility policy and professional standards, leading to potential cross contamination and infection control issues, as confirmed by interviews with the DON and Administrator.
Staff failed to follow infection control protocols during incontinence and colostomy care for two residents with severe cognitive impairment and complex medical needs. In both cases, staff did not perform required hand hygiene between glove changes after contact with contaminated materials. Additionally, staff did not use appropriate PPE, including N95 masks and eye protection, when entering the room of a resident on aerosol isolation for COVID-19 exposure, and improperly handled contaminated trash and PPE. These actions did not comply with the facility's infection control policies.
The facility did not ensure that several staff members, including a CNA, dietary aide, medication aide, dietary manager, and ADON, received and documented all required annual trainings in areas such as communication, ethics, resident rights, and behavioral health. Personnel records lacked evidence of completed trainings, and the facility could not provide a policy outlining these requirements when requested.
Three staff members, including a Dietary Aide, Dietary Manager, and ADON, did not receive required annual ethics training as documented in their personnel records. Despite the facility's use of a computer-based training system and notification procedures, the mandatory training was not completed for these employees, as confirmed by staff interviews and review of the employee handbook.
A nurse left a computer open and unattended on a hallway cart, displaying a resident's personal and medical information, including photo, name, date of birth, room number, age, and medications. The DON confirmed this was a privacy violation, and the nurse admitted to forgetting to lock the screen, resulting in a breach of confidentiality for a resident with multiple medical conditions.
A resident with an indwelling urinary catheter was incorrectly coded as "Always urinary incontinent" on the admission MDS, rather than "Not rated" as required. This error was confirmed by both the MDS nurse and DON, and was identified through record review, staff interviews, and observation.
A resident admitted with multiple complex medical conditions did not have a baseline care plan developed or implemented within 48 hours of admission, as required by facility policy. The responsible nurse did not initiate the care plan, and the DON confirmed the omission, resulting in the resident and their representative not receiving a copy of the plan.
A resident with cancer and on hospice had a documented DNR order, but the facility failed to update the care plan to reflect this code status. Staff interviews revealed confusion about responsibility for care plan updates, and the interdisciplinary team did not ensure the care plan included all necessary information.
A disposable razor was found unattended and dirty on the sink in a resident's restroom. The resident had severe cognitive impairment and required substantial assistance with personal hygiene, including shaving. Facility policy prohibited razors in resident rooms, and staff confirmed that razors should be discarded in a sharps container after use to prevent harm.
A CNA failed to properly separate and clean the labia area while providing incontinence care to a female resident with severe cognitive impairment and chronic incontinence. Despite recent peri-care training and a passed skill checkoff, the CNA omitted this step, which was required by the resident's care plan and facility policy. The DON confirmed the correct procedure was not followed.
A resident with a gastrostomy tube was flushed with 250 ml of water by an RN using a syringe plunger instead of gravity, contrary to facility policy. The resident had severe cognitive impairment and multiple medical conditions, and the care plan required monitoring for tube-related complications. The DON confirmed that gravity should have been used for flushing, as outlined in the facility's enteral medication administration policy.
A nurse failed to flush both lumens of a resident's PICC line as ordered by the physician during IV antibiotic administration, flushing only the medication port and omitting the blood port. The resident had multiple medical conditions requiring strict adherence to IV protocols, and the facility's policy and care plan specified that both lumens should be flushed according to orders.
Two residents did not receive respiratory care in accordance with professional standards: one had a nebulizer mask left uncovered when not in use, and another received oxygen therapy at 4 L/min via nasal cannula without a physician order. Staff acknowledged these lapses, and facility policy requires physician orders for oxygen administration.
Two staff members did not receive required annual communication training, as shown by a lack of documentation in their personnel files. Despite the facility's use of an online training system and stated procedures for assigning and tracking mandatory trainings, there was no evidence that these employees completed communication training during the review period. Facility leadership could not provide a policy outlining required annual training, including communication training, when requested by surveyors.
The facility did not provide or document required annual resident rights training for the Dietary Manager, as confirmed by personnel record review and staff interviews. The HR Coordinator, Administrator, and DON were unable to produce a policy on required annual training, and the training was not completed or documented in the facility's system.
A CNA did not receive the required 12 hours of annual in-service training, including communication training, as confirmed by personnel record review and staff interviews. The facility used a computer-based training system and email notifications, but lacked documentation and oversight to ensure completion of mandatory CNA training.
The facility did not ensure that the Dietary Manager received required annual behavioral health training, as shown by a lack of documentation in personnel records and confirmation from leadership interviews. The system in place for assigning and tracking annual trainings did not result in completion or documentation of this training for the Dietary Manager, and no relevant policy was provided when requested.
Two residents were not given the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when their skilled services ended before their Medicare days were exhausted. Although both residents received and signed the Notice of Medicare Non-Coverage (NOMNC), the SNF ABN, which would have informed them about the option to continue services at a private pay rate, was not completed. Staff interviews revealed a lack of awareness about the requirement, and facility policy confirmed the need for this notification.
A CNA was overheard making derogatory remarks about a resident, referring to them as lazy and treating staff as maids, within earshot of other residents. The resident, who was not present, has a history of cerebral infarction, diabetes, hemiplegia, and depression, and relies on staff for daily activities. The facility's policy prohibits such verbal abuse, indicating a failure to maintain an abuse-free environment.
A resident's bank card was stolen and used by facility staff, specifically two CNAs, at the facility's vending machines and local businesses. The resident's family member reported the unauthorized use, and the facility's investigation identified the CNAs as suspects. The facility contacted law enforcement but was unable to gather additional evidence from local businesses.
A nursing cart on the 400-hall was found unlocked and unattended, exposing medications and scissors, which could pose a risk to residents, visitors, and staff. LVN-A admitted to leaving the cart unsecured, and the DON confirmed the importance of keeping it locked to prevent unauthorized access, especially by residents with dementia.
A wound care nurse in an LTC facility failed to adhere to Enhanced Barrier Precautions by not wearing a gown during wound care for a resident with multiple health conditions, including Parkinson's disease and diabetes. Despite being trained, the nurse admitted to forgetting the gown due to nervousness, which was confirmed by the DON. The facility's policy mandates gown use during high-contact activities to prevent infection.
A resident's medical records inaccurately documented the administration of oxycodone, a pain relief medication, which was not given as scheduled. The error was discovered during a narcotic count, revealing only two doses were dispensed instead of three. RN B admitted to the mistake but did not report it to the DON or physician. The resident, with a history of multiple health issues, could not recall receiving the dose, and the family member was also unsure.
