Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Southland Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Staff did not use the required PPE during high-contact care for two residents on EBP. One CNA provided catheter and brief care to a resident with a urinary catheter without a gown, and an ADON and CNA provided incontinent care and a mechanical lift transfer to another resident with a g-tube and wounds without wearing gowns. Interviews confirmed staff knew gowns and gloves were required for EBP care, but they did not follow that practice during the observed care.
Improper incontinent care and perineal cleaning: A resident with BPH, UTI, dementia, and prostate cancer who was fully incontinent of urine and bowel was observed with wet clothing and feces in his brief. A CNA and the ADON did not fully clean the resident’s inner thighs, buttocks, scrotum, or uncircumcised penis before applying a clean brief, and the surveyor had to intervene before care was completed.
Staff failed to ensure safe use of mechanical lifts and slings for two residents requiring extensive assistance with transfers. One resident with lumbar disc degeneration and ADL self-care deficits was transferred with a mechanical lift while a CNA used a sling with faded loops present in the room and did not lock the lift brakes before raising the resident from bed or lowering him into a wheelchair, contrary to facility policy. Another resident with cerebral palsy and severe cognitive impairment was observed in a wheelchair sitting on a mechanical lift sling with fraying loops. Facility staff, including the Laundry Director and Resource RN, acknowledged that slings should be inspected for fading, rips, or tears and that brakes should be locked during transfers to prevent injury.
A resident who required staff assistance with toileting received incontinent care from a CNA who, after cleaning feces from the rectal area, removed one soiled glove and donned a clean glove without performing hand hygiene and without changing the other glove, then continued care and assisted with transfer. In interviews, the CNA admitted not sanitizing her hands, while the ADON and a resource RN stated that staff are expected to follow hand hygiene policy, including cleaning hands when moving from dirty to clean tasks and after glove removal, as outlined in the facility’s hand hygiene policy.
Kitchen Pest Control Failure: A live roach was observed in the dry pantry behind cereal and another was seen in the main prep area under the stove/oven. Staff reported roach activity for about a month, with sightings dating back to November and concerns that roaches were entering with delivered food. The ADM knew about the problem, and records showed ongoing pest activity with repeated exterminator treatments and a tracking form noting roach activity.
A resident with CHF and venous insufficiency had a care plan that did not include the resident’s active problems or ordered interventions, including daily compression stockings, edema monitoring, or diuretic therapy. The resident said staff had not applied compression stockings in months and none were in the room, and he was observed sitting in a wheelchair without stockings while his legs appeared dark pink with edema. The MDS Coordinator, DON, and Administrator acknowledged the care plan lacked the needed interventions.
Compression stockings were not applied as ordered for a resident with CHF and venous insufficiency. The resident was observed without stockings during multiple checks, stated staff had not applied them in months, and said he could not apply them himself. Although the MAR/TAR showed the task as completed, an LVN admitted signing it off without actually doing it, and the DON noted there was no documentation of refusals and no related care plan interventions.
Dirty oxygen concentrator filters were observed for two residents receiving O2 via nasal cannula. One resident had dementia and chronic respiratory failure with hypoxia, and the other had COPD and chronic respiratory failure; both had active O2 orders and care plans. The DON said staff were supposed to check the filters during rounds, but they had been missed because staffing was short, and the facility policy stated nursing staff is responsible for cleaning filters.
The facility failed to notify the physician of significant changes in the wound conditions of two residents, leading to an Immediate Jeopardy situation. One resident was hospitalized with sepsis and osteomyelitis due to a deteriorating pressure ulcer, while another developed an unstageable pressure ulcer that was not properly communicated to the physician. The facility's inadequate communication and assessment processes resulted in delayed medical treatment and worsening conditions.
The facility failed to prevent and manage pressure ulcers for two residents, leading to one resident developing a stage 4 ulcer and hospitalization with sepsis. The facility did not notify the Medical Director of wound changes and failed to accurately assess the wounds. The treatment nurse was not wound care certified, and there was no wound care physician visiting the facility, contributing to the deficiency.
The facility failed to remove worn and damaged Hoyer slings from service, posing a risk of injury to residents. Observations showed residents using slings with faded straps, despite staff training on identifying and removing such slings. Interviews confirmed that staff were aware of the procedures, but the slings were not removed. Laundry practices, including the use of bleach, contributed to the deterioration of the slings, and the facility's policy on sling inspection and replacement was not consistently followed.
