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 The Bartlett Skilled Nursing And Assisted Living during CMS and state inspections, most recent first.
A resident with dementia, mild intellectual disability, ESRD on dialysis, depression, and behavioral issues was hospitalized for SOB and low O2 saturation. The facility’s bed-hold policy required written notice of bed-hold and return rights and mandated that residents be permitted to return after hospitalization unless formal discharge procedures were followed. The Executive Director acknowledged that no bed-hold was offered, no written notice was provided, and no 30‑day discharge notice or discharge documentation was completed. When the hospital sought to return the resident, the Executive Director stated there were no available beds and that the resident could not share a semi-private room due to a prior incident of hitting a roommate, despite census records showing an available female bed. The PASRR supervisor and the resident’s guardian reported multiple unanswered attempts to coordinate the resident’s return and stated the Executive Director made it clear he did not want the resident back. The resident’s belongings were packed by staff and handed to the guardian at the entrance, with missing items not documented through a grievance process. These actions and omissions resulted in the resident not being readmitted from the hospital in accordance with the facility’s own bed-hold and return policy.
Surveyors found that the facility did not follow its own background check and abuse prohibition policies for an LVN MDS nurse and a housekeeper. Records and interviews showed that required criminal history checks were not initiated and completed within the timeframes specified in facility policy, including completion prior to employment for direct access staff. These lapses occurred despite written policies requiring timely background screening and prohibiting employment of individuals with certain abuse-, neglect-, or exploitation-related findings.
Two residents’ medical records were not accurately or completely documented. For one resident with dementia, intellectual disability, ESRD, and behavioral issues, the facility failed to record a room change, a multidisciplinary family meeting about discharge, communications with the hospital when the resident was not re-admitted after hospitalization, the absence of a bed-hold or 30-day notice, and the guardian’s retrieval of belongings and report of missing items. For another resident with ESRD, diabetes, hypertension, cognitive impairment, and poor vision, staff did not document a report from a dialysis center that the resident’s cell phone was missing, nor the subsequent awareness by the DON and an LVN of the lost phone, despite a policy requiring documentation of events and incidents in the medical record.
A resident with ESRD on dialysis, diabetes, and moderate cognitive impairment reported through a dialysis center that his cell phone was missing, but facility staff did not follow the written grievance policy. The receptionist documented the concern only on a sticky note and did not complete a grievance form, stating she was unaware of the grievance process. The DON recalled a call about the missing phone but did not document a grievance, and the CNA Manager, though notified, did not complete grievance paperwork and was unaware of the policy. Other staff gave inconsistent accounts about the missing phone, and the Administrator and Executive Director were unaware of the issue. Review of the grievance policy showed the grievance officer was not identified and required written investigation and reporting for complaints such as theft of property, which was not done in this case.
Care plans for three residents prescribed insulin did not include insulin-related information. One resident had moderate cognitive impairment and orders for insulin glargine and insulin lispro, while two other residents had diabetes diagnoses, intact cognition, and orders for basal and/or mealtime insulin. The DON, MDS nurse, and LVN stated that insulin and diabetes diagnoses needed to be included in the care plan and that the care plan was meant to guide individualized resident care.
Improper Food Storage and Unsanitary Kitchen Equipment: Surveyors observed freezer #1 with dried food drippings and crumbs, refrigerator #2 with dried meat juices, and refrigerator #3 with an unsealed bag of lettuce and an open stick of butter left uncovered. The Dietary Director, Head [NAME], Dietary Cook, DON, and Administrator all stated that food and kitchen equipment were expected to be clean, sanitized, labeled, sealed, and covered, and that the observed conditions were not acceptable.
The facility failed to provide documented annual infection prevention and control training for an MDS Nurse and the Administrator. HR stated the records were missing, the MDS Nurse could not explain the absence of documentation, and the Administrator could not identify when he last completed the training. The DON stated she was responsible for ensuring staff were up to date on training, and the facility policy required all staff to complete annual in-service training on infection prevention and control program standards, policies, and procedures.
Resident Not Groomed or Dressed Appropriately: A resident with a hx of acute ischemic stroke, tracheostomy, PEG tube, DM2, HTN, CAD, and PVD was observed in a wheelchair with uncombed hair and wearing a shirt with shorts that were shorter than mid-thigh, with a blanket covering his legs. The MDS showed he was dependent for personal hygiene and dressing, and the care plan called for staff assistance to maintain dignity. Staff interviews confirmed CNAs were responsible for grooming and dressing residents, and the DON agreed the resident appeared unkempt.