Inaccurate MDS Assessments for Medication Use and Diagnoses
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for 4 of 24 residents reviewed. For Resident #54, the admission MDS documented 2 insulin injections in the prior 7 days and identified diabetes mellitus, but the medication record showed she was receiving liraglutide subcutaneously once daily and was not prescribed insulin. The MDS nurse stated liraglutide is a diabetic medication but is not insulin, and the admission MDS should not have noted insulin injections. For Resident #57, the quarterly MDS did not document antidepressant use in Section N or scheduled pain medication in Section J. The resident’s orders included trazodone 150 mg daily, Tylenol 325 mg two tablets twice daily for pain, and Voltaren gel twice daily for left knee pain, and the MAR showed these medications were administered during the lookback periods. The care plan also identified a need for antidepressant medication and noted a potential for uncontrolled pain. For Resident #81, the quarterly MDS did not list respiratory failure as an active diagnosis even though the resident’s record included acute and chronic respiratory failure with hypoxia and an active order for acetazolamide for respiratory failure. The resident was observed with oxygen equipment in his room and stated he used oxygen at night because of his respiratory failure. For Resident #91, the MDS did not document opioid use in Section N or scheduled pain medication in Section J, despite an active order for tramadol 50 mg twice daily for chronic pain and MAR documentation showing it was administered during the lookback period. The MDS nurse stated she was responsible for ensuring MDS accuracy and that inaccurate information could mean care was not delivered correctly or something could be missed.
Incomplete Care Plans for Hospice, Sensor Pad, and Oxygen Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that reflected identified resident needs for three residents. The report states that the care plan for Resident #7 did not reflect hospice services, the care plan for Resident #44 did not reflect use of a sensor pad, and the care plan for Resident #81 did not reflect that he took off and put on his oxygen cannula. The facility policy required a comprehensive care plan with measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #7 was a female with diagnoses including cerebral infarction and malignant neoplasm of the colon. Her MDS reflected severe cognitive impairment, moderate assistance with ADLs, and hospice care. Her care plan dated 02/17/2026 did not include hospice services, even though active orders reflected admission to hospice for CVA starting 02/04/2026. During observation, she was in bed with a hospice aide applying lotion to her legs, and she stated hospice came and gave her baths and showers. Resident #44 was a male with Parkinsonism, muscle spasms, and seizures. His MDS reflected moderate cognitive impairment, substantial assistance to total dependence for most ADLs, use of a manual wheelchair, and maximal assistance for locomotion and mobility. His care plan dated 05/01/2026 included an ADL self-care deficit and an intervention to encourage use of the call bell, but it did not reflect his sensor pad. During observation, his sensor pad was lying on his bed while he was seated in a tall wheelchair in his room, and he stated he would use the sensor pad to call for help if needed. Resident #81 had acute and chronic respiratory failure with hypoxia and was noted to have moderate cognitive impairment and need for minimal to moderate assistance with ADLs. His care plan addressed oxygen therapy and nebulizer use, but it did not reflect that he removed and reapplied his oxygen cannula. During observation, oxygen equipment was present near his bed, and he stated he used oxygen at night, put it on and took it off himself, and turned the concentrator on and off; an RN confirmed he could remove and replace his nasal cannula.
Pharmaceutical Services and Controlled Substance Recordkeeping Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs and to ensure drug records were in order for two residents, one medication cart, and one medication room. Resident #8 had diagnoses including heart failure, high blood pressure, high cholesterol, and type 2 diabetes mellitus, and his MDS documented severe cognitive impairment and insulin use. During a medication pass observation, an LVN administered 15 units of Insulin Glargine pen without priming the pen first. The LVN stated priming was important to ensure the pen was working properly and that failure to prime could affect the dose received. Resident #20 had diagnoses including asthma, depression, high cholesterol, high blood pressure, and sciatica, and her MDS documented severe cognitive impairment and active sciatica. During observation of the nurse cart, the controlled medication log for Hydrocodone-Acetaminophen 7.5-325 mg did not match the blister pack count: the log showed 6 tablets should have been available, but the pack contained 5 tablets. The LVN stated the tablet should be logged out immediately after administration. The facility also observed that the controlled medication reconciliation log for the 500 hall medication aide cart had been signed in advance of the next shift change, and the medication aide stated it should not be signed early because the cart could be taken away and something could go missing. During observation of the LTC unit medication room, an expired IV tubing supply was found on the shelves with medication equipment and supplies. The LVN stated expired items should not be in the storage room, and the DON and Administrator both stated expired supplies should not be in the medication rooms. The facility policy for insulin pen use required a safety test before each injection, and the controlled medications policy required immediate documentation after administration and a physical inventory at each shift change.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled in accordance with accepted professional principles. During a medication pass observation, an LVN prepared to give Resident #51 hydrocodone-acetaminophen from the 700/800 hall nurse cart using a blister pack labeled Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours as needed, while the EMR order for that medication was Hydrocodone-Acetaminophen 10-300 mg, give 1 tablet by mouth every 6 hours as needed. The LVN stated the EMR order did not match the blister pack label and that the order would need to be clarified with the prescriber. A second medication pass observation showed another LVN preparing to administer hydrocodone-acetaminophen from the 800 hall medication aide cart to Resident #51 from a blister pack labeled Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours as needed, while the EMR order for that medication was Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth twice daily. The LVN stated the PRN-labeled blister pack should not have been in the medication aide cart and that the cart should have contained a blister pack with routine dosing for the resident. The DON stated the prescription labels on blister packs needed to match the EMR orders and that staff were expected to follow physician orders and clarify orders when needed. On another observation, a loose pill was found in the third drawer of the 500/600 hall nurse cart, and RN B stated loose pills should not be in medication carts because they are unlabeled and could be taken or consumed without knowing what they are. In the rehabilitation unit medication room, the lock box for controlled medications was observed not affixed to the refrigerator. RN G stated the box should be affixed so it could not be removed, and the DON and Administrator both stated lock boxes for controlled medications should be affixed to the refrigerator. Resident #51 had diagnoses including depression, anxiety, seizures, and diabetic neuropathy, with a BIMS score of 14 and opioid use documented in the MDS.
Incomplete Clinical Records and Missing Diagnoses
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 2 residents reviewed. For one resident with diagnoses including unspecified dementia, type 2 diabetes mellitus, and heart failure, the clinical record contained conflicting blood glucose notification orders: one order directed staff to notify the MD/NP if blood sugar was less than 90 or greater than 250, while another order for sliding-scale insulin stated to give 10 units if blood sugar was greater than 400 and call the MD. The resident also had a BIMS score of 6, indicating severe cognitive impairment, and the care plan identified diabetes mellitus. For another resident with vascular dementia, cerebral infarction, and paranoid personality disorder, the facesheet did not include diagnoses of insomnia and anxiety. The resident’s care plan stated the resident used anti-anxiety medications due to anxiety disorder, and a psychological services progress note listed diagnoses of primary insomnia and anxiety disorder. The DON confirmed that the diagnoses from outside providers should have been included in the facility clinical record and on the facesheet, and also confirmed that the facesheet was used to communicate the resident’s status to hospitals and other outside providers.
