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 Southern Specialty Rehab & Nursing during CMS and state inspections, most recent first.
Failure to maintain resident dignity and privacy during care: multiple residents reported CNAs used personal cell phones while assisting with showers, peri-care, and other care, including texting and talking in resident areas and during meals. A resident with stroke-related paralysis and severely impaired cognition was observed receiving wound care with the door open and the privacy curtain not pulled, allowing others to see into the room while the LPN provided care.
Catheter care and securement were not maintained for three residents with indwelling catheters. One resident's drainage bag was found lying in bed with tubing under the leg and no strap in place, another resident's tubing was under the leg with no strap present, and a third resident received catheter care from a CNA who cleansed the catheter using a back-and-forth motion and reused the same wipe instead of cleaning away from the penis in one direction. The DON and other staff stated the bag should be below the bladder, the strap should secure the tubing, and catheter care should be performed using proper technique.
Improper Hair Restraints During Food Preparation and Service: Kitchen staff were observed serving and preparing meals without properly covering all hair. One staff member wore a beanie that left braids uncovered while assisting with the noon meal, and another wore a headband with hair uncovered while preparing the noon meal. Interviews confirmed staff understood hair restraints were required to keep hair out of food, and the facility policy required all employees in food prep areas to wear a hairnet or hair covering.
A resident with a feeding tube, severe cognitive impairment, quadriplegia, and persistent vegetative state did not receive enteral water at the ordered rate. Staff observed the pump set at 30 ml/hr even though the physician order was for 45 ml/hr for 22 hours with 2 hours of gut rest. An LVN confirmed the incorrect rate and stated he was not aware of any order change, while the DON and ADM stated nurses were responsible for checking orders and pump rates.
A resident with a feeding tube, severe cognitive impairment, quadriplegia, and persistent vegetative state was observed receiving g-tube feeding at 55 mL/hr even though the physician order specified Isosource 1.5 at 85 mL/hr for 22 hours. An LVN confirmed the incorrect pump rate and stated he was unsure why it was set that way, while the DON and ADM stated staff were expected to verify orders and pump settings and that nursing was responsible for tube feeding administration.
Medication Administration Errors Exceeded Allowed Rate: The facility had a 5% med error rate based on 2 errors in 40 opportunities. During observation, an MA gave one resident guaifenesin 400 mg instead of the ordered 600 mg dose, and gave another resident cranberry 450 mg instead of the ordered 500 mg dose. The MA stated she caught one error but missed the other, while the DON said he was unsure when staff last received med admin training and the ADM expected staff to verify the correct dose before giving meds.
Unattended RT Medication Cart Left Unlocked: RT Medication/Treatment Cart A was observed unlocked and unattended in the 200 Hall with the keys hanging from the opened lock while no staff or residents were within eyesight. RT F stated she had stepped away briefly to check on a resident and acknowledged she should have locked the cart. Medications and supplies were visible in the cart, and RT F said she did not know when she was last trained on keeping the cart locked when unattended. The DON and ADM stated staff were expected to keep carts locked when not with them.
Failure to change gloves and perform hand hygiene during incontinence care. A CNA provided catheter and incontinence care to a resident with stroke-related paralysis, severe cognitive impairment, and a recent UTI, but did not remove dirty gloves or clean hands before placing a clean brief and draw sheet after wiping the resident's buttocks and removing the soiled brief. The CNA acknowledged the mistake and said she was supposed to change gloves between dirty and clean tasks; the DON and ADM stated staff were expected to use clean gloves and clean hands between those steps.
A resident with severe cognitive impairment, ventilator dependence, and sacral and left buttock pressure ulcers received wound care during which an LVN failed to follow proper infection control practices. Despite orders and a care plan requiring Enhanced Barrier Precautions for wound care, the LVN double gloved, did not remove the base gloves between wound sites, repeatedly changed only the top glove on one hand, and did not consistently perform hand hygiene between glove changes. The LVN reported relying on prior experience, was aware of the resident’s MDRO history and contact precautions, and believed the unused glove remained clean, while facility policy required hand hygiene after glove removal and stated that gloves do not replace handwashing.
