Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Carlyle At Stonebridge Park during CMS and state inspections, most recent first.
An LVN administered a PRN hydrocodone-acetaminophen dose to a resident with a hip fracture but did not document it on the EMAR, even though she signed the narcotic count sheet. The resident’s record showed the medication order and pain-related care plan, while the ADON, DON, and LVN all confirmed that narcotic doses were supposed to be documented on both the narcotic sheet and EMAR by the nurse who gave the medication.
Medications Left at Bedside Without Self-Administration Assessment: The facility failed to determine whether residents were clinically appropriate to self-administer meds when nasal sprays and cough syrup were found at bedside. One resident with CHF, hypothyroidism, CAD, and moderate cognitive impairment had three nasal sprays in the room without an assessment or order. Another resident kept Fluticasone at the bedside for PRN use without approval, and a third resident had cough syrup left by family in a cup on the nightstand without any self-administration assessment or order.
A resident with a hx of stroke, weakness, and impaired mobility was observed wearing an arm sling and leg brace, but the chart lacked physician orders for either device. The resident said he used both devices daily and needed help applying them, and CNA, ADON, DON, and Rehab staff all acknowledged the devices were in use and that orders should have been entered.
Failure to Provide Toenail Care: Two residents with diabetes and significant assistance needs were observed with toenails about half an inch long. One resident stated staff had not cut her toenails despite her asking, and the other said he wanted his toenails trimmed but was unsure when they were last done. CNAs and an LVN described shared responsibility for nail care, with shower staff noting needs and nursing or podiatry addressing diabetic residents, but the residents’ toenails remained long.
Two residents had unsecured medications found in their rooms. One resident with moderate cognitive impairment had Zoloft and Memantine pills on the floor after medication administration, and staff gave conflicting accounts about who administered the dose. Another resident had a cup of cough syrup and family medication bottles left at bedside without a self-administration assessment or medication order.
Failure to coordinate PASARR review after a new mental health dx. A resident with severe cognitive impairment, psychotic disorder, schizophrenia, bipolar disorder, and psychotropic med use was later diagnosed with schizoaffective disorder, including bipolar type, but the MDS Coordinator did not submit a new PASARR Level 1 because the resident was on hospice. The facility’s PASARR policy required prompt referral to the state mental health authority when a resident exhibits a newly evident serious mental disorder.
Stage 3 Sacral Pressure Ulcer Left Open to Air: A resident with severe cognitive impairment and an unhealed Stage III sacral pressure ulcer was found with the wound open to air and no dressing in place during wound care observation. The Treatment Nurse, Wound Care NP, assigned nurse, ADON, and DON all stated staff were expected to notify nursing when a dressing came off so it could be replaced, but no one had reported the missing dressing after the resident received a bed bath from a Hospice CNA.
Incomplete wound care documentation on TARs for two residents. One resident had a Stage III sacral pressure ulcer with ordered daily collagen and calcium alginate with silver treatment, and another resident had a right foot wound with an ordered foam dressing. The TARs had blanks for the wound care entries, and the DON, Treatment Nurse, and ADON B stated the treatments were provided but not signed off/documented.
Failure to use required PPE during g-tube care: an LVN provided a resident's water flush via gastrostomy tube while the resident was on EBP, but donned gloves only and did not wear a gown. The resident had a feeding tube, severe cognitive impairment, and orders for EBP with gown and glove use for high-contact care activities, including feeding tube care. The DON and ADON stated gown and gloves were required for g-tube flushing, and the facility policy called for targeted gown and glove use during this type of care.
A resident admitted after knee revision surgery did not receive several physician-ordered medications, including an IV antibiotic, Adderall, and a therapeutic nutrition powder, due to delays in acquiring and administering the drugs. Record review and staff interviews confirmed that multiple doses were missed over several days, and staff were unclear about the reasons for the delay or the steps taken to resolve it.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
The facility did not ensure accurate and complete clinical documentation for two residents: one resident's G-tube feedings were not administered as documented by an LPN, and another resident's wound care treatments were not consistently recorded on the TAR. These lapses resulted in medical records that did not accurately reflect the care provided or the residents' medical needs, as confirmed by interviews, record reviews, and direct observation.