Call Sensor Pad Not Within Reach
Penalty
Summary
The facility failed to provide reasonable accommodation for Resident #44 by not ensuring his call sensor pad was within reach. Resident #44 was a [AGE]-year-old male admitted on [DATE] with diagnoses including Parkinsonism, muscle spasms, and seizures. His quarterly MDS reflected that he was able to be understood and to understand others, had a BIMS score of 12 out of 15 indicating moderately impaired cognition, and required substantial assistance to total dependence for most ADLs. He used a manual wheelchair and required maximal assistance for locomotion and mobility. His care plan identified an ADL self-care performance deficit related to Parkinsons and muscle weakness and included an intervention to encourage him to use the call bell for assistance. During observation on 06/09/2026 at 10:45 AM, Resident #44 was sitting in a tall wheelchair in his room about 3 feet from his bed, and his sensor pad was lying on his bed. During interview, he stated he would use the sensor pad to call for help if needed, but he could not reach it and would have to yell if he needed help. CNA A stated she could not remember who helped him out of bed, but that he would not be able to reach the sensor pad if it was on his bed while he was in his chair a few feet away, and that he would not be able to get help in an emergency. RN B stated she did not notice the sensor pad placement that morning and that call lights or devices should be within reach. The DON and ADM also stated residents needed call lights or devices within reach so they had a way to get help.
Failure to Complete and Transmit Discharge MDS
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS system, including a required assessment upon a resident's transfer, reentry, discharge, and death, for one resident reviewed for completed MDS data. Resident #83 was admitted with diagnoses including other nondisplaced fracture of the upper end of the right humerus, hyperlipidemia, and a nondisplaced fracture of the shaft of the right clavicle. The resident's closed clinical record showed an entry MDS was completed on 01/12/2026, and a signed AMA form dated the same day indicated the resident discharged from the facility on the day of admission. Further review of the closed clinical record showed that a discharge MDS was not completed, encoded, or transmitted for Resident #83. During interview, the DON stated a discharge MDS should have been completed, encoded, and transmitted upon the resident's discharge. The MDS Coordinator also stated a discharge MDS should have been completed, encoded, and transmitted and said the omission was an oversight. The facility policy on MDS Assessment Data Accuracy stated that federal regulations require the assessment to accurately reflect the resident's status.
PASRR Screening Not Completed Correctly for Resident With Schizophrenia
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one resident with a documented history of schizophrenia. Resident #2 was admitted to the facility with diagnoses that included encephalopathy and other schizophrenia. The admission MDS showed the resident had unclear speech, was rarely or never understood by others, had a BIMS score of 00, used a manual wheelchair, and had schizophrenia marked in section I6000. The resident’s care plan included impaired cognitive function and impaired thought processes, and the resident required antipsychotic medications with monitoring and physician notification interventions. Hospital discharge paperwork also documented a history of schizophrenia, inability to answer questions appropriately, and calling out for a deceased sister. The resident’s PASRR level 1 screening was dated 5/12/26 and marked no for serious mental illness, and no corrected PASRR level 1 screening was found in the EHR. During interview, MDS Nurse 2 stated he could not identify who reviewed the PASRR screening for accuracy and believed schizophrenia would not require a level 2 evaluation unless the resident had been recently hospitalized for mental illness. The DON and MDS Nurse later stated the MDS Nurse was responsible for reviewing the PASRR level 1 for correctness and should have completed form 1012 to trigger a PASRR level 2 evaluation. The facility policy required review of the PASRR level 1 screening for completion and correctness prior to admission and submission of the PL1 form per regulations.
Care Plan Omissions for Resident Diagnoses and Valproic Acid Monitoring
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for 2 of 32 residents reviewed. Resident #1 was admitted with diagnoses including frequent urinary tract infections, bleeding hemorrhoids, traumatic brain injury, pneumonia, chronic kidney disease, and diverticulitis, and the quarterly MDS showed a BIMS score of 7 indicating severe cognitive impairment. The resident’s care plan, revised 03/05/2026, did not include those diagnoses even though they were part of the resident’s documented medical history. Resident #8 was admitted with diagnoses including unspecified dementia, type 2 diabetes mellitus, and heart failure, and the quarterly MDS showed a BIMS score of 6 indicating severe cognitive impairment. The resident’s order summary included a physician order dated 01/23/2025 for valproic acid level testing every 6 months in October and April, but the care plan, revised 05/14/2026, did not include that order. During interviews, the DON and MDS Coordinator stated that both residents’ omitted diagnoses and the valproic acid monitoring order should have been included in the care plans, and the MDS Coordinator identified the omission as an oversight.
Infection Control Lapses With PEG Medication Administration and Oxygen Tubing Storage
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 32 residents reviewed for infection control. One deficiency involved a resident with a PEG tube, severe cognitive impairment, stroke, colon cancer, diabetes, hyperlipidemia, hypertension, and kidney disease. During medication administration through the PEG tube, RN E did not sanitize her hands between glove changes while giving acetaminophen via the tube. RN E stated she was supposed to sanitize her hands between glove changes when giving medications through a PEG tube, and the DON stated hand sanitizing between glove changes was important to prevent cross contamination during PEG medication administration. The resident’s record showed an active order for acetaminophen via PEG tube and a care plan noting the resident required tube feeding, meds, and water flushes only. The care plan also noted the resident was on enhanced barrier precautions. The facility policy stated hand hygiene is the primary means of preventing transmission of infection and includes hand hygiene after removing gloves. RN E’s hand hygiene checkoff documented training on hand washing with soap and water and hand sanitizer. A second deficiency involved a resident with acute and chronic respiratory failure with hypoxia who used oxygen at night. Observation showed the resident sitting in his room with an oxygen concentrator near his bed and oxygen tubing unbagged and secured around the top. The resident stated his tubing was not bagged and staff had not provided a bag for when it was not in use. RN C stated the tubing should be bagged when not in use to prevent dust or dirt particles from entering and causing infection, and the DON and ADM stated unprotected oxygen tubing could lead to cross contamination. The facility respiratory policy stated the oxygen set-up should be dated and stored in a treatment bag when not in use.
