Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Sundance Inn Health Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide required written transfer/discharge notices, including appeal rights and Ombudsman notification, for three residents with dementia and elopement or wandering concerns. One resident with moderate cognitive impairment was moved to another city’s secure unit while a family member was out of the country, after only a handwritten notice was given the day before transfer and after the Ombudsman had advised the facility to provide proper notice. Another resident with vascular dementia was labeled as having eloped after going outside to see fireworks, then was discharged to another town without any 30‑day or prior written notice. A third resident with severe cognitive impairment and documented elopement risk was transferred to a secure unit at another facility based only on verbal agreement with the responsible party, with no written notice in the record. The ADM acknowledged that written notices were not provided because families were involved in discussions, and the SW reported uncertainty about the discharge process, despite a facility policy requiring 30‑day written notice (or as soon as practicable in exceptions) with specific content and evidence of notice to the LTC Ombudsman.
A resident admitted with bipolar disorder and other medical conditions was receiving Seroquel 100 mg twice daily, but the facility failed to maintain a complete and properly documented consent for this antipsychotic medication in the medical record. Nursing staff were responsible for medication consents, yet the DON reported being unfamiliar with the required state psychotropic consent form and unaware it was needed for the resident’s Seroquel. Two different consent documents dated the same day were found: one digitally signed by an LVN with only the resident’s initials, and another antipsychotic consent form that lacked diagnostic criteria and assessment findings, contained an altered provider name, and did not include the resident’s printed name, despite a requirement that the original form be in the clinical record. These practices did not comply with the facility’s policy requiring complete, accurate electronic clinical records with proper signatures and identifiers.
Failure to Notify Physician of Missed Ear Drop Doses: A resident with dementia, HTN, depression, anxiety, and renal insufficiency was ordered Cortisporin-TC otic drops for left ear pain, but several doses were missed while staff documented the treatment as given. MA and LVN staff reported the drops were delayed or not found, yet the physician was not promptly notified of the missed doses, and the DON confirmed nurses were expected to call the MD when treatment could not be followed.
A resident with COPD, acute respiratory failure with hypoxia, DM, anxiety, atrial fibrillation, and insomnia left the facility after being sent to the ER, but no discharge summary was completed. Staff interviews showed confusion about who was responsible for the discharge summary, with the SW, LVN, ADON, DON, and Administrator all acknowledging the missing document and describing unclear workflow when the resident left without signing paperwork.
Failure to Include PTSD in Care Plan: A resident admitted with stroke, DM, and PTSD had a care plan that did not include any intervention for PTSD, despite a BIMS score indicating he was cognitively intact. The MDS nurse stated she was responsible for transferring assessment information into the care plan and acknowledged the PTSD should have been added; the SW later ordered a psych consult, while the DON, ADON, and NP were unaware of the PTSD diagnosis.
Failure to Provide Timely Foot Care and Podiatry Follow-Through: A resident with DM, dementia, HTN, depression, and chronic venous insufficiency had toenails that were about an inch long, despite a care plan calling for podiatry referral for thick or long nails. Staff documented a podiatry request for thickened, dystrophic, and/or painful nails, but the resident said he had not been seen by podiatry during his stay and felt uncomfortable and sad after being missed. Interviews showed staff relied on podiatry referral processes, while the resident's nail care remained incomplete and his toenails were still long and jagged when observed.
Menu Not Followed for Meal Desserts: The facility failed to follow the lunch menu when pureed trays were served lemon pudding instead of the cherry cream cheese swirl brownie listed on the menu, while regular trays received the brownie. The cook said she only prepared the main courses and was not aware of the dessert issue, and the dietary manager acknowledged the desserts were different and stated all residents should receive the same menu items.