A resident with multiple medical conditions, including dysphagia and dementia, did not receive prescribed G-tube feedings for approximately 11 hours after a fall, when an LVN disconnected the feeding tube and failed to reconnect it. The lapse was discovered by the resident's family member via in-room camera footage, and the resident was without enteral nutrition until the issue was reported and addressed. No immediate adverse effects were documented.
A resident, who required a bedpan due to mobility issues, was instructed by a CNA to use her brief instead of receiving assistance with toileting. The resident was cognitively intact and her medical records indicated she was continent and used a bedpan. The CNA admitted to telling a resident to use their brief due to staffing constraints, although she could not recall if it was this specific resident. The facility's policy on resident rights mandates treating each resident with respect and dignity, which was not adhered to in this case.
A facility failed to develop a comprehensive care plan for a resident, omitting pain management and behavior issues. The resident, with moderate cognitive impairment, expressed concerns about not receiving pain medication and exhibited behaviors of picking at scabs, leading to reopened wounds. Despite receiving scheduled medications and wound care, these issues were not care planned, as confirmed by staff interviews.
The facility failed to store food in accordance with professional standards, as observed in the kitchen's dry pantry. Unsealed and unlabeled boxes of macaroni and linguine were found, contrary to the facility's policy requiring all opened items to be sealed, dated, and labeled. Staff interviews confirmed the policy and expressed concerns about potential resident illness due to non-compliance. The Dietary Manager was identified as responsible for ensuring food safety.
A resident with multiple health conditions was transferred to a hospital without the facility providing written notification to the resident, their representative, or the ombudsman. The facility staff were unaware of the requirement to send such notification, despite the facility's policy outlining the need to provide reasons for transfer, appeal rights, and ombudsman contact details.
A resident with moderate cognitive impairment experienced ant bites due to the facility's failure to maintain an effective pest control program. Ants were found in the resident's room, leading to medical treatment for itching. The maintenance director confirmed the presence of ants and contacted pest control for treatment. Staff interviews indicated a lack of prior reports of ants, despite a process for reporting pest sightings.
A resident with severe cognitive impairment and osteoporosis was improperly transferred by a CNA who failed to use a gait belt and did not seek assistance from another staff member, as required by the facility's policy. The CNA lifted the resident under her armpits, contrary to training and guidelines, which was captured in a video by the resident's family. Interviews with staff confirmed the resident's need for a two-person transfer with a gait belt.
A resident in an LTC facility was mistakenly given another resident's IV antibiotic due to a medication administration error by an LVN. The resident, who was supposed to receive Micafungin for candidiasis, was given Meropenem instead. The error was identified by the resident's family, who noticed the wrong IV bag. The facility's investigation confirmed the mistake, despite the LVN's denial, and highlighted a failure to follow medication administration protocols.
A resident with a history of infections and delusional disorders was mistakenly given another resident's IV antibiotic, Meropenem, instead of her prescribed Micafungin. The error was identified by the resident's family, who noticed the wrong name on the IV bag. Despite the LVN's denial, the facility confirmed the mistake and monitored the resident for adverse reactions.
A resident was admitted without physician orders for immediate wound care, despite having significant medical needs, including a wound vacuum. The orders were not entered until two days later, on the day of discharge. Interviews revealed that the admitting nurse is responsible for entering all hospital discharge orders, which was not done in this case.
A resident did not receive wound care for a left lower leg wound from admission until discharge, despite specific hospital discharge instructions. The admitting nurse failed to enter the wound care orders, and there was no documentation of wound care being provided. The resident's family was unhappy with the care, leading to a transfer to another facility.