Inaccurate MDS Diagnoses and Lack of RN Validation for Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ diagnoses and were properly reviewed and signed by a Registered Nurse (RN). For one resident, the face sheet listed diagnoses including cerebral infarction, gastro-esophageal reflux disease (GERD), and hypothyroidism, while the care plan incorrectly documented hyperthyroidism instead of hypothyroidism. The quarterly MDS assessment for this resident showed a BIMS score of 10, indicating moderate cognitive impairment, but did not list either hypo- or hyperthyroidism or GERD as diagnoses, despite the resident being treated with protonix for GERD and levothyroxine for hypothyroidism. The facility’s own policy required that assessments accurately reflect the resident’s status. The same quarterly MDS assessment for this resident was signed in section Z0500 by the MDS Coordinator, who is an LVN, under the field designated for the RN Assessment Coordinator verifying assessment completion, and there was no RN signature. A second resident’s face sheet listed diagnoses including acute kidney failure, essential hypertension, and rheumatoid arthritis, and her quarterly MDS assessment showed a BIMS score of 13 with total functional dependence for movement. That assessment was also signed in section Z0500 by the LVN MDS Coordinator as the RN Assessment Coordinator, with no RN signature present. Facility policy stated that a registered nurse must conduct or coordinate each assessment. In interviews, the LVN MDS Coordinator stated he was responsible for MDS assessments and care plans and confirmed that GERD and hypothyroidism were active, treated diagnoses for the first resident that were not included on the MDS. He explained that active diagnoses usually auto-populate into the MDS and that he did not see a button to add GERD or hypothyroidism, and acknowledged he should have written them in under “other,” describing the omission as an oversight. He also confirmed he was aware that MDS assessments required RN review and signature, and suggested that he may have signed assessments as completed to check for errors and failed to unmark them as incomplete. The DON stated that all active diagnoses should be included for accuracy, that an RN must sign and validate MDS assessments, and that an LVN could not sign them, but she could not explain why the two residents’ assessments lacked RN signatures or why the first resident’s GERD and hypothyroidism diagnoses were missing from the MDS.
Inaccurate Care Plan Diagnosis and Interventions for Thyroid Condition
Penalty
Summary
The facility failed to develop and implement an accurate, comprehensive person-centered care plan for a resident by listing an incorrect diagnosis and related interventions. The resident, an older female admitted with conditions including cerebral infarction, GERD, and hypothyroidism, had a face sheet and provider note documenting a diagnosis of hypothyroidism. However, the resident’s care plan dated 3/13/2025 incorrectly identified hyperthyroidism instead of hypothyroidism and included interventions tailored to hyperthyroidism, such as adjustment of lighting to prevent eye irritation, safety for altered mental status and altered muscle coordination, and encouraging periods of rest to reduce energy needs. The quarterly MDS assessment showed a BIMS score of 10, indicating moderate cognitive impairment and a need for moderate assistance with ADLs, and did not list either hypo- or hyperthyroidism as a diagnosis. Interviews with staff revealed gaps in the care planning and review process that contributed to the deficiency. The MDS Coordinator, responsible for MDS assessments and care plans, stated that any licensed charge nurse or management team member could change a care plan and that care plans were discussed in morning meetings and reviewed with quarterly assessments. He acknowledged that the resident’s care plan incorrectly listed hyperthyroidism and that the interventions were not all appropriate for hypothyroidism, explaining that the care plan had been created by an LVN who no longer worked at the facility and that the error was not identified during subsequent reviews, including the last review on 1/14/2026. The DON stated that important care plan items are added on admission by various team members and that active diagnoses are entered by the MDS nurse after the MDS assessment, which she is supposed to review for accuracy. She reported that she did not review this resident’s MDS assessment, despite recognizing that accurate care plans are important for accurate care.
Failure to Maintain Complete Physician Progress Notes in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records when physician progress notes for one resident were not obtained and uploaded into the electronic medical record. The resident was an older female admitted with acute kidney failure, essential hypertension, and rheumatoid arthritis, and a quarterly MDS showed she was cognitively intact with total functional dependence for movement. Record review on 1/28/2026 showed no physician notes in her electronic medical record. The DON confirmed that no physician progress notes had been uploaded and later produced paper physician notes dated 3/21/2025, 10/15/2025, and 11/17/2025, none of which were in the electronic record because the facility was behind with uploads. The Medical Records staff reported he was not on an email group with the facility physicians, had noticed physicians were behind in providing notes, and only requested and uploaded specific documents when someone asked for them, stating that physician notes were not coming to him unless specifically requested. He stated his role was to upload and scan documents and that he had no defined timeframe for doing so. The DON stated physician offices were behind in sending notes, that the Administrator was responsible for contacting physician offices, and that she was not providing medical record oversight, which was handled by an unspecified corporate person. The Administrator acknowledged awareness that some physician offices were behind in sending documentation, had no system for routinely requesting physician notes, and only requested what was needed at the time, despite a facility policy stating it was the facility’s responsibility to notify physicians when progress notes were due and that routine chart audits should identify which physicians needed to be notified.
Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including moderate cognitive impairment, was transferred using a mechanical lift by a single certified nursing assistant (CNA), contrary to the resident's care plan and facility policy. The care plan and recent assessments specified that transfers required the assistance of two staff members using a mechanical lift. Despite this, the CNA performed the transfer alone, removing the sling and completing the process without another staff member present. The CNA was new to the facility, on her first day of orientation, and had not yet received facility-specific training on mechanical lift transfers. The CNA stated she was aware that two people were required for mechanical lift transfers but proceeded alone because other staff were occupied and she did not request assistance. Interviews with other staff confirmed that the expectation was to use two people for such transfers, and that the CNA had been orienting with another aide who was temporarily unavailable. The resident involved did not sustain any injuries and reported not recalling how many staff usually assisted with transfers, but other residents and staff confirmed that two or more staff were typically used for mechanical lift transfers. Facility policies, as well as manufacturer and regulatory guidelines, require that mechanical lifts be operated by at least two trained staff members to ensure safety. The facility's care planning and hydraulic lift policies, as well as external guidelines from OSHA and the FDA, all support this standard. The incident was observed and confirmed through interviews and record review, demonstrating a failure to implement the comprehensive, person-centered care plan as required for the resident's identified needs.
Failure to Prevent Elopement and Provide Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with dementia and a history of repeated falls. The resident, who had a moderately impaired cognitive status as indicated by a BIMS score of 7, was identified as an elopement risk based on a recent assessment. Despite this, there were no interventions in place on the care plan to address the risk of elopement prior to the incident. On the night of the incident, the resident was last seen in the hallway by staff at approximately 1:20 AM. Shortly after, the exit door alarm in the dining room sounded, but staff response was delayed and the alarm was reportedly not loud enough to be clearly heard by all staff. The resident was subsequently found outside the facility, face down in the parking lot, with a nosebleed and skin tears on her forehead and cheek. She was transported to the emergency department and returned a few hours later. Interviews with staff revealed that although the resident had been assessed as high risk for elopement, staff did not perceive her as exit-seeking prior to the event and interventions were not implemented until after the incident. The facility's policy required assessment and care plan modifications for residents at risk of elopement, but these steps were not taken in this case. The lack of timely and appropriate supervision, as well as insufficient alarm volume, contributed to the resident's unsupervised exit and subsequent injury.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by regulation. For one resident with severe cognitive impairment and a history of wound care refusal, the care plan did not reflect the resident's refusals of wound treatment prior to a certain date, despite documentation and staff interviews confirming repeated refusals and the need for daily education involving the resident and family. The wound administration record also showed gaps in documentation for several days, and the care plan was not updated to reflect the resident's right to refuse treatment or the interventions used to address this issue. For another resident with moderate cognitive impairment and a diagnosis of dementia, the care plan did not address the resident's behaviors of making allegations and accusations about care, even though staff interviews and social work documentation confirmed a pattern of such behaviors. Staff accommodated the resident's preferences and worked with psychiatric and psychological services to address these behaviors, but these interventions and the resident's behavioral history were not included in the care plan. The facility's own policy required care plans to describe services furnished to attain or maintain the resident's well-being and the right to refuse treatment, but these elements were missing for both residents.