Bare-Hand Contact With Resident Meal: A CNA touched a resident’s cheeseburger with bare hands while assisting with lunch in the dining room and handed the food directly to the resident without using gloves or utensils. The DON, Dietary leadership, and the Administrator stated staff were not supposed to touch residents’ meals after they left the kitchen and should use utensils such as forks, spoons, or tongs when assistance is needed. Facility policies and the FDA Food Code require safe food handling and prohibit bare-hand contact with exposed ready-to-eat food.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, as evidenced by gaps in staff training and unclear guidance on reporting and prevention. This created an environment where such incidents could occur without prompt detection or intervention.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A facility failed to document a physician's verbal order to hold Donepezil for a resident with Lewy body dementia due to potential interactions with antibiotics. The medication was not listed in the resident's MAR, and the physician's progress notes incorrectly continued to include it. The DON confirmed the lack of documentation and stated that the resident remained stable during their stay.
A facility failed to change a resident's PICC line dressing as ordered, despite the dressing being intact and showing no signs of infection. The resident, with a history of falls, metabolic encephalopathy, and pneumonia, had a PICC line in her left upper arm. The physician's order required weekly dressing changes, but observations revealed the dressing was not changed by the seventh day. Interviews with staff confirmed the oversight, highlighting a deficiency in intravenous care management.
A medication cart was left unattended and unlocked in a facility hallway, posing a risk of unauthorized access to medications. A CNA noticed and locked the cart, while LVN A admitted to leaving it unsecured while attending to a resident. The facility's policy requires carts to be locked when not in use, and staff are trained on this protocol.
The facility failed to provide mandatory training on its QAPI program to all staff, including key personnel like the Administrator and DON. This deficiency was identified through interviews and record reviews, revealing that 16 employees did not receive training on the QAPI program's elements and goals, despite it being a required topic in the facility's policy. The lack of training was confirmed by the HR Manager and acknowledged by the Administrator-in-training, highlighting a risk to residents due to staff unawareness of quality control concerns.
The facility failed to document post-dialysis assessments for two residents, risking complications. One resident with severe cognitive impairment and end-stage renal disease had bleeding at the dialysis site, which was not documented. Another resident with chronic kidney disease lacked a care plan and post-dialysis documentation. The facility's policy did not address documentation, and the DON acknowledged the deficiency.
The facility failed to ensure appropriate use of psychotropic medications for residents, with two residents receiving Risperidone without proper diagnoses and another resident having a PRN order for Lorazepam without a 14-day limit. The DON acknowledged the oversight, highlighting the importance of regulatory compliance to prevent overuse and ensure medication effectiveness.
The facility failed to maintain food safety standards, with unlabeled and improperly stored food items found in the kitchen. Unsealed cilantro, overripe fruit, and improperly thawed meat posed contamination risks. The Dietary Director acknowledged these lapses, which violated the facility's food storage policy.
A long-term care facility failed to maintain an effective infection control program, as evidenced by a resident's catheter bag being left on the floor and staff not adhering to proper hand hygiene and glove-changing protocols during incontinent care. Interviews revealed a misunderstanding of infection control policies, contributing to these deficiencies.
A facility failed to create a comprehensive care plan for a resident with diabetes and renal dialysis needs. Despite the resident's medical history and treatment requirements, the care plan did not address these conditions. Staff interviews acknowledged the oversight, but relied on MAR documentation for monitoring. The facility's policies lacked guidance on comprehensive care plans.
A resident with dementia was prescribed Risperidone without appropriate diagnosis or GDR attempts. Despite repeated recommendations from the Pharmacist Consultant to reduce or discontinue the medication, the physician did not respond, and the medication continued. The facility's policy required documentation of why the benefits outweighed the risks, which was not provided.
A facility failed to maintain accurate clinical records for a resident on hemodialysis by not labeling communication forms with resident-identifying information. This oversight prevented proper documentation in the resident's electronic chart. The resident, with multiple health issues, required specific monitoring post-dialysis, which was not adequately documented. Interviews with the ADON and DON revealed a lack of awareness and adherence to documentation policies.