Missing EMAR Documentation for Controlled Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when an LVN did not document administration of a controlled pain medication on the resident’s EMAR after giving hydrocodone-acetaminophen to a resident with a left hip fracture. The resident’s record showed an active order for hydrocodone-acetaminophen 5-325 mg, 1 tablet by mouth every 6 hours as needed for pain, and the resident’s care plan identified pain medication therapy for hip pain. Review of the resident’s medication records showed hydrocodone-acetaminophen was documented on the EMAR only twice on the day in question, at 10:47 AM and 6:30 PM, but there was no EMAR documentation for a dose at 4:00 AM. The controlled drug receipt/record/disposition form showed that LVN C signed that she administered the hydrocodone at 4:00 AM, but there was no corresponding progress note or EMAR entry reflecting that administration. During interview, the resident said staff brought pain medication when requested and she had no concerns about her pain medications. The ADON, DON, and LVN C all stated that staff were expected to document narcotic administration on both the narcotic count sheet and the EMAR, and that the nurse who administered the medication was responsible for documenting it in the EMAR. The DON also stated staff had recently been trained on these documentation expectations, but LVN C was not listed on the in-service training reports.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure the interdisciplinary team determined whether residents were clinically appropriate to self-administer medications when medications were found at the bedside of three residents. The report states that the facility had no residents who were assessed or approved to self-administer medications, yet medications were observed in resident rooms without documentation of an assessment, physician order, or care plan addressing self-administration. For one resident, the quarterly MDS reflected chronic systolic heart failure, hypothyroidism, and chronic total occlusion of the coronary artery, with a BIMS score of 10 indicating moderate cognitive impairment. The resident’s care plan did not indicate any ability to self-administer medications, and no assessment was completed to determine whether self-administration was appropriate. During observation, three nasal spray bottles were found at the bedside, including Fluticasone Propionate, Azelastine HCL, and Major Deep Sea Premium Saline. The resident stated she had kept the bottles for a long time and used the nasal spray twice a day, while the assigned LVN stated she was not aware of the additional nasal sprays and that the resident had not been assessed or ordered to self-administer them. For another resident, the admission MDS was pending completion and the baseline care plan did not address bedside medications or self-administration. No assessment was completed to determine whether the resident could self-administer medication. A bottle of Fluticasone Propionate nasal spray was observed at the bedside, and the resident stated she had kept it since admission and used it as needed for dry nose and breathing comfort. Staff interviews reflected that the resident had not been approved to keep medications at the bedside, that the medication had been found in the room, and that the resident had refused to release it previously. For a third resident, no assessment or order supported self-administration, and no order or use of cough syrup was reflected in the clinical record. A medication cup containing dark liquid was observed on the nightstand, and the resident stated it was cough syrup left by family members. The ADON removed the medication and the bottles from the room after confirming what was in the cup.
Missing Orders for Arm Sling and Leg Brace
Penalty
Summary
The facility failed to obtain physician orders for Resident #45’s arm sling and leg brace. Resident #45 was admitted with diagnoses including stroke, muscle weakness, and abnormalities of gait and mobility, and his MDS reflected functional limitation in range of motion with impairment on one side of the upper and lower extremities. His care plan addressed assistance with dressing and skin inspection, but it did not address his need for or use of an arm sling or leg brace, and the physician orders reviewed did not include either device. During observation, Resident #45 was seen wearing an arm sling and wrap on his right arm and a leg brace on his right leg. He stated he had used both devices for at least two years, wore them daily, and needed daily assistance to apply them. CNA J confirmed the resident used the devices and usually asked for help daily. The ADON, DON, and Director of Rehabilitation each stated they were aware of the devices and that orders should have been in place, with nursing staff responsible for entering them when therapy was not involved. The facility’s restorative care guidance stated that residents wearing a medical device would have skin inspected every shift and that a physician’s order would be obtained if the device was used for orthopedic purposes.
Failure to Provide Toenail Care
Penalty
Summary
The facility failed to ensure proper foot care and toenail care for two residents, both of whom had diabetes and required staff assistance with bathing and personal hygiene. Resident #42’s quarterly assessment showed severe cognitive impairment, partial/moderate assistance needs for showering and personal hygiene, and diagnoses including arthritis, need for assistance with personal care, limitation of activities due to disability, and diabetes. Resident #75’s quarterly assessment showed moderate cognitive impairment, substantial/maximal assistance needs for showering and personal hygiene, and diagnoses including high blood sugar and diabetes. Both residents had care plans that included monitoring for skin issues and, for Resident #75, checking nail length and cleaning nails on bath day and as necessary. During observation and interview, Resident #42 was found in bed with toenails about half an inch long on each foot and stated she wished staff would cut her toenails because they had said they did not have anyone to do it. She also stated she had spoken with someone about having them cut but they had not returned. A CNA later observed that Resident #42’s toenails were long and needed to be cut, and stated CNA shower staff were responsible for ensuring toenails were cut or trimmed, with the nurse responsible when a resident had diabetes. An LVN stated she was responsible for trimming or cutting toenails for residents with diabetes and that diabetic residents were also placed on the list to be seen by the podiatrist monthly, but she had not paid much attention to Resident #42’s toenails lately. Resident #75 was also observed in bed with the right foot exposed and toenails measuring about half an inch long. He stated he would like someone to trim his toenails and said he thought a doctor should trim them, but he was not sure when they had last been trimmed. A CNA stated the toenails were too long and that CNAs were responsible for showers and for noting nail care needs on the shower sheet, with nurses reviewing the sheets and rounding weekly to trim toenails and podiatry coming monthly. The DON stated residents were expected to have nail care, that CNAs were to mark nail care needs on the shower sheet, and that if nursing staff did not provide nail care, nails could accumulate dirt, curl under, and grow into the resident’s skin. The facility’s ADL policy stated assignments should be consistent and that a Kardex should assist direct care staff in providing assistance with ADLs.