A resident with multiple infections received care from two CNAs who failed to sanitize or wash their hands between glove changes, violating the facility's infection control policies. This lapse in hand hygiene occurred during catheter and incontinent care, posing a risk of cross-contamination and infection.
The facility failed to post daily nurse staffing information in a visible location, placing it on a wall in hall A instead of a prominent area like the front entrance. The Treatment Nurse, responsible for the posting, was unaware of the requirement for visibility. The issue was identified and corrected the following day.
A resident with multiple health issues, including pneumonia and muscle wasting, was not provided with necessary ADL assistance, resulting in dirty bed linens and a strong ammonia odor in the room. Despite protocols for rounding every two hours, staff interviews revealed inconsistencies in care, with the resident often left wet and expressing dissatisfaction with the facility's services.
Two residents with cognitive impairments eloped from a secured unit due to inadequate supervision and security measures. One resident climbed out of a window and broke a fence, while another propelled herself out of the facility in a wheelchair. Staff failed to conduct head counts or respond adequately to alarms, and the incidents were not reported to the state agency.
Two residents in a LTC facility were not treated with dignity and respect during personal care. One resident was subjected to degrading language by a CNA, while another resident experienced inappropriate handling during an altercation with a CNA. Both incidents involved residents with severe cognitive impairments and highlight a failure in maintaining resident dignity.
A resident with dementia and a history of wandering eloped from a secured unit by unlocking a window and breaking through a fence. Despite minor injuries, the incident was not reported to the state agency within 24 hours, as facility staff believed it was not reportable since the resident did not leave the premises. Interviews revealed a lack of consensus among staff on reporting requirements, and facility policies were not followed.
Failure to Use Required PPE During EBP Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when staff did not use the appropriate PPE during resident care for two residents on Enhanced Barrier Precautions (EBP). One resident had diagnoses including UTI, ESBL resistance, and chronic kidney disease, and had a physician order for catheter care every shift. During observation, a CNA entered the room, put on gloves, and provided care involving the resident’s brief and urinary catheter without a gown. There was no sign on the door or PPE noted in the hallway or hanging on the door at the time of the observation. A second resident had diagnoses including COPD, gastrostomy status, and chronic atrial fibrillation, and had orders for enteral feedings and unstageable heel wounds. During observation, the room had an EBP sign on the door and PPE hanging outside the room. The ADON and a CNA provided incontinent care and transferred the resident with a mechanical lift, but neither staff member put on a gown before the transfer. They later handled the resident’s brief, wipes, and repositioning while repeatedly removing and replacing gloves and sanitizing hands, but the required gown use was not observed during the care activities described. Interviews confirmed the staff understood gowns and gloves were required for residents on EBP during high-contact care, including catheter care, hygiene, transferring, and changing briefs. The CNA who cared for the first resident said she should have worn a gown because the resident had a urinary catheter. The CNA and ADON who cared for the second resident both acknowledged they did not wear the appropriate PPE during the care provided. The DON and Administrator also stated that residents with urinary catheters, tubes, wounds, or IVs were to have staff wear the appropriate PPE according to facility policy.
Improper Incontinent Care and Perineal Cleaning
Penalty
Summary
The facility failed to ensure proper incontinent care for a resident with diagnoses including BPH, UTI, dementia, and prostate cancer who was always incontinent of urine and bowel and required substantial to maximal assistance with personal hygiene. The resident’s care plan directed staff to check him as required for incontinence and to wash, rinse, and dry the perineum. During observation, staff placed him in bed for incontinent care, but his pants were wet and his brief contained feces. During the care provided by a CNA and the ADON, the resident was not cleaned properly. Feces remained on his inner thighs, buttocks, and scrotum, and the CNA did not clean his penis properly even though he was uncircumcised. The CNA used wipes on his inner thighs and buttocks, removed and reapplied gloves multiple times, and applied a clean brief before the resident was fully cleaned. The surveyor intervened and had staff look at the resident to see if he was cleaned properly, after which staff completed the care. The CNA stated she should have paid more attention to how the resident was cleaned and acknowledged that he was uncircumcised and should have had his foreskin pulled back, cleaned, and replaced. The ADON stated the resident’s brief was 100% saturated with urine and should have been changed earlier, that feces indicated he had been sitting in it for a while, and that she did not notice he was still dirty before the surveyor intervened. The DON and Administrator stated residents should be cleaned properly and staff were expected to follow policy and procedures.
