Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Broadmoor At Creekside Park during CMS and state inspections, most recent first.
Inadequate supervision allowed a resident with severe cognitive impairment, dementia, and mobility limitations to elope from an unwitnessed exit and be found on nearby school property. Staff had seen him earlier pushing on an exit door and triggering the alarm, but he was only redirected and later successfully left the building. Records and interviews showed the resident was at risk for elopement and used a walker and wheelchair, yet the response to his initial exit-seeking behavior was inconsistent.
Failure to Provide Scheduled Bathing Assistance: Two residents who needed help with ADLs did not receive scheduled bathing support as documented. One resident with a healing hip fracture and moderate cognitive impairment reported only one shower since admission, while another resident with a fractured humerus, depression, and anxiety reported no shower since admission and was observed with extremely oily hair. Records showed missing or inconsistent bathing documentation, and staff gave conflicting accounts of how showers were scheduled and recorded.
Unsecured Medications Found in Resident Rooms and an Unlocked Cart Surveyors found eight unidentified tablets in a resident’s mini refrigerator and an albuterol inhaler in another resident’s purse, even though neither resident had an order to self-administer medications. An unlocked medication cart was also observed unattended in a hallway with prescription meds, nebulizer treatments, OTC meds, and supplements inside. Staff and the DON stated medications should be watched during administration and carts should be locked when unattended.
A resident with acute kidney failure, HF, COPD, DM, HTN, and other diagnoses missed an ordered outpatient dialysis treatment because transportation was not arranged. The resident’s care plan identified dialysis needs, and staff interviews showed the LVN notified the NP after the missed treatment, the Unit Manager expected the nurse to confirm transportation, and the Receptionist admitted she did not set up the ride after receiving notice of the admission. The dialysis center confirmed the resident was not booked for pickup and the facility had not confirmed the appointment.
Unaccounted Alprazolam Tablet: A resident with anxiety, depression, and a pubic fracture had an Alprazolam 0.5 mg order that was documented on the MAR and narcotic record inconsistently. Nursing staff found a count discrepancy on the cart, but one LPN had not signed the narcotic sheet after administering the dose, and the missing tablet was not explained when the discrepancy was discovered.
Medication administration errors resulted in a 7% error rate when an MA gave two anti-hypertensive meds to a resident with HTN and severe cognitive impairment without checking BP first. The resident’s orders and pharmacy labels required vital sign checks and hold parameters, but the MA said she relied on the eMAR prompt and did not obtain BP before giving Amlodipine and Lisinopril.
Dumpster Lid Left Open and Unsecured: Surveyors observed one of two commercial-sized dumpsters with its lid open and unsecured in the area behind the dietary dept. The Dietary Mgr stated kitchen, nursing, and laundry staff were responsible for closing the lids and thought it was okay for the lid to remain open if the gate was closed, while the Admin stated the dumpster should have been closed and that dietary, maintenance, and housekeeping were responsible for ensuring it stayed closed. The facility policy required waste containers to be covered and trash to be deposited into the sealed container outside the premises.
Surveyors found that a resident was admitted to a room with urine-stained sheets, fecal matter on the toilet, and leftover wheelchair equipment from a prior occupant, while another resident’s room had numerous small black bugs on the kitchenette counter and inside a food bag. Two vacant rooms were also observed with spider webs, a dead centipede, urine-stained bedding, dried fecal splatter in the toilet, hairballs, and food residue along baseboards. Staff interviews revealed that CNAs sometimes received linens from laundry that were still stained with urine or BM and that residents had complained about dirty linens and bugs, including roaches, despite a facility policy requiring a clean, sanitary, and homelike environment.
A resident with severe cognitive impairment and multiple risk factors did not receive a thorough head-to-toe skin assessment as required by care plan and facility policy. Nursing staff failed to examine all areas, specifically the groin, resulting in a missed abscess that was only discovered after the resident was transferred to a hospital for further care.
A resident with multiple medical conditions, including dementia and hemiplegia, did not receive scheduled showers and wore the same stained shirt for three days. The facility's incomplete care plan and lack of documentation contributed to the oversight, as staff were unaware of the resident's needs. The facility's policy on ADLs was not followed, risking the resident's hygiene and health.
The facility failed to maintain complete and accurate medical records for three residents, leading to potential missed treatments and inadequate care. A resident's wound treatments were not documented in the electronic system, while two other residents lacked current care plans for their complex medical needs, including pressure ulcers and catheter care.
