Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Belmont At Twin Creeks during CMS and state inspections, most recent first.
Respiratory masks were left unbagged when not in use for three residents receiving BiPAP or CPAP therapy. A resident with respiratory failure and two residents with sleep apnea had their masks observed sitting on bedside tables connected to the machines, with one mask covered by cloth and none stored in a bag. Staff and leadership stated the masks should be bagged when not in use to prevent contamination.
A facility failed to keep drugs and biologicals secured when a resident had zinc oxide left on a side table, another resident had two inhaled respiratory meds in plain view in his room without a self-administration assessment, and a third resident with dementia had a nasal spray on her side table. Staff stated these items should not have been accessible because residents could use them inappropriately or take them more than ordered, and the facility policy required medications to be stored in locked compartments with access limited to authorized personnel.
A resident’s pharmacy slip containing his name and medication information was left on the ledge of the nurse’s station and remained visible during repeated observations when no staff were present. The LVN said the slip should have been secured inside the nurse’s station, and the ADON, DON, and Administrator all identified the information as confidential and not meant to be left in view of others.
Surveyors found multiple failures in the safe management of oxygen and respiratory devices, including unbagged nebulizer masks and nasal cannulas left on surfaces, hanging from equipment, and lying on the floor. One resident with COPD had a nebulizer mask and nasal cannula left unbagged despite having physician orders for PRN nebulizer treatments and continuous oxygen, while three other residents using oxygen concentrators or mobile tanks had no corresponding physician orders or care plan interventions for oxygen use. Staff interviews, including CNAs, an LVN, an ADON, and the DON, confirmed that facility policy requires nasal cannulas and other respiratory apparatus to be bagged, dated, and changed weekly, and that failure to do so can lead to contamination and infection.
Surveyors found multiple instances where medications and supplements were left unsecured on resident nightstands instead of being stored in locked compartments. Several residents with pressure ulcers or at risk for skin breakdown had pink barrier cream or Nystatin powder in medication cups at the bedside, while another had a topical anesthetic spray accessible in the room without a corresponding physician order. Additional residents had Biofreeze spray and family-supplied supplement and probiotic bottles on their nightstands without staff oversight or documented orders. CNAs, the ADON, an LVN, and the DON all acknowledged that facility policy prohibits medications in resident rooms without supervision and that no residents had been assessed to self-administer medications, confirming that these items should have been secured and nurse-controlled.
A resident with glaucoma and severe cognitive impairment had eye drop medication ordered twice daily, and after administration an LVN left the labeled medication on top of a med cart in a hallway rather than securing it. A surveyor observed the medication with the resident’s name visible on the cart, and the ADON and DON both acknowledged this as a privacy and HIPAA concern. This incident occurred despite facility policies requiring respect for resident rights and storage of medications in locked compartments.
A resident with cognitive impairment and a history of malnutrition, stroke, and swallowing difficulties did not receive the ordered ground diet and was not properly assisted during a meal. Staff failed to check the accuracy of the meal tray, did not ensure the resident was positioned upright, and did not provide the required supervision, resulting in the resident being served a whole sandwich instead of ground meat and being left unable to reach her food.
A resident receiving morphine for pain management experienced discrepancies in medication administration records and narcotic logs, with staff documenting doses as given when they were not, and saving unused half-tablets instead of destroying them with a witness. The facility did not update records to reflect the correct dose after a physician order change, and required signatures for drug destruction were missing, resulting in inaccurate controlled substance documentation.
A resident with cancer, bone fracture, and Parkinson's disease did not receive morphine for pain as ordered over several days due to discrepancies in medication administration and documentation. Staff inconsistently recorded doses, failed to properly waste unused narcotics, and did not update records after a change in the physician's order, resulting in missed doses and improper handling of controlled medications.
Staff failed to follow infection control protocols during incontinence care for two residents, including using soiled gloves to handle clean wipes and not performing hand hygiene between tasks. Both instances involved staff acknowledging they did not follow proper procedures, which was confirmed by facility leadership as being against policy.
A resident with a history of intracerebral hemorrhage and quadriplegia received PRN Xanax for anxiety on multiple occasions over a period exceeding 14 days, without a documented rationale for continued use or a specified end date. The DON confirmed that PRN psychotropic medications should not be prescribed for more than 14 days, but could not explain why the order remained active. The facility also lacked a written policy for PRN antianxiety/psychotropic medication use.
A resident discharged to another facility did not have a completed recapitulation of stay, with missing information from Social Services, Nursing, Activities, Dietary, and Rehabilitation departments. The discharge summary was neither completed nor signed, and the DON confirmed that each department was expected to complete their section, but no written policy was in place for this process.
A resident with mild cognitive impairment and a history of depression and fibromyalgia was subjected to verbal and physical abuse by a CNA during incontinent care. Despite the resident's protests and another CNA's presence, the abusive behavior continued, causing the resident to feel fearful. The incident was initially dismissed by the facility due to the CNA providing a false name, and it was only after the resident recognized the CNA during an activity that the issue was reported to the ADON and DON. The witnessing CNA failed to report the abuse immediately, contributing to the deficiency.
A resident with multiple health conditions did not receive routine dental care despite requests and referrals, leading to issues with her dentures. The facility's records lacked documentation of dental visits, and the social worker was unaware of the resident's dental needs.
