Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Enclave during CMS and state inspections, most recent first.
Surveyors found a treatment cart unlocked and unattended in a resident area, with a bottle of betadine accessible in a side basket and no staff at the nurses’ station while residents were moving about. A Human Resources staff member confirmed the cart should not have been unlocked and indicated the TN had just arrived, while the TN stated the night nurse was responsible for the cart. The DON reported that carts must be locked when not in use or unattended, that mobile residents were present, and that the assigned nurse was responsible for securing the cart, consistent with the facility’s written policy requiring medication carts and storage bins to be kept closed, secured, and/or in line of sight when not in use.
A resident with vascular dementia, moderate cognitive impairment, hemiplegia, and dependence on staff for ADLs was subjected to kissing and intimate physical contact by a CNA, as captured on in-room video. The CNA was seen sitting close to the bed with his arm under the resident’s blanket near her chest, kissing the resident near the head, later holding her hand with both hands, kissing her near the mouth and then on the mouth, stating "I like you," and caressing her face. In a facility interview, the resident reported that a man had kissed and touched her, and an anonymous source stated the resident had said the CNA kissed her, prompting review of the video and its transmission to the Administrator and DON. Despite this, leadership characterized the conduct as unprofessional consoling behavior, did not treat it as an allegation of abuse, and did not report it to HHSC, even though facility policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required prompt reporting of all alleged or suspected violations.
A resident with vascular dementia, moderate cognitive impairment, and significant physical dependence reported that a male CNA had kissed and touched her. Video from the resident’s room showed the CNA seated close to the bed with his arm under the blankets near the resident’s chest, kissing her near the head, later holding her hand, kissing her near and then on the mouth, and caressing her face while she remained in bed. An anonymous source reported the resident’s statement, and the video was emailed to the Administrator and DON, who acknowledged receipt. Despite the resident’s documented statement and the video evidence, facility leadership concluded there was no reportable allegation and characterized the conduct as merely unprofessional, and the incident was not reported to HHSC as required by the facility’s abuse reporting policy and federal/state regulations.
Inaccurate MDS Coding for Catheters and Opioid Use: MDS assessments for two residents failed to reflect indwelling urinary catheters, and another resident’s MDS failed to reflect opioid use. Records, orders, MARs, and observations showed the catheters were in place and that the resident with pain had PRN Tylenol with Codeine, but the assessments did not match the residents’ actual status.
Care Plans Did Not Reflect Required Resident Needs: The facility failed to ensure care plans accurately addressed key resident needs for three residents. One resident who could not reach his call light was observed with the device out of reach even though staff knew he needed a call bell. Another resident had an indwelling Foley catheter documented in orders, nursing notes, and hospital records, but the care plan did not include the catheter. A third resident was receiving ordered O2 therapy for COPD, yet the care plan did not address the oxygen requirement.
Medication services were deficient when staff failed to ensure timely access to ordered meds and proper insulin handling. A resident with diabetes missed a scheduled dose of Janumet because it was not available in the cart or emergency supply, and an LPN reported the issue after the dose was due. Another resident with glaucoma and dry eyes did not receive ordered eye drops because they were unavailable, and the LVN did not notify the DON or MD. A third resident’s Humalog pen was found in the nursing cart after the open-use period, and the DON stated staff were responsible for discarding it after 28 days.
Kitchen staff were observed with improper hair and beard restraints, unlabeled prepared foods and liquids were found in the walk-in refrigerator, and wet dishes were stored in a way that did not allow air drying. Staff interviews confirmed that items should be labeled and dated, hair restraints should fully cover hair, and dishes should be stored to air dry, but these practices were not followed.
Infection Control Lapses During Resident Care: An LVN provided direct care to a resident on EBP without wearing a gown, two CNAs performed incontinent care for a resident but left fecal contamination at the anal/rectal area and left soiled socks in place, and an LVN measured another resident’s BP with an uncleaned cuff. The residents had significant medical conditions including a wound with EBP orders, severe cognitive impairment with incontinence, and multiple chronic diagnoses.
A resident with severe cognitive impairment, incontinence, and multiple serious diagnoses was found during incontinent care with urine-soaked linens and wet anti-skid socks left on his feet after peri-care. In a separate event, an LVN entered another resident’s room without knocking before administering G-tube meds. Staff interviews confirmed both incidents involved a failure to preserve resident dignity and respect.