The facility failed to document catheter care for two residents with indwelling catheters, risking urinary tract infections. Physician orders for catheter care were not entered into the system, and staff could not document care from December 1 to December 17, 2024. Observations confirmed the presence of Foley catheters, but medical records lacked care plans and documentation. Staff interviews revealed issues with order entry following a switch to a new EMR system.
A facility failed to provide colostomy care for a resident due to missing physician orders in the EMR system. The resident, with multiple medical conditions and a colostomy, had no care plan or documentation of colostomy care from December 1 to December 17, 2024. Staff interviews revealed that the recent switch to a new EMR system led to missed orders, and the absence of orders could result in missed treatments.
A resident with severe cognitive impairment and multiple health issues was incorrectly documented as self-administering Potassium Chloride due to a transcription error. Staff failed to verify the order, leading to potential medication administration errors. The Unit Manager identified the mistake during a transition to a new EMR system, and the DON noted the need for proper order verification.
A facility failed to coordinate hospice care for a resident during an EMR transition, resulting in a missing hospice order from the system. The resident, with multiple health issues and on hospice care, had their hospice order omitted from the EMR from December 1 to December 17, 2024. Interviews revealed the order was in a previous EMR but not transferred correctly. The facility's policies emphasize accurate record-keeping, which was not followed, risking inadequate end-of-life care.
A facility failed to maintain proper infection control when a Med Aide did not sanitize a blood pressure cuff between uses on two residents. One resident had serious infections and was on Enhanced Barrier Precautions, while the other was admitted for rehabilitation. The oversight was confirmed by staff interviews, highlighting a lapse in following the facility's infection control policy.
Two residents who were fully dependent on staff for toileting and hygiene did not receive timely incontinence care, resulting in them being left soiled for extended periods. Family members, EMS personnel, and staff interviews confirmed that short staffing and lack of regular checks contributed to the deficiency, with residents unable to use call lights or reach staff for assistance.
The facility did not maintain adequate nursing staff on several days, resulting in residents, including one with significant medical and cognitive needs, remaining in soiled briefs for extended periods. Staffing levels were below the facility's own requirements, and staff and external responders confirmed that residents' care needs, particularly incontinence care, were not met in a timely manner.
A resident's purse, containing personal valuables, was lost after a housekeeper retrieved it from the Admissions office and gave it to another resident, mistakenly believing the individual was a family member. Staff did not verify the identity of the person receiving the property, and the purse was never recovered. The incident revealed inconsistent practices and lack of awareness among staff regarding the proper handling and release of resident belongings.
A CNA did not perform hand hygiene or change gloves as required while providing incontinence care to a resident with hemiplegia, diabetes, and cognitive impairment. The CNA used a single pair of gloves throughout the care, handled multiple items, and left the resident and bedding wet, contrary to facility policy and training. The DON confirmed the expected infection control procedures and the importance of compliance.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall, resulting in a head laceration and shoulder skin tear. The facility staff failed to remain with the resident, perform a complete assessment, and consistently document neuro checks, leading to deficiencies in the care provided.
Inadequate Supervision Allowed Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with severe cognitive impairment who eloped from an unwitnessed point of exit and was later found on the rear school property connected to the facility grounds. The resident was an older male with diagnoses including unsteadiness on his feet, vascular dementia, urinary retention, and infection and inflammatory reaction related to an indwelling urethral catheter. His admission MDS showed a BIMS score of 7 out of 15, indicating severe cognitive impairment, and he used a walker and wheelchair for mobility. The resident’s admission assessment did not identify him as having a history of elopement, wandering, or attempts to leave the facility. However, his care plan later identified him as at risk for elopement and included interventions such as frequent checks, diversions, and one-to-one monitoring until his acute condition improved. On the day of the incident, staff observed him at the 100-hall exit pushing on the door with his walker, which activated the alarm. He was redirected away from the door, but the record and staff interviews showed that the initial attempt was not fully escalated or clearly followed by a documented assessment at that time. Later that same day, the resident successfully exited the facility through an unwitnessed point of exit and was found outside on school property. The incident report described him as wandering in the back of the facility and unable to give a description. The Administrator later stated he had been outside for approximately 12 minutes. Interviews with staff showed differing accounts of the response to the first exit attempt, and one CNA stated she saw him push open the exit door and was later in the dining room when he eloped. The resident’s family reported that he had dementia and was in very poor health, and that his condition worsened within hours after the elopement.