Failure to Ensure Safe Mechanical Lift Use and Sling Integrity
Penalty
Summary
Surveyors identified that staff failed to maintain a safe environment during mechanical lift use and sling management for two residents. For one male resident with intervertebral disc degeneration and an ADL self-care performance deficit requiring staff assistance for transfers, surveyors observed a lift sling on his overbed table with loops that were faded in color. When questioned, the CNA initially denied the fading but then acknowledged the loops were faded compared to when the sling was new and obtained another sling for the transfer. During the same observation, the CNA did not lock the brakes on the mechanical lift before raising the resident from the bed or before lowering him into his wheelchair, despite facility policy requiring the base to be stable and locked and the CNA’s own acknowledgment in interview that failure to lock brakes could cause the lift to tip and residents to get hurt. For a female resident with cerebral palsy, severe cognitive impairment (BIMS score of 00), and dependence on staff for transfers using a mechanical lift with two staff members, surveyors observed her seated in a wheelchair in a common area with a mechanical lift sling underneath her. The sling’s loops were noted to be fraying. The Laundry Director stated that slings were laundered without bleach and air dried and that she would show any sling with discoloration, fading, rips, or tears to the DON so it could be removed if needed, acknowledging that residents could be hurt if a sling broke during transfer. The Resource RN stated she expected staff to follow policy and procedures for mechanical lift use, including locking brakes and inspecting slings for damage or wear, and stated that failure to lock brakes or use of an unsafe sling could result in resident injury. Facility policy required ensuring mechanical lift equipment was in good working condition, performing safety checks per manufacturer recommendations, inspecting slings for damage or wear before use, and positioning the lift with a stable, locked base.
Failure to Perform Hand Hygiene During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during incontinent care, as required by its infection prevention and control program and hand hygiene policy. A male resident, admitted with intervertebral disc degeneration of the lumbar region and documented to need staff assistance for toileting due to an ADL self-care performance deficit, received incontinent care from a CNA. During this care, after the CNA cleaned feces from the resident’s rectal area, she removed the glove from her right hand and immediately donned a clean glove on that hand without performing hand hygiene. She did not change the glove on her left hand and then proceeded to place a clean brief on the resident and assist with transferring him from bed to chair. In a subsequent interview, the CNA acknowledged that she did not sanitize her hands during perineal care and confirmed she only changed the glove on her right hand after cleaning the rectal area, explaining she had not anticipated needing to perform incontinent care and was not prepared. The ADON stated she expected staff to perform hand hygiene when providing incontinent care and recognized that failure to do so could increase residents’ risk for infections. The Resource RN similarly stated she expected staff to follow policy and perform hand hygiene, especially when moving from dirty to clean tasks, and that residents could get an infection if hand hygiene was not performed. The facility’s hand hygiene policy, dated 10/2022, requires use of alcohol-based hand rub or soap and water before moving from a contaminated body site to a clean body site during resident care and after removing gloves, which was not followed in this incident.
Kitchen Pest Control Failure
Penalty
Summary
The facility failed to maintain an effective pest control program and failed to keep the kitchen free from roaches. During an initial tour of the dry pantry area on 1/05/2026 at 9:00 AM, a live roach was observed crawling up the wall behind bags of cereal, and dried roach excrement was seen on the wall after the cereal was moved. During the initial tour of the main kitchen cooking and preparation area on 1/05/2026 at 9:05 AM, a live roach was observed crawling on the floor under the stove and oven area. Staff interviews indicated the roach problem had been ongoing for about a month, with one staff member stating the food delivery company had delivered a box of potatoes that contained roaches and that this was believed to be the source. Another staff member said roaches had been seen in the kitchen since about November 2025, and multiple staff reported seeing roaches in the kitchen and reporting them to management. The Administrator acknowledged awareness of the roach problem and said the facility changed pest control companies in November 2025 in an effort to address it. The Maintenance Director stated the new exterminator first sprayed on 11/17/25, was supposed to return on 12/1/25 but did not, and next sprayed on 12/19/25. Record review showed the facility’s Quality Team Tracking Form identified roach activity and directed pest control treatment twice every two weeks for a month then monthly, with dietary staff to monitor for new or worsening sightings and notify the vendor the same day. The pest control invoices reviewed documented live roaches found and treated in the cafeteria on 11/13/2025, 11/17/2025, and 12/19/2025.