A resident with cognitive impairment and multiple chronic conditions was prescribed otic drops for left ear pain, but staff documented doses as given when the medication had not yet been received from central supply. The MAR showed missed and recorded doses that did not match staff statements, and an LPN and MA later acknowledged the treatment was checked off in error and not accurately documented. The DON stated staff were responsible for following the order and documenting when the medication was not given.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report does not provide further details about the specific events or residents involved.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found that necessary safeguards were missing or not consistently followed, resulting in inadequate protection for residents.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment presented risks that were not properly mitigated, and supervision was not sufficient to ensure resident safety.
A treatment cart containing drugs and biologicals was left unlocked and unattended by a nurse while wound care was provided to a resident with multiple medical conditions, contrary to facility policy and accepted practice. The nurse believed the cart was locked, but observations showed it remained accessible until after the treatment was completed.
CNAs failed to fully close a privacy curtain while providing incontinent care to a resident with multiple medical conditions and moderate cognitive impairment, resulting in exposure of the resident's genital area. The curtain was too short to provide adequate coverage, and a housekeeper nearly entered the room during care before being stopped. Both CNAs and the administrator confirmed that privacy should have been maintained and that staff had received resident rights training.
A housekeeper accepted a $350 check from a resident, who was cognitively intact and had multiple medical conditions, after the resident offered financial help. The incident was discovered by the resident's family member, reported to facility administration, and investigated internally. The housekeeper admitted to accepting the money despite knowing it was against policy, and the incident was not reported to law enforcement as required by facility protocol.
A facility failed to report an allegation of exploitation to law enforcement after a cognitively intact male resident gave a $350 check to a housekeeper, despite the family member's request for escalation and the facility's own protocols requiring such reporting. The administrator handled the matter internally, believing it was a voluntary gift rather than misappropriation, and did not notify law enforcement as mandated.
A container of Clorox disinfecting wipes, labeled as causing eye irritation, was found unsecured on a bedside table in a resident's room. The resident was severely cognitively impaired and required assistance with ADLs. Staff confirmed the wipes should not have been present and that a family member had brought them in, despite prior education on prohibited items.
A resident's urinary collection bag was found uncovered, violating the facility's policy to maintain resident dignity. The resident, who was cognitively intact, was unaware of the issue and expressed a preference for the bag to be covered. Facility staff, including an LVN, DON, and ADM, confirmed that covering the bag is necessary to uphold dignity, as per the facility's policy.
A resident with legal blindness and limited shoulder mobility was unable to reach their call light, leading to unmet needs and frustration. Despite facility policy and staff acknowledgment of the importance of call light accessibility, the call light was placed out of reach, contrary to standard practice.
A resident with multiple active wounds did not have an updated comprehensive care plan reflecting current treatments, despite physician orders and interventions being in place. The care plan only addressed a bruise and lacked updates for wounds on the right foot, left foot, and contracted right hand. Facility staff were unaware of the oversight, which could lead to inadequate care.
A resident with a gastrostomy tube was incorrectly administered hydralazine, prescribed orally, through the tube due to a transcription error. The RN and DON acknowledged the mistake, highlighting a failure to verify medication orders as per facility policy.
A facility failed to maintain proper infection control practices during incontinent care for a resident with multiple health conditions. CNAs did not follow hand hygiene protocols, such as sanitizing hands after touching a trash can and between glove changes, despite having received training and passing competency checks. The DON confirmed the need for proper hand hygiene as per facility policy.