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide scheduled bathing and grooming assistance for 2 residents who required help with activities of daily living. Resident #34 was admitted with a healing right hip fracture, falls, and muscle weakness, and her MDS showed moderate cognitive impairment with partial/moderate assistance needed for showering and toileting hygiene. Her care plan noted she needed assistance moving between surfaces, and her Kardex listed a bathing schedule of every day, but bathing documentation from 02/28/2026 through 03/06/2026 was marked not applicable. During interview, Resident #34 stated she had only one shower since admission and said staff were too busy when she asked for help with bathing. Resident #123 was admitted with a displaced fracture of the right humerus, depression, and anxiety, and her MDS showed noticeable memory and thinking difficulties with substantial/maximal assistance needed for showering and toileting. Her care plan identified limited physical mobility and an ADL self-care performance deficit, but no interventions were listed, and her Kardex did not specify bathing needs. Bathing documentation showed showers or a bed bath on 03/06/2026, 03/07/2026, and 03/08/2026, but no checkmarks for 03/09/2026 through 03/12/2026. Progress notes did not show documentation of refused showers. On 03/13/2026, review of shower sheets for all halls showed no documentation of showers or baths for Resident #34 and Resident #123 from 02/25/2026 through the date of review. Resident #123 stated she had not had a shower since admission and said it made her feel nasty; her hair was observed to be extremely oily. Staff interviews reflected differing practices for identifying and documenting showers, including use of a shower book, paper shower sheets, and the electronic health record, while the DON stated shower sheets were intended to be the sole method of documenting showers and that she had not audited them. The facility policy stated residents unable to perform ADLs would receive necessary services to maintain grooming and personal and oral hygiene.
Unsecured Medications Found in Resident Rooms and Unlocked Medication Cart
Penalty
Summary
The facility failed to keep medications and biologicals secured in locked storage areas and under proper control. Surveyors found eight unidentified tablets in a medication cup inside Resident #40’s mini refrigerator, even though the resident did not have an order to self-administer medications. Resident #40 had diagnoses including Parkinson’s disease, diabetes, falls, hypertension, dementia, and depression, and his care plan noted behaviors including keeping medications at bedside and refusing medications. His active orders included multiple scheduled oral medications, but there was no self-administration order or care plan for self-administration. Resident #68, who had diagnoses including paroxysmal atrial fibrillation, obesity, kidney disease, diabetes, and epilepsy, was observed with an open purse on her lap containing an albuterol sulfate inhaler. She stated she used it when wheezing or coughing and that staff were aware she had it. Her active orders included inhalation medications, but there was no diagnosis related to albuterol sulfate and no order for self-administration. Surveyors also observed an unlocked and unattended medication cart in a hallway in front of a resident room. The cart contained medication bubble packs, nebulizer treatments, prescription medications, over-the-counter medications, and supplements. Staff stated the cart belonged to the nurse and was locked after the surveyor pointed out that it was unsecured. The DON stated that if a cart was not within view of the nurse, it needed to be locked, and the Administrator stated medication carts should be locked if unattended. The facility policy stated that all drugs and biologicals must be stored in locked compartments and that during a medication pass, medications must be under direct observation or locked in the medication storage area/cart.
Missed Dialysis Due to Unarranged Transportation
Penalty
Summary
The facility failed to ensure that a resident who required dialysis received transportation for a physician-ordered outpatient dialysis appointment. Resident #124 was admitted with diagnoses including acute kidney failure, heart failure, COPD, diabetes, hypertension, liver disease, and osteomyelitis of the right ankle and foot. Her admission assessment showed intact cognition with a BIMS score of 15, use of a wheelchair for mobility, and need for assistance with several activities of daily living. Her care plan identified dialysis needs and included interventions to encourage attendance at scheduled dialysis appointments and to monitor for signs of renal insufficiency. The resident had an active physician order for dialysis at an outpatient clinic every Tuesday, Thursday, and Saturday, with the first treatment scheduled for Tuesday at 3:30 PM. The dialysis center’s welcome letter also documented that first appointment. The resident stated she was supposed to have dialysis on that Tuesday, but there was a transportation problem. She reported that the facility was supposed to make the transportation arrangements and that her last dialysis had been while she was in the hospital. The resident also reported feeling tightness and heaviness in her legs and pain related to her right foot amputation. Staff interviews showed that the transportation arrangement was not completed. The LVN assigned to the resident stated she notified the NP after the missed dialysis treatment and explained that the resident’s schedule had changed while in the hospital. The Unit Manager stated she expected the nurse who took the dialysis order to follow up by arranging transportation and confirming the appointment with the dialysis center. The Receptionist stated she received notice that the resident was arriving at the facility but did not enter the dialysis transportation because she was unsure whether the resident would actually admit, then forgot to arrange it. The dialysis nurse stated the facility did not confirm the appointment and the resident was not booked for transportation with either of the transportation companies checked. The DON stated the receptionist was designated to arrange dialysis transportation and that transportation was not arranged.