Care Plan Missing CHF and Venous Insufficiency Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident whose revision date was 11/10/2025. The care plan did not reflect problems, goals, or interventions for congestive heart failure or vascular insufficiency, and it did not include interventions such as daily application of compression stockings, monitoring for edema, or administration of diuretic therapy. The resident’s record showed diagnoses of congestive heart failure and venous insufficiency, and the quarterly MDS indicated intact cognition with a BIMS score of 15 and active diagnoses of heart failure and chronic peripheral venous insufficiency. A physician order dated 08/29/2025 directed staff to apply light to moderate compression stockings above the knees every morning and remove them at bedtime. During observation and interview on 01/06/2026, the resident stated he had not had compression stockings applied by staff in months, did not have any stockings in his room, and was not aware staff were supposed to apply them daily and remove them each evening. At the time of observation, the resident was sitting in his wheelchair without compression stockings, and his legs appeared dark pink with edema. The MDS Coordinator stated she was responsible for revising and updating care plans and acknowledged the risk that the IDT might not know what was going on with residents or what changes in interventions were needed. The DON and Administrator also stated that if interventions for congestive heart failure, including compression stockings, were not included in the care plan, staff may not know the resident’s needs and changes in care provided.
Compression Stockings Not Applied as Ordered
Penalty
Summary
The facility failed to ensure that services provided or arranged in accordance with the comprehensive care plan met professional standards of quality for one resident reviewed for following physician orders. Resident #3, a male admitted with diagnoses including congestive heart failure, venous insufficiency, bipolar disorder, and major depressive disorder, had a physician order dated 08/29/2025 for light to moderate compression stockings above the knees every morning and removal at bedtime. During observations on 01/05/2026, he was seen in his wheelchair in the common area, hallway, and dining area without compression stockings on his lower extremities. On 01/06/2026, Resident #3 stated he had not had compression stockings applied by staff in months, did not have any in his room, and could not apply them himself because it was too difficult. He said he was not aware staff were supposed to apply them every day and remove them every evening. At that time, he was observed sitting in his wheelchair in his room without compression stockings, and his legs were described as dark pink with edema. Later that day, he was observed in the dining room participating in an activity with compression stockings on both lower legs. The Medication and Treatment Administration Summary for January 2026 showed entries indicating compression stockings were completed on 01/05/2026 and 01/06/2026. However, during interview, LVN B stated she had signed off on the task without putting the stockings on the resident and acknowledged she should not have signed it without completing the order. The DON stated orders should not be signed off if not completed and noted she had been informed the resident was refusing application, but there was no documentation in the progress notes and refusals were not included in the current care plan. The comprehensive care plan reviewed on 01/06/2026 contained no problem area, goals, or interventions related to congestive heart failure, including compression stockings, edema monitoring, or diuretic therapy.
Dirty oxygen concentrator filters found for two residents
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care received care consistent with professional standards of practice for 2 residents who were receiving oxygen therapy. Resident #11 had diagnoses including dementia and chronic respiratory failure with hypoxia, was severely cognitively impaired, dependent for all ADLs, and had an order for oxygen at 2-4 L/min via nasal cannula. Resident #44 had diagnoses including COPD and chronic respiratory failure, was cognitively intact, dependent for most ADLs, and had an order for oxygen at 2-5 L/min continuously via nasal cannula. Both residents had care plans addressing oxygen therapy. During observations, Resident #11 was seen in bed wearing oxygen via nasal cannula, and the outer filter of the oxygen concentrator was dirty with a thick buildup of dust. Resident #44 was also observed in bed wearing oxygen via nasal cannula, and the outer filter of the oxygen concentrator was dirty with a buildup of thick dust and hair. The DON stated that administrative staff were supposed to check concentrator filters during department head rounds and that angel rounds were supposed to be done every day, but later said the filters had been missed because staff had been pulled short working weekends. The Administrator stated the ADON would be made responsible for monitoring and ensuring the concentrator filters were cleaned. The facility policy titled Oxygen Administration stated that nursing staff is responsible for cleaning filters.