A resident with myopathy, epilepsy, severe depression, and severely impaired cognition was observed lying in bed with his call light about three feet away, wrapped around a wheelchair armrest and not within reach. He stated he could not reach or use it, while the charge nurse and DON acknowledged the call bell should have been available because he chewed on the call light and needed it to request assistance.
A resident with dementia, diabetes, and total bowel/bladder incontinence had an indwelling Foley placed for urinary retention after a PVR order, then returned from the hospital with the catheter still in place. The EMR did not show an updated dx or MD order for the catheter or catheter care in the current month, and the DON confirmed the missing documentation.
Respiratory Equipment Not Covered When Not in Use: A resident with COPD, acute respiratory failure, and a nebulizer order was observed sleeping while the tubing and mask attached to the nebulizer sat on the nightstand uncovered when not in use. An LVNM and the DON stated the tubing and mask should have been covered in a plastic bag to help prevent possible infection, consistent with the facility's respiratory equipment policy.
Medication Error Rate Exceeded Allowed Threshold: A resident with anemia, glaucoma, and muscle wasting had two medication errors during a med pass. An LPN did not give ordered eye drops for dry eyes because the med was unavailable and did not report it to the DON or PCP, and also gave glaucoma eye drops at the wrong time instead of the ordered schedule. The DON later confirmed both were med errors.
A treatment cart was found unlocked and unattended, with drawers open to multiple meds, ointments, scissors, and bottles, and the wound care nurse and DON acknowledged it should have been secured. In a separate finding, a resident with intact cognition and pain-related diagnoses had a jar of medicated chest rub on her nightstand despite no order or self-medication authorization; she said she used it on her lips, and the charge nurse and DON stated they were unaware it was in the room.
Failure to post daily nursing staffing information. Surveyors observed that the daily staffing sheet was not updated for several days, and the DON stated the usual person responsible for posting was out and the posting was missed. The DON said the staffing post shows how many staff are available in case of emergency and for needed care. Facility policy required continuous time schedules showing the number and classification of nursing personnel, including relief personnel, for each tour of duty.
A resident’s discharge MDS was completed and signed but was not transmitted to CMS in a timely manner. Staff gave conflicting statements about who was responsible for MDS completion and transmission and how long they had to submit it, and the facility policy required MDS data to be transmitted within 7 days after completion and at least monthly.
A resident with dementia and GERD did not receive a scheduled dose of Famotidine because the medication was not found in the medication cart at the time of administration. The nurse searched for the medication, ordered a replacement from the pharmacy, and informed the resident of the delay, but the dose was missed. The medication was later found and administered by another nurse, revealing a lapse in the facility's medication management procedures.
The facility did not maintain complete and accurate medical records for several residents who were dependent on staff for bathing, as required by professional standards. Multiple instances were found where it was not documented whether a bath or shower was given or refused on scheduled days, despite care plans and schedules indicating the need for regular bathing. Interviews with the DON and CNAs confirmed that care was provided or refused but not properly recorded in the electronic system or nursing notes, resulting in incomplete records.
The facility failed to meet food service safety standards, with issues including improper hair restraint use by the CDM, incorrect storage of raw beef over cooked pies, uncovered foods in the cooler, and incorrect temperature logging for dishwashing and food items. Additionally, refrigerator temperatures were inadequately monitored, potentially risking foodborne illness for residents.
A resident with a history of atrial fibrillation and hypertension experienced significant medication errors at an LTC facility. Diltiazem HCl was administered outside prescribed parameters, with instances of missing documentation and incorrect administration despite low blood pressure readings. Staff interviews confirmed these discrepancies, highlighting a failure to adhere to the facility's medication administration policy.
The facility failed to implement a policy for the use and storage of foods brought by family and visitors, resulting in unsanitary conditions in personal refrigerators for several residents. Issues included dirty refrigerators, undated and expired foods, and a broken refrigerator door. Nursing staff acknowledged the need for routine checks and proper labeling to prevent potential food-borne illnesses.
The facility failed to ensure call lights were within reach for two residents, impacting their ability to request assistance. One resident with moderate cognitive impairment had her call light out of sight and reach, while another with severe cognitive impairment had her call light inaccessible from her wheelchair. Staff confirmed the improper placement, and the facility's policy requires call lights to be easily accessible.
The facility failed to ensure accurate MDS assessments for two residents. One resident's therapeutic diet was not documented correctly, and another resident's discharge status was inaccurately recorded. These errors were acknowledged by the MDS staff, highlighting the importance of accurate assessments for care and billing.
