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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Simpson Place during CMS and state inspections, most recent first.
Failure to Complete Required EMR and NAR Checks Before Hire: The facility failed to complete required EMR and NAR screening before hire for multiple newly hired or rehired staff members. Records showed several registry checks were completed after the date of hire, and one LVN file had no evidence of a NAR search. The HR Director stated the checks were often done up to 24 hours after hire, and the Administrator stated she did not know there was a required timeframe.
The facility failed to verify Nurse Aide Registry status before hiring or starting work for three employees, including CNAs and a CMA. Record review showed the registry checks were completed after hire and after New Employee Orientation, and the HR Director and Administrator stated they did not know the checks had to be done before date of hire or start of employment.
Food Items Left Undated, Expired, and Uncovered in Kitchen Storage In the facility’s only kitchen, two bags of burger buns were left outside the walk-in refrigerator without dates, leftover scrambled egg in a plastic bag had no label and was past its use-by date, and three bags of shredded cheese in the walk-in refrigerator were missing the date received and use-by date. The Dietary Aide and Dietary Mgr stated staff were responsible for dating, labeling, refrigerating, and discarding food items, and an uncovered dessert cart was also observed in the walk-in refrigerator because the facility had run out of bun rack covers.
A facility failed to maintain infection control for two residents. One resident had dried feces on privacy curtains that had reportedly been seen and mentioned to staff before, while housekeeping and nursing staff said curtain checks and replacement were their responsibility. Another resident’s urine-soiled mattress was covered with a clean fitted sheet without first being cleaned and disinfected, and the CNA acknowledged the missed step. The DON confirmed staff were expected to clean the mattress before applying clean linen.
Failure to provide nail care and personal hygiene assistance: A resident with dementia and severely impaired cognition, who required extensive assist with ADLs and nail care per the care plan, was observed with long fingernails that were discolored and had yellow-green residue under and on the nail beds. A CNA said she had not noticed the nails, and the DON stated nail care should be completed as needed and observed daily, with CNAs expected to clean and trim nails when long and dirty.
Failure to Follow Wound Care Orders: A resident with cellulitis, DM2, and severe PVD did not receive wound care as ordered for the right lower extremity. The chart showed wound treatment orders for cleansing and dressings, but the resident was observed with the leg open to air and a blister present. An RN said wound care had been completed, while the DON stated the resident should have had the leg wrapped and that any refusal should have been documented.
A facility failed to provide supplemental O2 at the physician-ordered flow rate for two residents receiving respiratory care. One resident with COPD had O2 ordered PRN at 2 LPM, but the concentrator was observed both below and above the ordered setting, and an RN later lowered it to 2 LPM. Another resident with acute respiratory failure had O2 ordered continuously at 2 LPM, but the concentrator was repeatedly observed set below the ordered rate. The DON stated nurses were expected to verify O2 settings each shift, and the facility procedure required staff to verify the flowmeter setting and prescribed flow rate.
Missing Controlled Substance Count Signatures: The facility failed to ensure controlled drug counts were properly documented for Medication Cart 617 - 631. During observation and record review, the narcotic count sheet had missing off-duty and on-duty signatures for two 6:00 PM to 6:00 AM shift changes. The DON stated nurses were expected to sign after completing the count, and both LPNs acknowledged they had counted the narcotics but did not sign the sheet as required.
A resident with intact cognition and multiple psychiatric and medical diagnoses required supervision or touching assistance with personal hygiene ADLs per the MDS, but surveyors found the comprehensive care plan lacked any measurable objectives, goals, interventions, or timeframes for ADLs. The DON reported that every resident should have a care plan reflecting preferences and routines and acknowledged that missing ADL information reduced staff communication and knowledge of preferences. The DON and Administrator both stated that the MDS Coordinator was responsible for updating care plans, charge nurses for triggering acute plans, and that the facility did not have an MDS Coordinator, resulting in the resident’s ADL needs not being incorporated into the care plan despite facility policy.
A cognitively intact male resident with multiple psychiatric and medical diagnoses, who required supervision or touching assistance for personal hygiene, was observed with an overgrown mustache and a long chin beard despite his admission photo showing a trimmed mustache and clean-shaven face. He reported receiving regular showers but stated he had been asking for weeks to have his mustache trimmed and beard shaved, and was told by staff he needed to schedule and pay for beauty salon services, which he could not afford. The CNA assigned to him had showered him but did not shave him, did not ask about his grooming preferences, and did not consult the charge nurse, despite stating CNAs are responsible for shaving on shower days if requested. The RN, DON, and Administrator each stated that CNAs are responsible for grooming, including shaving, and that nursing leadership is responsible for ensuring care is provided, but none were aware of the resident’s repeated requests. The resident’s care plan lacked ADL goals and interventions, and the facility’s policy required provision of hair care and shaving per standard practice guidelines.
Surveyors found that a resident with complex medical conditions, including COPD, chronic respiratory failure on O2, diabetes, CKD, and prior episodes of hypernatremia and hypoxia, experienced multiple hospitalizations and returned with changes in diet (thickened liquids), respiratory treatments, and IV therapy, but the facility did not complete a required Significant Change in Status Assessment (SCSA) MDS. Review of the admission and quarterly MDSs showed missing or inaccurate coding, including an empty BIMS summary score on one assessment and Section O indicating no special treatments despite documented use of oxygen and IV fluids. Interdisciplinary notes and MD orders confirmed ongoing O2 use, IV fluids, and aspiration precautions, while interviews with the CRN, DON, and ADM confirmed that no significant change MDS was present and that it was the responsibility of leadership and MDS staff to ensure timely and accurate assessments.