Failure to Follow Bed-Hold and Return Policy After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to follow its own written bed-hold and return policy and to permit a long-term resident to return after a hospitalization. The resident had been originally admitted in 2019, with a re-admission in 2023, and had multiple diagnoses including unspecified dementia, mild intellectual disability, major depressive disorder, anxiety, and end-stage renal disease requiring dialysis. Her MDS documented severe cognitive impairment (BIMS score 4), impaired vision, and a need for assistance with ADLs, as well as behavioral issues such as yelling, hitting herself, and prior aggression toward others. Care plan and psychiatric documentation showed ongoing use of psychotropic medications (Risperidone) for dementia and aggressive behavior, and staff and psychiatric notes described temper tantrums, verbal aggression, and a history of harming others and combativeness when she did not get her way. On a date in early February, nursing notes and transfer documentation show the resident was sent to the hospital for shortness of breath and decreased oxygen saturation. EMS records indicate she was found on oxygen at the facility with reported O2 saturation dropping to 84%, was placed on a non-rebreather mask, and transported with improved oxygenation. The facility’s own “Bed-Holds and Returns” policy, revised October 2022, states that residents and/or representatives are to be informed in writing of bed-hold policies well in advance of transfer and again at the time of transfer (or within 24 hours for emergencies), and that residents must be permitted to return following hospitalization unless specific discharge criteria are met and facility-initiated discharge requirements are followed. The Executive Director acknowledged that no bed-hold was offered to the resident’s guardian at the time of this hospitalization and that there was no documentation in the clinical record of a bed-hold notice or of the guardian being notified in writing. When the hospital was ready to discharge the resident back to the facility, the Executive Director reported that the resident was not re-admitted because he believed the facility was full and that only a semi-private bed was available, which he deemed inappropriate due to a prior incident in July 2025 when the resident had hit a roommate. He stated he had decided the resident could not have a roommate and that the facility had been cited previously related to that incident. Census reports for mid-February, however, showed an empty female bed in a specified room on multiple consecutive days. The PASRR Unit Supervisor and the resident’s guardian reported that the Executive Director made it clear he did not want the resident to return, did not respond to multiple calls and an email from PASRR and the guardian regarding the resident’s hospital discharge, and told them there were no beds available. The Executive Director also confirmed that no 30‑day discharge notice was issued, that there was no documentation of the October family meeting in the resident’s record, and that the facility did not document the guardian’s report of missing personal items or complete a grievance form. The guardian stated that when she came to pick up the resident’s belongings, she was kept at the entrance, handed pre-packed boxes, noted missing items, and was told staff did not know what happened to them. The facility’s actions and omissions resulted in the resident not being allowed to return after hospitalization, contrary to the facility’s written bed-hold and return policy and without following required facility-initiated discharge procedures. Interviews with multiple staff members, including LVNs and a CNA, confirmed the resident’s long-term status at the facility, her behavioral patterns (temper tantrums, cursing, hitting herself, throwing items), her dialysis schedule, and that she had been moved from a private to a semi-private room prior to the July 2025 roommate incident. Staff recalled being told, informally, that the resident could not have a roommate but did not know the formal basis. The PASRR Unit Supervisor and guardian described an earlier family conference in October 2025 with the Executive Director, DON, MDS nurse, ombudsman, and others, during which the Executive Director stated the facility had converted to a short-term stay model and that the resident should be placed in a more stable LTC setting. Despite this, there was no documentation of a formal discharge plan or 30‑day notice in the record, and when the resident was hospitalized for pneumonia and ready for discharge, the facility did not readmit her, did not provide required written notices, and did not document the decision as a facility-initiated discharge in accordance with policy and regulatory requirements. The facility’s own policy states that residents, regardless of payer source, must be permitted to return following hospitalization or therapeutic leave, and that if the facility determines a resident cannot return, it must comply with facility-initiated discharge requirements, including appropriate notice and documentation. The Executive Director acknowledged that the facility did not offer a bed-hold at the time of transfer, did not issue a 30‑day discharge notice, did not document the October family meeting, and did not document the guardian’s grievance about missing belongings. The PASRR Unit Supervisor and guardian reported that the resident remained in the hospital until another facility could be found, and the guardian stated that the resident had been at the original facility for seven years and considered it her home. These documented actions and inactions by the facility and its leadership led directly to the deficiency related to failure to follow bed-hold and return policies and failure to properly manage a facility-initiated discharge when the resident was hospitalized and ready for return.
Failure to Follow Background Check Policy for Direct Access Staff
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation through timely criminal history checks. Interview and record review with the Human Resources staff showed that an LVN MDS nurse and a housekeeper did not have criminal history checks completed in accordance with facility policy. For the LVN MDS nurse, the date of hire was documented as 10/06/21, while the criminal history check was completed on 09/21/21, indicating the check was not initiated within two days of an offer of employment as required by policy. For the housekeeper, the date of hire was 03/09/26, and the criminal history check was completed on 03/10/26, showing that the check was not completed prior to employment as required. Review of the facility’s 2019 background check policy revealed that background checks, including criminal conviction checks, were to be initiated within two days of an offer of employment or contract agreement and completed prior to employment for all direct access employees. The policy defined direct access employees as individuals with access to residents and one-to-one contact through employment or contract. Additionally, the facility’s Abuse Prohibition Policy, revised April 2021, required the facility to conduct employee background checks and not knowingly employ or engage individuals with findings or disciplinary actions related to abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. The survey findings showed that these policies were not fully implemented for the LVN MDS nurse and the housekeeper.