Failure to Notify Physician of Wound Changes
Penalty
Summary
The facility failed to consult with the physician when two residents experienced a change in condition, specifically regarding their skin and wound care. Resident #1, who had Alzheimer's disease and heart failure, was admitted to the hospital with sepsis and osteomyelitis after his sacrococcygeal wound deteriorated to a stage IV pressure ulcer. The facility did not notify the Medical Director of the changes in Resident #1's wound condition, despite the wound showing signs of infection and necrosis. The Treatment Nurse and other staff were aware of the wound's progression but failed to ensure proper physician notification and intervention. Resident #2, diagnosed with dementia and prostate cancer, developed an unstageable pressure ulcer that was not properly communicated to the physician. The facility's skin report did not list Resident #2 as having a wound, and the Treatment Nurse did not notify the Medical Director of the wound's condition. The wound was observed to have black eschar and surrounding skin issues, but the facility did not take timely action to address the severity of the wound. Interviews with staff revealed a lack of consistent communication and assessment of the wound, leading to inadequate care. The facility's failure to follow its skin and wound policy and notify the Medical Director of significant changes in the residents' conditions resulted in an Immediate Jeopardy situation. The lack of proper notification and assessment placed the residents at risk for delayed medical treatment and worsening conditions. The facility's documentation and communication processes were insufficient to ensure timely and appropriate care for residents with changing medical conditions.
Removal Plan
- The Medical Director was notified of IJ.
- Review of the 24-hour report was completed to ensure family and MDs were notified by DON, ADON.
- Education was initiated with Nurses by the DON, ADON, and Clinical Resource. The training included Nurse Assessment, Change in Condition Process, documentation of the change in condition, notification to the physician, notification of family, reviewing the resident's health condition with the attending physician, and when to reach out to the Medical Director if the assigned physician is not available.
- A knowledge check form, to ascertain staff understanding of training, will be initiated with nurses. The Clinical Resource will complete tracking for education and knowledge check form completion for each nurse.
- This education and knowledge check will be completed with facility nurses, all nurses will complete education prior to start of their next shift. This reeducation may be in-person or over the phone with the DON, ADONs, or Clinical Resource. This education will also be included in the new hire orientation and will be included for agency /PRN staff (currently the facility does not utilize agency).
- An ad hoc meeting regarding items in IJ template will be completed. Attendees include Administrator, DON, Medical Director, and Clinical Resource. The Plan of removal items and interventions were developed, reviewed, and will be agreed upon.
- Changes in condition will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designees to attend weekly clinical meetings to include review of residents with change in conditions, hospital transfers and update of care plan interventions, notifications of Resident Responsible Parties, and Physicians.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for two residents. One resident, who was initially not at risk for pressure ulcers, developed a wound on the sacrum that progressed from excoriation to a stage 4 pressure ulcer, leading to hospitalization with sepsis and osteomyelitis. The facility did not notify the Medical Director of the changes in the resident's wound condition, and the wound assessments were not accurately conducted. Another resident developed a wound on the sacrum that became unstageable. The facility's skin report did not list this resident as having a wound, and there was a lack of proper notification and assessment of the wound's condition. The treatment nurse and weekend RN were responsible for wound care, but there was no wound care physician visiting the facility, and the treatment nurse was not wound care certified. The facility's failure to follow its skin and wound policy, including notifying the Medical Director and accurately assessing pressure sores, led to the identification of an Immediate Jeopardy situation. The facility's lack of communication and proper wound care management placed residents at risk for worsening pressure injuries and decreased quality of life.
Removal Plan
- The Medical Director was notified by the Executive Director.
- The Attending Physician was notified by the Executive Director, of the IJ.
- New Braden scales for the total census initiated and will be completed by Clinical Resources, Clinical Leaders MDS Nurse, ADON, and DON.
- Audit completed by DON of all residents who are at risk for PU/PI, care plans and care profiles were updated for all residents at high risk to include personalized/individualized interventions/prevention.
- Skin assessments were completed on all residents. These were conducted by the DON, ADON, MDS Nurse, Wound Care Nurse, and Clinical Resource.
- Education initiated by Clinical Resource with, DON, ADON, Nurses, CMAs, and CNAs that included change in condition procedures for wounds, change in behaviors, refusal of care, turning and repositioning, notification of changes in wounds, interventions, and preventions, as well as communication between Nursing staff and health care professionals; will be completed. Any staff unable to attend will not be allowed to work unless they have received their training and knowledge check.
- All licensed nurses will complete competency on skin assessments initiated and will be completed by DON, ADON, and Clinical Resource.
- All CNA's will complete competency on skin check initiated and will be completed by DON, ADON, MDS Nurse, and Clinical Resource.
- This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check.