Failure to Document Wound Care and Refusals in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was reviewed for clinical records. Specifically, the wound treatment administration record for a male resident with severe cognitive impairment and a history of wound care refusal did not contain any documentation of wound care from 10/01/25 to 10/06/25, despite orders for daily wound care. Interviews with nursing staff revealed that the resident frequently refused wound care, and staff had to involve the resident's family to encourage compliance. However, these refusals and the attempts to provide care were not documented in the treatment administration record as required by facility policy. The facility's own policies require that all treatments be documented on the Treatment Administration Record and that complete and accurate documentation be maintained for each resident. Both the administrator and the DON acknowledged during interviews that refusals of wound treatment should have been documented to ensure the accuracy of the resident's records. The lack of documentation for the specified period was confirmed through record review and staff interviews.
Failure to Immediately Notify Physician and Representative After Resident Injury
Penalty
Summary
A deficiency occurred when a nurse failed to immediately notify a resident's physician and representative after the resident was found injured and confused on the floor by her bedside. The nurse, LVN A, did not report the incident to the physician or the resident's representative at the time of the event, despite documenting that she intended to do so. The resident was later hospitalized and diagnosed with acute congestive heart failure with fluid overload and multiple right rib fractures. The incident was not recognized as a fall by LVN A, and she did not consider the need for immediate notification, even though the resident had visible injuries and a change in mental status. The resident involved had a complex medical history, including end-stage renal disease, hypertension, and metastatic pancreatic cancer. She had previously been assessed as cognitively intact, with minimal hearing and vision difficulties, and was independent in activities of daily living. Prior to the incident, the resident had experienced increased confusion, which had been reported to the physician and family. On the day of the event, the resident was found kneeling on the floor with abrasions to both knees, and was assisted back to bed by CNAs before being assessed by LVN A. Interviews and record reviews revealed that LVN A did not notify the physician or the resident's representative immediately after the incident, as required by facility policy. The resident's representative only learned of the fall and injuries upon arriving at the facility later that morning. The medical director confirmed that the expectation was for nursing staff to report unwitnessed falls with injuries to a physician within a reasonable time, such as within an hour. The deficiency was identified as past noncompliance, with the immediate jeopardy period beginning on the date of the incident and ending several days later.
Failure to Follow Fall Protocols and Timely Notification After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with complex medical conditions, including end stage renal disease, hypertension, and metastatic cancer, experienced an unwitnessed fall with injuries. The resident was found on the floor by her bedside by two CNAs, who repositioned her back into bed without first notifying a nurse or having the nurse assess her for injuries. The nurse on duty, LVN A, subsequently assessed the resident in bed, noted abrasions to her knees, and provided basic first aid. However, LVN A did not initiate neurological assessments as required for unwitnessed falls with injuries, nor did she promptly notify the physician or the resident's representative as per facility protocol and policy. LVN A documented that she had notified the nurse practitioner and the resident's representative, but later admitted she had not actually done so at the time of the incident, only intending to call the nurse practitioner during business hours and leaving a message for the representative. The resident's representative was not informed of the fall until arriving at the facility later that morning, at which point the resident was found to be confused and injured. After the representative alerted another nurse, the resident was assessed and subsequently transferred to the hospital, where additional injuries, including rib fractures and significant changes in mental status, were identified. Interviews and record reviews confirmed that the facility's protocols required immediate assessment by a nurse after a fall, prompt notification of the physician and family, and initiation of neurological checks for unwitnessed falls or head injuries. The failure to follow these protocols, including the lack of timely notification and assessment, constituted noncompliance with professional standards of practice and the facility's own policies. The deficiency was identified as past noncompliance, with the Immediate Jeopardy period beginning on the date of the incident and ending several days later.
Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored in locked compartments as required. The long-term care medication room was found unlocked and open without staff supervision, with both over-the-counter and prescribed medications accessible inside. The Director of Nursing (DON) confirmed that the medication room was supposed to be locked at all times, but acknowledged that nurses might not fully close the door, resulting in it being left open and unlocked. Facility policy requires all medications and treatment items to be stored in a locked cabinet or room, inaccessible to patients and visitors. Additionally, a 10 cc syringe of normal saline intended for flushing a resident's peripherally inserted central catheter (PICC) line was found unattended on the resident's nightstand while the resident was sleeping. The resident had been admitted with multiple diagnoses, including pneumonia, hypertension, lymphedema, respiratory failure, and pulmonary embolism, and had physician orders for intravenous antibiotics and saline flushes. Both the LVN and DON confirmed that the normal saline should have been stored in a nursing cart rather than left in the resident's room, in accordance with facility policy.
Improper Food Handling and Infection Control Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food safety and infection control practices. The Dietary Manager was seen wearing a facial hair restraint that only covered his chin and not his mustache while taking food temperatures and cooking, including stirring soup and onions. He continued to work in this manner until he later adjusted the restraint to cover his mustache after leaving and returning to the kitchen. The Dietary Manager acknowledged that the restraint was intended to prevent hair from contaminating food and that staff were required to wear hair restraints upon entering the kitchen. Further observations revealed that a dietary staff member, while wearing gloves, handled plates by touching the inner surfaces with her thumb and fingers, patted the plates, and moved tray racks without changing gloves or washing hands. She also used a towel to open the warmer doors and then continued to handle food and plates without performing hand hygiene or changing gloves. During an interview, the staff member recognized that she should have washed her hands and changed gloves after these activities to prevent cross contamination. Interviews with the Dietary Manager, DON, and Administrator confirmed that these actions were not in line with facility policy or professional standards. The facility's policy required proper use of hair restraints, avoidance of touching food contact surfaces, and appropriate glove use with hand hygiene after touching potentially contaminated surfaces. The Administrator and DON both identified these lapses as infection control issues that could lead to foodborne illness, and the Dietary Manager stated that improper hand hygiene and glove use could result in harm to residents.