Failure to Accurately Document Key Events in Resident Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete medical records in accordance with its own documentation policy and accepted professional standards for two residents. For the first resident, who had long-term placement, dementia, mild intellectual disability, ESRD on dialysis, and significant behavioral issues, the facility did not document multiple key events in the electronic clinical record. There was no documentation of the resident’s move from a private room to a semi-private room in July 2025, despite the Executive Director stating this move and a prior altercation with a roommate influenced later decisions about room placement and readmission. The record also lacked any written notification to the resident’s responsible party or the LTC Ombudsman regarding the resident’s discharge when she was sent to the hospital on 2/02/26 for shortness of breath and low oxygen saturation. The facility further failed to document in the first resident’s record that a family meeting was held on 10/09/25 with the Executive Director, MDS nurse, care coordinator, DON, local ombudsman, PASRR supervisor, nurse practitioner, and the resident’s guardian to discuss the need to discharge the resident to another LTC facility. Participants, including the Executive Director and MDS nurse, confirmed the meeting occurred and that it was convened to explain why the resident should be discharged and why the facility believed it could not meet her needs, but they acknowledged that no notes of this meeting were entered into the clinical record. Additionally, when the resident was hospitalized with pneumonia beginning 2/02/26 and was later ready for discharge, the Executive Director informed hospital staff on 2/14/26 that the resident would not be re-admitted due to lack of an appropriate bed and his decision that she could not have a roommate; this communication and decision were not documented in the resident’s record. The Executive Director also acknowledged there was no documentation of offering a bed-hold, no 30-day discharge notice, and no record entry when the guardian came on 2/17/26 to pick up the resident’s belongings, nor any signed personal inventory form or grievance documentation when the guardian reported missing clothing and tennis shoes. For the second resident, who had ESRD on dialysis, diabetes, hypertension, moderate cognitive impairment, and poor vision, the facility failed to document a reported loss of the resident’s cell phone. The receptionist received a call from the dialysis center reporting that the resident stated his cell phone was missing; she wrote the concern on a sticky note and gave it to a nurse, but did not complete a grievance or concern form and was unaware of the grievance policy. The DON later recalled receiving a call from the dialysis center about the missing phone but did not document this in the resident’s clinical record. An LVN also remembered that the resident’s old basic cell phone, which he used to communicate with family via a video-calling app, was lost over a weekend and never found, and she acknowledged she did not document this event. Review of IDT notes and the resident’s record showed no entries about the missing phone, despite the facility’s written policy requiring documentation of events, incidents, or accidents involving the resident in the medical record.
Failure to Follow Grievance Policy for Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance/complaint policy and ensure efforts were made to resolve a resident’s grievance regarding a missing cell phone. The resident was an adult male with end stage renal disease on dialysis, Type 2 diabetes, and hypertension, admitted for rehabilitation and occupational therapy, with a BIMS score of 10 indicating moderate cognitive impairment. His admission inventory form documented that he did not want an inventory and his items were not labeled. Interdisciplinary team notes from early September through early October did not document that he had lost his cell phone. A concern about the missing cell phone was first communicated from the resident’s dialysis center to the facility. The receptionist reported receiving a call from someone at the dialysis center stating that the resident reported his cell phone was missing. She wrote the information on a sticky note, gave it to an unidentified nurse, and asked that it be given to the CNA Manager, but she did not complete a grievance/concern form and stated she was unaware of the grievance policy or the need to document such complaints. The DON recalled receiving a call from the dialysis center about the missing phone but did not remember whom she spoke with about it and acknowledged that she did not complete a grievance/concern form. The CNA Manager stated she was notified by the receptionist about the missing phone and alerted laundry staff to look for it, but she did not receive or complete a grievance/concern form and reported she was not aware of the grievance policy. Other staff interviews showed inconsistent awareness and lack of documentation regarding the missing phone. The Administrator stated he was not aware of missing cell phones and could not recall if the Executive Director had reported this concern to him. The DON and LVN ADON did not remember anything about the resident missing a cell phone. One LVN remembered the resident had a cell phone and frequently called his daughter but could not recall if it was lost, while another LVN recalled that the resident lost his old cell phone over a weekend and it was never found, and that staff assisted him with dialing so he could communicate with his family. The Executive Director stated the Social Worker was designated as the Grievance Officer but said he did not know the resident had lost his cell phone. Review of the facility’s grievance policy showed that the grievance officer was not identified by name or contact information, and required that grievances, including those related to theft of property, be investigated and documented, with written findings provided to the resident or representative. No grievance form or written investigation related to the missing cell phone was found in the record.