- An ad hoc QAPI meeting regarding items in the IJ template will be completed. Attendees will include the Medical Director, Clinical Resource, Administrator, DON, ADON, and will include the plan of removal items and interventions.
- The DON, ADON or Clinical Resource will verify staff competency with 10 staff weekly using the skin check competency checklists.
- All residents with pressure ulcers will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions, as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director, and Wound Nurse. The DON and Administrator will be responsible for ensuring this meeting is held weekly and all residents with pressure ulcers/pressure injury are reviewed.
- Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance.
- Resident #1 is no longer a resident in the facility.
- Wound Care nurse was checked off on wound care, in-serviced on policies and procedures, change of condition, notification of physician, and responsible party.
Failure to Remove Damaged Hoyer Slings
Penalty
Summary
The facility failed to ensure the residents' environment was free from accident hazards, specifically by not removing worn and damaged mechanical lift slings from service. Observations revealed that several residents were using Hoyer slings with faded straps, which were not removed despite staff training on identifying and removing such slings. The faded slings were observed under residents in wheelchairs, indicating a potential risk of injury if the slings failed during transfers. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN), and Physical Therapy Assistant, confirmed that staff had been trained to remove slings with rips, tears, or fading. However, the slings in question were not removed, suggesting a lapse in adherence to the training. The Director of Nursing (DON) acknowledged that staff had been in-serviced on Hoyer lift safety, which included removing damaged slings from use. Further investigation revealed that the facility's laundry practices contributed to the deterioration of the slings. The Laundry Staff admitted to using bleach on slings washed with isolation items, which could cause fading and weakening of the material. The Housekeeping Supervisor was unaware of the bleaching practice and acknowledged the need for a plan to disinfect slings without bleach. The facility's policy required slings to be inspected before each use and replaced if damaged, but this was not consistently followed, leading to the deficiency.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices observed during the care of a resident. The resident, who was admitted with diagnoses including a urinary tract infection, Alzheimer's disease, and urogenital candidiasis, required substantial assistance with personal hygiene and was incontinent of urine and frequently incontinent of bowel. During a care procedure, two CNAs were observed not sanitizing or washing their hands between glove changes while providing catheter and incontinent care to the resident. The CNAs, identified as CNA F and CNA G, were observed performing catheter and incontinent care without adhering to proper hand hygiene protocols. They failed to sanitize or wash their hands between glove changes, which is a critical step in preventing cross-contamination and infection. The CNAs also improperly disposed of gloves, with some falling to the floor due to an overflowing trash can. These actions were contrary to the facility's policies on hand hygiene and catheter care, which require hand hygiene before care, between glove changes, and after care. Interviews with the CNAs and facility management revealed a lack of consistent skills check-offs and training reinforcement. Both CNAs acknowledged the risk of cross-contamination and infections due to their actions and admitted to not following proper procedures. The facility's policies on hand hygiene and catheter care were not effectively implemented, as evidenced by the CNAs' failure to perform hand hygiene as required, leading to a deficiency in infection control practices.
Failure to Post Daily Nurse Staffing Information in a Visible Location
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a location that was readily accessible to residents and visitors. On 11/4/2024, the daily staffing information was not posted in a prominent place, such as the front entrance or the nurse's station, as required. Instead, it was found on a wall in hall A, which was not visible to those entering the facility. This oversight was identified during an observation on 11/4/2024 at 9:15 AM and confirmed during a subsequent observation and interview on 11/5/2024 at 7:55 AM. The Treatment Nurse, who was responsible for placing the staffing posting, stated that she had been instructed by management to post it on hall A and was unaware that it needed to be in a visible location for all residents and visitors. The Administrator confirmed that the Treatment Nurse was responsible for the daily staffing census posting and that it should be displayed within two hours of her arrival at work. The issue was rectified on 11/5/2024, with the posting relocated to the front entrance by 11/6/2024.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living (ADLs), specifically in maintaining good nutrition, grooming, and personal and oral hygiene. This deficiency was observed in a resident who had been admitted with diagnoses including pneumonia, muscle wasting, weakness, and difficulty walking. The resident required supervision or touching assistance for all ADLs and was occasionally incontinent of bladder. During an observation, the resident's bed linens were found to be visibly dirty with a dark yellow stain and a brown ring, and the room had a strong odor of ammonia. Interviews with the resident and staff revealed that the resident had been left wet for hours, and staff had not checked her bed despite the odor. The resident expressed dissatisfaction with the care provided, noting that this was an ongoing issue and she was considering moving to another facility. Staff interviews indicated that the standard was to round on residents every two hours, but there was a lack of consistent adherence to this practice. The Assistant Directors of Nursing (ADONs) and Certified Nursing Assistants (CNAs) acknowledged the risks of skin impairment from wet linens and briefs but noted that the resident was usually independent and changed her own linens. Further interviews with the facility's administration, including the Administrator and Director of Nursing (DON), confirmed that the expectation was for residents to be rounded on every two hours. The DON stated that special briefs with wetness indicators were used, and staff were expected to investigate any odors of ammonia. Despite these protocols, the resident's room was frequently found to smell of urine, and the resident's needs were not consistently met, leading to the deficiency in care.