A resident with mild cognitive impairment reported abuse by a CNA during care, which was witnessed by another CNA who failed to report it. The facility delayed reporting the incident to the State Survey Agency due to initial disbelief and confusion over the staff member's identity. This delay in reporting placed residents at risk.
A resident with severe cognitive impairment and multiple health conditions did not receive adequate foot care, as evidenced by pink areas, flaky skin, and discolored toenails. Despite a podiatry visit in July, observations in August showed ongoing issues. Interviews with staff and a family member revealed concerns about the adequacy of care, and the facility failed to provide a podiatry policy.
A medication administration error occurred when a resident received medications intended for another resident due to a CMA's mistake. The resident, who was cognitively intact and had a history of hemiplegia, was given Oxybutynin and Trazodone, leading to hospitalization after experiencing adverse symptoms. The error was discovered when a family member noticed the wrong room number on the medication cup.
The facility failed to maintain a clean and safe environment for two residents due to one resident's refusal of care, resulting in a strong urine odor in the shared room. Despite being moderately cognitively impaired and occasionally incontinent, the resident did not participate in a toileting program and refused assistance with hygiene and housekeeping. Staff documented refusals but did not implement effective interventions, and the care plan lacked strategies for maintaining cleanliness.
The facility failed to maintain an effective infection prevention and control program, as CNAs did not perform proper hand hygiene during incontinence care for two residents. Despite receiving training, CNAs changed gloves without washing hands, increasing the risk of infection. The DON confirmed the expectation for staff to follow hand hygiene protocols, and the facility's policy emphasizes its importance in preventing infections.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, leading to improperly labeled and expired food items, dented cans not segregated, and unlabeled packages. The refrigerator and freezer contained uncovered and unlabeled food items, improperly stored chicken with blood leakage, and food with frostbite, placing residents at risk for exposure to adulterated or contaminated food.
The facility failed to change a resident's central line dressing weekly as required, missing a scheduled change and potentially risking infection. The resident had severe cognitive impairment and multiple diagnoses, including an infection of the humerus. Staff interviews and record reviews confirmed the lapse, with the DON unaware of the missed change and the RN admitting to not remembering specific orders.
A facility failed to report and investigate a resident's fall and injuries as required. The resident, with moderately impaired cognition, was found on the floor with multiple bruises and blood coming from her head. Despite the visible injuries and the resident's inability to explain the fall, the incident was not reported to the State agency, leading to a deficiency in ensuring resident safety and proper investigation.
A resident with bipolar disorder and anxiety disorder was admitted with a PASRR Level I indicating no mental illness, missing the required PASRR Level II evaluation. The resident was observed to be clean and well-groomed but visibly distressed. The Baseline Care Plan was found incomplete, highlighting deficiencies in the facility's assessment and care planning processes.
The facility failed to identify a resident with mental illness and did not complete a new PASRR Level I Screening, leading to the resident not receiving a necessary PASRR Level II evaluation. The resident had diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder, which were not captured in the initial screening.
The facility failed to develop and implement a baseline care plan for a newly admitted resident with bipolar disorder, major depressive disorder, and anxiety disorder. The resident's care plan was incomplete, lacking information on her care needs and status, which could result in staff not knowing how to best care for her. The facility's policy on baseline care plans was not provided.
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to a deficiency in meeting their individualized needs. One resident's care plan did not address his schizophrenia, and another resident did not have a care plan at all, potentially compromising their care and well-being.
A facility failed to ensure proper treatment for a resident with a feeding tube, as an LVN did not check for residual volume before administering medication. This oversight, confirmed by both the LVN and the DON, could lead to complications such as aspiration. The resident involved had severe cognitive impairment and multiple diagnoses, including Gastrostomy status and chronic kidney disease.
Respiratory masks left unbagged when not in use
Penalty
Summary
The facility failed to ensure that respiratory equipment was properly stored when not in use for three residents who used BiPAP or CPAP therapy. Resident #2 was cognitively intact, diagnosed with respiratory failure with hypercapnia, and had a care plan and physician order for BiPAP use. During an observation, the resident was in bed with a BiPAP machine on the side table and the mask connected to it, but the mask was unbagged and sitting on top of the machine. The resident stated she used the BiPAP every night and that nurses applied and removed it. Resident #3 was diagnosed with sleep apnea, had severe cognitive impairment, and had a care plan and physician order for CPAP use. During an observation, the resident was in bed with eyes closed while a CPAP machine sat on the side table with the mask connected to it. The mask was not bagged, and a piece of cloth was on top of it. An LVN observed the mask was not bagged, stated it should be bagged to prevent respiratory issues, removed the cloth, and said the cloth could be dirty and should not contact the mask. Resident #4 was diagnosed with sleep apnea, had severe cognitive impairment, and had a care plan and physician order for CPAP use at night with oxygen. During an interview, the Financial Manager stated the CPAP mask should be bagged so it would not be dirty. The ADON and DON later stated that BiPAP and CPAP masks should be inside plastic bags when not in use to prevent cross contamination and respiratory infection, and that staff were responsible for bagging the masks. The Administrator stated the facility was currently correcting the same non-compliance from a prior visit.