A facility failed to ensure accurate PASRR Level I assessments for residents with mental illness. A resident with PTSD was incorrectly marked as having no mental illness in their PASRR screening, risking missed services. The MDS Coordinator acknowledged the error, and the DON admitted to random monitoring, which may have led to the oversight.
A resident with severe cognitive impairment and dependency on staff for all ADLs was not provided with adequate personal and oral hygiene care. Observations showed long fingernails, dry patches on the face, and cracked lips with residue. Interviews with staff indicated that CNAs were responsible for ADL care, but there was a lack of consistent grooming and oversight by the nursing staff.
A resident receiving enteral feeding did not receive the correct water flush rate as prescribed by the physician. The LVN set the water flush to 175 milliliters every four hours instead of the prescribed 275 milliliters, due to not checking the physician's order. This error was confirmed by the DON and could potentially lead to dehydration.
A resident with asthma did not receive proper respiratory care as their nebulizer mask was found improperly stored and undated. The mask was left on the nightstand without a plastic bag, contrary to facility policy requiring weekly changes and proper storage. This was confirmed by both an LVN and the DON, highlighting a failure in adhering to the facility's respiratory equipment management policy.
The facility failed to periodically assess the safety of bed rails for two residents, leading to potential risks of entrapment. One resident with moderate cognitive impairment used side rails for repositioning, but her consent was outdated, and the last review was months prior. Another resident with dementia also used side rails, with consent dated years ago and the last review months before. Staff interviews revealed inconsistencies in policy implementation regarding assessment frequency.
A resident's Ciprofloxacin eye drops were left unsecured on a bedside table without a self-administration order, violating medication storage protocols. The resident confirmed the nurse left the drops for use after breakfast, but no assessment or order was documented. The DON acknowledged this breach of policy.
The facility did not follow the planned menu for a lunch meal, serving mixed vegetables and rice instead of the expected corn and broccoli, and failed to update the menu for residents. A resident, at risk for nutritional deficits, did not eat the meal provided due to the lack of preferred items and was offered an alternative. Staff interviews revealed the kitchen ran out of certain items, and the menu was not updated to reflect these changes.
The facility failed to meet the dietary needs of two residents, one of whom did not receive a proper protein source despite being at risk for nutritional deficits, and another who was served fish despite having a documented allergy. The staff failed to update meal tickets and adhere to dietary protocols, leading to deficiencies in care.
A facility failed to adhere to infection control protocols for two residents under Enhanced Barrier Precautions (EBP). An LVN did not wear a gown while applying cream to a resident with skin abrasions, and an ADON did not wash hands or wear a gown while handling a G-tube. Both incidents violated the facility's infection prevention policy, risking cross-contamination.
A resident, who required a Total Lift for transfers, experienced pain in her right ankle after a nursing assistant transferred her without the lift, despite the resident's request. The resident's care plan and Kardex indicated the need for a Total Lift, and the nursing assistant admitted to not using it because it was faster. The resident reported pain, and an x-ray showed no fracture. The nursing assistant had been trained on safe transfer equipment and resident safety.
A resident with Alzheimer's Disease was found outside the facility on two occasions without supervision. The facility failed to document or report these incidents as elopements and did not implement new interventions. The front doors were not locked until 8:00 PM, and there was no memory care unit. Staff were not adequately trained on elopement prevention, and the administration was not fully aware of the incidents.
A resident did not receive multiple critical medications upon admission due to the LVN's failure to access the emergency medication kit or seek assistance. The resident's medical history included type 2 diabetes, paroxysmal atrial fibrillation, and heart failure. The facility's policy on timely medication administration was not followed.
The facility failed to treat residents with dignity and respect, as observed in the interactions of an LVN with three residents. The LVN used terms of endearment like 'honey' and 'sweetheart' instead of their preferred names, which could make residents feel uncomfortable and disrespected. The DON confirmed that such terms should not be used, emphasizing the importance of respect and dignity.
The facility failed to report two incidents of a resident with Alzheimer's Disease eloping from the facility to the appropriate authorities within the required timeframe. Despite being aware of the incidents, the staff did not consider them as potential neglect and did not report them to the Administrator or the State Survey Agency.
A resident with a history of diabetes, atrial fibrillation, and heart failure did not receive critical medications upon admission due to the LVN's failure to access the emergency medication kit or seek assistance. The medications were administered several days later, against the facility's protocol.
The facility failed to maintain an infection control program when an LVN left wound care supplies unattended and improperly cleaned a resident's wound, increasing the risk of cross-contamination. The resident had a complex medical history, including acute respiratory failure and osteomyelitis.