Unsecured medications found in resident room and at bedside
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored securely for 2 of 33 residents reviewed. For one resident with diagnoses including anxiety disorder, depression, hepatic encephalopathy, and non-Alzheimer’s dementia, and a BIMS score of 10 indicating moderate cognitive impairment, two pills identified as Zoloft and Memantine were found on the floor by the closet door in her room. Her MAR showed Memantine was administered that morning, while the Zoloft dose was ordered for the evening. The resident stated she had been given her medications and did not know whose pills were on the floor. The nurse assigned to the resident observed the pills on the floor and picked them up, stating he had not given the resident her morning medications and that the DON had done so. The DON stated she administered medications on the hall that morning and observed the resident take them, but denied giving the pills found on the floor. She stated nurses should stay in the room and observe residents take medications, and if a pill is dropped it should be picked up and placed in biohazard waste. She also stated leaving medication unattended could allow someone else to pick it up and cause harm. For another resident, a medication cup containing dark liquid was observed on the nightstand at bedside, along with family medication bottles in a bag. The resident stated the liquid was cough syrup brought by family members and that he had not used it. The ADON stated no assessment had been completed to determine whether the resident could self-administer medications, and no resident in the facility had been assessed to self-administer medications. She removed the cough syrup and bottles from the room and stated medications found in resident rooms were to be removed and reported. The resident’s records did not include an assessment for self-administration, and there was no order or MAR entry for cough syrup.
Failure to Coordinate PASARR Review After New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate assessment with the PASARR program for one resident who had a new mental health diagnosis. Resident #49 was a female admitted to the facility with diagnoses including anxiety disorder, depression, psychotic disorder, schizophrenia, bipolar disorder, and chronic diastolic heart failure. Her quarterly MDS showed a BIMS score of 06, indicating severe cognitive impairment, and that she was receiving antipsychotic medication. Her care plan stated she used psychotropic medications Zyprexa and Haldol related to bipolar disorder, depression, and anxiety, and noted she was not eligible for PASRR services due to election of hospice services. Record review showed the resident’s PASARR Level 1 screening dated 04/23/25 reflected that she did not have a mental illness. Later record review showed she was diagnosed with schizoaffective disorder, unspecified, and then schizoaffective disorder, bipolar type. During interview, the MDS Coordinator stated she was responsible for submitting PASARRs for new admissions and for updates when residents received new diagnoses, and that she had been informed the resident did not require a new PASARR Level 1 because she was receiving hospice services. The Administrator stated the MDS Coordinator was responsible for completing and updating PASARR assessments and submitting them timely, and that a new diagnosis should have been followed up with the mental health authority. The facility policy stated that any resident who exhibits a newly evident or possible serious mental disorder will be referred promptly to the state mental health authority for a level II resident review.
Stage 3 Sacral Pressure Ulcer Left Open to Air
Penalty
Summary
The facility failed to ensure necessary treatment and services were provided to promote healing for a resident with a Stage 3 sacral pressure ulcer. Resident #10 had a quarterly MDS assessment documenting severe cognitive impairment, risk for pressure ulcers, and an unhealed pressure ulcer. Her care plan identified the Stage III sacral pressure ulcer and directed staff to administer treatments as ordered and provide wound care per treatment order. The physician order dated 01/04/26 directed collagen and calcium alginate with silver to the sacrum as needed if the dressing became saturated, soiled, or dislodged. During observation on 01/08/26, the resident’s brief was removed and the sacral wound was found open to air with no dressing in place. The wound had a moderate amount of soft stool nearby, and the wound was then cleansed and debrided by the Treatment Nurse and Wound Care NP. The Treatment Nurse stated there should have been a dressing in place and believed it may have come off during a bed bath earlier that day, but she had not been notified to replace it. The Hospice CNA stated he did not observe any dressing on the sacrum when he provided the bed bath. The assigned nurse, ADON, and DON all stated that when a dressing comes off, CNAs or Hospice CNAs were expected to notify nursing staff so the wound could be redressed.