Failure to Provide Required Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer and discharge notices, including appeal rights and Ombudsman notification, for three residents who were discharged or transferred due to wandering and elopement concerns. For the first resident, an older male with NSTEMI, malnutrition, acute respiratory failure with hypoxia, BPH, and moderate dementia, the record showed moderate cognitive impairment with a BIMS score of 8 and a SLUMS score of 8/30. His care plan documented resistance to care and a wish to be discharged to another facility for elopement risk and wandering. Family members reported concerns about possible urinary infection, anxiety, and wandering behavior, and the facility informed them that the resident had tried going to exit doors. While the family was out of the country, the facility decided to move the resident to another facility with a secure unit. The family and the Ombudsman objected to the move and requested that he not be transferred until the family could be present, but the resident was still sent to another facility in another city. The Ombudsman reported that the facility only provided a handwritten notice the day before the move, which did not meet the 30‑day requirement and did not provide a reason for immediate discharge. The second resident, an older female with major depressive disorder, generalized anxiety disorder, cognitive communication deficit, peripheral vascular disease, and vascular dementia, had a BIMS score of 11 indicating moderate cognitive impairment. Her care plan addressed impaired cognition but did not address wandering. According to her representative, the resident became upset about a roommate’s frequent male visitor and was moved to a room near exit doors. On New Year’s Eve, she went outside to see fireworks and was locked out, after which the facility considered this an elopement. The representative had placed a camera in the room and reported that staff failed to check on the resident for 14 hours, which was reported as a complaint. The facility told the representative that the resident needed a secured unit due to confusion and wandering and insisted on discharge. The resident was discharged to another town without any 30‑day or prior written notice of transfer or discharge being provided to the resident or representative. The third resident, an older male admitted with metabolic encephalopathy, altered mental status, and moderate dementia, had a BIMS score of 7 indicating severe cognitive impairment. His care plan identified him as at risk for elopement, with interventions including elopement risk assessment and distraction from wandering. The social worker stated that this resident was wandering from the day of admission, was more combative, and refused care, and that the facility contacted the family and sent clinical information to a local facility with a secure unit. However, record review showed no discharge notice provided to the resident or responsible party; the record only documented that the responsible party agreed to move the resident. In interviews, the social worker acknowledged she was not sure about the discharge process and that only the administrator or business office manager issued notices. The administrator stated that because the families of all three residents were involved in decision‑making about alternate placement, the facility did not feel written notices were needed, and confirmed that only a late, non‑compliant notice was given for the first resident after Ombudsman involvement, with no notices given for the second and third residents. The facility’s own transfer and discharge policy, however, required written notice with specific content, 30‑day timing (or as soon as practicable in exceptions), and evidence of notice to the Ombudsman, which was not followed in these cases. The facility also failed to send copies of the transfer/discharge notices to the State Long‑Term Care Ombudsman as required. The Ombudsman reported that she generally received a monthly list of discharged residents but, in the case of the first resident, only received a handwritten notice the day before the move, after she had already advised the facility to provide proper notice and not to move the resident without it. The facility’s policy required that notices be provided to the resident and representative in a language and manner they understand, include specific reasons for transfer or discharge, the effective date, the receiving location, appeal rights and how to obtain assistance, and the Ombudsman’s contact information, and that the facility maintain evidence that the notice was sent to the Ombudsman. The survey findings showed that these policy elements and regulatory requirements were not met for any of the three residents reviewed for discharge rights.
Incomplete and Improperly Documented Antipsychotic Medication Consent in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident receiving an antipsychotic medication. The resident, a female admitted with metabolic encephalopathy, acute respiratory failure with hypoxia, bipolar disorder, and insomnia, had a discharge MDS showing a BIMS score of 13, indicating fully intact cognition. Her care plan, initiated on 3/8/26, identified the use of psychotropic medications with interventions to administer them as ordered and monitor for side effects and effectiveness every shift. The order summary dated 4/17/26 showed an active order for Seroquel 100 mg by mouth twice daily for bipolar disorder, starting 3/8/26 with no end date. A document titled Psychoactive Medication Consent dated 3/8/26 indicated the resident consented to Seroquel 100 mg twice daily, was digitally signed by LVN A, and contained the resident’s initials at the bottom. During interviews, the SW stated that nursing staff handled medication consents, and the DON stated that charge nurses usually completed medication consents on admission. The DON reported being unfamiliar with the required 3713 form for psychotropic medication consent and stated the facility was not aware that such a form was needed for the resident’s Seroquel. Later, the DON produced a different consent form, dated 3/8/26, titled “Consent for Antipsychotic or Neuroleptic Medication Treatment” (version September 2021-E). This form documented the resident’s bipolar disorder, Seroquel 100 mg twice daily as a home regimen, listed side effects, and described the need for treatment, but it did not list diagnostic criteria and assessment findings exhibited by the resident, had alterations to the provider’s last name, and lacked the printed name of the resident in Section II, although it contained the resident’s initials and date. The bottom of the form required that the original copy be included in the clinical record. The facility’s policy on Maintenance of Electronic Clinical Records required complete and accurate electronic clinical records, including pre-admission screening assessments with required signatures and individualized identifiers for staff attestations with date and time recorded, which was not fully met in this case.