Medications and topical products left accessible in resident rooms
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and were not left accessible in residents’ rooms. Resident #2, a cognitively intact female with muscle weakness and bowel and bladder incontinence, was observed awake in bed with a tube of zinc oxide on top of her side table. She stated staff used it when they cleaned and changed her, and that it had always been on her side table. An LVN later stated barrier creams should not be left accessible to residents because they could be used inappropriately or cause irritation if placed in the eyes. Resident #5, a cognitively intact male with COPD, had physician orders for Trelegy Ellipta and Symbicort for shortness of breath, but no assessment for self-administration of medications was found in the record. During observation, two respiratory medications were seen on top of his overbed table in plain view while he was awake in bed. He stated he seldom used the medications depending on need and that the nurse knew he had them in his room. An LVN stated she did not know the medications were in the room and noted the resident could potentially administer them in addition to the nurse-administered doses, which could result in overdosing. Resident #6, a female with COPD and dementia and a BIMS score of 11, had an order for Flonase Allergy Relief nasal spray, and no self-administration assessment was documented. During observation, she was awake in bed with a nasal spray on top of her side table, and she stated it had been there since the previous day. An LVN stated she did not know the nasal spray was in the room and said it should not be there because the resident might be confused and use it more than required. The DON and Administrator both stated medications and zinc oxide should not be inside residents’ rooms or accessible to residents, and the facility policy required all drugs and biologicals to be stored in locked compartments with access limited to authorized personnel.
Confidential resident medication slip left visible at nurse’s station
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when a pharmacy slip with Resident #1’s name and medication information was left on the ledge of the nurse’s station and remained there during two observations. Resident #1 was an [AGE] year-old male admitted to the facility with peripheral vascular disease and a non-pressure ulcer to the left calf. His MDS reflected that he was cognitively intact with a BIMS score of 13, and his care plan included treatment for an actual skin impairment related to a venous wound of the left calf. The pharmacy slip was observed on top of the nurse’s station ledge at 7:30 a.m. and again at 7:58 a.m., with no staff inside the nurse’s station during either observation. The slip contained the resident’s name and medication information. During interviews, an LVN stated the slip was the facility’s copy for the medication delivered for the resident and should have been secured inside the nurse’s station. The ADON and DON both stated the information should have been protected and kept confidential, and the Administrator stated the slip should not have been visible to others and noted the facility was correcting the same non-compliance from a prior visit.
Improper Storage and Lack of Orders/Care Plans for Oxygen and Respiratory Devices
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care and to follow its own oxygen concentrator policy requiring delivery devices to be kept covered in a plastic bag when not in use. For one resident with COPD and a physician’s order for PRN nebulizer treatments and oxygen at 2 L every shift, surveyors observed a nebulizer mask sitting unbagged on the nightstand and a nasal cannula attached to an oxygen tank unbagged in a pouch. Nursing leadership, including the ADON and DON, acknowledged during interviews that these items should have been bagged when not in use to avoid contamination and that nursing staff were responsible for ensuring respiratory devices were properly stored. Additional deficiencies were identified for three other residents using oxygen equipment. For one resident with chronic diastolic CHF and type 2 diabetes, surveyors observed a nasal cannula connected to an oxygen concentrator hanging on the concentrator while the resident sat in a wheelchair. For another resident with unspecified diastolic CHF, a nasal cannula connected to an oxygen concentrator was observed hanging on the head of the bed while the resident was out of the room. In both cases, record review showed no active physician orders for oxygen administration and no care plan problems, goals, or interventions related to oxygen use. For a resident with COPD, surveyors observed a nasal cannula connected to a mobile oxygen tank attached to the wheelchair lying on the floor while the resident was in bed using a different nasal cannula connected to an oxygen concentrator. This resident reported not being aware that the nasal cannula should be bagged and stated that staff had not provided a bag or instructions to bag the device when not in use. Multiple CNAs, an ADON, an LVN, and the DON all stated in interviews that nasal cannulas and other respiratory apparatus that contact the respiratory system should be bagged, dated, and changed weekly per facility policy, and that failure to bag these items could result in contamination and infection. Record review of the facility’s oxygen concentrator policy confirmed that delivery devices were to be kept covered in a plastic bag when not in use and that oxygen was to be administered under physician orders.