Incomplete wound care documentation on TARs
Penalty
Summary
The facility failed to ensure clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 2 of 5 residents reviewed for treatment documentation. The deficiency involved blanks on the January 2026 Treatment Administration Record (TAR) for wound care treatments that were ordered for two residents. Resident #10’s record showed a quarterly MDS dated 11/20/25 with diagnoses including Alzheimer’s disease, a pressure ulcer of the sacral region, COPD, and anxiety disorder, and a BIMS score of 04 indicating severe cognitive impairment. Her care plan, revised 01/04/26, identified a Stage III pressure ulcer to the sacrum and directed staff to administer treatments as ordered and provide wound care per treatment order. A physician order dated 01/04/26 directed wound treatment with collagen and calcium alginate with silver every day shift, with cleansing of the sacral wound and application of dressings starting 01/05/26. The TAR for January 2025 reflected no documentation that wound care was provided on 01/05/26 and 01/06/26. During observation on 01/06/2026, Resident #10 was in bed and stated she received daily wound care and staff turned her side to side. Resident #104’s record showed a quarterly MDS dated 11/20/25 with diagnoses including unspecified dementia, generalized edema, and hyperlipidemia, and a BIMS score of 09 indicating moderate cognitive impairment. Her care plan, revised 12/22/25, identified a current skin concern involving the right medial foot related to a surgical wound by podiatry and directed treatments per order. A physician order directed application of a foam dressing to the right foot lesion medial side. The TAR for January 2025 showed no documentation that treatment was provided on 01/05/26. The Treatment Nurse stated nurses were responsible for wound care when she was on leave and that treatments should be documented after completion. The DON stated ADON B provided wound care while the Treatment Nurse was on leave but forgot to sign them off on the TAR, and ADON B stated she completed wound care for Resident #10 and Resident #104 on 01/05/26 but could not recall whether she documented it.
Failure to Use Required PPE During G-Tube Flush
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 1 of 6 residents reviewed for infection control. Resident #8 had a significant change in status MDS assessment dated 10/22/25 showing a [AGE] year-old female admitted on [DATE], with a diagnosis of gastrostomy status and a BIMS score of 07 indicating severe cognitive impairment. Her care plan, revised 12/06/2025, identified that she had a tube feeding related to poor appetite and that the tube was flushed with water three times daily. A physician order dated 12/18/2025 directed Enhanced Barrier Precautions every shift for residents with wounds or indwelling medical devices, including feeding tubes. On 01/08/26 at 8:41 AM, LVN C prepared to provide the resident's 250 ml water flush via gastrostomy tube. The resident's door displayed an Enhanced Barrier Precautions sign stating staff must clean hands and wear gloves and gown for high-contact resident care activities, including device care or use of a feeding tube. LVN C performed hand hygiene and donned gloves, but did not put on a gown before administering the flush. During interview, LVN C stated she believed a gown was not needed for a water flush and said she had been in-serviced on infection control but could not recall the date. ADON A and the DON both stated that staff should don gown and gloves when flushing a g-tube and that flushing a g-tube was direct care. The facility's in-service training report dated 06/27/25 reflected staff were in-serviced on infection control and proper PPE use, and the facility's Enhanced Barrier Precautions policy dated March 2024 required targeted gown and glove use during high-contact resident care activities, including feeding tube care.