Unaccounted Alprazolam Tablet
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident by not accounting for one Alprazolam 0.5 mg tablet. The resident was a [AGE]-year-old female admitted with diagnoses including anxiety disorder, fracture of the right pubis, and depression. Her admission MDS showed a BIMS score of 13 out of 15, indicating intact cognition. Her MAR for March 2026 showed Alprazolam 0.5 mg ordered as 1 tablet every 8 hours as needed for pain, with one documented administration on 3/11/26 at 1:32 p.m. The narcotic record for Alprazolam showed four entries between 3/11/26 and 3/13/26, including documentation of one tablet administered on 3/11/26 at 8:00 p.m., 3/12/26 at 2:00 p.m., and 3/12/26 at 9:00 p.m. The record showed 66 tablets remaining at 9:00 p.m. on 3/12/26, then 65 tablets remaining on 3/13/26 at 3:00 p.m., with the word correction written in parentheses and one nurse signature. There was no explanation for the missing tablet. During observation and interview, the LVN counting the 400-hall nurses' cart said there were 65 tablets remaining and she was unsure what happened to the missing tablet. She stated she and another LVN had counted narcotics during shift change and tried to determine what happened, but the other LVN did not sign the narcotic sheet because she got busy. She said they did not report the missing tablet at the time because they wanted to find the error before escalating it. The other LVN later said she had administered one Alprazolam tablet to the resident but did not document it on the narcotic sheet, and the DON stated staff should count narcotics and notify her if there were discrepancies.
Medication Error Rate Exceeded Due to Missed Blood Pressure Check Before Antihypertensives
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors found a 7% medication error rate, based on 2 errors out of 27 opportunities, involving one resident and one medication aide reviewed for medication administration. The errors involved the administration of two anti-hypertensive medications without checking the resident’s blood pressure as required by the physician orders, the pharmacy labels, and facility policy. Resident #48 was an elderly female admitted with diagnoses including hypertension, Alzheimer’s disease, kidney failure, and hypertensive heart disease without heart failure. Her quarterly MDS showed a BIMS score of 2 out of 15, indicating severe cognitive impairment, and she required set-up or clean-up assistance with ADLs. Her care plan addressed hypertension related to hypertensive heart disease and directed staff to give anti-hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate. During a medication pass observation, MA G prepared and administered Amlodipine 5 mg and Lisinopril 20 mg, along with other medications, without taking the resident’s blood pressure. The pharmacy labels for the blood pressure medications stated to check the patient’s parameters before administering, and the orders included hold parameters for low blood pressure and, for Amlodipine, low pulse. MA G stated she did not check the blood pressure because the eMAR did not show a heart symbol prompting her to do so, and she acknowledged the medications had hold orders and label instructions to check parameters. The Unit Manager and DON stated staff were trained to take blood pressure before administering blood pressure medications and that the resident’s orders should have included prompts to enter vital signs. A nursing note later documented a blood pressure of 130/72 and pulse of 72, with medications administered by the medication aide and no adverse reactions noted.
Dumpster Lid Left Open and Unsecured
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when surveyors observed one of two commercial-sized dumpsters with its lid open and unsecured in the dumpster area behind the dietary department. The dumpster was located inside a gate, and the open lid was noted during the observation with the Dietary Manager present. During interview, the Dietary Manager stated that kitchen, nursing, and laundry staff were responsible for closing the dumpster lids and that the lid should be closed after each use, although she believed it was acceptable for the lid to remain open if the gate was closed. She was not sure who last used the dumpster and stated the risk of leaving it open could be raccoons. The Administrator later stated the dumpster should have been closed, that dietary, maintenance, and housekeeping were responsible for ensuring the dumpsters were closed, and that the risk of the lid not being closed was pest. The facility policy dated 12/01/25 stated waste containers shall be covered and trash shall be deposited into the sealed container outside the premises.