A breakdown in nursing coverage and communication led to multiple residents not receiving their scheduled medications, including antihypertensives, antiepileptics, antipsychotics, and anticoagulants. The morning medication pass was missed for several residents who required G-tube administration, and required blood pressure monitoring was not performed. Staff interviews revealed that no nurse was assigned to these residents during the critical period, and the errors were not discovered until days later during an external investigation.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
Staff failed to consistently follow hand hygiene protocols during personal and wound care for two residents, including not washing hands after glove removal and after providing care, despite being trained and aware of facility policies. These lapses were observed during care for residents with incontinence and chronic conditions, and were confirmed through staff interviews and policy review.
A CNA failed to fully clean a resident with bowel and bladder incontinence during perineal care, leaving visible BM on the skin before applying a new brief. The CNA only completed cleaning after surveyor intervention and did not perform hand hygiene after glove removal, contrary to facility policy. Interviews confirmed the CNA was aware of proper procedures but did not follow them during the observed care.
Surveyors found that several open containers of spices were left uncovered on kitchen shelves, contrary to facility policy and staff training. Staff interviews confirmed that all spices should be closed when stored, and that all staff were responsible for ensuring proper storage, but the deficiency was observed on multiple occasions.
The facility failed to ensure that four residents receiving hospice care had the necessary physician orders documented. Despite being listed as receiving hospice services from various companies, the residents' records lacked the required orders. Interviews with the DON and Adm revealed a lapse in the facility's process for ensuring these orders, as the DON was unaware of the missing documentation, and the Adm expected the orders to be in place. The facility's policy required documentation of a Physician Certification of Terminal Illness, which was not followed.
The facility failed to maintain an effective infection control program due to improper hand hygiene practices by CNAs during wound care for three residents. CNAs did not adhere to the recommended 20-second handwashing protocol, risking cross-contamination and infection spread. Despite being trained, staff did not follow the facility's hand hygiene policy, as confirmed by the DON and Administrator.
A medication cart in Hall 200 was left unlocked and unattended, posing a risk of unauthorized access to medications. RN A admitted to leaving the cart unlocked due to being in a rush, despite recent training on medication security. The DON confirmed this was against facility protocol, which requires carts to be locked when unattended.
A staff member at a LTC facility failed to adhere to infection control protocols by not wearing PPE or practicing hand hygiene when entering the room of a resident on contact isolation for Carbapenem Resistant Pseudomonas Aeruginosa. The staff member removed a reusable cup from the resident's room, refilled it at a community water station, and returned it, further entering additional resident rooms without following proper infection control measures. This breach in protocol placed residents at risk for infection and cross-contamination.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and privacy by allowing staff to use personal cell phones while providing care and by failing to maintain privacy during wound care for one resident. Twelve confidential residents stated that CNAs used personal cell phones while assisting with showers, providing care in resident rooms, and performing peri-care, and that staff also texted and talked on phones while walking in hallways, at nurses’ stations, and in the dining area during meals. The residents stated this occurred on every shift and made them feel embarrassed, concerned about the quality of care, and that their privacy was violated. During interviews, the DON and ADM stated staff should not use cell phones or earbuds while providing care and should keep phones in breakroom lockers. They stated residents should receive undivided attention and that staff were trained on resident rights, dignity, privacy, and cell phone use during orientation, ongoing education, and in-services. They also stated staff were monitored through rounds, and both acknowledged that cell phone use in resident care areas could violate privacy and reduce attention to care. Resident #7 was a male resident with a history of cerebral infarction, left-sided hemiplegia and hemiparesis, and urinary tract infection, and his MDS indicated severely impaired cognitive skills for daily decision making. During observed wound care, LVN D did not close the door or pull the privacy curtain around the resident, and two female residents were seen passing by and looking into the room while care was being provided. LVN D stated she had been trained to close the door and pull the curtain but did not do so because she was waiting for the CNA, and the DON and ADM stated they expected the door to be closed and the curtain pulled for privacy during resident care.