Failure to Timely Acquire and Administer Physician-Ordered Medications Upon Admission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident who was admitted following knee revision surgery with a polymicrobial infection and a chronic open wound. Upon admission, the resident had physician orders for an intravenous antibiotic (Daptomycin-Sodium Chloride), a central nervous system stimulant (Adderall), and a therapeutic nutrition powder (Juven) for wound healing. However, the facility did not acquire and administer these medications in a timely manner, resulting in the resident missing one dose of the antibiotic, six doses of Adderall, and seven doses of Juven over several days after admission. Record reviews showed that the first dose of the antibiotic was not given until the day after admission, Adderall was not administered until several days later, and multiple doses of Juven were missed. Interviews with the resident and staff revealed confusion and lack of clarity regarding the delay in medication delivery. The resident reported not receiving some medications for a few days and was told the facility was trying to obtain them from the pharmacy. Staff interviews indicated that the pharmacy did not deliver all medications as expected, and there was uncertainty about the steps taken to resolve the issue. The facility's policy required that upon admission, the charge nurse and DON or designee review and reconcile physician orders for accuracy in the electronic medical record. However, interviews with staff, including the ADON and RDCS, indicated that the process for ensuring timely medication acquisition and administration was not effectively followed, and there was no clear documentation or explanation for the missed doses. The failure to provide the ordered medications as prescribed was confirmed through both record review and staff interviews.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the resident’s medical history or condition at the time, are not provided in the report.
Failure to Maintain Accurate and Complete Clinical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, resulting in documentation that did not reflect the actual care provided. For one resident with a history of dementia, gastro-esophageal reflux, hypertension, Parkinson's disease, and seizure disorder, the care plan required tube feeding via a G-tube. The Medication Administration Record (MAR) indicated that the resident received tube feedings as ordered on a specific date, but video evidence and family observation revealed that the resident was disconnected from the feeding pump for approximately 11 hours. The nurse responsible documented that the feedings were given, despite the resident not receiving them during that period. In another case, a resident with heart failure, hypertension, hypothyroidism, and a colostomy had physician orders for wound care to be performed three times a week. The Treatment Administration Record (TAR) for this resident showed multiple blank entries on days when wound care was ordered, and there was no alternative documentation in the progress notes to indicate that the treatments were provided. The wound care nurse acknowledged that she was supposed to document each treatment but was unaware that her documentation was not appearing on the TAR. The DON confirmed that documentation was missing and that she had not recently provided staff training on documentation practices. These failures resulted in clinical records that did not accurately represent the care provided or the residents' medical conditions and needs. The lack of accurate documentation was confirmed through interviews, record reviews, and direct observation, including review of video footage and resident interviews. The facility's own policy required proper documentation of medication administration and treatments, which was not followed in these instances.
Failure to Provide Continuous Enteral Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident who was dependent on enteral nutrition via a G-tube did not receive prescribed feedings for approximately 11 hours. The resident, who had diagnoses including dementia, dysphagia, Parkinson's disease, and seizure disorder, was ordered to receive Isosource 1.5 at 70cc/hr for 22 hours daily. On the day of the incident, the resident's feeding tube was disconnected by an LVN around 11:30 AM after the resident experienced a fall. The feeding tube was not reconnected until approximately 10:54 PM that night. During this period, the resident was observed to be without his feeding pump, and the pump itself was left in the room turned off. The lapse in care was discovered when the resident's family member, who had a camera in the room, noticed the disconnection and notified facility staff. Documentation and interviews confirmed that the nurse responsible forgot to reconnect the feeding tube after assisting the resident post-fall. The physician and DON were notified after the incident was brought to their attention. The resident did not experience any immediate adverse effects, as confirmed by assessments, lab results, and weight checks. However, the failure to follow physician orders and provide continuous enteral feeding as prescribed constituted a deficiency in care for residents receiving nutrition by enteral means.
Failure to Assist Resident with Toileting Needs
Penalty
Summary
The facility failed to provide care and services in accordance with the comprehensive assessment of a resident, specifically in assisting with activities of daily living (ADLs) such as toileting. A certified nursing assistant (CNA) instructed a resident, who was cognitively intact and required a bedpan due to mobility issues, to use her brief instead of providing the necessary assistance with a bedpan. This incident was reported by the resident, who stated that the CNA did not have time to assist her. The resident's medical records indicated she was continent and used a bedpan, requiring extensive assistance from one person for ADLs. Interviews with staff revealed that the CNA admitted to telling a resident to use their brief due to staffing constraints, although she could not recall if it was the specific resident in question. The Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) were unaware of such incidents, and the Director of Nursing (DON) emphasized that residents should not be told to use their briefs as it could lead to dignity issues and skin breakdown. The facility's policy on resident rights mandates treating each resident with respect and dignity, which was not adhered to in this case.