Unsanitary Resident and Vacant Rooms, Soiled Linens, and Pest Activity
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, and sanitary environment in resident-occupied and vacant rooms. One complaint resident (CR#1), a woman admitted with spinal stenosis of the lumbar region with neurogenic claudication and prior lumbar-sacral fusion, was admitted to a room that had urine-stained sheets, brown fecal matter on the toilet seat and toilet bowl, and wheelchair leg-rest equipment left on the closet floor from a previous resident. CR#1, who was alert and oriented x4, reported that the room was unsanitary upon admission, stating that her family had to clean the room and that they observed urine stains on the bed linens. Photographs taken by CR#1 on the day of admission showed brown fecal matter on the bottom of the toilet seat and directly underneath the toilet seat, short black hair in the bathroom soap dish, and wheelchair leg rests left on the closet floor. Another resident, identified as Resident #1, had a room with multiple small black bugs crawling on the kitchenette counter and inside a plastic bag containing a cookie. Resident #1’s family member reported that the move-in process had gone fine but stated there had been a lot of bugs by the kitchenette sink and counter and that the bugs had been present in the room for an unspecified period of time. Resident #1’s medical record showed she was admitted with noninfective gastroenteritis and colitis and a perforation of the intestine, and her care plan documented an ADL self-care performance deficit related to activity intolerance and impaired balance due to declined health. The presence of bugs in her room was directly observed by the surveyor during the interview with the family member. Two vacant rooms were also found to be in unsanitary condition. In vacant room A, which appeared empty of personal belongings but still had a resident’s name on the door, there were spider webs along the baseboards with a dead centipede caught in the web, a faint urine stain on the fitted sheet when the bed covers were pulled back, and dried fecal matter splatter inside the back of the toilet bowl. In vacant room B, hairballs and food residue were observed along the floor baseboards, and when the bed sheets were pulled back, over 30 strands of short black hair were seen on the fitted sheet. Staff interviews revealed that housekeeping staff were responsible for cleaning both occupied and vacant rooms and that some CNAs reported receiving linens from laundry that were stained with urine or bowel movement and that they would return visibly stained linens to the dirty pile. A CNA reported receiving complaints from residents about bugs and having seen roaches, and another CNA reported finding a roach in the hallway. A laundry aide described separating heavily soiled linens for special washing and sometimes re-washing items multiple times, and the DON stated that her expectation for new admissions and discharges was that housekeeping would perform a deep clean of the room, with the harm of an unclean environment identified as an infection control concern. Record review of the facility’s “Homelike Environment” policy, revised February 2021, showed that residents were to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment and clean bed and bath linens in good condition. Despite this policy, the observations, interviews, and record reviews documented that CR#1 was admitted to a room with visibly soiled linens and bathroom fixtures, Resident #1’s room had visible bugs on the kitchenette counter and food packaging, and two vacant rooms contained dirty linens, pest evidence, and unclean bathroom fixtures and baseboards. These conditions formed the basis of the cited deficiency for failure to maintain a safe, functional, and comfortable environment for residents, staff, and the public.
Failure to Complete Thorough Head-to-Toe Skin Assessment
Penalty
Summary
A facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, an elderly male with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and skin cancer, was at risk for pressure ulcers and had documented interventions requiring regular skin assessments, particularly due to his incontinence and decreased mobility. The care plan and physician orders required weekly head-to-toe skin assessments, with special attention to skin condition and signs of breakdown. On several occasions, staff documented that head-to-toe skin assessments were completed, but interviews and record reviews revealed that these assessments were not thorough. Specifically, on the day before the resident was sent to the hospital, the nurse responsible for the assessment admitted she did not examine the resident's groin area, stating she did not suspect any issues and the resident did not complain of discomfort. Other staff also reported difficulty in providing care due to the resident's dementia and reluctance to allow assistance, but there was no documentation or evidence that a complete skin assessment, including all skin folds and creases, was performed as required by facility policy. The deficiency became evident when the resident was found to have a draining, foul-smelling abscess in the left groin area, which was only discovered after a family member insisted on a more thorough examination. The abscess required surgical intervention after the resident was transferred to an acute care hospital. Interviews with staff confirmed that the required comprehensive skin assessments were not fully completed, particularly in the groin area, despite policy and care plan directives to examine all areas of the body, including moist areas and skin folds.
Failure to Provide Scheduled ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. The resident, a male with multiple medical conditions including kidney failure, dementia, and hemiplegia, was dependent on staff for showers, toileting hygiene, and dressing. Despite this, the resident did not receive scheduled showers on two occasions and wore the same stained shirt for three consecutive days. Observations and interviews confirmed that the resident had not been assisted with personal hygiene tasks such as brushing teeth and washing his face. The facility's records revealed that the resident's care plan was incomplete, and there was a lack of documentation regarding shower schedules in the electronic medical records. Interviews with staff indicated a lack of awareness and communication about the resident's needs and scheduled care. The Director of Nursing and the Administrator acknowledged the oversight and the potential risk of infections due to missed showers. The facility's policy on ADLs emphasized the importance of providing care to maintain residents' hygiene and grooming, which was not adhered to in this case.