Failure to Notify Physician of Missed Ear Drop Doses
Penalty
Summary
The facility failed to immediately inform or consult the physician and the resident’s representative when treatment was delayed for a resident who had been prescribed Cortisporin-TC otic suspension for left ear pain. The resident had moderate cognitive impairment with a BIMS score of 8, required assistance with ADLs, and had diagnoses including renal insufficiency, non-Alzheimer’s dementia, hypertension, depression, and anxiety. The physician order was for 4 drops in the left ear four times daily for 7 days, starting 08/22/25. Record review showed missed doses of the ear drops on 08/22/25 at 5:00 PM and 9:00 PM, and on 08/23/25 at 9:00 AM and 12:00 PM. The medication administration record also showed the treatment was marked as administered on some occasions when staff later stated the medication had not actually been given. Staff notes indicated the ear drops were pending delivery from central supply, and during interview MA X stated the resident had not been receiving the drops because they had not been delivered yet. MA X also stated staff were checking off the MAR as administered even though the medication had not been given. On 08/28/25, LVN G and the DON confirmed the resident had not received the ear drops as documented and that LVN G had checked the medication as administered by mistake. LVN G stated she had not notified the physician earlier about the missed doses and that she was responsible for communicating missed doses to ensure the resident completed treatment as ordered. The DON stated nurses were expected to call the physician when orders could not be followed or when there was a delay in administering treatment, and the physician stated he expected nursing staff to call him with any missed doses of medication treatment.
Missing Discharge Summary for Resident Leaving the Facility
Penalty
Summary
The facility failed to ensure that Resident #92 had a discharge summary completed after leaving the facility. Resident #92 was a male resident with diagnoses including COPD with acute exacerbation, acute respiratory failure with hypoxia, diabetes mellitus, anxiety disorder, unspecified atrial fibrillation, and insomnia. His discharge MDS reflected a discharge home with home health and current medications, PT, OT, ST, nursing evaluation and treatment as indicated, and no DME listed. Record review showed that Resident #92 was sent to the ER after a nursing progress note documented the transfer. The clinical record contained no discharge summary for the resident. The facility’s discharge summary and plan stated that the discharge summary would include a recapitulation of the resident’s stay and a final summary of the resident’s status at discharge, in accordance with regulations governing release of resident information and as permitted by the resident. During interviews, the LVN, ADON, Social Worker, DON, and Administrator each acknowledged that Resident #92 did not have a discharge summary. The LVN stated the social worker was responsible for the discharge summary, while the ADON stated every discharged resident should have one and that nursing was responsible for ensuring a discharge note was completed. The Social Worker stated the resident exited the facility and the responsible party refused to sign paperwork, and she was unclear on the procedure when a resident left without signing documentation. The DON and Administrator both stated that discharge summaries were expected and important for continuity of care, but the Administrator was not familiar with the specific procedure.
Failure to Include PTSD in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #12 that included measurable objectives and timeframes to meet his medical, nursing, mental, and psychosocial needs. Record review showed the resident was admitted with diagnoses including stroke, diabetes, and PTSD, and his BIMS score was 14, indicating he was cognitively intact. The care plan dated 8/8/25 did not include any intervention for PTSD, even though the resident’s comprehensive assessment and admission MDS reflected that diagnosis. During interviews, the DON stated the MDS nurse was responsible for ensuring care plans were comprehensive and up to date, and the MDS nurse stated she was primarily responsible for completing care plans and transferring assessment information into them. She acknowledged she should have added the resident’s PTSD to the care plan. The Social Worker stated she ordered a psychiatric consult on 8/22/25, but did not know why it had not been ordered when the MDS was completed on 8/14/25, and said the consult was pending insurance approval. The ADON stated she had not been aware of the PTSD diagnosis, and the Nurse Practitioner stated she had been unaware of the PTSD diagnosis and had not ordered a psych consult.