A resident with metabolic encephalopathy, DM, hypernatremia, and acute/chronic respiratory failure experienced multiple hospitalizations and returned with clinical changes including thickened liquids, respiratory treatments, and IV/enteral feeding, but these changes were not accurately captured on the MDS. One MDS had an undocumented assessment type and an empty BIMS summary score, and a subsequent quarterly MDS documented severe cognitive impairment and SOB but failed to include the need for thickened liquids in Section K and showed no special treatments such as oxygen or IV in Section O. The care plan and staff interviews confirmed oxygen therapy and diet changes, while leadership acknowledged that MDS assessments were not timely or accurate and that no change in condition MDS could be located, contrary to facility policy requiring comprehensive, accurate, and timely MDS completion.
Staff failed to follow infection control protocols during care of two residents, including not wearing required PPE such as gowns during high-contact procedures for a resident on Enhanced Barrier Precautions, not performing hand hygiene between glove changes, and placing soiled linen on the floor instead of in a designated bag. These actions were contrary to facility policies and were acknowledged by staff and leadership as lapses that could lead to cross-contamination.
A resident with multiple chronic conditions and significant ADL assistance needs did not have a comprehensive care plan addressing ADLs, including measurable objectives and timeframes, despite these needs being identified in assessments. Facility staff confirmed that the omission reduced communication and awareness of the resident's preferences and required care.
A resident with frequent incontinence and multiple chronic conditions did not receive timely incontinence care, as her brief was not changed throughout the morning. The CNA responsible had not provided care since the start of the shift, citing a heavy workload. Staff interviews and facility policy confirmed that care should be provided every two hours or as needed, but this expectation was not met.
A resident with an indwelling urinary catheter did not receive proper catheter care during a transfer, as a CNA placed the drainage bag above bladder level, resulting in observed urine backflow. Staff interviews confirmed knowledge of correct procedures, but the facility's policy did not address this issue.
The facility's kitchen failed to label opened food items, such as liquid eggs, with use-by dates, as required by professional standards and the facility's policy. This oversight was confirmed through observations and staff interviews, highlighting a risk of food-borne illness to residents. The facility's policy mandates that all foods be covered, labeled, and dated, in accordance with FDA guidelines.
The facility failed to complete and transmit discharge MDS assessments for two residents within the required 14-day period. A change in the electronic health record system contributed to the oversight, as staff were unable to access previous assessments. The MDS Nurse and Regional MDS RN acknowledged the lapse, which resulted in incomplete records for the residents.
A facility failed to include dialysis in a resident's care plan, despite the resident being admitted as a dialysis patient. The resident, who was cognitively intact, had multiple diagnoses including peripheral vascular disease and hypotension of hemodialysis. The omission was acknowledged by the DON and MDS Coordinator, who noted the importance of reflecting physician orders in the care plan.
The facility failed to provide necessary nail care for two residents, both of whom were unable to maintain personal hygiene independently. One resident, dependent on staff for personal hygiene, had dirty and jagged nails, while another resident, requiring moderate assistance, had long, discolored nails. Staff interviews revealed that nail care was the responsibility of CNAs and nurses, to be performed on shower days and as needed. Despite this, the residents did not receive adequate nail care, potentially increasing their risk of infections.
A resident with an indwelling urinary catheter was at risk for infection when a CNA placed the catheter drainage bag above bladder level during wound care, causing urine backflow. Despite training, the CNA failed to follow the care plan, which required the bag to be kept below the bladder. The facility's policy did not address this specific concern.
A facility failed to label an insulin pen with an open date, as observed on a nurses' cart. An LVN administered insulin without checking for an open date, acknowledging the importance of labeling for effectiveness. The DON confirmed the requirement for dating insulin pens and vials, with monthly checks by a pharmacy consultant and random checks by the DON and ADON.
The facility failed to maintain an effective pest control program, resulting in bed bug sightings on the 600 floor. Two residents reported bed bugs in their rooms, and the facility did not follow its bed bug policy, which required checking all rooms on the affected floor and training staff on prevention. Some staff were unaware of the issue, and there was a lack of documentation and communication regarding the sightings and treatments. The pest control treatments were not effective, contributing to the ongoing bed bug issue.
A resident with moderate cognitive impairment and complex medical conditions was verbally and mentally abused by a CNA. The incident was captured on video, showing the CNA removing the call light from the resident's hand, refusing to change her when wet, and speaking disrespectfully. The facility's investigation confirmed the inappropriate behavior, violating the resident's right to be free from abuse.
Two residents were found using wheelchairs with damaged armrests, exposing them to potential injury. Staff, including the ADON and Maintenance Director, were unaware of the issues, and there was no documentation in the maintenance log. The facility lacked a structured process for reporting and repairing equipment, placing residents at risk.
The facility failed to ensure proper hair restraint use by dietary staff, as observed with a dietary aide who did not fully cover her hair while preparing meals. Despite having sufficient hairnets available, the aide's hair was not completely restrained, posing a risk of food contamination. Interviews revealed that staff were aware of the importance of hairnets, but compliance was inconsistent.
A facility failed to implement a comprehensive care plan for a resident, missing a weekly skin assessment required by the care plan. The resident, with a history of dementia and hemiplegia, had a stage 3 pressure wound. Interviews revealed that the ADON and DON were responsible for the assessments but missed the audit, risking inadequate care. The facility's policy mandated weekly skin checks to prevent pressure ulcers.
A resident with multiple health conditions experienced a breach in infection control when an RN removed gloves and used hand sanitizer over an open wound. Despite being trained, the RN admitted to being nervous and unaware of the risk of contamination. Facility staff confirmed the RN's understanding of proper wound care protocols.
Failure to Complete Required EMR and NAR Checks Before Hire
Penalty
Summary
The facility failed to implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property by not completing required pre-employment registry checks before hire for five of six employee personnel files reviewed. The records showed that RN A, CNA B, MA C, CNA D, and LVN E were hired or rehired on various dates in 2026, but the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) searches were completed after the date of hire for RN A, CNA B, MA C, and CNA D, and there was no evidence that a NAR search was completed for LVN E. The Human Resources Director stated that criminal history searches were completed before an offer of employment, but EMR and NAR searches were done up to 24 hours after the employee's date of hire. The Administrator stated she did not know there was a timeframe for completing the EMR and NAR searches and said the searches were done before the employees worked on the floor with residents, although they had already attended New Employee Orientation before those searches were completed. The facility policy stated that employment offers were conditioned on satisfactory completion of background checks, including verification with the Nurse Aid Registry and Misconduct Registry for non-licensed staff.