Catheter Care and Securement Not Maintained
Penalty
Summary
The facility failed to ensure appropriate catheter care and catheter securement for three residents with indwelling catheters. Resident #20 had diagnoses including respiratory failure, anoxic brain damage, overactive bladder, and urinary retention, and was dependent for ADLs with severe cognitive impairment. Her care plan directed staff to keep the drainage bag below the bladder at all times, and the order summary required the catheter strap to be in place and holding every shift. During observation, her catheter drainage bag was lying in the bed at the foot of the bed, the tubing was under her right leg and curled on the bed, and no catheter strap was present. RN B stated the drainage bag was not in the right place. Resident #46 had diagnoses including respiratory failure, quadriplegia, epileptic seizure, and dysphagia, and was also severely cognitively impaired and dependent for ADLs. His care plan included catheter care under enhanced barrier precautions, and the order summary required the catheter strap to be in place and holding every shift. During observation, his catheter tubing was under his right leg and no catheter strap was in place. LVN A stated the resident had a shower that day and may have come off in the shower, and he verified that there was an order for the catheter strap to be in place. Resident #7 had a history of cerebral infarction, hemiplegia and hemiparesis, and urinary tract infection, with severe impairment in cognitive skills for daily decision making. His care plan directed staff to ensure tubing was anchored to the resident's leg or linens so it was not pulling on the urethra. During observation, CNA E provided catheter and incontinence care while the resident was without a leg strap for the catheter tubing. CNA E cleansed the catheter by rubbing it back and forth at the point where it met the penis and then used the same wipe again in a manner that did not follow the expected one-direction cleansing technique. The DON later stated staff were expected to clean away from the penis in one fluid motion and not go back with the same soiled wipe.
Improper Hair Restraints During Food Preparation and Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. During an observation on 06/10/2026 at 12:00 p.m., DA was assisting with serving the noon meal while wearing a black beanie that covered the top of his head but left his hair braids uncovered. During an observation on 06/11/2026 at 10:45 a.m., DM was preparing the noon meal while wearing a black headband with her hair uncovered. During interviews, DA stated the purpose of a hair net was to keep hair from getting into food and said he did not need to cover his braids, only his beard and top of head. He stated he had been trained in hair restraints while in the kitchen. DM stated all kitchen staff were to wear hair restraints covering all hair, including braids, and said she was aware DA was not properly wearing his hair restraint and had done an in-service with him on proper hair restraints on 06/10/2026. She also stated she wore a hair net over her head band but forgot to put it on. The ADM stated he was not aware kitchen staff were not properly wearing hair restraints and said all staff had been in-serviced on proper hair restraints while in the kitchen. Record review showed the facility policy required all employees in food preparation or utensil washing areas to wear a hairnet or hair covering.
Incorrect Enteral Hydration Rate
Penalty
Summary
The facility failed to offer sufficient fluid intake to maintain proper hydration for Resident #6 and did not follow the physician’s enteral hydration order. Resident #6 was a male admitted with acute and chronic respiratory failure, quadriplegia, and persistent vegetative state. His quarterly MDS showed a BIMS score of 00 and that he had a feeding tube. His care plan identified a potential fluid deficit related to depending on staff for water via g-tube, with an intervention to administer fluids per g-tube as ordered. The order summary showed an order dated 03/27/2026 for H2O 45 ml/hr for 22 hours with 2 hours of gut rest. During observations on 06/09/2026 and 06/10/2026, the feeding pump screen displayed H2O at 30 ml/hr instead of the ordered 45 ml/hr. During interview, LVN A confirmed the pump was set at 30 ml/hr and stated he was not sure why it was set that way and was not aware of any order changes. He later stated he was not aware the rate was wrong and that nurses were responsible for setting the correct rate and monitoring the pump. The DON stated nurses should check the orders and rates every shift and when hanging a new bag, and the ADM stated nurses were to monitor the feeding pump rate daily and when new bags were hung. The facility policy on enteral nutrition stated nursing services were responsible for feeding equipment and administration of tube feedings, and that problems with tube feeding administration were monitored and corrected by nursing.