Deficiencies in Medical Record Documentation and Care Planning
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices for three residents. For Resident #151, there was a lack of documentation of wound treatments in the electronic record from December 14 to December 15. The resident, who had a history of skin integrity issues and was at high risk for pressure ulcers, did not have his wound care orders entered into the system promptly. Despite the presence of hospice orders posted in the resident's room, the orders were not specific, and there was a delay in entering them into the electronic system due to confusion and lack of clarification from hospice. This led to a situation where treatments were performed but not documented in the system, potentially causing missed treatments. For Resident #18, the facility failed to have current care plans in the electronic health system. The resident, who had multiple complex medical conditions including a sacral pressure ulcer, diabetes, quadriplegia, and was on hospice care, did not have his foley catheter, colostomy, hospice services, and pressure ulcers care planned. This lack of care planning could lead to inadequate care and oversight of the resident's needs. Similarly, Resident #87's care plans were not updated to reflect his current medical needs, including his foley catheter, pressure ulcer, and wound vac treatment. The resident, who had neuromuscular dysfunction of the bladder, paraplegia, and a stage 4 pressure ulcer, did not have these critical aspects of his care documented in the care plan. The absence of updated care plans for these residents indicates a systemic issue in the facility's documentation practices, which could result in residents not receiving the necessary care and treatments.
Failure to Document Catheter Care for Residents
Penalty
Summary
The facility failed to ensure that residents with indwelling catheters received appropriate treatment and services to prevent urinary tract infections. Specifically, the facility did not enter physician orders for catheter care into the system for two residents, Resident #18 and Resident #87, and staff were unable to document care provided from December 1 to December 17, 2024. This oversight could place residents with Foley catheters at risk for urinary tract infections and skin breakdown. Resident #18, a male with multiple diagnoses including a sacral pressure ulcer, diabetes mellitus, quadriplegia, and neurogenic bladder, had an indwelling catheter that was not care planned. His medical record lacked orders for a Foley catheter from December 1 to December 17, 2024, and there was no documentation of catheter care during this period. An observation on December 17, 2024, confirmed the presence of a Foley catheter, but it was not visible during the initial observation. Similarly, Resident #87, a male with diagnoses including neuromuscular dysfunction of the bladder, paraplegia, and schizophrenia, also had an indwelling catheter that was not care planned. His medical record showed no orders for a Foley catheter from December 1 to December 17, 2024, and there was no documentation of catheter care. An observation on December 15, 2024, confirmed the presence of a Foley catheter clipped to the side of the bed. Interviews with staff revealed that the facility was experiencing issues with order entry following a switch to a new electronic medical record system, which contributed to the lack of documentation and care planning for these residents.
Failure to Provide Colostomy Care Due to Missing Physician Orders
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident, identified as Resident #18, who required such services. The deficiency was identified through observation, interview, and record review, revealing that physician orders for colostomy care were not entered into the system for Resident #18. Consequently, staff were unable to document the care provided from December 1 to December 17, 2024. This oversight could potentially place residents at risk of infection, skin breakdown, or discomfort. Resident #18 is a male with multiple medical conditions, including a sacral pressure ulcer, diabetes mellitus, quadriplegia, colostomy, neuromuscular dysfunction of the bladder, anemia, and anxiety. The resident's Quarterly MDS assessment indicated moderately impaired cognition and dependency on all activities of daily living. Despite having a colostomy, there was no care plan in place for it, and the medical record lacked documentation of colostomy care during the specified period. Interviews with facility staff, including the Unit Manager, DON, and an LVN, revealed that the facility had recently switched to a different electronic medical record (EMR) system, which led to missed or incorrectly transferred orders. The DON acknowledged that the orders should have been in the system and that the absence of orders could result in missed treatments. The LVN confirmed that she had not yet provided colostomy care to Resident #18 on the day of the interview, and without orders, there was no place to document any care provided, leaving it unclear if prior care had been administered.
Pharmaceutical Services Deficiency in Medication Administration
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for a resident, specifically in the transcription and administration of Potassium Chloride. The resident, who had severe cognitive impairment and multiple health issues including kidney failure and heart failure, was incorrectly documented as self-administering Potassium Chloride. This error occurred from December 7 to December 17, 2024, despite the resident not self-administering any medications. The medication was signed off as unsupervised self-administration by various staff members without proper assessment or verification. Interviews with staff revealed a lack of awareness regarding the incorrect order entry, and the Unit Manager acknowledged the error, attributing it to a mistake during the transition to a new electronic medical record system. The Director of Nursing noted that the orders should have been verified with the provider and entered correctly into the system. The facility's policies on pharmaceutical services and physician orders were not adhered to, leading to the potential risk of the resident not receiving their medication or receiving it more than once.