Unlocked, Unattended Treatment Cart with Medications Accessible in Resident Area
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that all drugs and biologicals were stored in locked compartments under proper controls and that only authorized personnel had access to the keys for a treatment cart. During an observation at 6:59 a.m., Treatment Cart #1 was found unlocked and unattended, with a bottle of betadine in a basket affixed to the side of the cart. There were no staff present at the nurses’ station, and residents were moving about the facility at the time. The Human Resources staff member present acknowledged that the cart was not supposed to be unlocked and stated he did not know who was responsible for the cart because he worked in Human Resources, but indicated that the Treatment Nurse had just arrived. In a subsequent interview, the Treatment Nurse stated that the night nurse was responsible for the treatment cart, as that nurse worked the night shift and would have provided treatments for residents. An interview with the DON confirmed that her expectation was that medication and treatment carts be locked when not in use and unattended, and that medications and treatments must be secured and not left outside or on top of the cart. The DON stated that the facility had mobile residents and that any staff member could lock a cart if they passed by it, but the nurse assigned to the cart was responsible for ensuring it was locked when not in use. Review of the facility’s “Medication Cart Use and Storage” policy, revised January 2023, showed that licensed nurses and CMAs were responsible disciplines and that the medication cart and its storage bins should be kept closed, secured, and/or in the line of sight when not in use.
Failure to Protect Cognitively Impaired Resident From Sexualized Contact by CNA
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from abuse when a CNA engaged in kissing and physical contact of a sexual and unprofessional nature with the resident, as captured on video and later corroborated by the resident’s own statement. The resident was an elderly female with vascular dementia, moderate cognitive impairment (BIMS 11/15), anxiety, memory deficits following a stroke, left-sided hemiplegia/hemiparesis, and dependence on staff for most ADLs including toileting and transfers. Her care plan identified memory problems affecting her ability to communicate needs, cognitive impairment impacting communication, and risk for emotional distress and behaviors, with interventions focused on reassurance, monitoring for emotional issues, and speaking in a calm tone. Video evidence from the resident’s room on the morning in question showed CNA A seated close to the resident’s bed with his right arm under the resident’s blanket near her chest while she lay in bed covered with blankets. The CNA leaned over the resident and appeared to kiss her near the head, with an audible kissing sound, while his arm remained under the blankets at her chest. In a subsequent video a few minutes later, the CNA was seen standing at the bedside holding the resident’s hand with both of his hands, then leaning down and kissing her near the side of her mouth, after which the resident said, “Thank you.” The CNA then again leaned down and kissed the resident on her mouth; the resident smiled and made a pecking sound. The CNA told the resident, “I like you,” continued to hold her hand, caressed the right side of her face several times with the back of his hand and fingers, and discussed returning later to check on her. Record review showed that during a facility interview conducted after the incident, the resident initially responded “Yes, some man kissed me and touched me” when asked if she had ever been treated in a rough, inappropriate, or unkind manner. In a later interview with surveyors, the resident stated she had been told by administration that the CNA was only trying to console her because she was sad, and she reported that he kissed her on the forehead, denied being kissed on the mouth, and said she did not feel threatened, though she was surprised anyone would want to kiss her at her age. An anonymous source reported that the resident had stated the CNA kissed her, which prompted review of the camera footage and transmission of the video to the Administrator and DON. The Administrator acknowledged there had been previous unsubstantiated concerns about inappropriate touching with another resident and an incident of the CNA holding this resident’s hand. The DON and Administrator characterized the conduct as unprofessional and stated it was not reported to HHSC because they believed there was no allegation and the resident felt safe, despite facility policy defining sexual abuse as non-consensual sexual contact of any type with a resident and requiring all alleged or suspected violations to be promptly reported to appropriate state agencies. Further review of CNA A’s personnel file showed he had completed competency training on privacy, dignity, resident rights, and abuse/neglect, and had been deemed competent in knowledge of abuse, neglect, and reporting. A disciplinary action was documented for rude, disrespectful, or unprofessional behavior and failure to maintain professional boundaries, categorized as a violation requiring written coaching. Time sheets confirmed that the CNA worked on the date of the incident and the following day, with no further shifts afterward. In a telephone interview, the CNA stated the resident had expressed loneliness, suicidal thoughts, and feelings of being forgotten by family, and that he hugged and kissed her on the cheek in what he described as a mutual, consoling interaction, while denying kissing her on the lips or being inappropriate. Despite these statements, the video evidence and the resident’s earlier report that a man had kissed and touched her demonstrate that the facility failed to protect the resident from abuse and failed to treat the conduct as an allegation requiring reporting and full recognition as potential sexual abuse under its own policy and regulatory definitions. The facility’s abuse policy, revised January 2024, stated that every resident has the right to be free from abuse and neglect and that residents should not be subjected to abuse by anyone, including team members and other residents. The policy required that all alleged or suspected violations and all substantiated incidents of abuse be promptly reported to appropriate state agencies per state and federal requirements. It also referenced the federal definition of sexual abuse as non-consensual sexual contact of any type with a resident and defined “willful” as deliberate action, not requiring intent to cause harm. In this case, the CNA’s deliberate kissing and intimate physical contact with a cognitively impaired, dependent resident, combined with the facility’s failure to recognize and report the conduct as an allegation of abuse despite video evidence and the resident’s statement that a man had kissed and touched her, formed the basis of the cited deficiency for failure to ensure the resident was free from abuse.