Incorrect Enteral Feeding Rate
Penalty
Summary
The facility failed to follow the physician’s enteral feeding order for Resident #6, a male admitted with acute and chronic respiratory failure, quadriplegia, and persistent vegetative state. His quarterly MDS showed a BIMS score of 00, indicating severe cognitive impairment, and documented that he had a feeding tube and received 51% or more of his total calories through tube feeding. His care plan identified a risk for malnutrition related to BMI and directed staff to administer enteral feedings as ordered. The physician order in the record directed Isosource 1.5 at 85 mL/hr for 22 hours. Observations on 06/09/2026 and 06/10/2026 showed the resident receiving g-tube feeding with the pump rate displayed at 55 mL/hr instead of the ordered 85 mL/hr. During interview, an LVN confirmed the pump was set at 55 mL/hr and stated he was not sure why it was set that way and was not aware of any order changes. He also stated he was responsible for setting the correct rate and monitoring the pump during the shift. The DON and ADM stated staff were expected to check orders and rates and ensure they matched, and the facility policy stated nursing was responsible for tube feeding administration and correcting problems with tube feeding.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate was less than 5 percent. Based on observation, interview, and record review, the facility had a medication error rate of 5% based on 2 out of 40 opportunities for 2 of 4 residents reviewed for medication administration. The errors involved MA G giving Resident #56 guaifenesin 400 mg instead of the ordered Mucinex oral tablet extended release 12 hour 600 mg, and giving Resident #47 cranberry 450 mg instead of the ordered cranberry soft oral tablet chewable 500 mg. Resident #56 was a [AGE] year-old male admitted and readmitted with diagnoses including acute respiratory failure, protein-calorie malnutrition, and quadriplegia, and had a physician order for guaifenesin 600 mg once daily for cough. During medication administration observation, MA G dispensed guaifenesin 400 mg to the resident. Resident #47 was a [AGE] year-old male admitted and readmitted with diagnoses including acute respiratory failure, immunodeficiency, and neuromuscular dysfunction of bladder, and had an order for cranberry 500 mg twice daily related to neuromuscular dysfunction of bladder. During observation, MA G dispensed cranberry 450 mg to the resident. MA G stated she caught the error for Resident #56 and another nurse obtained the correct dose, but she did not notice the wrong dose for Resident #47 and stated it was her fault. The DON stated he was unsure when staff last received medication administration training and was not aware of such training during his time as DON. The ADM stated staff were expected to verify the correct dose before giving medications.
Unattended RT Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles for 1 of 2 RT carts reviewed. During an observation on 06/11/26 at 8:44 AM, RT Medication/Treatment Cart A was seen in the 200 Hall unlocked and unattended, with the keys hanging from the opened lock. No staff or residents were within eyesight of the cart at that time. During an observation and interview at 8:46 AM, RT F stated she had gone into a resident's room quickly to see what he needed and acknowledged she should have locked her cart when she stepped away from it. RT F opened the top drawer, and medications and supplies were observed in the cart. RT F stated she did not know when she was last trained to keep her cart locked when unattended and did not know of a potential negative outcome to residents. The DON and ADM later stated they expected staff to keep carts locked when not with them and that keys should be kept in their pocket or on their person. The facility policy stated medication carts and supplies are to be locked or attended by authorized persons.
Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when CNA E did not change gloves or perform hand hygiene before moving from dirty to clean during incontinence care for Resident #7. Resident #7 was a [AGE]-year-old male admitted and readmitted to the facility with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, and urinary tract infection. The resident's MDS assessment dated 12/20/25 indicated that his cognitive skills for daily decision making were severely impaired. During observation of catheter care and incontinence care, CNA E wiped the resident's buttocks, removed the dirty brief, and then placed a clean brief and clean draw sheet under the resident without changing gloves or performing hand hygiene between the dirty and clean tasks. In interview, CNA E stated she caught her mistake after the fact and said she was supposed to change her gloves after cleaning the resident and before putting on a new drawsheet and brief. She also stated she did not remember the last time she was trained on infection control. The DON stated he expected staff to have clean gloves and clean hands when putting on a clean brief, and the ADM stated staff should take off gloves, wash hands, and put on clean gloves between dirty and clean tasks to prevent the spread of infection.