Failure to Coordinate Hospice Care in EMR Transition
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, the facility did not ensure that the hospice order for a resident was entered into the electronic medical record (EMR) from December 1 to December 17, 2024. This oversight could potentially place residents receiving hospice services at risk of inadequate end-of-life care due to a lack of coordination and communication regarding their needs. The resident in question was an elderly male with multiple diagnoses, including a sacral pressure ulcer, diabetes mellitus, quadriplegia, colostomy, neuromuscular dysfunction of the bladder, anemia, and anxiety. His quarterly Minimum Data Set (MDS) assessment indicated moderately impaired cognition and complete dependence on assistance for all activities of daily living (ADLs). Despite being on hospice care, as noted in his medical history and physical examination, the hospice care was not properly care planned, and the hospice order was missing from the EMR during the specified period. Interviews with facility staff, including the Unit Manager and the Director of Nursing (DON), revealed that the hospice order was present in a previous EMR system but was not transferred correctly when the facility switched to a new EMR system on December 1, 2024. The DON acknowledged that orders should have been verified and entered into the system to prevent missed treatments. The facility's policies on hospice services, charting and documentation, and physician orders emphasize the importance of maintaining accurate and up-to-date records to ensure effective communication and care coordination, which was not adhered to in this case.
Inadequate Infection Control: Blood Pressure Cuff Not Sanitized Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Med Aide G, who did not sanitize a blood pressure cuff between uses on two residents. Resident #250, who had multiple serious infections including bacterial meningitis and MSSA, was on Enhanced Barrier Precautions (EBP) and receiving IV antibiotics. Despite this, Med Aide G used the blood pressure cuff on Resident #250 and then placed it on Resident #23 without disinfecting it, which could lead to cross-contamination and infection transmission. Resident #23, who had moderately impaired cognition and was admitted for rehabilitation following a urinary tract infection, was exposed to potential infection due to this oversight. Interviews with Med Aide G and RN K confirmed the failure to disinfect the equipment, and the Director of Nursing acknowledged that staff had been recently in-serviced on EBP. The facility's infection control policy mandates the prevention of infection spread through proper sanitation practices, which were not followed in this instance.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically timely incontinence care, for two residents who were dependent on staff for toileting and hygiene. One resident, a female with diagnoses including dementia, urinary system disorder, and mobility issues, was found to be fully dependent for toileting and bathing. Her care plan identified an ADL self-care deficit, and her family member reported frequent instances of her being left soiled due to staff not checking on her regularly. The resident was non-verbal and unable to use the call light, further contributing to the lack of timely care. Another resident, with a history of stroke, hemiplegia, dementia, and vision impairment, was also dependent on staff for toileting, hygiene, and dressing, and was always incontinent of bowel and bladder. Her care plan required assistance with ADLs to maintain cleanliness and dignity. She reported having to wait several hours to be changed earlier in the year, with staff not responding to call lights or the telephone. Staff interviews confirmed that the facility had been short staffed, resulting in residents being left soiled at shift changes and during overnight hours. External interviews with emergency medical services and local authorities corroborated these findings, with reports of responding to calls from residents who were unable to reach staff and were found soiled. Staff cited short staffing and shift changes as reasons for the delays in care. The facility's policy required provision of care to maintain residents' hygiene and dignity, but this was not consistently followed, leading to the identified deficiency.
Failure to Provide Sufficient Nursing Staff for Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents on multiple days, as evidenced by staffing records and interviews. On five out of six days reviewed, the number of Certified Nursing Assistants (CNAs) and nurses scheduled was below the facility's own assessment tool requirements, despite a census of over 100 residents on some days. This staffing shortage resulted in residents not receiving timely incontinence care, with multiple complaints of residents remaining in soiled briefs for four to five hours. One resident with a history of acute respiratory failure, hemiplegia, stroke, dementia, and incontinence was dependent on staff for all activities of daily living, including toileting and hygiene. The resident's care plan required assistance with incontinence care every two hours and interventions to maintain skin integrity. However, interviews and record reviews revealed that these needs were not consistently met due to inadequate staffing, leading to prolonged periods without care. Staff interviews confirmed that there were periods of short staffing, with some staff reporting that they would find residents soiled at the beginning of their shifts. Emergency medical services personnel and local authorities also reported frequent complaints and calls for assistance from residents who could not get timely help from facility staff. The facility's own policy required adequate staffing to meet resident needs, but this was not maintained during the period in question.