Failure to Provide Timely Foot Care and Podiatry Follow-Through
Penalty
Summary
The facility failed to ensure Resident #7 received foot care consistent with professional standards of practice and treatment for diabetes and other foot-related conditions. Resident #7 was a male resident with intact cognition, dependent on staff for showering and bathing, and had diagnoses including diabetes mellitus, non-Alzheimer's dementia, hypertension, depression, and chronic venous insufficiency. His care plan directed staff to refer him to a podiatrist if he had thick nails, corns, or calluses, and to refer him to podiatry to monitor and document foot care needs and cut long nails as needed. Record review showed a podiatry request was completed for thickened, dystrophic, and/or painful nails with increased risk of infection, and the resident was placed on the list for podiatry. However, when observed, his toenails were at least an inch long on both feet. The resident stated he had been in the facility over a year and had not been seen by podiatry during his stay, and he said he had spoken with the Social Worker about having his toenails trimmed but was not seen when podiatry last visited the building. He also stated he felt uncomfortable and sad because he believed he was not seen due to his weight. Staff interviews showed confusion about responsibility for nail care and podiatry follow-through. An LVN stated she knew the toenails were very long and had requested a podiatry referral, but she had never tried to trim them and believed diabetic residents were referred to the Social Worker to be seen by podiatry. The Social Worker stated the resident was placed on the podiatry list for the first time and was missed during the visit because the provider only saw 30 residents per visit. The DON and ADON stated diabetic residents were referred to podiatry for toenail cutting and trimming, and the ADON observed the resident's toenails appeared not to have been cut or trimmed in a long time and had jagged edges.
Menu Not Followed for Pureed and Regular Meal Desserts
Penalty
Summary
The facility failed to ensure the menu was followed for the lunch meal on 08/27/25. Record review of the menu showed that lunch was to include an open face sandwich, breaded corn nuggets, marinated vegetable salad, and a cherry cream cheese swirl brownie. Observation at 10:35 AM showed the pureed trays included pureed rye bread, the sandwich ingredients, creamed corn, and vegetables, but no cherry cream cheese brownie was pureed or served to residents who were supposed to receive pureed meals. During interview, the cook stated she only prepared the main courses and was unaware of the desserts served, and said no one brought her a cherry cream cheese swirl brownie to puree. The cook, dietician, and dietary manager each stated that pureed meals should match regular meals and that all residents should receive the same items on the menu. The dietary manager acknowledged that the pureed dessert was lemon pudding while the regular tray had a cherry cream cheese swirl brownie, and stated she did not notice the desserts were different that day.