Improper Glove Use and Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when a nurse did not follow proper hand hygiene and glove practices during wound care for one resident. The resident was an older male with acute respiratory failure, ventilator dependence, quadriplegia, and pressure ulcers of the sacrum and left buttock. His care plan included weekly wound assessments and specified Enhanced Barrier Precautions, including donning gloves and gown for wound care and other high-contact activities. Physician orders directed specific daily and PRN wound treatments for the stage 4 pressure wound on the left buttock and the sacral wound. During a wound care observation, the LVN donned a gown with thumb holes over a first pair of gloves, then applied a second pair of gloves over the first pair. She removed the resident’s sacral and left buttock dressings, then removed only the top glove from her right hand and replaced it with a new glove, leaving the original base gloves on both hands and not performing hand hygiene. She used the right hand to clean the sacral wound, again removed only the right top glove with her left gloved hand, donned a new right glove, applied treatment and dressing to the sacrum, and then removed the right glove. She continued to use the unchanged left base glove to remove soiled right-hand gloves and did not change both gloves between wound sites. She then used the unchanged base gloves to clean the left buttock wound before finally removing both gloves, using alcohol-based hand sanitizer, and donning new gloves. The LVN later stated she had not received wound care competency check-off upon hire and relied on prior experience from another state. She acknowledged awareness that the resident had a history of MDRO and required contact precautions. She reported that she double gloved based on prior home care practice and concern about glove breakage and contamination, and believed the left glove remained clean because she did not use that hand directly in the wound. She also stated she used hand hygiene between some glove changes due to potential contamination. Facility policy on infection control specified that hand hygiene must be performed after removing gloves and that gloves are not a substitute for hand hygiene, and identified failure to change gloves between resident contacts as an infection control hazard.
Failure to Administer Scheduled Medications Due to Nursing Coverage Breakdown
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the omission of scheduled medications for six out of ten residents reviewed for pharmacy services. On a specific date, multiple residents did not receive their prescribed medications, including antihypertensives, antiepileptics, antipsychotics, anticoagulants, and other critical medications. The medication administration records for these residents showed blank entries for the morning medication pass, indicating that medications were not administered as ordered. Additionally, required blood pressure monitoring was not performed or documented for several residents. The deficiency was primarily caused by a breakdown in nursing coverage and communication. The scheduled day nurse failed to report for duty, and no replacement was assigned to cover the affected residents. The night nurse was directed to leave her shift, and the Administrator, who temporarily took over, did not complete the medication administration. Subsequent staff, including an LVN who started later in the morning, were not informed in a timely manner that they were responsible for the residents in question. By the time the new nurse became aware of her assignment, she determined it was too late to administer the missed morning medications. Multiple staff interviews confirmed that no nurse was assigned to administer medications to these residents during the critical morning window. The residents affected had complex medical histories, including hypertension, heart failure, seizure disorders, and schizophrenia, and many were dependent on G-tube medication administration. Observations confirmed that these residents were unable to reliably communicate about their care or recall if they had received their medications. The medication errors were not discovered until several days later during an external investigation. Staff did not notify physicians or families about the missed doses at the time of the incident, and the facility's leadership confirmed that the errors were not identified until after the fact.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Hand Hygiene 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 hand hygiene protocols during personal and wound care for two residents. During peri care for a male resident with severe cognitive impairment and chronic medical conditions, a CNA was observed gathering supplies after exiting another resident's room without washing her hands. Although the CNA performed some handwashing steps, she did not consistently follow the facility's policy for hand hygiene, including not washing hands for the required duration and failing to wash hands after providing care and removing gloves. In a separate incident, two CNAs provided peri and wound care for a female resident with a history of urinary tract infection and incontinence. Both CNAs washed their hands before donning gloves and performing care, but after completing the care and removing gloves, neither washed their hands as required by facility policy. Additionally, one CNA failed to adequately clean the resident, leaving visible soiling until prompted by a surveyor to continue cleaning. Both CNAs acknowledged their training in infection control and hand hygiene but did not adhere to the established procedures during the observed care. Record reviews confirmed that the facility's policies require hand hygiene before and after glove use, after resident care, and after contact with soiled materials. Interviews with staff and administration indicated awareness of the policies and the importance of hand hygiene, but the observed actions did not align with these requirements. The failure to follow proper hand hygiene and infection control procedures was directly observed and documented by surveyors during the provision of care.