Failure to Verify Nurse Aide Registry Before Hire
Penalty
Summary
The facility failed to obtain Nurse Aide Registry verification that three employees had met competency evaluation requirements before they worked in the facility as nurse aides or medication aides. Record review showed CNA B was hired on 02/27/2026 and attended New Employee Orientation that same day, but the Nurse Aide Registry search was not completed until 03/08/2026. MA C was hired on 02/18/2026 and attended New Employee Orientation on the same day, but the Nurse Aide Registry search was not completed until 02/19/2026. CNA D was rehired on 04/21/2026 and attended New Employee Orientation on 04/28/2026, but the Nurse Aide Registry search was not completed until 04/29/2026. During interview, the Human Resources Director stated that after interviews, the Administrator completed the criminal history search, then Human Resources set up the new employee's date of hire and New Employee Orientation. The Human Resources Director stated that the Nurse Aide Registry searches were conducted up to 24 hours after the employee's date of hire and that she did not realize the searches should be done prior to date of hire or start of employment. The Administrator stated she did not know there was a timeframe for completing the Nurse Aide Registry searches and acknowledged that the searches were done after the employees had attended New Employee Orientation. The facility policy required verifying with the Nurse Aid Registry for all non-licensed staff, including CNAs and CMAs, that the potential employee was not listed as ineligible for employment.
Food Items Not Properly Labeled, Dated, Refrigerated, or Covered
Penalty
Summary
The facility failed to store food in accordance with professional standards in its only kitchen. During observation on 04/28/2026, two bags of burger buns were found stored in a bread crate outside the walk-in refrigerator and were undated and not returned to refrigeration. At the same time, a plastic bag containing scrambled egg in the walk-in refrigerator had no label and had a use-by date of 04/27/2026. Three bags of shredded cheese in the walk-in refrigerator were also observed without a date received or a use-by date. During observation and interview, the Dietary Aide stated the burger buns were missing the date received and use-by date and should have been put back in the refrigerator. She identified the plastic bag as leftover scrambled egg and stated it had to be labeled and discarded because the use-by date had passed. She also stated the shredded cheese only had a packed-on date of 03/30/2026 and was missing the date received and use-by date. She said all dietary staff were responsible for dating, labeling, refrigerating leftover food items, and discarding expired food items, and that failure to do so could put residents at risk for food borne illnesses. On 04/29/2026, the dessert cart in the walk-in refrigerator was observed uncovered. The Dietary Manager stated the cart should have been covered with a bun rack cover and that the facility had run out of covers. She stated she was responsible for ordering the covers in a timely manner and that leaving the dessert uncovered would put residents at risk for food contamination and food borne illnesses. Record review showed the facility policy required perishable food to be refrigerated immediately and all foods to be covered, labelled, and dated.
Infection Control Lapses With Soiled Curtains and Urine-Contaminated Mattress
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 2 residents. One resident was a [AGE]-year-old male with hypertension, asthma, COPD, morbid obesity, intact cognition, and occasional bowel and urine incontinence. During observation, dried feces was seen on both sides of his privacy curtains while he was lying in bed. The resident stated he had reported the feces on the curtain to several employees over the prior three months, including aides and housekeeping staff, but said nothing was done. The Housekeeping Supervisor later stated she had seen the soiled curtain during rounds after staff left for the day and told housekeeping staff the next day to replace it. Housekeeping staff and nursing leadership stated housekeeping was responsible for checking and replacing soiled curtains, and the resident’s curtains were eventually replaced with clean ones. A second resident was a [AGE]-year-old male with morbid obesity, muscle wasting, moderately impaired cognition, and frequent bowel and bladder incontinence. During incontinent care, a CNA removed a urine-saturated brief and soiled fitted sheet, and urine was observed on the mattress. The CNA placed a clean fitted sheet on the mattress without cleaning and disinfecting it first. The CNA stated she should have cleaned the mattress with sanitary wipes and said failing to do so increased the risk for contamination and spread of infections. The DON stated staff were expected to clean the mattress with wipes before placing a clean fitted sheet when the sheet was soiled with urine or bowel movement. Record review showed the facility’s environmental services policy required staff to inspect resident rooms, report soiled curtains, and check curtains for soiling. The facility’s infection prevention and control surveillance policy did not address the concern identified with the mattress cleaning issue. Interviews with the ADON, DON, housekeeping staff, and CNA confirmed the responsibilities for room cleaning, curtain checks, and mattress cleaning practices, and the observations showed those practices were not followed for the two residents reviewed.
Failure to Provide Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary ADL services to maintain good grooming and personal hygiene for Resident #9, who required moderate assistance with personal hygiene and extensive assist with ADL functions per the care plan. Resident #9 was a female with diagnoses including dementia and depression, and her BIMS score of 3 indicated severely impaired cognition. Her care plan directed staff to provide shower, oral, hair, nail care per schedule and as needed, and the facility policy on bathing stated staff would perform hand hygiene and nail care. During an observation, Resident #9 was found lying in bed with both hands showing fingernails approximately 0.4 cm long, extending beyond the fingertips, with discoloration and yellow-green residue under and on the nail beds. The resident was confused and her responses were not pertinent to the subject. A CNA stated she had not noticed the resident's nails and would do them right then, and stated the risk would be infection control and injury. The DON stated nail care should be completed as needed and every time aides wash residents' hands, that nails should be observed daily, and that CNAs were expected to offer to cut and clean nails if they were long and dirty.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident with cellulitis, type 2 diabetes mellitus, and a history of lower-extremity skin problems received wound treatment and care in accordance with physician orders and the resident’s care plan. The resident’s record showed a BIMS score of 15, indicating intact cognition, and the care plan identified peripheral vascular disease with a goal to prevent lower-extremity skin breakdown and to observe and report any sores, wounds, or ulcerations. The resident’s April treatment records included orders for wound care to the right heel and right lower heel/right lower extremity, including cleansing with Vashe and applying dressings on Monday, Wednesday, and Friday. A wound note later documented severe PVD and stated to continue using Aquaphor and wrapping with rolled gauze per the previous order, but the previous order was not restarted after the stop date. During observation, the resident was seen sitting on the bed with the right leg open to air, with a skin condition on the right lower extremity and a blister on the right shin. During interview, an RN stated she had soaked the resident’s right lower leg in warm water and applied cream and said wound care had already been completed for the day. The resident stated he had been dealing with wounds on his legs for years, that the leg usually had to be soaked and wrapped, and that the nurse had soaked the leg and applied ointment that morning. The DON later stated the resident should have had his legs wrapped, that the resident’s reported refusal should have been documented, and that there should have been physician orders for daily and PRN treatments if bandages were soiled. The DON also stated the order for the right lower heel should have been clarified as the right lower extremity and that the resident should not have gone without his legs wrapped.