Unsecured Medications and Supplements Left in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored in locked compartments and controlled by authorized personnel, as required by state and federal regulations. Surveyors observed multiple medications and supplements left in resident rooms, accessible on nightstands, rather than secured. These items included prescription and facility-provided topical agents such as barrier creams, Nystatin powder, topical anesthetic spray, Biofreeze, and resident- or family-supplied supplements and probiotics. One resident with a diagnosis of a pressure ulcer of the right buttock had a physician’s order for wound care that included application of barrier cream. This resident’s comprehensive care plan documented pressure ulcer prevention interventions and an ADL self-care performance deficit requiring staff assistance. During observation, a pink barrier cream in a medication cup was found on the resident’s nightstand. Another resident with dementia and a sacral pressure ulcer, who also had an ADL self-care performance deficit and impaired cognitive function, had an order for Nystatin external powder to be applied to the groin twice daily. Surveyors observed Nystatin powder in a medication cup on this resident’s nightstand, and the resident’s representative reported that nursing staff applied the powder after cleaning and that it was already on the bedside table when she entered the room. A third resident with a sacral pressure ulcer and total dependence on staff for ADLs had an order for daily application of house barrier cream to the sacral area. During observation, a pink barrier cream in a medication cup was found on this resident’s nightstand. Another resident with diagnoses including multiple sacral pressure ulcers and pain had a care plan indicating use of barrier cream and assistance with ADLs, but active physician orders did not include barrier cream or topical anesthetic, and the MDS did not show pressure ulcers. Surveyors observed a pink barrier cream in a medication cup and a bottle of topical anesthetic on this resident’s nightstand; the resident stated the cream was used for an abdominal rash and the topical anesthetic for wound dressings, and that CNAs and nurses brought and used these products in the room. A further resident with muscle weakness and a care plan for pressure ulcer prevention with barrier cream, but no active physician order for barrier cream and no pressure ulcers on MDS, had plastic bottles of supplements (daily energy and papaya enzyme digestive aid) on the nightstand. The resident stated that a family member brought the supplements, that she kept them visible on the nightstand, and that she had not informed the nurses about them. Another resident with muscle weakness, a care plan including barrier cream, and documented skin/ulcer treatments on the MDS had a spray bottle of Biofreeze on the nightstand. This resident stated she used it for pain, had not told the nurses about it, but that staff were aware she possessed it. Staff interviews confirmed that medications, including barrier creams and over-the-counter products, were not supposed to be left in resident rooms unsupervised. One CNA stated that the wound nurse gave her pink barrier cream for residents with pressure ulcers and redness, and that she placed the cream in resident rooms and applied it during incontinence care, acknowledging that medications should not be left in rooms because unsupervised use could be dangerous. Another CNA stated that no medications should be in resident rooms and that any found should be reported to the charge nurse, noting concerns about expired products and incorrect dosing. The ADON stated that no medications were allowed unsupervised in resident rooms and that no residents had been assessed to self-administer medications. An LVN reported that per facility policy, residents should not have medications in their rooms, that nurses inform new residents that all medications, including OTC products, must be administered by nurses and stored in the medication cart, and that nursing is responsible for ensuring medications are not left unsupervised. The DON stated that pink barrier cream should be stored in drawers out of residents’ reach and that items such as medications should be identified and removed during rounds, confirming that no residents had self-administration assessments and that unsupervised medications in rooms posed risks of overmedication and adverse reactions.
Resident Privacy Breach Due to Medication Left Unsecured on Med Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident’s personal and medical information when the resident’s medication, labeled with his name, was left on top of a medication cart in plain view. The resident was an older male with glaucoma, severe cognitive impairment as evidenced by a BIMS score of 3, and moderately impaired vision. His physician orders included Artificial Tears Ophthalmic Solution 1%, to be instilled as one drop in both eyes twice daily. During an observation on the 100-hall, surveyors noted medication with the resident’s name on it sitting on top of the medication cart rather than being secured. When the ADON observed the surveyor standing near the cart, he removed the medication and acknowledged that it should always be secured and that having the resident’s name visible on the medication was a privacy concern. The DON later stated that the medication should not have been out in the open because it went against HIPAA practice and the resident’s right to privacy. The LVN assigned to the resident reported she had just finished administering the medication and had left it on top of the cart when she had to go to the bathroom, and she agreed it should have been secured because the resident’s name was visible. Facility policies on resident rights and on medication labeling and storage required that residents be treated with dignity and that all medications be stored in locked compartments, which was not followed in this instance.
Failure to Provide Ordered Therapeutic Diet and Meal Assistance
Penalty
Summary
A resident with a history of stroke, diabetes, non-Alzheimer's disease, and malnutrition, who was cognitively impaired and required supervision while eating, did not receive the therapeutic diet ordered by her healthcare provider. The resident was supposed to be on a regular, ground diet with specific instructions for meal assistance and positioning due to swallowing problems. On the observed date, the resident was found lying in bed at a 30-degree angle, unable to reach all the food on her tray, and was served a whole sandwich instead of ground meat, contrary to her dietary order. Staff interviews revealed that the LVN was unaware of the resident's correct diet and had to check the order, while the ADON confirmed the resident should not have received a whole sandwich due to choking risk. The CNA who delivered the tray admitted to not checking the tray for accuracy or assisting the resident to sit up, citing being rushed. The dietician confirmed the resident was on a ground diet and that the kitchen and nursing staff were responsible for verifying the tray contents. The DON also acknowledged that the resident was not properly supervised and was at risk for choking if served the wrong diet. Facility policy required that all dining services staff follow the prescribed diet orders and ensure proper food texture and resident positioning. However, the failure to provide the correct diet, ensure proper tray delivery, and supervise the resident during meals led to the deficiency, as the resident did not receive the ordered therapeutic meal and was not assisted as required.