Care Plans Missing Insulin-Related Information
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for three residents who were prescribed insulin. Resident #6 was admitted on 07/21/2025, had a 5-day MDS BIMS score of 11 indicating moderate cognitive impairment, and had physician orders to continue an insulin regimen and oral diabetic medication. The MAR showed insulin glargine 30 units subcutaneously in the morning and insulin lispro by sliding scale before meals and at bedtime, but the care plan contained no information regarding insulin medication. Resident #33 was admitted on [DATE], had a diagnosis of diabetes mellitus type II, and the health and physical stated the resident would be placed on sliding scale for management of hyperglycemia. The 5-day MDS showed a BIMS score of 13 indicating intact cognition. The order summary listed Lantus SoloStar 15 units subcutaneously two times a day, insulin lispro 8 units before meals, and Novolog pen fill 8 units before meals, but the care plan had no information regarding insulin medication. Resident #44 was admitted on [DATE], had a diagnosis of diabetes with hyperglycemia, and the 5-day MDS showed a BIMS score of 15 indicating intact cognition. The MAR showed insulin glargine 15 units subcutaneously in the morning for diabetes mellitus type II, but the care plan also had no information regarding insulin medication. Staff interviews stated that care plans were intended to ensure individualized treatment, that MDS nurses were responsible for updating them, and that insulin and diabetes diagnoses needed to be included in the care plan.
Improper Food Storage and Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an initial kitchen tour, surveyors observed freezer #1 with dried drippings that appeared to be lemon ice cream on the bottom, along with crumbs of unknown food residue. Refrigerator #2 had dried drippings of meat juices on the bottom that were dark red and pink in color. Surveyors also observed refrigerator #3 with a bag containing two heads of lettuce that were not sealed and appeared yellow in color. An open box containing 11 bars of 1/4 lb. sticks of butter had one stick that was not sealed or covered. These observations were made during the kitchen review and were documented as failures in food storage and handling. During interviews, the Dietary Director, Head [NAME], Dietary Cook, DON, and Administrator all stated that food and kitchen equipment were expected to be clean, sanitized, labeled, sealed, and covered, and that food residues, drippings, and open packages were not acceptable. The Dietary Director, DON, and Administrator each stated that such conditions created a risk of cross contamination and foodborne illness, and the DON identified herself as the facility infection preventionist.
Missing Infection Control Training Documentation for Administrator and MDS Nurse
Penalty
Summary
The facility failed to provide mandatory infection prevention and control training that included the written standards, policies, and procedures for the infection prevention and control program for 2 of 8 staff reviewed: the MDS Nurse and the Administrator. Review of the facility staff roster showed the Administrator had a hire date of 03/07/2016 and the MDS Nurse had a hire date of 11/10/2021. During an interview, Human Resources stated she did not have documentation for the annual infection control training for either staff member and did not know why the facility lacked that documentation. The MDS Nurse stated she did not have a reason why there was no documentation of her infection control training and said the DON was responsible for monitoring staff for infection control training, though she was unsure how often it was followed up. The Administrator stated he was sure he had completed infection control training but could not state when he last completed it, and he acknowledged CMS required annual documented trainings. The DON stated she was responsible for ensuring staff were up to date with training and that all staff were to be updated on their training. The facility policy titled, In-Service Training, All Staff, stated all staff must participate in initial orientation and annual in-service training, and listed infection prevention and control program standards, policies, and procedures as a required training topic.