Oxygen Flow Rates Not Kept at Ordered Levels
Penalty
Summary
The facility failed to ensure that supplemental oxygen was provided at the physician-ordered flow rate for two residents who were receiving respiratory care. Resident #21 had a diagnosis of COPD and was prescribed oxygen at 2 LPM by nasal cannula as needed for shortness of breath, while the care plan also referenced oxygen therapy related to COPD and maintaining oxygen saturation above 90%. During observation, the resident’s oxygen concentrator was found set below the ordered rate at one point and later set above the ordered rate, and the RN confirmed the concentrator was almost at 3 LPM before lowering it to 2 LPM. The RN stated she did not know why the setting had been changed. Resident #39 had a diagnosis of acute respiratory failure and was prescribed oxygen at 2 LPM by nasal cannula continuously, with oxygen saturation checks every shift and monitoring for signs and symptoms of COPD exacerbation. The care plan directed staff to administer oxygen at the prescribed flow rate and delivery device. Observations on multiple occasions showed the oxygen concentrator set between 1 and 1 1/2 LPM rather than the ordered 2 LPM. When interviewed, the resident stated he thought his oxygen was supposed to be set at 3 liters, and the RN later confirmed the concentrator was set below the ordered rate. The DON stated the facility’s policy was for the nurse to verify oxygen settings each shift to ensure they matched the physician’s order. The facility’s oxygen delivery procedure also required staff to verify the flowmeter setting and prescribed flow rate. The record showed that both residents had physician orders and care plans for oxygen therapy, but the observed oxygen settings did not match the ordered flow rates.
Missing Controlled Substance Count Signatures
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate controlled substance counts were completed and documented for Medication Cart 617 - 631. During observation of the cart with MA M, the narcotic count sheet showed missing signatures for both the off-duty and on-duty nurses for the 6:00 PM to 6:00 AM shift on 04/03/2026 and 04/13/2026. The missing signatures were identified on review of the narcotic count sheet, showing that the required shift-change documentation was not completed for those controlled drug counts. During interview, the DON stated nurses were expected to sign the narcotic count sheet at the beginning and end of their shifts after completing the count with the incoming and off-going nurse, and stated that without signatures she could not prove the counts were done. LVN K stated he should have signed the narcotic sheet after counting the narcotics on 04/13/2026 and acknowledged he got busy and did not return to sign it. LVN L stated he should have signed the narcotic sheet after counting the narcotics on 04/03/2026 and said he counted with the other nurse but did not remember why he did not sign. The facility policy titled, Medication Storage - Controlled Medication Storage, stated that at each shift change a physical inventory of all controlled substances is conducted by two licensed nurses or approved individuals and documented on the controlled substances accountability record.
Failure to Develop Comprehensive ADL Care Plan for a Resident
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for activities of daily living (ADLs) for one resident. Record review showed this male resident, with diagnoses including UTI, anxiety disorder, bipolar disorder, schizophrenia, and depression, had an MDS assessment indicating intact cognition (BIMS score of 15) and a need for supervision or touching assistance with personal hygiene tasks such as combing hair, shaving, and washing/drying face and hands. However, review of the resident’s care plan, last reviewed on 02/11/26, revealed no plan of care addressing ADLs with measurable objectives, goals, interventions, and timeframes, despite the facility’s written policy requiring a comprehensive person-centered care plan to meet medical, nursing, mental, and psychosocial needs. During interviews, the DON stated that every resident should have a care plan reflecting their likes, dislikes, everyday routine, and anything that affected them, and acknowledged that the absence of ADLs in the care plan diminished staff communication and knowledge of resident preferences. The DON explained that the MDS Coordinator was responsible for updating residents’ care plans, but the facility did not have an MDS Coordinator nurse and instead used a corporate person for MDS assessments, while the DON handled acute and new resident care plans. The Administrator similarly stated that the care plan told a story about the resident’s care and preferences and confirmed that without ADLs listed, staff would not know what residents liked. The Administrator indicated that charge nurses were responsible for triggering acute care plans and the MDS Coordinator for updating care plans, but again noted the absence of an MDS Coordinator.
Failure to Provide Requested Shaving and Grooming Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required assistance with activities of daily living (ADLs) received necessary grooming and personal hygiene services, specifically shaving. The resident was an adult male with diagnoses including urinary tract infection, anxiety disorder, bipolar disorder, schizophrenia, and depression. His MDS showed intact cognition with a BIMS score of 15 and indicated he required supervision or touching assistance with personal hygiene tasks such as combing hair and shaving. His face sheet photo showed him with a trimmed mustache and clean-shaven face at admission. During observation, he was seen clean and groomed but with a full mustache growing over his lip and a chin beard approximately two inches long, which differed from his admission appearance. The resident reported he received showers three times a week but wanted his mustache trimmed and beard clean-shaven, and stated he had been asking to be shaved for weeks. He said staff told him he needed to make an appointment with the facility’s beauty salon, which he could not afford, and he confirmed he was not admitted with a beard. There was no care plan addressing ADLs with measurable objectives, goals, interventions, and timeframes. The CNA assigned to him on the day of observation stated she had showered him but had not shaved him or asked about his grooming preferences, and she had not consulted the charge nurse. She stated CNAs were responsible for shaving residents on shower days if requested. The RN, DON, and Administrator each stated that CNAs were responsible for grooming, including shaving, on shower days and that charge nurses, the DON, and the Administrator were responsible for ensuring residents received appropriate care. None of them were aware the resident had been requesting shaving. The facility’s policy stated that hair care, combing, and shaving would be provided in accordance with standard practice guidelines.