Failure to Maintain Accurate Narcotic Logs and Proper Destruction of Controlled Substances
Penalty
Summary
The facility failed to provide proper pharmaceutical services for a resident who was prescribed morphine for pain management related to cancer and a bone fracture. The resident had orders for morphine 15 mg to be given as half a tablet (7.5 mg) three times daily, with an additional as-needed order. However, discrepancies were found between the medication administration record (MAR) and the narcotic log, with the MAR documenting 19 doses administered and the narcotic log showing only 17 doses signed out. Staff interviews revealed that doses were sometimes documented as given in the MAR when they were not actually administered, and that the timing of administration did not always match the records. Further investigation showed that staff were saving the unused half-tablets of morphine instead of properly destroying them with a witness, as required by facility policy. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were unaware that this practice was occurring until it was brought to their attention. The facility's narcotic records and morphine card were not updated to reflect the correct dose after the physician's order was changed, and staff did not use correction stickers or obtain a new dose card from the pharmacy as required. Additionally, there were missing signatures on the narcotic record, indicating that proper witnessing of drug destruction did not occur. Competency checks for medication aides (MAs) were on file, but the MAs admitted to documenting doses as given when they were not, and to saving half-tablets in the medication cart. The DON confirmed that staff should have contacted the pharmacy and physician to obtain the correct dose and documentation, and that two staff members were required to witness drug destruction. The facility's policies on pharmacy services and controlled medication management were not followed, resulting in inaccurate narcotic logs and improper handling of controlled substances.
Failure to Administer and Document Morphine Doses as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cancer, bone fracture, and Parkinson's disease did not receive morphine as ordered for pain management over a period of nine days. The resident was cognitively intact and had a care plan that required administration of pain medications as ordered by the physician. The physician's orders specified morphine 15 mg, to be given as half a tablet (7.5 mg) three times a day, with an as-needed order also in place. However, discrepancies were found between the Medication Administration Record (MAR) and the Narcotic Record, with the total doses documented as administered not matching the doses signed out, and missing signatures for narcotic waste. The morphine card count was correct, but documentation and administration practices were inconsistent. Interviews with medication aides (MAs) and licensed vocational nurses (LVNs) revealed that doses were sometimes documented as given at times when they were not actually administered, and that staff did not always follow procedures for wasting the unused half-tablet of morphine. One MA admitted to documenting a dose as given at a scheduled time even though it was administered later, and another MA reported saving the half-tablet in the medication cart instead of destroying it with a witness, as required. Staff also reported confusion about whether doses had already been administered, leading to further discrepancies in documentation. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that staff were not consistently following procedures for narcotic destruction and documentation, and that the correct dose and records had not been updated promptly after the physician's order was changed. Facility policy required accurate reconciliation of physician orders upon admission, proper accounting for controlled medications, and destruction of unused narcotics with a witness. Despite these policies, the failure to administer morphine as ordered, improper documentation, and lack of adherence to controlled medication procedures resulted in the resident missing doses of pain medication. The resident was unaware of the missed doses and reported a pain level of 6 at the time of interview.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinence care for two residents. In the first instance, a cognitively intact female resident with a history of falls and incontinence required partial assistance with toileting. During observed care, a CNA washed her hands and donned gloves, but after cleaning the resident, she used soiled gloves to retrieve clean wipes from the container and did not perform hand hygiene after removing the soiled gloves. The CNA acknowledged she was aware of the correct procedure but did not follow it due to stress, recognizing the risk of infection to the resident. In the second instance, a cognitively impaired female resident with cancer and total incontinence also required partial assistance. During care, two CNAs washed their hands and donned gloves, but one CNA used soiled gloves to handle the wipes container and did not immediately change a soiled sheet after incontinence care, stating she would do so later because she was in a hurry. Both CNAs and facility leadership confirmed that these actions were not in accordance with facility policy, which requires glove changes and hand hygiene when moving from dirty to clean areas and prohibits touching clean supplies with soiled gloves.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints that were not required to treat medical symptoms. Specifically, a male resident with a history of nontraumatic intracerebral hemorrhage, quadriplegia, and restlessness/agitation was prescribed Xanax 0.5mg as a PRN antianxiety medication. The physician's order for Xanax did not specify an end date, and the medication was administered on multiple occasions over a period exceeding 14 days. There was no documented rationale for the continued provision of the medication beyond the 14-day period. The resident's care plan indicated the use of antianxiety medication for anxiety disorder, with goals to avoid discomfort or adverse reactions. However, the facility did not discontinue the PRN prescription after 14 days as required, nor did it document a justification for ongoing use. During an interview, the DON acknowledged the expectation that PRN psychotropic medications should not be prescribed for more than 14 days and was unable to explain why the order remained active. Additionally, the facility did not have a written policy regarding PRN antianxiety/psychotropic medication use.