Failure to Address Pain Management and Behaviors in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which did not address pain management and behaviors. The resident, a male with moderate cognitive impairment, had concerns about not receiving his pain medication as scheduled and exhibited behaviors of picking at scabs on his toes, leading to reopened wounds. Despite receiving scheduled pain medications and wound care, these issues were not included in the resident's care plan. Interviews with facility staff, including an LVN, MDS Coordinator, Wound Care Nurse, and ADON, revealed that the care plan was not updated to address the resident's pain management and behaviors. The staff acknowledged that these aspects should have been care planned, and the lack of a comprehensive care plan could result in the resident receiving improper care. The facility's policy requires individualized comprehensive care plans with measurable objectives and timetables, which were not met in this case.
Improper Food Storage in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, specifically in the storage of food items. During an observation and interview with the Dietary Manager, it was discovered that the dry pantry contained an unsealed and unlabeled 10-pound box of enriched macaroni and a similar box of linguine. The Dietary Manager admitted to being unaware of these improperly stored items and acknowledged that it was the Cook's responsibility to ensure food was stored in sealed, dated, and labeled containers. The facility's policy mandates that all opened items should be sealed, dated, and labeled, which was not followed in this instance. Interviews with staff members, including [NAME] A and [NAME] B, confirmed that the facility's policy required all items in the dry pantry to be in sealed containers, labeled, and dated. Both staff members expressed concern that failure to follow this policy could lead to residents becoming sick. The Administrator also confirmed that opened packages should be sealed, labeled, and dated, and that the Dietary Manager was responsible for ensuring food safety. However, the Administrator did not comment on the potential risk to residents if these procedures were not followed. The facility's Food Storage policy, dated March 2009, specifies the use of plastic containers with tight-fitting covers for storing various food items, which was not adhered to in this case.
Failure to Notify Resident and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident, their representative, and the Office of the State Long-Term Care Ombudsman regarding the resident's transfer to a hospital. The resident, a male with multiple health conditions including COVID-19, heart failure, and asthma, was experiencing shortness of breath and chest pain. Despite receiving some treatment, the resident refused further medication and was subsequently transferred to a hospital. The facility did not provide the required written notice detailing the reasons for the transfer, the resident's right to appeal, or contact information for the ombudsman. Interviews with facility staff revealed a lack of awareness regarding the requirement to send written notification. The Social Worker was unsure if any discharge paperwork had been sent with the resident, and the Administrator admitted to not knowing that written notification was necessary, as they anticipated the resident's return. The facility's policy, revised in November 2016, clearly outlines the need to provide such information, including the reason for transfer, appeal rights, and ombudsman contact details, but these procedures were not followed in this instance.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a resident experiencing ant bites. The resident, who had a moderate cognitive impairment and multiple health conditions, reported ant bites on his arms, legs, and stomach. Upon assessment, ants were found in the resident's room, including on the carpet, walls, and bed. The nursing notes indicated that the resident complained of itching due to the ant bites, and medical treatment was provided. The facility's maintenance director was notified and confirmed the presence of ants in the resident's room and another room. The pest control company was contacted to address the issue. Interviews with staff revealed that the facility had a process for reporting pest sightings, but no ants had been reported prior to this incident. The maintenance director and staff conducted inspections and found no further ant infestations in other rooms. The facility had a pest control program in place, with monthly treatments and additional treatments as needed.
Inadequate Supervision and Improper Transfer Technique
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices during a transfer for a resident, leading to a deficiency. The incident involved a CNA who transferred a resident from her bed to a shower chair without using a gait belt and without the assistance of another staff member, as required. The CNA lifted the resident under her armpits, which is against the facility's policy and training guidelines. The resident involved was an elderly female with osteoporosis and severe cognitive impairment, requiring substantial assistance for transfers. Her care plan specified that transfers should be conducted with two staff members and a gait belt. Despite this, the CNA proceeded with the transfer alone and without the proper equipment, as captured in a video provided by the resident's family member. Interviews with various staff members, including the Administrator, LVN, PT, ADON, and DON, confirmed that the resident was a two-person transfer with a gait belt. The CNA admitted to not following the proper procedure, citing a lack of readily available help. The facility's policy and training materials clearly state that gait belts must be used for all transfers, and lifting by the armpits is prohibited.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services by administering the incorrect IV antibiotic to a resident. The incident involved a resident who was supposed to receive Micafungin for candidiasis but was instead given Meropenem, which was intended for another resident. This error was discovered when the resident's family noticed the wrong IV bag hanging in the resident's room and reported it to the facility staff. The resident in question was a female with a history of malnutrition, bloodstream infection, recurrent enterocolitis due to Clostridium difficile, and delusional disorders. She had been receiving parenteral/IV therapy and was on Micafungin until a specified date. The error occurred when LVN A administered the wrong medication, despite the resident's care plan and medication sheet clearly indicating the correct medication and dosage. The facility's investigation revealed that the LVN responsible for the error denied administering the wrong medication, even though her initials were on the IV bag. The Director of Nursing and Assistant Director of Nursing were involved in addressing the situation, verifying the error, and ensuring the resident was monitored for adverse reactions. The incident highlighted a failure to adhere to the facility's medication administration protocol, which includes verifying the right person, medication, dose, time, route, reason, and documentation before administering any medication.