Failure to Complete Significant Change MDS After Multiple Hospitalizations and Treatment Changes
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive, accurate Significant Change in Status Assessment (SCSA) MDS within 14 days after a resident experienced significant changes in condition and multiple hospitalizations. The resident, an older male admitted with diagnoses including metabolic encephalopathy, diabetes mellitus with hyperosmolality, hypernatremia, and acute and chronic respiratory failure with hypoxia, had an MDS dated with the type left blank and key sections either incomplete or inaccurately coded. Section C (Cognitive Patterns) showed an empty BIMS summary score and staff assessment indicating memory problems and inattention. Section J documented shortness of breath with exertion, at rest, and when lying flat, and Section K noted parenteral/IV feeding while not a resident. Section O (Special Treatments) was left empty and did not address the resident’s oxygen and IV use. A subsequent quarterly MDS documented a BIMS score of 07, indicating severe cognitive impairment, and again noted shortness of breath in multiple positions and parenteral/IV feeding under Section K. However, Section O again indicated that the resident did not require any special treatments such as IV or oxygen, despite medical records showing orders and use of these treatments. The record showed MD orders for IV fluids, PRN albuterol nebulizer treatments, and PRN peripheral IV restarts for infiltration or extravasation. MD progress notes documented initiation of IV normal saline, completion of a BIMS with a score of 15/15 at one point, and the presence of a peripheral IV line. Interdisciplinary notes described a history of chronic respiratory failure on 2L nasal cannula O2, COPD, CKD, mood disorder, prior admissions for atypical chest pain, leukocytosis, hypernatremia, hypoxia with AMS, pulmonary embolism, aspiration pneumonia, GI bleed, AKI, and the need for thickened liquids with aspiration precautions. The resident experienced multiple hospitalizations for atypical chest pain, hypoxia, altered mental status, leukocytosis, and later for severe hypernatremia, with documented changes in diet (thickened liquids), respiratory treatments, and IV therapy upon return to the facility. The facility’s own change of condition policy defined acute changes of condition and circumstances requiring communication and evaluation, including transfer to another healthcare community and unexpected deterioration in condition or status. Despite these significant clinical events and changes in treatment approaches, there was no significant change in condition MDS assessment in the resident’s file. Interviews with the CRN and DON confirmed that the resident had several hospitalizations and returned with clinical changes to diet, respiratory treatments, and IV therapy, and that the MDS should accurately reflect current care status and needs. The DON and ADM acknowledged that it was the responsibility of the ADON, MDSC, and DON to ensure timely and accurate completion of MDS assessments, and that the facility had not completed a change in condition assessment for this resident. The care plan documented cognitive loss, dietician referral, prescribed diet, altered nutrition status related to weight loss, shortness of breath, risk of dehydration, oxygen therapy related to COPD, and extensive assistance needs with ADLs, but there remained no corresponding significant change MDS to capture the resident’s updated status following the hospitalizations and treatment changes. During surveyor interviews, the resident provided minimal information about recent hospitalization, oxygen treatments, and thickened water, responding only "whatever they said." The CRN initially stated that updated MDS assessments were in the EMR but was unable to produce a significant change MDS. The ADM reported that the facility had recently terminated the MDSC after observing a pattern of failing to complete timely and accurate assessments and confirmed that the DON was responsible for monitoring and ensuring that the MDS was updated. Overall, the survey findings showed that despite clear evidence of significant changes in the resident’s physical and clinical status, the facility did not complete the required significant change MDS assessment and did not accurately code existing MDSs to reflect oxygen and IV treatments and diet changes. The facility’s written policy on change of condition emphasized the importance of recognizing and managing acute changes of condition and defined an acute change as a sudden, clinically important deviation from baseline that, without intervention, may result in complications or death. The resident’s multiple hospitalizations for serious conditions, including hypernatremia, hypoxia, and aspiration pneumonia, along with changes in diet consistency, respiratory support, and IV therapy, met the criteria for significant change. Nonetheless, the record review and staff interviews confirmed that no significant change MDS was completed, and existing MDS assessments were incomplete or inaccurate in key sections, particularly Section O for special treatments. This failure to conduct and accurately complete a significant change assessment within the required timeframe formed the basis of the cited deficiency.