Incomplete Discharge Summary and Recapitulation of Stay
Penalty
Summary
The facility failed to complete a discharge summary, specifically a recapitulation of stay, for a resident who was discharged to another facility. The recapitulation of stay was missing required information from multiple departments, including Social Services, Nursing Services, Activities, Dietary Services, and Rehabilitation Services. The document was neither completed nor signed, and this omission was identified during a review of the resident's records. The resident in question had a medical history that included a urinary tract infection, type 2 diabetes mellitus with hyperglycemia, and an unspecified head injury. During an interview, the DON stated that it was expected for each department to complete their respective sections of the recapitulation of stay, but was unsure why it had not been done in this case. The facility did not have a written policy regarding the completion of recapitulation of stays, but the administrator indicated that the facility was expected to follow state guidelines. The lack of a completed recapitulation of stay was noted as a deficiency in the resident's discharge process.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a Certified Nursing Assistant (CNA) was witnessed being verbally and physically abusive. The incident involved a resident with mild cognitive impairment and a history of depression and fibromyalgia, who required extensive assistance with Activities of Daily Living (ADL). During an episode of incontinent care, the resident asked the CNA to stop rolling her over due to pain, but the CNA continued despite protests from both the resident and another CNA present. The resident reported feeling fearful and believed the CNA might harm her. The resident initially reported the incident to multiple staff members but was told that no one matching the CNA's description worked at the facility. It was later discovered that the CNA had provided a false name during the incident. The resident recognized the CNA during a facility activity and reported this to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The resident's family member also expressed frustration that the facility initially dismissed the resident's claims and installed a camera in the resident's room for added security. Interviews with staff revealed that another CNA witnessed the abuse but did not report it due to personal reasons. The facility's investigation was hampered by inconsistencies in the resident's account and the lack of immediate reporting by the witnessing CNA. The facility eventually identified the abusive CNA and took action, but the initial failure to protect the resident and the delay in addressing the abuse constituted a deficiency in ensuring the resident's right to be free from abuse.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure that a resident received routine dental care, which was necessary for maintaining oral health and hygiene. The resident, an elderly female with multiple health conditions including Alzheimer's disease and multiple sclerosis, was dependent on staff for personal hygiene. Despite requests from the resident's representative for dental services due to issues with her top denture, the resident had not been seen by a dentist. Observations confirmed that the resident's top denture was not secured and kept sliding down, and she did not recall receiving any dental services. The facility's records showed that a referral for dental services had been made, but there was no documentation indicating that the resident was seen by a dentist. The social worker, responsible for ensuring the resident received dental services, was unaware of whether the resident had been seen and noted that the resident was not on her dental list. The facility's policy stated that routine and emergency dental services should be available to meet residents' oral health needs, but this was not adhered to in the case of the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were immediately reported to the State Survey Agency, as required by regulations. This deficiency was identified in the case of a resident who reported an incident involving two CNAs. The resident, who had mild cognitive impairment and required extensive assistance with activities of daily living, reported that one CNA was verbally abusive and physically rough during incontinent care, causing her pain and fear. Despite the resident's report to multiple staff members, the incident was not immediately reported to the appropriate authorities. The incident was initially dismissed by the facility because the resident provided a name and description that did not match any known staff member. It was only after the resident recognized the CNA during a later encounter that the facility began to take action. Interviews with staff revealed that another CNA had witnessed the abuse but failed to report it due to personal feelings about the perpetrator's living conditions. This failure to report was a significant factor in the delay of the investigation and notification to the State Survey Agency. The facility's administration, including the DON and Administrator, were informed of the incident but did not report it to the State Survey Agency within the required timeframe. The Administrator believed the resident was confused and did not feel the abuse was intentional, which contributed to the delay in reporting. The facility eventually conducted an internal investigation, but the initial failure to report the alleged abuse in a timely manner placed residents at risk of further harm.
Deficiency in Resident Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, leading to a deficiency in maintaining good foot health. The resident, a severely cognitively impaired elderly female with multiple health conditions, required maximal assistance with mobility and was dependent on staff for activities of daily living. Her care plan included preventative measures for pressure ulcer prevention, such as skin prep to her toes and the use of a pressure redistribution mattress. However, the facility did not ensure consistent application of these measures, as evidenced by the presence of pink areas and flaky skin on her toes, as well as curled and discolored toenails. The resident's medical records indicated that she had been seen by a podiatrist in July, who performed a complete foot examination and toenail debridement. Despite this, observations in August revealed ongoing issues with her foot care, including pink areas and flaky skin on her toes. Interviews with the treatment nurse and the Director of Nursing (DON) suggested that the resident's toes appeared better than in previous months, yet there was a lack of clarity regarding the specific wound care being provided. The treatment nurse acknowledged that the resident would benefit from routine skin prep, which was intended to harden the skin on her toes. Interviews with facility staff and a family member highlighted concerns about the adequacy of the resident's foot care. The family member reported that the resident had wounds on her toes in July, which were not being adequately addressed by the facility. The DON admitted that the appearance of the resident's toes could have been improved with lotion and acknowledged the risk of skin breakdown. Despite requests, the facility did not provide a podiatry policy, indicating a potential gap in their procedures for ensuring proper foot care.