Incomplete Perineal Care and Infection Control Lapse
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide complete perineal care to a female resident who was always incontinent of bowel and bladder and had a history of urinary tract infection. During an observed care episode, the CNA did not fully remove all bowel movement (BM) from the resident's buttocks and anus, even after using several wipes. The CNA proceeded to place a clean brief on the resident while visible BM remained, only cleaning the area thoroughly after being prompted by the surveyor. The resident's care plan required application of barrier cream after every incontinent episode, checking and assisting with toileting every two hours, and providing perineal care after each episode. The facility's perineal care policy specified that staff should use proper hand hygiene, wear gloves, and clean from front to back, using a clean wipe for each stroke, and ensure all soiling is removed. The CNA did not adhere to these procedures, as evidenced by incomplete cleaning and failure to perform hand hygiene after glove removal. Interviews with the CNA and facility leadership confirmed that the CNA was aware of the correct procedures and the importance of thorough cleaning to prevent infection and skin breakdown. However, the CNA did not follow the established policy during the observed care, and the administrator acknowledged unfamiliarity with the policy due to being new to the facility.
Failure to Properly Store Open Spices in Kitchen
Penalty
Summary
Surveyors observed that multiple food spices, including Italian seasoning, oregano, garlic salt, garlic powder, granulated garlic, and ginger, were stored open on kitchen shelves on two separate occasions. Staff interviews confirmed that all spices should be clean and closed when stored, and there was no acceptable reason for them to be left open. Staff acknowledged that they had received training on proper storage of spices and food in the kitchen. A review of the facility's policy on dry storage and supplies indicated that open packages of food are to be stored in closed containers with tight covers and dated as to when opened. Despite this policy, the observed practice did not align with the established procedures, as open spices were left exposed on shelves. Staff, including dietary management and administration, confirmed their understanding of the policy and the expectation that all staff are responsible for ensuring proper storage.
Lack of Physician Orders for Hospice Care
Penalty
Summary
The facility failed to ensure that residents receiving hospice care had a physician's order for such services, affecting four out of five residents reviewed. This deficiency was identified through observation, interviews, and record reviews. The residents involved were receiving hospice services from different hospice companies, but their records lacked the necessary physician orders to authorize these services. Resident #1, a female with severe cognitive impairment and multiple diagnoses, was receiving hospice services from Hospice Company A, as indicated in her care plan and MDS. However, her physician orders did not include an order for hospice care. Similarly, Resident #2, a male with severe cognitive impairment and a terminal illness, was using Hospice Company B, but his physician orders also lacked a hospice care order. Resident #3, a female with severe cognitive impairment, and Resident #4, a male with moderate cognitive impairment, were both receiving hospice services from Hospice Company A, yet neither had the required physician orders documented. Interviews with the Director of Nursing (DON) and the Administrator (Adm) revealed that the facility's process for ensuring physician orders for hospice care was not followed. The DON acknowledged the responsibility to ensure such orders were in place and admitted to not knowing why the orders were missing. The Adm also expected physician orders to be present and noted that the DON and ADON were responsible for auditing the charts. The facility's policy required documentation of a Physician Certification of Terminal Illness, which was not adhered to in these cases.