Inaccurate Documentation of Ear Drop Administration
Penalty
Summary
The facility failed to maintain Resident #8’s clinical record in accordance with accepted professional standards by inaccurately documenting administration of prescribed ear drops and failing to document missed doses completely. Resident #8 was a female with moderate cognitive impairment, a BIMS score of 8, and diagnoses including renal insufficiency, non-Alzheimer’s dementia, hypertension, depression, and anxiety. Her physician ordered Cortisporin-TC Otic Suspension, 4 drops in the left ear four times daily for left ear pain for 7 days, beginning on 08/22/25 at 9:00 AM. Record review showed the medication administration record reflected doses as given on some occasions when staff later stated the medication had not actually been administered. On 08/22/25, the MAR showed doses at 9:00 AM and 12:00 PM, but no doses at 5:00 PM and 9:00 PM. On 08/23/25, the MAR showed no doses at 9:00 AM and 12:00 PM, but doses at 5:00 PM and 9:00 PM. Progress notes documented that the ear drops were pending delivery from central supply, and staff later stated the medication had not been received yet and had been checked off on the MAR by mistake. During interview, the resident stated she had an earache for about a week and believed staff were applying drops four times a day, but she felt the treatment was not working. The MA and LVN later stated the medication had not been administered as documented, that it had been placed on hold because it was not available, and that missed doses on 08/22/25 and 08/23/25 were not accurately reflected. The DON stated staff were responsible for following physician orders and accurately documenting when treatment could not be given, and the facility policy required proper documentation of medication administration and notation when medication was not given.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through surveyor observations and review of facility documentation, which revealed that the required safeguards and protocols were either not in place or not consistently followed. As a result, the facility did not ensure adequate protection of residents from potential harm related to abuse, neglect, or theft. Surveyors noted the absence of comprehensive preventive measures and a lack of staff adherence to existing procedures, contributing to the facility's inability to safeguard residents as required by regulations.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for their daily personal care and routine activities.
Failure to Maintain Accident-Free Environment and 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 posed risks that were not properly addressed, and supervision measures were insufficient to prevent potential incidents. No further details about the specific hazards, the individuals involved, or the circumstances at the time of the deficiency are provided in the report.
Unattended and Unlocked Treatment Cart with Medications
Penalty
Summary
A deficiency occurred when a nursing treatment cart containing drugs and biologicals was left unlocked and unattended by the Treatment Nurse. During the provision of wound care to a resident with heart failure, high blood pressure, and an open wound on the right toes, the nurse entered the resident's room to wash her hands, leaving the cart in the hallway, out of her line of sight, and in an unlocked state as indicated by the visible red portion of the lock handle. The nurse subsequently removed betadine from the cart to apply to the resident's toes and continued to leave the cart unlocked while providing wound care, only locking it after completing the treatment and retrieving another item from the cart. Interviews confirmed that the Treatment Nurse believed she had locked the cart, as was her usual practice, but observations showed otherwise. The Director of Nursing (DON) stated that the cart should be locked when unattended to prevent unauthorized access to medications. Review of facility policy confirmed that all compartments containing drugs and biologicals must be locked when not in use and not left unattended if open or accessible.
Failure to Ensure Resident Privacy During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) C and D failed to ensure complete privacy for a resident during incontinent care. On the observed date, the privacy curtain in the resident's room was not fully closed, leaving the end of the bed uncovered and exposing the resident's genital area. The curtain was noted to be too short to provide full coverage, and a housekeeper began to enter the room during care before being stopped by the surveyor and the CNAs. Both CNAs acknowledged that the curtain was not completely closed and stated that the curtain had recently been changed, resulting in inadequate coverage. The resident involved had multiple medical conditions, including a non-traumatic acute subdural hemorrhage, dysphagia, prostate cancer, type 2 diabetes mellitus, hypertension, and depression. The resident was moderately cognitively impaired, required extensive assistance with activities of daily living, and was always incontinent of bowel and bladder. The care plan required incontinent care every two hours and as needed, with privacy to be maintained during care. Both the CNAs and the facility administrator confirmed that staff had received training on resident rights, including the right to privacy.
Staff Accepted Money from Resident in Violation of Facility Policy
Penalty
Summary
A deficiency occurred when a housekeeper accepted a $350 check from a resident over a two-day period. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including rhabdomyolysis, alcohol abuse, hypertension, anxiety disorder, and depression, was under the care of the facility. The resident's family member, who managed his checkbook, discovered a missing check after leaving it at the facility for bill payments. Upon questioning, the resident admitted to giving the check to the housekeeper, stating she needed help for a trip. The family member reported the incident to the facility's receptionist, who then notified the Administrator. The Administrator investigated and found that the housekeeper had accepted the check, despite knowing it was against facility policy. The housekeeper later admitted to taking the money after the resident offered it, and did not report the incident to her supervisor or management. The facility's policy clearly prohibits staff from accepting gifts or money from residents, and defines such actions as misappropriation of resident property. The Administrator did not report the incident to law enforcement, reasoning that the resident had voluntarily given the check and was cognitively intact. However, the facility's own protocol requires reporting any reasonable suspicion of misappropriation or exploitation to the state agency and law enforcement. The failure to prevent the housekeeper from accepting money from the resident and the lack of immediate reporting to authorities constituted the deficiency.