Medication Administration Error
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications, resulting in a medication error involving two residents. A resident received medications, Oxybutynin and Trazodone, that were prescribed for another resident. This error occurred when a Certified Medication Aide (CMA) mistakenly administered the wrong medication cup to the resident after being distracted from the medication cart. The resident who received the incorrect medications was a cognitively intact female with a history of hemiplegia following a cerebral infarction. The error was discovered when a family member noticed the medication cup was labeled with another resident's room number. Despite attempts to have the resident spit out the medication, she had already swallowed two pills. The resident was subsequently monitored for adverse reactions, and her condition deteriorated, leading to hospitalization. The incident was documented in progress notes, indicating that the resident experienced slurred speech, muscle weakness, and decreased oxygen saturation, which required medical intervention and hospitalization. The facility's policy on medication administration, which includes verifying the right patient and medication, was not adhered to, leading to this deficiency.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for two residents, specifically in maintaining a room free of urine odors. Resident #4, who shared a bathroom with Resident #5, was noted to have a room with a strong smell of urine. This was due to Resident #4's refusal to allow staff to assist with personal hygiene, change bed linens, or clean the room. The resident was moderately cognitively impaired and occasionally incontinent of urine, yet did not participate in a urinary toileting program. The facility's records indicated multiple instances where Resident #4 refused care, including housekeeping services, which contributed to the unsanitary conditions. Staff documented the resident's refusals but did not record any effective interventions to address the situation. The resident's care plan did not adequately address the physical environment, focusing instead on minimizing resistance to care without specific strategies for maintaining cleanliness. Interviews with staff, including the DON and Housekeeping Supervisor, revealed ongoing challenges in managing Resident #4's care refusals. Despite attempts to encourage participation in activities and physical therapy to facilitate room cleaning, the resident continued to decline assistance. The facility was in the process of seeking alternative placement for the resident due to her non-compliance and worsening dementia, but no immediate solutions were implemented to resolve the environmental issues.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs during incontinence care for two residents. CNA A and CNA B did not perform proper hand hygiene during the care of residents, which is a critical step in preventing the spread of infections. Specifically, CNA A did not wash her hands or use hand sanitizer after removing gloves while providing care to a resident with severe cognitive impairment and multiple health conditions, including a current urinary tract infection. Similarly, CNA B failed to wash her hands or use hand sanitizer between glove changes while caring for another resident with intact cognition and a history of incontinence. The observations revealed that CNA A, who was orienting a new CNA, did not adhere to the hand hygiene protocol despite having received training on infection control and hand hygiene two months prior. During the care of a resident with a suprapubic catheter, CNA A changed gloves without washing hands, increasing the risk of infection. CNA B, who also received similar training, repeated the same mistake by not washing hands between glove changes while applying barrier cream and cleaning the perineal area of another resident. The Director of Nursing (DON) confirmed that the CNAs were expected to follow hand hygiene protocols, which include washing hands upon entering and exiting resident rooms and with glove changes. The facility's hand hygiene policy emphasizes the importance of hand hygiene in preventing the spread of infections. The DON also noted that there had been recent cases of E. coli in urine cultures, which could be linked to improper wiping techniques during incontinence care.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. During an initial tour of the dry storage area, several deficiencies were observed, including improperly labeled and expired food items, dented cans not segregated, and unlabeled packages of tea bags. Additionally, the facility's refrigerator and freezer contained uncovered and unlabeled food items, improperly stored chicken with blood leakage, and food with frostbite. These observations indicate a lack of adherence to proper food storage and labeling protocols, which could potentially expose residents to adulterated or contaminated food. Interviews with the Head Cook and Dietary Manager revealed that the Dietary Manager was responsible for ensuring proper food storage and training staff on food storage procedures. However, the observations made during the survey indicated that these responsibilities were not adequately fulfilled. The Head Cook and Dietary Manager acknowledged the issues and stated that they had taken steps to address them, but the deficiencies were still present at the time of the survey. The facility's failure to adhere to the U.S. Public Health Service Food Code and the U.S. Department of Health and Human Services Food Code was evident in the improper storage, labeling, and handling of food items. This non-compliance with food safety standards placed the majority of the facility's residents at risk for exposure to adulterated or contaminated food, which could lead to severe health effects such as diarrhea, nausea, allergic reactions, diabetes, and cardiovascular disease.
Failure to Timely Change Central Line Dressing
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident, specifically in the management of a central line. The central line dressing for a resident was not changed per the physician's order and facility policy, which required weekly changes to prevent infection. The resident, who had severe cognitive impairment and multiple diagnoses including an infection of the humerus and hypertensive heart disease, had a central line for antibiotic administration. The dressing was changed on 01/19/24 but was not changed again until 02/02/24, missing the scheduled change on 01/26/24. This lapse was confirmed through record reviews and interviews with staff, including an RN who acknowledged the failure to change the dressing timely and the DON who was unaware of the missed dressing change but stated it should have been done weekly to prevent infection. The deficiency was further highlighted by the lack of a care plan for the central line and incomplete physician orders regarding the frequency of dressing changes. The responsible RN admitted to not remembering if there were specific orders for the dressing change and only changed the dressing once during the resident's stay. The DON also admitted to not following up on the central line dressing changes, which were crucial for preventing infections. The facility's policy on dressing changes did not specify the frequency, contributing to the oversight and potential risk to the resident's health.
Failure to Report and Investigate Resident Fall
Penalty
Summary
The facility failed to ensure all allegations of abuse were reported immediately to the State agency, thoroughly investigated, and residents were protected during the investigation. This deficiency was identified for one resident who was found alone on the floor in her room with multiple bruises on her face. The resident, who had a BIMS score indicating moderately impaired cognition, was unable to verbalize how the fall occurred. Despite the visible injuries and the resident's inability to explain the fall, the facility did not report the incident to the State agency, as they believed it did not meet the criteria for reporting. Interviews with various staff members, including an RN, LVN, receptionist, and aide, revealed that the resident was found on the floor with blood coming from her head. The staff provided immediate care, including cleaning the wound and performing neurological checks, but did not report the incident as required. The facility's administrator, who is also the Abuse Coordinator, confirmed that the incident was not reported, stating it did not meet the criteria for reporting. The facility's Reportable Incident Protocol Policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported to the State agency within five working days. The policy defines injuries of unknown source as those not observed by any person or not explained by the patient, and suspicious due to the extent or location of the injury. Despite this policy, the facility failed to report the incident involving the resident's fall and injuries, leading to a deficiency in ensuring resident safety and proper investigation of potential abuse or neglect.