Inadequate Supervision Leads to Resident Elopements
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for two residents, leading to incidents of elopement. Resident #1, who had a history of dementia and was identified as a high risk for elopement, managed to climb out of a window in the secured unit and broke a fence in the courtyard. This incident occurred despite the resident being on a secure unit with interventions in place to document wandering behavior. The resident was found outside the facility with minor injuries, indicating a lapse in supervision and security measures. Resident #4, who had severe cognitive impairment and used a wheelchair for mobility, also eloped from the facility. Despite being assessed as a low risk for elopement, the resident managed to propel herself out of the facility and was found near the dumpsters outside. The staff failed to conduct a head count or adequately respond to the door alarm, which allowed the resident to remain outside for an extended period before being found by a third party. Interviews with staff revealed a lack of consistent procedures and understanding regarding elopement risks and responses. The facility's policies on elopement and unsafe wandering were not effectively implemented, as evidenced by the failure to conduct post-incident evaluations and the inadequate response to alarms. The incidents were not reported to the state agency, as the facility did not consider the residents to be missing since they did not leave the premises, highlighting a misunderstanding of reporting requirements.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, compromising their quality of life. For the first resident, a CNA spoke degradingly during personal care after the resident vomited and had a bowel movement. The CNA used inappropriate language and continued to yell and curse at the resident despite being asked to leave the room by an LVN. The LVN, who was new and in training, was unsure how to handle the situation and reported the incident to the administrator the following day. In the second incident, another CNA was involved in an altercation with a resident during personal care. The resident, who had severe cognitive impairment and behavioral issues, was reportedly aggressive and attempted to hit the CNA. The CNA allegedly tapped the resident's hand in a manner perceived as degrading by a family member who observed the incident on video. The CNA was suspended and received training before returning to work. Both incidents highlight the facility's failure to ensure that staff treated residents with dignity and respect during personal care. The actions of the CNAs involved were inappropriate and not in line with the facility's policy on resident rights, which emphasizes treating residents with kindness, dignity, and respect.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a resident who eloped from a secured unit. The resident, diagnosed with dementia, depression, and anxiety disorder, was identified as an elopement risk and had a history of wandering. On the day of the incident, the resident managed to unlock a window, exit into the courtyard, and break through a wooden fence. The resident was found with minor injuries, including scratches and a skin tear, but the incident was not reported to the state agency within the required 24-hour timeframe. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, revealed a lack of consensus on whether the incident was reportable. The ADON and DON believed the incident was not reportable because the resident did not leave the facility premises. The Administrator, who was also the abuse coordinator, shared this view, stating that the resident's improved cognitive state at the time of the incident and the short duration of the elopement did not warrant reporting. The facility's Resource Leader was consulted but did not provide specific guidance on this incident. The facility's policies on elopement and reporting alleged violations of abuse, neglect, and mistreatment were reviewed. The policies indicated that incidents involving a missing resident should be reported to the state agency within 24 hours, even if the resident did not suffer serious bodily injury. Despite this, the facility did not report the incident, citing their interpretation of the resident not being considered missing since he remained on the premises.
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What surveyors actually found near you
We read the 82 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lufkin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinecrest Retirement Community | 2.9 mi | ★★★★★ | 2 | 0 |
| Parkwood In The Pines | 3.4 mi | ★★★★★ | 11 | 0 |
| Kennedy Health & Rehab | 4.1 mi | ★★★★★ | 14 | 7 |
| Larkspur | 4.3 mi | ★★★★★ | 3 | 0 |
| Castle Pines Health And Rehabilitation | 4.3 mi | ★★★★★ | 1 | 1 |
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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.