Inaccurate MDS Assessments for Diet and Respiratory Treatments After Change in Condition
Penalty
Summary
Surveyors identified a failure to ensure that a resident’s Minimum Data Set (MDS) assessments accurately reflected the resident’s current clinical status, specifically related to diet and respiratory treatments. Record review showed that the resident, an older male with diagnoses including metabolic encephalopathy, diabetes mellitus with hyperosmolality, hypernatremia, and acute and chronic respiratory failure with hypoxia, had an MDS dated 09/09/2025 with an undocumented assessment type and an empty BIMS summary score field. This MDS documented shortness of breath with exertion, at rest, and when lying flat, and noted parenteral/IV feeding while not a resident, but did not clearly capture subsequent clinical changes. The resident was hospitalized multiple times and returned with changes in diet approaches, including thickened liquids, and with respiratory treatments and IV for enteral feeding. The quarterly MDS completed later by an LVN/MDS nurse documented a BIMS score of 07, indicating severe cognitive impairment, and again noted shortness of breath with exertion, at rest, and when lying flat. In Section K, the quarterly MDS continued to list parenteral/IV feeding as a nutritional approach but did not address the resident’s need for thickened liquids. In Section O, the assessment indicated that the resident did not require any special treatments, such as IV or oxygen, despite other information indicating oxygen therapy and respiratory treatments. Section Z of this quarterly MDS was signed by an RN on 12/23/2025, certifying completion of the assessment. Additional documentation and interviews confirmed that the resident’s care needs had changed and were not reflected in a corresponding change in condition MDS. The care plan dated 01/14/2026 included problems and interventions such as cognitive loss, dietician referral, prescribed diet, altered nutritional status, shortness of breath, risk of dehydration, and oxygen therapy related to COPD, and noted that the resident recently received thin liquids and was progressing in speech. The CRN stated the resident had been hospitalized several times and returned with clinical changes including thickened liquids, respiratory treatments, and IV for enteral feeding, and acknowledged the need to check updated MDSs. The DON stated that MDS clinical assessments and plans should be updated to reflect the resident’s current status and that failing to complete or update MDS assessments placed the resident at risk of missing individualized clinical care, treatment, and tasks. The ADM reported that the facility had observed a pattern of failing to complete timely and accurate assessments and that the MDS coordinator had been terminated, and staff were unable to produce a change in condition MDS for this resident. The facility’s policy required comprehensive, accurate MDS assessments, coordinated and certified by an RN, and completed on admission, annually, quarterly, and within 14 days of a significant change, but this process was not followed for this resident’s change in condition.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple staff not adhering to required infection control practices during care of two residents. For one resident with a suprapubic catheter and wounds, who was under Enhanced Barrier Precautions (EBP) isolation, several staff members, including an LVN and three CNAs, provided care without wearing gowns as required for high-contact procedures. Observations showed that while gloves were used, gowns were not donned, and staff were unaware or forgot the necessity of this PPE despite the presence of a PPE supply cart outside the room. There was also no EBP isolation signage present. Interviews revealed that some staff did not know the purpose of the PPE cart or the need for gowns, and one staff member admitted to rushing and forgetting proper PPE due to time constraints. In another instance, during incontinent care for a different resident, a CNA failed to perform hand hygiene between glove changes, and an LVN placed dirty linen on the floor instead of in a designated plastic bag. The CNA acknowledged knowing the correct procedure but did not follow it due to nervousness, while the LVN stated that placing dirty linen on the floor was not an issue, despite facility policy requiring dirty linen to be bagged. The administrator and DON confirmed that staff were expected to perform hand hygiene before and after care, between glove changes, and to properly handle soiled linen, but these protocols were not followed during the observed care. Record reviews and staff interviews confirmed that the facility had policies in place for hand hygiene and EBP, requiring gowns and gloves for high-contact care and proper handling of soiled linen. However, the observed failures in PPE use, hand hygiene, and linen handling during resident care directly contradicted these policies and placed residents at risk for cross-contamination and infection, as acknowledged by staff and leadership during interviews.
Failure to Develop Comprehensive Care Plan for ADLs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for activities of daily living (ADLs) for a resident. Record review showed that the resident, a 90-year-old individual with multiple diagnoses including idiopathic peripheral autonomic neuropathy, depression, secondary hypertension, atrial fibrillation, and chronic diastolic congestive heart failure, required varying levels of assistance with ADLs such as toileting hygiene, bathing, dressing, eating, and oral hygiene. Despite these needs being identified in the most recent MDS assessment, the resident's care plan did not include a plan of care for ADLs, nor did it specify measurable goals, interventions, or timeframes related to these needs. Interviews with facility staff, including the Administrator, DON, and MDS Nurse, confirmed that the absence of ADLs in the care plan diminished staff communication and knowledge of the resident's preferences and routines. The staff acknowledged that the care plan should reflect the resident's functioning, preferences, and required assistance, and that the MDS Coordinator was responsible for updating the care plan. Review of the facility's care plan policy indicated that the interdisciplinary team is required to coordinate and review care plans based on assessments within specified timeframes, but this process was not followed for the resident in question.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was frequently incontinent of bladder and bowel did not receive timely incontinence care. The resident, a cognitively intact female with multiple diagnoses including autonomic neuropathy, depression, hypertension, atrial fibrillation, and chronic heart failure, reported not having her incontinence brief changed all morning. She also stated her call light had not worked for two months, and she relied on a bell to alert staff. Record review confirmed her incontinence status, and interviews with staff revealed that the certified nursing assistant (CNA) assigned to her had not changed her since the start of the shift at 6:00am, despite facility policy and staff expectations that incontinence care be provided every two hours or as needed. The CNA reported being responsible for 16 residents and having multiple competing duties, which contributed to the delay in providing care. Both the licensed vocational nurse (LVN) and the director of nursing (DON) confirmed that the facility's expectation was for incontinence care to be provided every two hours or when requested, and that delays could result in skin breakdown, depression, or infection. Facility policy required perineal/incontinent care after each episode of incontinence. The failure to provide timely care was directly observed and confirmed through interviews and record review.
Improper Catheter Bag Positioning During Resident Transfer
Penalty
Summary
A deficiency occurred when a resident with an indwelling suprapubic urinary catheter did not receive appropriate catheter care during a transfer from bed to Geri-chair. During the transfer, CNA C placed the catheter drainage bag flat on the foot of the bed, which was above the resident's bladder level, and later hung the bag on the shaft of the mechanical lift. This positioning allowed urine to flow back toward the resident's bladder. The resident required extensive assistance with mobility and had a history of obstructive uropathy and cancer, with moderately impaired cognition. Interviews with CNA C, the Administrator, and the DON confirmed that staff were trained and expected to keep the catheter drainage bag below the bladder to prevent backflow and potential infection. However, the facility's policy on catheter care did not address this specific concern. The failure to maintain the drainage bag below bladder level during the transfer was observed directly and acknowledged by staff as contrary to proper procedure.