Medication Error: Wrong IV Antibiotic Administered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was administered the incorrect intravenous (IV) antibiotic. The resident, a female with a history of malnutrition, bloodstream infection, recurrent enterocolitis due to Clostridium difficile, and delusional disorders, was supposed to receive Micafungin for candidiasis. However, she was mistakenly given Meropenem, which was intended for another resident. The error was discovered when the resident's family noticed that the IV bag hanging in the resident's room had another resident's name on it. This prompted them to report the issue to the facility's staff, who confirmed that the wrong medication had been administered. The Licensed Vocational Nurse (LVN) responsible for the administration denied giving the wrong medication, despite evidence to the contrary, including her initials on the medication bag. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were involved in addressing the situation, verifying the error, and ensuring the resident was monitored for adverse reactions. The incident highlighted a failure in following the facility's medication administration protocol, which includes verifying the right person, medication, dose, time, route, reason, and documentation before administering any medication.
Failure to Enter Physician Orders for Immediate Wound Care
Penalty
Summary
The facility failed to ensure that a resident had physician orders for immediate care upon admission. Specifically, RN A did not enter physician orders for the resident's wound vacuum and wound care, despite the resident having a significant medical history that included a bone infection of the sacrum and an open wound requiring a skin graft and wound vacuum. The resident was admitted with hospital discharge instructions that specified the need for immediate wound care, including the application of a hospital-grade wound vacuum. However, these orders were not entered until two days later, on the day the resident was discharged from the facility. Interviews with RN A and the Director of Nursing (DON) revealed that the admitting nurse is responsible for entering all hospital discharge orders, including wound care orders. RN A could not recall the specific resident but stated she always inputs all hospital discharge orders. The DON confirmed that there was no reason for the admitting nurse not to put in wound care orders and acknowledged that the admission note did not indicate that wound care had been done. The facility's policy on physician orders requires detailed treatment orders, which were not followed in this case.
Failure to Provide Wound Care
Penalty
Summary
The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, RN-A did not provide wound care for a resident's left lower leg wound from 1/10/24 to 1/12/24. The resident, a [AGE] year-old female, was admitted with diagnoses including a bone infection of the sacrum, an open wound to the left lower leg requiring a skin graft and wound vacuum, and emphysema. The hospital discharge paperwork included specific instructions for wound care, but these orders were not entered into the resident's physician orders until the day she was discharged from the facility. There was no documentation of any wound care being provided during the two days the resident was at the facility. Interviews with RN-A and the DON revealed that the admitting nurse was responsible for entering all admission orders from the hospital, but RN-A could not recall why the wound care orders were not entered until two days later. The DON confirmed that RN-A's note did not indicate that wound care was done upon the resident's arrival. Additionally, the Social Worker reported that the resident's family was unhappy with the treatment and lack of care, leading to the resident's transfer to another facility. The facility's policy on wound care was requested but not provided prior to the exit.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Southlake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Discovery Village At Southlake | 0.5 mi | ★★★★★ | 2 | 0 |
| Keller Oaks Healthcare Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Bear Creek Nursing And Rehabilitation | 3.9 mi | ★★★★★ | 14 | 2 |
| Heritage House At Keller Rehab & Nursing | 4.2 mi | ★★★★★ | 7 | 1 |
| Oakmont Guest Care Center | 4.9 mi | ★★★★★ | 2 | 1 |
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.