Failure to Protect Resident Property During Discharge Process
Penalty
Summary
A deficiency occurred when a facility failed to protect a resident's right to be free from misappropriation of property. The incident involved a cognitively intact female resident with multiple medical diagnoses, including a lumbar fracture, major depressive disorder, hyperlipidemia, and COPD. After the resident was discharged to the hospital, her purse was found in her room by a housekeeper, who bagged and tagged it with the resident's name and placed it in the Admissions Coordinator's office for safekeeping. Subsequently, the housekeeper requested the purse from the Admissions Coordinator, stating that the resident's family was present to retrieve it. The purse was handed over to the housekeeper, who then gave it to another resident, mistakenly believing the individual was a family member. The purse was not recovered despite a search of the facility, and the resident's family reported not having received it. The facility's investigation confirmed that identification was not checked before releasing the purse, and the whereabouts of the purse remained unknown. Interviews with staff revealed inconsistent practices regarding the handling and release of residents' valuables, with some staff unaware of the proper procedures or the need to verify the identity of individuals retrieving personal property. The resident and her family continued to inquire about the missing purse, which contained important items such as a driver's license and debit card. The facility's policy required protection against misappropriation of property, but this was not followed in this instance, resulting in the loss of the resident's belongings.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures while providing incontinence care to a resident. The CNA did not perform hand hygiene prior to care, used only one pair of gloves throughout the entire process, and did not change gloves after contact with potentially contaminated materials. During the care, the CNA applied barrier cream, moved pillows, adjusted sheets, and repositioned the resident without changing gloves, and left the resident and bedding wet. The CNA acknowledged not changing gloves during the care and stated that she would typically change gloves only if they became visibly soiled. The resident involved was a female with hemiplegia following a stroke, type 2 diabetes, and major depressive disorder, who was always incontinent and required substantial assistance with toileting hygiene. Facility records and interviews confirmed that the CNA had received recent training, and the facility's policies and skills checklists required hand hygiene and glove changes at specific points during incontinence care. The Director of Nursing confirmed the expected procedures for infection control and acknowledged the importance of these practices in preventing infections.
Failure to Provide Appropriate Post-Fall Care and Assessment
Penalty
Summary
The facility failed to ensure that Resident #1 received appropriate treatment and care following an unwitnessed fall. The resident, who had severe cognitive impairment and multiple medical conditions including idiopathic peripheral autonomic neuropathy, head and neck cancer, and a history of falls, was found on the floor bleeding from his head. Despite the severity of the situation, the staff did not remain with the resident after discovering him on the floor, and an appropriate assessment was not completed. The resident sustained a laceration to the head and a skin tear to the shoulder, but the size, depth, and amount of bleeding or drainage from the injuries were not documented. Additionally, the resident's range of motion was not assessed, and neuro checks were not consistently performed as ordered, particularly during the period when the resident was sent to the hospital for further evaluation. The lack of thorough assessment and documentation could have placed the resident at risk of not receiving the necessary care and services to meet his physical, mental, and psychosocial needs. The report details that the resident was found on the floor by a CNA who then notified LVN A. LVN A performed a head-to-toe assessment, cleaned the resident's wounds, and administered pain medication. However, the assessment was incomplete as it did not include the size, depth, and amount of bleeding from the laceration, nor the size and color of the hematoma. The resident was assisted back into bed without a documented range of motion assessment. Neuro checks were initiated but were not consistently documented, especially during the time the resident was sent to the hospital. The resident was later diagnosed with a pelvic fracture, scalp hematoma, and multiple abrasions at the hospital. Interviews with staff revealed inconsistencies in the response to the fall. LVN A and other staff members did not follow the facility's policy for fall management and head injury follow-up, which required a thorough assessment and documentation of the resident's condition. The DON and other supervisory staff acknowledged that the documentation was incomplete and that the staff did not fully adhere to the protocols for assessing and documenting the resident's condition after the fall. The facility's policies on fall management and head injury follow-up were not adequately followed, leading to deficiencies in the care provided to Resident #1.
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 404 citations issued within 25 miles in the last 12 months — including the 34 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 The Woodlands
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Woodlands Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 7 | 0 |
| Ridgewood At The Woodlands | 2.1 mi | ★★★★★ | 1 | 0 |
| The Village At Gleannloch Farms | 5.1 mi | ★★★★★ | 4 | 0 |
| Park Manor Of The Woodlands | 5.5 mi | ★★★★★ | 7 | 0 |
| Tomball Rehab & Nursing | 6.8 mi | ★★★★★ | 10 | 0 |
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 July 2026) and official state health department websites.