Failure to Report Alleged Exploitation to Law Enforcement
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act. Specifically, the facility did not report an allegation of exploitation to law enforcement after a housekeeper received a $350 check from a resident. The incident was brought to the attention of the facility by the resident's family member, who noticed a missing check and confronted both the resident and facility staff. The family member expressed concern and requested immediate action, including escalation to law enforcement, but the facility administrator assured her that he would handle the matter internally. The resident involved was a male with a history of rhabdomyolysis, alcohol abuse, hypertension, anxiety disorder, and depression. He was assessed as cognitively intact with a BIMS score of 15 and was able to perform activities of daily living independently or with some assistance. The resident's care plan included monitoring for involuntary behaviors and protecting him from self-harm or harm to others. Despite these measures, the resident gave a check to the housekeeper, who initially refused but ultimately accepted the money. The housekeeper did not report the gift to her supervisor, and the incident was only discovered after the family member raised concerns. Interviews with facility staff revealed that the administrator did not report the incident to law enforcement, believing that the resident's cognitive status and voluntary action did not constitute misappropriation but rather the acceptance of a gift. The facility's own protocol required reporting any reasonable suspicion of a crime, including misappropriation or exploitation, to both the state agency and law enforcement within specified timeframes. However, the administrator failed to follow this protocol, and the incident was not reported to law enforcement as required.
Hazardous Cleaning Product Left Unsecured in Resident Room
Penalty
Summary
A deficiency was identified when a container of Clorox disinfecting wipes, which carries a hazard statement indicating it causes eye irritation, was found on top of a bedside table in a resident's room. The resident had a history of hydrocephalus, dementia, hypertension, type 2 diabetes mellitus, and anxiety disorder, and was assessed as severely cognitively impaired with a BIMS score of 00. The resident also had a self-care deficit and required assistance with activities of daily living (ADLs), as documented in the care plan. During the survey, staff confirmed that the disinfecting wipes should not have been left in the resident's room. It was further revealed that the wipes had been brought in by the resident's wife, despite previous education provided to her about not bringing certain items into the facility. The presence of the hazardous cleaning product in the resident's room was observed and acknowledged by both nursing and administrative staff as a failure to maintain an environment free from accident hazards.
Failure to Maintain Resident Dignity by Not Covering Urinary Collection Bag
Penalty
Summary
The facility failed to ensure that a resident's urinary collection bag was covered with a privacy bag, which is a requirement to maintain the resident's dignity. This deficiency was observed during an interview and observation of a male resident who was admitted with several diagnoses, including hypertension, gastroesophageal reflux disease, acute kidney failure, muscle weakness, and a cognitive communication deficit. The resident, who was cognitively intact with a BIMS score of 15, was found with an uncovered urinary collection bag in his room. The resident expressed that he was unaware of the lack of coverage and expressed a preference for the bag to be covered at all times. Interviews with facility staff, including an LVN, the DON, and the ADM, confirmed that it is the facility's policy and expectation that all residents' catheter drainage bags should be covered to prevent dignity issues. The facility's policy on resident rights, dated December 2016, emphasizes treating all residents with kindness, respect, and dignity. The staff acknowledged that the responsibility for ensuring the catheter bags are covered lies with the nursing staff, and failure to do so constitutes a dignity issue.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was placed within their reach, which is a necessary accommodation for their needs. The resident, a legally blind male with a history of congestive heart failure, urinary tract infection, generalized anxiety, unspecified falls, and a risk for falling, was observed sitting in a wheelchair with the call light placed on the opposite side of the bed, out of reach. The resident expressed frustration at being unable to reach the call light due to limited range of motion in his right shoulder and his legal blindness, resulting in long periods of waiting for assistance. Interviews with facility staff, including a CNA, RN, and the DON, revealed that it was standard practice to attach the call light to the resident's shirt to ensure accessibility. However, this practice was not followed in this instance, leading to the deficiency. The staff acknowledged the importance of having the call light within reach to prevent falls and ensure residents' needs are met. The facility's policy also emphasized the necessity of keeping call lights within easy reach for residents confined to a bed or chair.