Failure to Maintain Infection Control Practices and Proper PPE Use
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents, resulting in multiple observed deficiencies. In one instance, a CNA provided incontinence care to a female resident with severe cognitive impairment and chronic medical conditions, including COPD, diabetes, and hemiplegia. After removing a soiled brief and cleaning the resident's perineal and buttock areas, the CNA did not change gloves before placing a clean brief under the resident, despite handling contaminated materials. The CNA only removed gloves and washed hands after completing the care, which was confirmed during interviews with both the CNA and the DON. In another case, an LVN performed colostomy care for a female resident with severe cognitive impairment, dementia, and a history of COVID-19 and intestinal obstruction. After cleaning feces from the resident's stoma, the LVN changed gloves but did not sanitize or wash hands before donning new gloves and applying a new colostomy bag. The LVN acknowledged during interview that hand hygiene should have been performed between glove changes, and the DON confirmed this expectation. Additionally, the facility did not ensure that staff wore appropriate PPE when entering the room of a resident on aerosol isolation precautions due to COVID-19 exposure. Two staff members were observed entering the room wearing only regular face masks, gowns, and gloves, rather than the required N95 respirators and eye protection. They also improperly removed and transported contaminated PPE and trash out of the isolation room. Interviews with the staff, DON, and Administrator revealed confusion and lack of adherence to the facility's posted isolation protocols, which required specific PPE and disposal procedures to prevent cross-contamination.
Failure to Ensure Completion and Documentation of Required Annual Staff Trainings
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, as evidenced by the lack of required annual trainings for five employees, including a CNA, a dietary aide, a medication aide, the dietary manager, and the assistant director of nursing. Personnel records reviewed for these staff members showed missing documentation of annual trainings in key areas such as communication, ethics, resident rights, and behavioral health. The HR Coordinator confirmed that the facility used an online training platform (Relias) and that department heads were responsible for ensuring staff completed their assigned annual trainings, but records did not show completion of all required topics for the reviewed period. Interviews with the HR Coordinator, Administrator, and DON revealed that while the facility had processes in place for assigning and notifying staff of required trainings, there was a lack of oversight to ensure completion and documentation of all mandated annual trainings. Additionally, when requested, the facility was unable to provide a policy specifically addressing the required annual trainings in communication, resident rights, ethics, and behavioral health prior to the survey exit. The employee handbook referenced mandatory training but did not specify the required topics or provide evidence of compliance for the staff reviewed.
Failure to Provide Annual Ethics Training to Staff
Penalty
Summary
The facility failed to provide mandatory annual ethics training to three employees: a Dietary Aide, the Dietary Manager, and the Assistant Director of Nursing (ADON). Personnel records for these staff members showed no evidence of ethics training being completed during the review period. The facility utilized Relias, a computer-based training program, to assign and track annual trainings, with notifications sent to both employees and their supervisors. However, despite these systems, the required ethics training was not documented as completed for the identified staff. Interviews with the HR Coordinator, Administrator, and DON confirmed that annual trainings were assigned and that department heads were responsible for ensuring completion. The HR Coordinator and Administrator both emphasized the importance of annual training for staff, noting that it is necessary to ensure resident safety and compliance with facility policy. Review of the facility's employee handbook also confirmed that all employees are required to complete mandatory training as defined by federal, state, and company policies.
Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
A registered nurse (RN) failed to maintain the confidentiality of a resident's personal and medical records by leaving her computer open and unattended on a nursing cart in a hallway. The computer screen displayed the resident's picture, name, date of birth, room number, age, and medication information. This was observed for a period of five minutes without any staff present at the cart, making the information accessible to unauthorized individuals. The resident involved was an elderly female with diagnoses including nonalcoholic steatohepatitis, seizures, anemia, and type 2 diabetes mellitus. She was cognitively intact but required substantial to maximal assistance with mobility and transfers. The Director of Nursing (DON) confirmed the privacy violation upon observing the unattended computer, and the RN acknowledged forgetting to lock the computer screen, admitting it was a mistake.
Inaccurate MDS Coding for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident who had an indwelling urinary catheter. Specifically, the admission MDS for a female resident with chronic kidney disease, type 2 diabetes mellitus, fluid overload, dementia, and a urinary tract infection was coded as "Always urinary incontinent" in Section H (Bladder and Bowel), despite documentation and observation confirming the presence of an indwelling urinary catheter. According to MDS coding guidelines, the continence status should have been marked as "Not rated" when a urinary catheter is present. Interviews with the MDS nurse and the Director of Nursing confirmed that the incorrect coding was a mistake and acknowledged that it was the responsibility of the MDS nurse to ensure accurate assessments. The facility's policy on resident assessment requires that results be recorded to assure continued accuracy, which was not followed in this instance. The error was identified through record review, staff interviews, and direct observation of the resident and her catheter.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Record review showed that the resident was admitted with multiple diagnoses, including acute kidney failure, type 2 diabetes mellitus, hyperlipidemia, hypertension, peripheral vascular disease, gastro-esophageal reflux disease, and a history of pulmonary embolism. Despite these complex medical needs, there was no completed baseline care plan in the resident's electronic medical record, and the Admission MDS assessment did not identify a BIMS score. The resident and their representative confirmed that they had not received a copy of a baseline care plan. Interviews with facility staff revealed that the admitting nurse or charge nurse was responsible for initiating the baseline care plan upon admission. The DON stated that the nurse assigned to the resident's admission had recently given notice and had not been present since, which contributed to the failure to initiate the care plan. The DON acknowledged that, as a result, the resident was at risk for not receiving care that addressed their specific needs. Facility policy required that a baseline care plan be developed within 48 hours of admission, but this was not followed in this case.
Failure to Include DNR Status in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with multiple medical conditions, including cancer, shortness of breath, and pain, who was also receiving hospice services. Despite the resident having a documented out-of-hospital do not resuscitate (DNR) order and a physician's order for DNR, the care plan did not reflect the resident's code status. The care plan review did not include this critical information, and there was no evidence that the interdisciplinary team had reviewed or updated the care plan to include the DNR status. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating the care plan with code status changes. The social worker stated she would update the care plan when code status changed, but had not signed off on the relevant section. The MDS coordinator acknowledged the absence of a code status care plan and indicated that it should have been included, noting that care plans are interdisciplinary documents. The administrator confirmed that the care plan should be person-centered and complete to ensure staff have the necessary information to provide proper care.