Failure to Date Opened Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their only kitchen, as observed during a survey. Specifically, the facility did not ensure that food items, such as liquid eggs, were labeled with use-by dates after being opened. During an observation, it was noted that two packets of liquid eggs in the walk-in refrigerator were opened but lacked a use-by date. Interviews with the Dietary Manager and kitchen staff confirmed that all open food items should have an 'open date' and a 'use-by date,' and that the liquid eggs should have been labeled with a use-by date of three days after opening. The Dietary Manager and staff acknowledged the risk of not dating food items, which could lead to food-borne illnesses among residents. The facility's policy on food storage, revised in February 2024, mandates that all foods be covered, labeled, and dated, aligning with the FDA Food Code requirements. The failure to date opened food items, as per the facility's policy and FDA guidelines, posed a risk of food contamination and illness to residents consuming meals from the facility's kitchen.
Failure to Transmit Discharge MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that discharge Minimum Data Set (MDS) assessments for two residents were electronically completed and transmitted to the CMS System within 14 days after completion. Resident #23, a female who was admitted to the facility and later passed away, did not have a discharge MDS assessment completed, which was identified as being over 120 days late. Similarly, Resident #43, a male who was discharged against medical advice, also lacked a completed discharge MDS assessment, which was also over 120 days late. This oversight was discovered during a review of the residents' records and interviews with facility staff. Interviews with the MDS Nurse and the Regional MDS RN revealed that a change in the electronic health record system in November 2024 contributed to the inability to access previous assessments. The MDS Nurse was responsible for completing all MDS assessments, while the Regional MDS coordinator handled the transmission to CMS. Both staff members acknowledged the requirement to complete and transmit discharge assessments within 14 days of discharge or death. The facility's policy mandates that MDS assessments be conducted and transmitted in a timely manner, but this was not adhered to, leading to incomplete records for the residents involved.
Failure to Include Dialysis in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not address the resident's need for dialysis, despite the resident being admitted as a dialysis patient. The omission was identified during a survey, and the care plan had not been updated to include dialysis prior to the survey date. The resident, a cognitively intact male with a BIMS score of 15, had been admitted with diagnoses including peripheral vascular disease, hypotension of hemodialysis, muscle wasting and atrophy, and enterocolitis due to clostridium difficile. The Director of Nursing (DON) and the MDS Coordinator acknowledged the oversight, with the MDS Coordinator noting that the care plan should reflect physician orders and the facility's actions for the patient. The facility's policy required the interdisciplinary team to coordinate an appropriate care plan based on assessments within required timeframes.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for two residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #30, a male with a history of stroke, hypertension, hyperlipidemia, and anxiety, was totally dependent on staff for personal hygiene. On observation, his fingernails were found to be dirty and jagged, extending 0.4 cm from the tip of his fingers. Resident #30 expressed a desire for his nails to be clipped and cleaned, indicating his dependence on staff for nail care. Similarly, Resident #19, a male with fractures, hypertension, peripheral vascular disease, hyperlipidemia, and schizophrenia, required moderate assistance for personal hygiene. His nails were observed to be long, jagged, and discolored, extending 0.3 cm from the tip of his fingers. Resident #19 also expressed a need for assistance with nail care, noting that his nails had not been clipped for several days. Interviews with facility staff, including a CNA and RN, revealed that both CNAs and nurses were responsible for nail care, which was to be performed on shower days and as needed. The CNA mentioned that Resident #30 sometimes refused nail care, and refusals were reported to the Charge Nurse. The RN acknowledged that dirty, jagged nails could increase the risk of infections. The DON confirmed that nail care was the responsibility of all CNAs and nurses, and nails should be observed daily. The facility's policy on bathing indicated that nail care should be performed to keep nails clean and trimmed. Despite these protocols, the facility failed to ensure that the residents received the necessary nail care, potentially placing them at risk for infections and decreased quality of life.
Improper Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a risk of urinary tract infections. During a wound care procedure, a CNA placed the resident's catheter drainage bag on the bed, above the bladder level, which caused urine to flow back toward the bladder. This action was contrary to the resident's care plan, which specified that the catheter tubing should be kept below the bladder level to prevent complications. Both the CNA and the LVN involved acknowledged the mistake, with the CNA stating she placed the bag on the bed to prevent it from pulling, despite being trained to keep it below the bladder. The resident involved was an elderly male with a history of prostate cancer and a pressure ulcer, requiring extensive assistance with mobility and transfer. His care plan included specific instructions for catheter management to avoid complications. The facility's Director of Nursing confirmed that the improper placement of the catheter bag could lead to urinary tract infections and cross-contamination. Despite the CNA's previous competency check indicating proficiency in catheter care, the facility's policy on catheter care did not address the specific concern of maintaining the drainage bag below bladder level.
Failure to Label Insulin Pen with Open Date
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles, specifically regarding the labeling of an insulin pen for a resident. During an observation of the nurses' cart on Hall 600, it was noted that an insulin pen for a resident did not have an open date. The pen was not full and had been used, indicating it was in active use without proper labeling. This oversight was confirmed by LVN A, who admitted to administering insulin from the pen without checking for an open date. LVN A acknowledged the importance of labeling the pen with an open date to ensure the insulin's effectiveness, as it is only viable for 28 days after opening. Further interviews revealed that the Director of Nursing (DON) was aware of the requirement for insulin pens and vials to be dated upon opening, as they have a specific shelf life. The DON stated that the pharmacy consultant conducts monthly checks of the medication carts, and both the DON and Assistant Director of Nursing (ADON) are responsible for performing random checks to monitor compliance. A review of the facility's policy on medication labeling confirmed the necessity of documenting the open date on multi-dose vials to maintain product integrity, aligning with the manufacturer's specifications.