Resident Not Groomed or Dressed Appropriately
Penalty
Summary
The facility failed to treat Resident #28 with respect and dignity by not ensuring he was groomed and dressed appropriately. Resident #28 was a [AGE]-year-old male with an original admission date of 09/18/24 and a re-admission date of 08/11/25. His medical history included acute ischemic stroke, tracheostomy, PEG tube, BPH, DM2, hypertension, CAD, and PVD. The MDS assessment showed he was unable to complete the BIMS interview and was dependent for personal hygiene, including brushing hair, and for upper and lower body dressing. His care plan identified an ADL self-care deficit related to stroke and included a goal for him to maintain a sense of dignity by being clean, dry, odor-free, and well groomed, with staff interventions to assist with dressing. During observation, Resident #28 was seen in a wheelchair in the 500-hall across from the nurse's station with hair uncombed and sticking up, wearing a white shirt and grey shorts that were shorter than mid-thigh, with a white blanket covering his legs. Staff interviews confirmed that CNAs were responsible for preparing residents in the morning, including dressing and grooming them so they looked presentable, and that nurses were responsible for monitoring residents' needs and appearance. One CNA stated the resident was not presentable and should have had pants and combed hair, while another CNA stated the shorts were per the family's request and that she asked staff to cover his legs because she thought he would be cold. The DON stated the family only provided shorts, that she observed the resident on the day in question and agreed he appeared unkempt because his hair was not groomed, and that she notified CNA A of her concern. The facility policy stated employees shall treat all residents with kindness, respect, and dignity.
Bare-Hand Contact With Resident Meal
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 1 of 6 residents reviewed for infection control when CNA A touched Resident #9’s cheeseburger with bare hands during lunch service in the dining room. During observation, CNA A approached the resident at the table, took a quarter-cut piece of the cheeseburger with her bare hands, and handed it to the resident. Resident #9 then took the food with her hands and ate it. CNA A was not wearing gloves and did not use utensils when assisting with the meal. During interviews, the Director of Dietary stated it was not acceptable for staff to touch a resident’s meal after it left the kitchen and that staff assisting with meals needed to wear gloves and use utensils such as a fork, spoon, or tongs. CNA A stated she should not have touched the resident’s food with her bare hands and that the proper procedure was to assist with utensils if needed. The Dietary [NAME] and the DON both stated staff were not supposed to touch residents’ meals with bare hands and should use utensils when assistance was needed. The Administrator also stated it was not acceptable for staff to touch Resident #9’s meal with bare hands and that staff should never touch a resident’s meal once it left the kitchen. Review of the U.S. FDA Food Code 2022 showed food employees may not contact exposed ready-to-eat food with bare hands and must use suitable utensils, and the facility’s policies stated employees handling or serving food would be trained in safe food handling and preventing foodborne illness, including personal hygiene practices and safe food handling.
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 documents 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. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are 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. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and preventing such incidents. The absence of robust preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Document Medication Hold Order for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the medication Donepezil. The resident, diagnosed with Lewy body dementia, was admitted to the facility following surgery. Despite the physician's verbal order to hold Donepezil due to potential interactions with antibiotics, this instruction was not documented in the resident's medical records. The physician's progress notes erroneously continued to list Donepezil as part of the treatment plan, and the medication was absent from the Medication Administration Records (MAR) for the months reviewed. Interviews revealed that the family member was unaware of the medication not being administered and facility staff were not informed of the resident's prescription for Donepezil. The Director of Nursing (DON) acknowledged the lack of documentation regarding the verbal hold order and confirmed that the hospital's medication reconciliation did not specify a dosage for Donepezil. Despite the documentation errors, the resident was reported to have been in stable condition during their stay and upon discharge.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of practice for the care of a PICC line for a resident, leading to a deficiency in intravenous care. The resident, a female with a history of repeated falls, metabolic encephalopathy, and pneumonia, had a PICC line in her left upper arm. The physician's order required the PICC line dressing to be changed once a week using sterile technique, as well as when the dressing was soiled, wet, or loose. However, observations revealed that the dressing, dated 01/27/25, was not changed by the seventh day as required, despite being intact and showing no signs of infection. Interviews with staff, including an LVN and the DON, confirmed that the dressing should have been changed by the seventh day, and that the responsibility for managing PICC lines lay with the nursing staff. The DON stated that nurses were expected to check the dressing every shift and during every antibiotic administration. The facility's policy also required dressing changes at least every seven days. Despite the lack of immediate signs of infection, the failure to change the dressing as ordered placed the resident at risk of complications associated with PICC lines.