Unattended Disposable Razor Found in Resident Restroom
Penalty
Summary
A deficiency was identified when a disposable razor was found unattended on the sink inside a resident's restroom. The resident in question was a male with severe cognitive impairment, as indicated by a BIMS score of 6 out of 15, and required substantial to maximal assistance with activities of daily living, including personal hygiene and shaving. Facility records and the resident's care plan specified that staff were to assist with personal hygiene and that razors were considered safety hazards not allowed in resident rooms. During observation, the disposable razor was noted to be dirty with old hairs, and staff interviews confirmed that the resident required assistance with shaving. Staff acknowledged that razors should be discarded in a sharps container after use to prevent harm and infection, and that it was the responsibility of all staff to ensure razors were not left accessible. The facility's policy also listed razors as items not permitted in resident rooms due to safety concerns.
Failure to Provide Proper Perineal Care for Incontinent Resident
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was incontinent of bladder. During an observation, the CNA did not separate and clean the resident's labia area while providing incontinence care, despite removing the soiled brief and cleaning other areas. The CNA later acknowledged forgetting to perform this step due to nervousness, even though she had received peri-care training and had recently passed a skill checkoff for female perineal care. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 5 out of 15, and was always incontinent of both bowel and bladder. Her care plan required incontinence care at least every two hours and the application of a moisture barrier after each episode. Facility policy specified that perineal care for female residents should include separating and cleaning the labia majora from front to back. The Director of Nursing confirmed that the CNA should have separated and cleaned the labia area to prevent possible infection.
Improper Flushing Technique Used for Enteral Feeding Tube
Penalty
Summary
A deficiency occurred when a registered nurse (RN) flushed a resident's gastrostomy tube with 250 ml of water by pushing the water into the syringe barrel with a plunger, rather than allowing the water to flow by gravity. This action was observed during a medication administration for a female resident with severe cognitive impairment, a history of cerebrovascular accident, chronic obstructive pulmonary disease, type 2 diabetes mellitus, hemiplegia, cerebral infarction, and hypertension. The resident's care plan specified tube feeding and required monitoring for complications such as aspiration, fever, tube dislodgement, and infection at the tube site. The RN acknowledged using the plunger to flush the tube and stated she believed it was acceptable because there was no residual, but typically used gravity for medication administration. The facility's Director of Nursing confirmed that facility policy requires gravity to be used for flushing gastrostomy tubes, with gentle plunger pressure only if gravity cannot be used due to blockage. The facility's policy explicitly states not to force fluids into the tube and to allow gravity to work, applying gentle pressure only if necessary after repositioning the resident.
Failure to Follow Physician Orders for PICC Line Flushing
Penalty
Summary
A registered nurse (RN) failed to follow physician orders for the administration of intravenous (IV) fluids for a male resident with a peripherally inserted central catheter (PICC) line. The resident, who had been admitted with diagnoses including pneumonia, hypertension, lymphedema, respiratory failure, and pulmonary embolism, had a physician order specifying that both lumens of the PICC line should be flushed with 10 cc normal saline—one before and after medication administration, and the blood port specifically every evening antibiotic dose. During an observed medication administration, the RN only flushed the medication port and did not flush the blood port as ordered. Upon interview, the RN acknowledged not flushing the blood port and admitted to not remembering the specific order to do so. The Director of Nursing (DON) confirmed that the nurse was responsible for flushing both lumens according to the physician's order and facility policy, which requires each lumen to be flushed with a separate syringe as ordered. Facility policy and the care plan both supported the need for flushing the ports as directed by the physician.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring such care, as evidenced by direct observations, interviews, and record reviews. One resident with severe cognitive impairment and chronic obstructive pulmonary disease had a nebulizer mask left uncovered on the nightstand when not in use, contrary to professional standards and staff acknowledgment that it should have been covered to prevent possible infection. The facility did not have a specific policy regarding covering respiratory equipment when not in use, and responsibility was left to the nursing staff. Another resident, admitted with pneumonia and respiratory failure, was observed receiving oxygen at 4 liters per minute via nasal cannula without a corresponding physician order. The care plan indicated oxygen therapy as ordered, but no physician order for oxygen was found in the resident's records. Facility staff confirmed that the resident was receiving oxygen without an order due to an oversight in entering the order into the system, which was acknowledged as a mistake and inconsistent with the facility's own policy requiring physician orders for oxygen administration.
Failure to Provide Annual Communication Training to Staff
Penalty
Summary
The facility failed to provide annual communication training to two employees, specifically a CNA and a medication aide, as evidenced by a review of their personnel records. The records showed no documentation of communication training for the period reviewed, despite the facility's use of an online training platform (Relias) for annual mandatory trainings. Interviews with the HR Coordinator, Administrator, and DON confirmed that annual trainings were assigned and tracked through Relias, with department heads responsible for ensuring completion. However, there was no evidence that the required communication training was completed by the two staff members in question. Additionally, when requested, neither the HR Coordinator, Administrator, nor DON were able to provide a policy specifically addressing required annual training, including communication training, prior to the survey exit. The facility's employee handbook did state that all employees are required to complete mandatory training as defined by federal, state, and company policies, but did not provide specific details about communication training. This lack of documentation and policy contributed to the deficiency cited by surveyors.
Failure to Provide Annual Resident Rights Training for Dietary Manager
Penalty
Summary
The facility failed to provide mandatory and effective annual training on resident rights for one of its employees, specifically the Dietary Manager. Review of the personnel records showed that the Dietary Manager, hired in April 2023, did not have documented evidence of completing resident rights training for the period reviewed. The HR Coordinator confirmed that the facility uses a computer-based training program (Relias) to assign and track annual trainings, and that both employees and their department heads receive email notifications when trainings are due. However, there was no record indicating that the Dietary Manager completed the required resident rights training during the specified timeframe. Interviews with the HR Coordinator, Administrator, and DON revealed that the responsibility for ensuring completion of annual trainings lies with both the employees and their supervisors. Despite this system, the required documentation for the Dietary Manager's resident rights training was missing. Additionally, when requested, neither the HR Coordinator, Administrator, nor DON could provide a policy specifically addressing the requirement for annual resident rights training prior to the survey exit.
Failure to Provide Required Annual In-Service Training to CNA
Penalty
Summary
The facility failed to ensure that a certified nurse aide (CNA) received the required minimum of 12 hours of annual in-service training. Review of personnel records for one CNA, who was hired on 07/31/2023, showed no evidence that the facility provided the mandated annual in-service trainings, including communication training, within the previous 12 months. The HR Coordinator confirmed that the facility used a computer-based training program (Relias) to assign and track annual trainings, and that both employees and department heads received email notifications regarding training assignments. However, it was the responsibility of department heads to ensure completion, and there was no documentation that the required training was completed for the CNA in question. Interviews with the HR Coordinator, Administrator, and DON revealed that while the facility had systems in place to assign and notify staff of required trainings, there was a lack of oversight to ensure completion. The DON, who was new to the facility, was not familiar with the process for assigning annual trainings. Additionally, when requested, neither the HR Coordinator, Administrator, nor DON could provide a policy specifically addressing the required minimum 12 hours of annual in-service training for CNAs prior to the survey exit.