Deficiency in PASRR Process and Incomplete Baseline Care Plan
Penalty
Summary
The report identifies a deficiency related to the Pre-Admission Screening and Resident Review (PASRR) process for a resident. The resident, a female with diagnoses including bipolar disorder and anxiety disorder, was admitted to the facility with a PASRR Level I completed at the hospital, which indicated no mental illness. However, upon review, the MDS Coordinator found that the resident's diagnoses of bipolar disorder and anxiety disorder were not included in her medical history, which should have necessitated a PASRR Level II evaluation. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged that the resident should have received a PASRR Level II evaluation but did not believe there were any immediate risk factors due to this omission. Throughout the survey process, the resident was observed to be clean, well-groomed, and appropriately dressed, with no visible marks or bruises. Despite being alert and oriented, the resident was visibly distressed and grief-stricken due to recent traumatic events, including her own illness and the death of her daughter. The Baseline Care Plan for the resident, initiated by an RN/Charge Nurse, was found to be incomplete, with no areas filled out. This incomplete documentation further highlights the deficiency in the facility's assessment and care planning processes for the resident.
Failure to Complete PASRR Level II Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that individuals with mental disorders were properly evaluated and received care in the most integrated setting appropriate to their needs. Specifically, the facility did not correctly identify a resident as having a mental illness and did not complete a new PASRR Level I Screening. This oversight was discovered during a review of the resident's face sheet and MDS assessment, which indicated diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder. However, the PASRR Level I Screening completed prior to the resident's admission did not reflect any indicators of mental illness. During an interview, the resident expressed satisfaction with the care received but was visibly distressed and grief-stricken due to recent traumatic events. The MDS Coordinator confirmed that the PASRR Level I Screening was completed at the hospital and did not capture the resident's mental health diagnoses. The coordinator acknowledged that the resident should have received a PASRR Level II evaluation based on her diagnoses but was unaware of any risk factors due to the lack of this evaluation.
Failure to Implement Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #95 within 48 hours of her admission. Resident #95, a [AGE] year-old female with diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder, was admitted to the facility on [DATE]. Her MDS Assessment indicated she required assistance with activities of daily living (ADLs) such as bathing and dressing. However, her baseline care plan, dated 02/14/24, was found to be incomplete with no information regarding her care needs or status at the time of admission. During an interview, the Administrator confirmed that the expectation was for baseline care plans to be completed upon a resident's admission by the nursing staff. The failure to complete Resident #95's baseline care plan could result in staff not knowing how to best care for her. The facility's policy regarding baseline care plans was requested but not provided by the Administrator.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to a deficiency in meeting their individualized needs. Resident #08, a male with diagnoses including dementia, psychotic disturbance, anxiety disorder, and schizophrenia, had an incomplete care plan that did not address his schizophrenia. Despite being prescribed Seroquel for schizophrenia, this diagnosis was not included in his care plan, which could prevent him from receiving necessary care. The MDS coordinator admitted to overlooking the diagnosis, and the DON acknowledged that missing information in the care plan could result in missed care needs. Resident #35, a female with acute kidney failure, hypertension, type 2 diabetes mellitus, and other conditions, did not have a care plan at all. Despite being alert and oriented with a BIMS score of 15, her care needs were not documented. The LVN responsible for completing the care plan admitted to missing it, and the DON confirmed that she had not checked if the care plan was completed. This lack of documentation could lead to staff not meeting the resident's care needs. The facility's policy requires a comprehensive person-centered care plan to be developed within seven days of the MDS assessment and updated regularly. However, the failure to adhere to this policy for Residents #08 and #35 indicates a lapse in the facility's processes, potentially compromising the residents' care and well-being.
Failure to Check Residual Volume Before Medication Administration
Penalty
Summary
The facility failed to ensure that residents who are fed by enteral means receive appropriate treatment and services to prevent complications. Specifically, LVN F did not check for residual volume prior to administering medication to a resident with a feeding tube, as required by the physician's order. This oversight could lead to complications such as aspiration, which occurs when food, liquid, or other material enters a person's airway and eventually the lungs by accident. The resident in question, a [AGE] year-old female with severe cognitive impairment and multiple diagnoses including Gastrostomy status, hypertension, type 2 diabetes, and chronic kidney disease, was observed receiving medication without the necessary residual volume check. During an interview, LVN F admitted to forgetting to check for residual volume, acknowledging the importance of this step in preventing overfeeding and ensuring proper digestion. The Director of Nursing (DON) confirmed that the residual check is crucial for verifying the feeding tube's placement and preventing aspiration. Despite the facility's policy on administering medication through an enteral tube and recent in-service training, the required procedure was not followed. The facility's policy did not address checking for residual, which contributed to the oversight.
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 836 citations issued within 25 miles in the last 12 months — including the 31 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 Allen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Victoria Gardens Of Allen | 1.5 mi | ★★★★★ | 13 | 0 |
| Mckinney Healthcare And Rehabilitation Center | 4.6 mi | ★★★★★ | 1 | 0 |
| The Park In Plano | 5.3 mi | ★★★★★ | 11 | 0 |
| Stonemere Rehabilitation Center | 5.6 mi | ★★★★★ | 3 | 0 |
| Victoria Gardens Of Frisco | 6.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Belmont At Twin Creeks.
100% money-back within 48 hours.
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.