Ineffective Pest Control Program Leads to Bed Bug Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in bed bug sightings on the 600 floor. Two residents reported bed bugs in their rooms, with one resident seeing a bed bug on his bed sheet and another resident's room being treated for bed bugs after a report. The facility's pest control program was not effectively implemented, as evidenced by the lack of comprehensive inspections and staff training on bed bug prevention. Interviews with staff and residents revealed that the facility did not follow its bed bug policy, which required checking all rooms on the affected floor and training staff on bed bug prevention. Some staff members were unaware of the bed bug issue, and there was a lack of documentation and communication regarding the sightings and treatments. The facility's pest control provider was reportedly not thorough, and there were inconsistencies in the pest control treatments and inspections. The facility's pest control policy required immediate notification of the Administrator and Director of Nursing upon realization of a bed bug infestation, but this was not consistently followed. The facility had a history of bed bug issues, and the pest control treatments were not effective in eliminating the problem. The lack of a coordinated response and proper training contributed to the ongoing bed bug issue, which posed a risk to residents' well-being.
Verbal and Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with moderate cognitive impairment and multiple complex medical conditions, including dementia and anxiety. The resident required substantial assistance with daily activities and was observed to have no history of recurrent outbursts or excessive use of the call light until the day of the incident. On the day of the incident, the resident was reportedly on the call light all day and was observed to be anxious. A family member reported witnessing the CNA verbally abusing the resident and forcing her to get out of bed against her will via a video camera in the resident's room. The video footage showed the CNA removing the call light from the resident's hand, refusing to change her when she was wet, and speaking to her in a threatening and disrespectful manner. The CNA was heard making statements that were verbally abusive and dismissive of the resident's needs. The facility's investigation into the incident included reviewing video footage and interviewing staff and the resident. The CNA involved denied the allegations, claiming she was speaking to someone else via earbuds during the incident. However, the video evidence and interviews with the resident and staff indicated that the CNA's behavior was inappropriate and abusive. The facility's policy on abuse and neglect emphasizes the right of residents to be free from abuse and the facility's duty to protect these rights, which was not upheld in this case.
Failure to Maintain Wheelchair Safety
Penalty
Summary
The facility failed to ensure that assistive devices, specifically wheelchairs, were maintained and free of hazards for two residents. Resident #2, a male with a history of stroke and high fall risk, was observed in a wheelchair with damaged armrests, exposing jagged edges and metal parts. Multiple staff members, including a medication aide, MDS coordinator, CNA, ADON, and Central Supply Director, were unaware of the condition of the wheelchair, indicating a lack of communication and oversight in maintaining equipment. Resident #3, a female with cognitive deficits and high fall risk, was also found using a wheelchair with torn armrests, exposing the cotton padding. Despite her attempts to address the issue by taping the armrests and speaking to the Maintenance Director, the problem persisted for over a year. Interviews with staff, including the ADON and Maintenance Director, revealed a lack of awareness and a failure to document repair requests in the maintenance log, further highlighting the facility's inadequate system for reporting and addressing equipment maintenance issues. The facility's failure to maintain the wheelchairs in good repair was compounded by the absence of a documented maintenance policy and incident/accident prevention policy, as requested during the survey. The lack of a structured process for identifying and repairing damaged equipment placed residents at risk of injury, as acknowledged by various staff members during interviews. The Administrator and former Administrator were also unaware of any issues with the wheelchairs, indicating a systemic oversight problem within the facility.
Improper Hair Restraint Use by Dietary Staff
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed with Dietary Aide G, who did not properly wear a hair restraint while preparing meals for residents. During an observation, it was noted that Dietary Aide G's hair, approximately 3 inches in length, was not fully covered by the hairnets she wore. She had two small hairnets on either side of her head, leaving the front, sides, and back of her hair exposed. Dietary Aide G admitted to forgetting to put on an additional hairnet due to rushing back from outside to prepare the meal trays. Interviews with other dietary staff and the Dietary Director (DD) revealed that there was an expectation for all hair to be restrained using hairnets to prevent contamination of food. Despite having sufficient hairnets available, the staff did not consistently ensure proper usage. The DD acknowledged the importance of hairnets in maintaining food safety and stated that she would address the issue with Dietary Aide G. The facility's policy and federal food code require effective hair restraints to prevent contamination, but the deficiency in compliance was evident in this instance.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the facility did not complete a weekly skin assessment for a resident from April 14 through April 20, despite the care plan requiring a head-to-toe skin inspection every week. This lapse in care was identified during a record review and interviews with facility staff. The resident involved was an elderly female with a history of urinary tract infection, dementia, absence of the left leg above the knee, and hemiplegia and hemiparesis following a cerebral infarction. The resident had a stage 3 pressure wound on the left ischium, and the lack of a weekly skin assessment could have placed her at risk of receiving inadequate care. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that they were responsible for ensuring the completion of weekly skin assessments, but they missed the audit for the week in question. The facility's policy required weekly skin assessments to prevent pressure ulcers and ensure proper wound care.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of RN D during wound care for a resident. RN D was observed removing gloves and performing hand hygiene with hand sanitizer directly over the resident's open wound on the left ischium. This practice was contrary to infection control protocols, as it posed a risk of micro-organisms or sanitizer contaminating the wound. RN D acknowledged being nervous during the procedure and admitted to not realizing the potential risk of his actions. The resident involved was an elderly female with a history of urinary tract infection, dementia, absence of the left leg above the knee, and hemiplegia and hemiparesis following a cerebral infarction. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that RN D was trained in proper wound care techniques and understood the risks associated with his actions. The facility's infection prevention and control policy emphasized the importance of preventing contamination during wound care, yet the observed practices did not align with these guidelines.
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 1,180 citations issued within 25 miles in the last 12 months — including the 50 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) |
|---|---|---|---|---|
| Avir At Dallas | 0.6 mi | ★★★★★ | 1 | 0 |
| Ventana By Buckner | 1 mi | ★★★★★ | 3 | 0 |
| Fair Park Health & Rehabilitation Center | 1.4 mi | ★★★★★ | 7 | 0 |
| Autumn Leaves | 4.7 mi | — | 0 | 0 |
| Southern Oaks Therapy And Living Center | 4.9 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.