Failure to Update Comprehensive Care Plan for Resident's Wounds
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with multiple active wounds, including those on the right heel, left foot second toe, and a contracted right hand. Despite having physician orders for wound treatments and interventions, the care plan did not reflect these current skin issues. The resident, who had a history of hemiplegia, dysphagia, type 2 diabetes, peripheral vascular disease, and hypertension, was at moderate risk for skin breakdown according to the Braden Scale. The resident's care plan focused on the risk of pressure development and impaired skin integrity but did not include specific treatments for the existing wounds. The care plan only addressed a bruise on the left side of the neck and lacked updates for the wounds on the right foot, left foot, and contracted right hand. Observations confirmed the presence of these wounds, and the resident indicated that staff changed his wound dressings as ordered. Interviews with the DON and MDS Coordinator revealed that they were unaware of any wounds not being care planned. They stated that care plans should be updated when new concerns arise, and they discussed resident issues in daily meetings. However, the care plan for this resident was not updated to reflect the current wound treatments, which could lead to a failure in providing appropriate care.
Medication Administration Error via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of medications through a gastrostomy tube. A resident, who was dependent on a gastrostomy tube for nutrition and medication due to conditions such as hemiplegia, essential hypertension, and dysphagia, was prescribed hydralazine to be administered orally. However, the medication was transcribed incorrectly, and the resident received it through the gastrostomy tube. This error was observed during a medication administration session, where the RN noted that the medication order on the computer screen indicated oral administration, yet it was given via the gastrostomy tube. The RN, who was also the Assistant Director of Nursing (ADON), acknowledged the discrepancy and stated that the order should have been clarified with the physician to prevent the risk of aspiration. The Director of Nursing (DON) confirmed that nurses were expected to double-check medication orders before administration and that there was a skills check-off in the training packet for nursing, although the frequency of its completion was uncertain. The facility's policy on administering medications through an enteral tube emphasized verifying physician orders and confirming medication details with the Medication Administration Record, which was not adhered to in this instance.
Inadequate Hand Hygiene Practices 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 provision of incontinent care for a resident. The resident, who was admitted with multiple diagnoses including chronic respiratory failure, type 2 diabetes mellitus, and severe obesity, required extensive assistance and was always incontinent of bladder and bowel. During the care, CNA A touched a trash can with bare hands and did not wash or sanitize her hands before putting on gloves and assisting with care. Similarly, CNA B did not sanitize or wash her hands between changing gloves while providing care. Interviews with the CNAs confirmed their failure to follow proper hand hygiene protocols, despite having received infection control training within the year. The Director of Nursing (DON) acknowledged that CNAs should sanitize or wash their hands after touching the trash can and between glove changes. The facility's policy on hand hygiene, dated August 2014, requires the use of an alcohol-based hand rub after contact with objects in the resident's vicinity and after removing gloves. Despite passing annual competency checks for incontinent care and infection control, the CNAs did not adhere to these protocols during the observed incident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Braunfels
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At New Braunfels | 1.3 mi | ★★★★★ | 38 | 2 |
| Legend Oaks Healthcare And Rehabilitation - New Br | 2 mi | ★★★★★ | 11 | 0 |
| Eden Home | 2.2 mi | ★★★★★ | 23 | 0 |
| Kirkwood Manor | 4.6 mi | ★★★★★ | 19 | 0 |
| Cypress Healthcare And Rehabilitation Center | 11.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.