Failure to Provide Annual Behavioral Health Training to Dietary Manager
Penalty
Summary
The facility failed to provide annual behavioral health training to the Dietary Manager, as required by federal regulations and the facility's own assessment. Review of the Dietary Manager's personnel records showed no evidence of behavioral health training being completed for the period reviewed. The HR Coordinator confirmed that the facility uses Relias, a computer-based training program, to assign and track annual trainings, and that both employees and department heads receive email notifications regarding required trainings. However, the Dietary Manager did not have documentation of completing the required behavioral health training for the specified timeframe. Interviews with the HR Coordinator, Administrator, and DON revealed that the responsibility for ensuring completion of annual trainings lies with both the employees and their supervisors or department heads. Despite this system, the required behavioral health training was not completed or documented for the Dietary Manager. Additionally, when requested, no policy specifically addressing required annual training, including behavioral health training, was provided by facility leadership prior to the survey exit.
Failure to Provide Required SNF ABN Notification for Discontinued Skilled Services
Penalty
Summary
The facility failed to provide required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) CMS form 10055 to two residents when their skilled services were discontinued prior to exhausting their covered Medicare days, despite both residents receiving and signing the Notice of Medicare Non-Coverage (NOMNC). The SNF ABN would have informed the residents of their option to continue services at a private pay rate. Record reviews confirmed the absence of the SNF ABN forms for both residents, even though facility policy required this notification when a resident remains in the facility after skilled services end but before Medicare days are exhausted. Interviews with staff revealed a lack of awareness regarding the requirement to provide the SNF ABN in these circumstances. The MDS coordinator acknowledged not knowing that residents who remained in the facility after skilled services ended, but before exhausting their benefit period, needed to receive the SNF ABN. The administrator confirmed that the MDS coordinator was responsible for completing the SNF ABN forms and recognized that not providing them meant residents or families were not informed about the option to continue services privately or the associated costs.
Verbal Abuse Incident Involving Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as observed by a state surveyor. On the specified date, a CNA was overheard speaking negatively about a resident in a hallway, referring to the resident as lazy and suggesting that the resident treated the staff as maids. This conversation took place within earshot of open resident rooms, potentially exposing other residents to the derogatory remarks. The resident in question, who was not present during the conversation, has a history of cerebral infarction, type 2 diabetes, hemiplegia, and depression, and is dependent on staff for daily activities. Interviews conducted with the involved staff members revealed differing accounts of the conversation. The CNA admitted to discussing the resident's lack of cooperation but denied using derogatory terms. However, another staff member confirmed hearing the CNA make inappropriate comments about the resident's abilities and attitude. The facility's policy on abuse and neglect clearly prohibits such verbal abuse, which includes the use of disparaging language within the hearing distance of residents. The incident highlights a failure to maintain an environment free of abuse and neglect, as required by the facility's policies.
Misappropriation of Resident's Bank Card by Facility Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her property, specifically her bank card, which was stolen and used without her consent. The resident, an elderly woman residing in the facility for long-term care, had her bank card used at the facility's vending machines and various local businesses. The resident's family member alerted the facility to the unauthorized transactions, as the resident herself was unable to use the card and did not have visitors who could have done so. The facility's investigation identified two CNAs, who were twins, as potential suspects, but it was unclear which one or if both were involved in the theft and misuse of the card. The facility contacted local law enforcement, provided them with relevant information, and attempted to gather additional evidence from local businesses, but these efforts were unsuccessful. The facility's policy on abuse and neglect, which includes misappropriation of resident property, was in place, but the incident still occurred, indicating a lapse in its enforcement or effectiveness at the time of the event.
Unattended and Unlocked Nursing Cart Poses Safety Risk
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an incident involving the 400-hall nursing cart. During an observation, the cart was found unlocked and unattended, allowing access to multiple medication blister packs, scissors, and bottles of medications. This oversight was confirmed by LVN-A, who admitted to leaving the cart unlocked and acknowledged the importance of keeping it secured to ensure the safety of residents, visitors, and staff. The Director of Nursing (DON) also confirmed that the nursing cart should not have been left unlocked, as it posed a safety risk, particularly to residents with dementia who might access the medications. The facility's policy on medication storage, which was reviewed, specifies that the medication supply should only be accessible to licensed nursing personnel, pharmacy personnel, or staff members authorized to administer medications. The 400-hall nurse was identified as responsible for ensuring the cart was locked, although monitoring was only done sometimes.
Infection Control Deficiency Due to Non-Compliance with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a wound care nurse who did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident. The resident, a male with a history of Parkinson's disease, dermatitis, type 2 diabetes mellitus, and hypertension, was on EBP due to a risk of developing pressure ulcers. During a wound care procedure, the nurse entered the resident's room, sanitized her hands, and donned gloves but failed to wear a gown as required by the facility's policy for high-contact activities such as wound care. The nurse's failure to wear a gown was confirmed through interviews with both the nurse and the Director of Nursing (DON). The nurse admitted to being nervous and forgetting to wear the gown, despite having been trained on EBP. The DON corroborated that the nurse should have worn a gown when providing wound care to the resident. The facility's policy, revised in April 2024, clearly states that gloves and gowns must be worn during high-contact care activities, including wound care, to prevent possible contamination and infection.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the administration of oxycodone, a medication prescribed for pain relief. On June 10, 2024, the resident was scheduled to receive oxycodone every 8 hours, but the 4:00 PM dose was not administered. Despite this, the medication administration record (MAR) inaccurately documented that the dose was given by RN B. This discrepancy was discovered during a narcotic reconciliation count, which showed that only two doses were dispensed that day instead of the prescribed three. Interviews with the nursing staff revealed that RN B did not administer the 4:00 PM dose because it was too close to the next scheduled dose at midnight. RN B admitted to the mistake but failed to notify the Director of Nursing (DON) or the physician about the missed dose. The DON confirmed that the error was not reported until the end of RN B's shift, and there was no explanation for the inaccurate documentation in the MAR. The resident, who has a history of end-stage renal disease, anxiety, metabolic encephalopathy, and hypertension, was unable to recall whether the dose was received. The family member also could not confirm the administration of the medication. The facility's policies on physician's orders and medication administration procedures emphasize the importance of accurate documentation and adherence to prescribed orders, which were not followed in this instance.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Schertz
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Schertz | 3.1 mi | ★★★★★ | 41 | 2 |
| Advanced Rehabilitation & Healthcare Of Live Oak | 4.2 mi | ★★★★★ | 3 | 0 |
| Trucare Living Centers - Selma | 4.4 mi | ★★★★★ | 11 | 0 |
| Avir At Converse | 5.3 mi | ★★★★★ | 13 | 0 |
| The Army Residence Community Health Care Center | 6.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.