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with one of the two medication carts reviewed. On February 3rd, a medication cart located in the 400 hall was left unattended and unlocked, with two staff members present in the hallway. Shortly after, a CNA noticed the unlocked cart and proceeded to lock it. The CNA acknowledged the importance of keeping the cart secured to prevent unauthorized access to medications, emphasizing that it was the nurses' responsibility to ensure the cart remained locked. LVN A, who was responsible for the medication cart, admitted to leaving it unlocked while attending to a resident who was leaving for dialysis. LVN A confirmed having received training on the importance of locking the medication cart and recognized the risk of residents accessing the medications. The Director of Nursing and the Administrator both reiterated that medication carts should be locked at all times when unattended, and that nurses are trained on this requirement upon hire and during annual training. The facility's policy, dated April 2007, mandates that the cart must be locked before the nurse enters a resident's room.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to include mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for all staff members, which is a requirement as per their policy. This deficiency was identified during interviews and record reviews, where it was found that 16 employees, including the Administrator, Director of Nurses, Infection Control Preventionist, and other key staff, did not receive training on the elements and goals of the facility's QAPI program. The HR Manager confirmed that no such training was provided to these employees, despite their varying dates of hire. The lack of training was further corroborated by the facility's orientation and training documents, which showed no evidence of QAPI program training for the reviewed employees. The Administrator-in-training acknowledged the absence of formal training on the QAPI program and recognized the potential benefits of such training in making staff aware of the facility's quality-related efforts. The facility's policy on in-service training, revised in August 2022, lists the QAPI program as a required training topic, yet this was not implemented, putting residents at risk of receiving poor-quality services due to staff unawareness of quality control concerns.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that dialysis services were provided consistently with professional standards of practice for two residents who required such services. Specifically, the facility did not document post-dialysis assessments in the charts of two residents, which could place them at risk for complications. Resident #7, a female with severe cognitive impairment and end-stage renal disease, was observed with bandages on her dialysis access site, indicating bleeding that was not documented in her chart. Despite having a care plan that included monitoring for complications, there was no post-dialysis documentation in her progress notes for several months. Resident #40, a male with severe cognitive impairment and chronic kidney disease, also did not have a care plan in place for dialysis, and there was no post-dialysis documentation in his progress notes since his readmission. The facility's communication binder for his hall contained only blank forms, indicating a lack of documentation for his dialysis care. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lack of documentation and were unsure of the facility's policy regarding post-dialysis documentation. The facility's policy on hemodialysis catheter care did not address documentation of pre- and post-dialysis assessments, contributing to the deficiency. The DON admitted that the current documentation was lacking and that the nurses should have been documenting in progress notes when residents returned from dialysis. The absence of proper documentation and care planning for these residents highlights a significant oversight in the facility's dialysis care practices.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that residents who had not previously used psychotropic drugs were not administered these medications unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was observed in two residents who were given Risperidone without appropriate diagnoses. Additionally, the facility did not limit PRN orders for psychotropic drugs to 14 days for another resident, which is a regulatory requirement. Resident #98, who was receiving hospice care, had a PRN order for Lorazepam without a 14-day limit. Despite the medication not being administered, the lack of a time limit on the PRN order was a violation of regulations. The Director of Nursing (DON) acknowledged the oversight and explained that the 14-day limit is intended to prevent overuse and ensure the medication's effectiveness and tolerance. Resident #7 and Resident #3 were both prescribed Risperidone without appropriate diagnoses. Resident #7's care plan included the use of Risperidone for impulsive disorder, but her psychiatric evaluation did not support this diagnosis. Similarly, Resident #3 was prescribed Risperidone for behavioral disturbances associated with dementia, but pharmacy reviews repeatedly indicated that the medication was not justified. Despite recommendations for gradual dose reduction (GDR) and discontinuation, the medication continued to be administered without proper justification.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was noted that food items were not properly labeled, covered, or sealed. Specifically, an unsealed plastic bag of cilantro and a clear plastic container with unlabeled, overripe fruit were found in the refrigerator. The staff member acknowledged the risk of using such perishable items without knowing their freshness, which could potentially lead to foodborne illnesses among residents. Additionally, a bottle of ranch dressing with dried dressing on the outside and a container of tomato sauce with an unsecured cover were found, posing risks of contamination and pest attraction. Furthermore, the facility did not follow proper procedures for thawing meat. Two briskets were found thawing directly on the refrigerator floor, with juices pooling around them, which could lead to contamination of other foods. The Dietary Director confirmed that the meat should have been placed on a tray to prevent drippings from contaminating the refrigerator. The facility's policy requires all foods to be covered, labeled, and dated, and raw animal products to be stored in drip-proof containers, which was not adhered to in these instances.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during a survey. One significant issue involved a resident's catheter drainage collection bag being left on the floor, which poses a risk of contamination and infection. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), confirmed that the bag should not touch the floor due to the potential for germs to infect the resident. Despite staff being trained to prevent such occurrences, the catheter bag was observed on the floor, indicating a lapse in adherence to infection control protocols. Additionally, the facility's staff did not adhere to proper hand hygiene and glove-changing protocols during incontinent care for two residents. CNAs were observed failing to change gloves after they became contaminated and did not practice adequate hand hygiene. This included not washing hands for the required duration and not using a clean paper towel to turn off the faucet. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that these practices could lead to cross-contamination and were against the facility's infection control policies. The facility's policy on hand hygiene emphasizes the importance of washing hands with soap and water when visibly soiled and using hand sanitizer between glove changes. However, staff interviews revealed a misunderstanding of these protocols, with some staff members believing that double-gloving was an acceptable substitute for proper hand hygiene. This misunderstanding contributed to the observed deficiencies in infection control practices, potentially placing residents at risk for infections.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, specifically neglecting to address the resident's diagnosis of diabetes and dependence on renal dialysis. The resident, who was initially admitted and later readmitted to the facility, had a documented history of diabetes mellitus and was receiving insulin injections. Despite these medical needs being identified in the comprehensive assessment, the care plan did not include diabetes as a focus of care, nor did it specify goals or interventions to manage the condition. Additionally, the care plan lacked any mention of renal dialysis, which was a necessary treatment for the resident's kidney injury. Interviews with facility staff, including the MDS nurse and the DON, revealed an acknowledgment that diabetes should have been included in the resident's care plan. However, they believed that the resident's condition was being monitored through the Medication Administration Record (MAR), which documented blood sugar monitoring. Despite this, the absence of a formal care plan for diabetes and dialysis was noted as a deficiency. Furthermore, when requested, the facility's policies did not provide guidance on developing comprehensive care plans, indicating a gap in policy adherence or availability.
Failure to Act on Pharmacist Recommendations for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that drug regimen irregularities reported by the Pharmacist Consultant were acted upon by the physician for a resident reviewed for physician response to medication regimen review. The resident, who had a history of dementia with behavioral disturbances, was prescribed Risperidone, an antipsychotic medication, without an appropriate diagnosis or attempt at gradual dose reduction (GDR). Despite recommendations from the Pharmacist Consultant to reduce or discontinue the medication, the physician did not respond appropriately, and the medication continued to be administered. The resident's medical records indicated that she had severe cognitive impairment and no recent symptoms of delirium or psychosis. Despite this, she was receiving antipsychotic medication routinely, and no GDRs had been attempted. The pharmacy review notes repeatedly highlighted the lack of justification for the continued use of Risperidone and recommended dose reductions or discontinuation, but these recommendations were not acted upon by the physician. The facility's policy required physicians to document why the benefits of such medications outweighed the risks, but this was not done in this case. Interviews with the Director of Nursing (DON) revealed that the resident should not have been prescribed Risperidone for behavioral disturbance, as it was an inappropriate diagnosis. The DON acknowledged the risks associated with antipsychotic medications, including their potential use as chemical restraints and the associated side effects. Despite the pharmacy's recommendations and the facility's policy, the physician did not provide a justification for disagreeing with the recommendations, leading to a deficiency in the facility's medication management practices.
Deficiency in Hemodialysis Record-Keeping
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident receiving hemodialysis. Specifically, the facility did not place resident-identifying information on 5 out of 17 Hemodialysis Communication forms in the Dialysis Communication Binder. This omission could lead to inadequate monitoring and inaccurate records, as the forms were not properly labeled and could not be scanned into the resident's electronic chart as part of her permanent record. The resident in question, a female with multiple diagnoses including dementia, end-stage renal disease, and severe cognitive impairment, was dependent on hemodialysis three times a week. Her care plan included specific interventions for monitoring her condition pre- and post-dialysis, such as checking the dialysis shunt for bleeding and infection. However, during an observation, it was noted that the resident returned from dialysis with bandages on her arm, which she indicated were applied at the facility, not the dialysis center, suggesting a lapse in following the facility's policy for post-dialysis care. Interviews with the facility's ADON and DON revealed that they were unaware of why the communication forms lacked resident names and were not scanned into the resident's chart. The ADON acknowledged that the absence of names on the forms was problematic, as it hindered proper documentation and record-keeping. The facility's policy on hemodialysis catheter care did not address documentation of pre/post-dialysis assessments, contributing to the deficiency in maintaining accurate clinical records.
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 305 citations issued within 25 miles in the last 12 months — including the 8 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 El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White Acres Wellness & Rehabilitation | 0.6 mi | ★★★★★ | 1 | 0 |
| Franklin Heights Nursing & Rehabilitation | 1.3 mi | ★★★★★ | 9 | 0 |
| Avir At El Paso | 3.1 mi | ★★★★★ | 2 | 0 |
| The Montevista At Coronado | 3.1 mi | — | 0 | 0 |
| Mountain View Health & Rehabilitation | 5.5 mi | ★★★★★ | 31 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.