Inadequate Hand Hygiene Practices During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices observed among staff members during wound care for three residents. Certified Nursing Assistant (CNA) A did not adhere to proper handwashing techniques before and after assisting with wound care for two residents. Specifically, CNA A washed her hands for only 6 seconds and 4 seconds, respectively, instead of the recommended 20 seconds, and failed to wash her hands before putting on gloves. Similarly, CNA B also demonstrated inadequate hand hygiene practices while assisting with wound care for another resident. CNA B applied soap and immediately rinsed her hands without allowing the soap to lather, and used the same paper towel to dry her hands and turn off the faucet, which is against the facility's hand hygiene policy. These actions were observed during wound care procedures, which are critical moments for infection control. Interviews with the CNAs revealed that they were aware of the handwashing policy but did not follow it during the observed incidents. The Director of Nursing (DON) and the Administrator confirmed that handwashing is a critical component of infection control, especially for residents with wounds, and acknowledged that staff had been trained multiple times. However, the failure to adhere to proper hand hygiene practices poses a risk of cross-contamination and infection spread among residents.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. Specifically, a medication cart in Hall 200 was left unlocked and unattended, with its drawers facing a public access walkway. This incident was observed by a surveyor, who noted that the cart contained medications for Hall 200 residents. RN A, responsible for the cart, admitted to leaving it unlocked because he was in a rush, despite having received recent training on medication security. The facility's Director of Nursing (DON) confirmed that RN A did not follow the facility's protocol, which mandates that medication carts be locked at all times when unattended. During the observation, cognitively impaired, independently ambulatory residents were seen moving through the facility corridors, which included two residents at different times. The DON expressed concern that residents could access the unlocked cart, potentially leading to adverse reactions. The facility had conducted an in-service training on medication security, which RN A attended, emphasizing the importance of keeping medication carts locked and keys secure. The facility's policy also requires that the unlocked side of the cart be in full view of the nurse during medication administration and that the cart be locked afterward.
Infection Control Breach Due to Staff Non-Compliance
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of a staff member who did not adhere to proper infection control protocols. The staff member, identified as SW, entered the room of a resident on contact isolation for Carbapenem Resistant Pseudomonas Aeruginosa without wearing appropriate personal protective equipment (PPE) or practicing hand hygiene. The SW then removed a reusable cup from the resident's room, refilled it at a community water station, and returned it to the resident's room, further entering additional resident rooms without following proper infection control measures. The resident involved was a female with multiple complex medical conditions, including acute and chronic respiratory failure, chronic obstructive pulmonary disease, and dependence on a ventilator. The resident was on contact precautions due to the presence of Pseudomonas Aeruginosa in her sputum. Despite clear signage and protocols in place for contact precautions, the SW did not follow the required procedures, which included donning gown and gloves and performing hand hygiene before and after entering the resident's room. Interviews with facility staff, including the Director of Nursing (DON) and Corporate RN, confirmed that the SW's actions were contrary to the facility's infection control policies. The SW admitted to not seeing the contact precaution sign and acknowledged not practicing hand hygiene or wearing PPE. The facility's policies clearly outlined the necessity of PPE and hand hygiene to prevent the transmission of infections, yet these were not adhered to, placing residents at risk for infection and cross-contamination.
Removal Plan
- Staff will be in-serviced on Infection Control Overview.
- Staff will be in-serviced on proper PPE use for MDRO isolation and Enhanced Barrier Precautions.
- Staff will be in-serviced with return demonstration related to hand hygiene and donning and doffing PPE.
- Staff will be in-serviced on management of multi-use or non-disposable items leaving isolation rooms.
- Staff will be in-serviced on Carbapenem-resistant pseudomonas aeruginosa (CRPA).
- Staff will be in-serviced over management of all dietary items including beverage cups using disposable items only.
- Community water station was removed from service and sanitized prior to continued use.
- Nursing station was immediately sanitized to prevent cross contamination.
- Disposable cups will be placed behind the nursing station for use with MDRO isolation residents.
- All non-disposable cups were removed from the resident room.
- Disposable blood pressure cuffs, thermometer, stethoscope to be kept in room to prevent cross contamination.
- MDRO isolation signs will be printed in bright orange color to attract staff attention prior to entering resident rooms.
- The DON / designee will observe PPE use by randomly selecting staff members on various shifts.
- The DON/designee will observe all MDRO resident rooms to assure that non-disposable dietary items are not in resident room.
- The QA committee will review findings and make changes as needed.
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 138 citations issued within 25 miles in the last 12 months — including the 12 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 Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lubbock Health Care Center | 0.3 mi | ★★★★★ | 6 | 0 |
| Lakeside Rehabilitation And Care Center | 0.4 mi | ★★★★★ | 7 | 0 |
| Mi Casita Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 15 | 0 |
| Mesquite Post Acute Care | 0.8 mi | ★★★★★ | 11 | 0 |
| The Mildred & Shirley L. Garrison Geriatric Educat | 1 mi | ★★★★★ | 14 | 5 |
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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.