Failure to Timely Report Alleged Sexual Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a cognitively impaired resident to the State Survey Agency (HHSC) and other required authorities. The resident was an elderly female with vascular dementia, moderate cognitive impairment (BIMS score of 11/15), memory deficits following a stroke, left-sided weakness, and generalized anxiety disorder. She was dependent or required substantial/maximal assistance for most ADLs, including transfers, toileting, and bathing, and was frequently incontinent. Her care plan identified memory problems, difficulty communicating needs due to cognitive impairment, and risk for emotional distress and behaviors, with interventions focused on reassurance and monitoring for emotional issues. The events leading to the deficiency began when the resident reported that a male staff member had kissed and touched her. In a documented interview dated the day after the incident, when asked if she had ever been treated in a rough, inappropriate, or unkind manner, the resident responded, "Yes, some man kissed me and touched me." Video recordings from the resident’s room showed a CNA seated close to the resident’s bed with his arm under the blankets near her chest, leaning over and audibly kissing her near the head, and later standing at the bedside holding her hand, kissing her near the mouth, and then on the mouth while caressing her face. The resident verbally responded to the CNA, including thanking him after a kiss and engaging in conversation, but the videos documented repeated kissing and physical contact of an intimate nature while the resident was in bed and dependent on care. An anonymous source reported that the resident had stated the CNA kissed her, which prompted review of the room camera and the sending of the video to the Administrator and DON via email. The email with the video was sent the day after the incident, and the DON acknowledged receipt and stated they would address the issue. In subsequent interviews with surveyors, the Administrator and DON stated they did not consider the incident reportable because they believed there was no allegation by the resident or her family and characterized the conduct as unprofessional rather than abuse or exploitation. They also referenced a previous unsubstantiated allegation of inappropriate touching by the same CNA with another resident. Despite the resident’s documented statement that a man had kissed and touched her, the video evidence of kissing and intimate contact, and the facility’s own abuse policy requiring prompt reporting of all alleged or suspected violations, the facility did not report the allegation and incident to HHSC as required, resulting in the cited deficiency for failure to timely report suspected abuse. Additional interviews further illustrated conflicting accounts and the facility’s determination not to treat the incident as a reportable allegation. In an interview with surveyors, the resident later denied being kissed on the mouth and stated she was told by administration that the CNA was only trying to console her because she was sad, adding that she did not feel threatened and was surprised anyone would want to kiss her at her age. The DON reiterated to surveyors that there was no allegation from the resident or family member and that the video showed only unprofessional conduct. In a telephone interview, the CNA stated the resident had expressed loneliness and suicidal thoughts, asked for a hug, and that he hugged and kissed her on the cheek, describing the interaction as mutual and denying kissing her on the lips or being inappropriate. Despite these varying descriptions, the documented resident statement that a man kissed and touched her, combined with the video evidence and the facility’s policy defining and requiring reporting of all alleged or suspected abuse, formed the basis for the surveyors’ finding that the facility failed to ensure the alleged violation was reported immediately, but not later than two hours after the allegation was made.
Inaccurate MDS Coding for Catheters and Opioid Use
Penalty
Summary
The facility failed to provide MDS assessments that accurately reflected resident status for three residents reviewed for assessment accuracy. The deficiency involved inaccurate coding of an indwelling urinary catheter for two residents and inaccurate coding of opioid use for one resident. The report states this deficient practice affected residents with MDS assessments and could result in missed or inappropriate care. Resident #41’s quarterly MDS assessment with an ARD of 07/17/2025 did not indicate an indwelling urinary catheter, even though the record showed a physician order on 07/15/2025 to collect urine via PVR and leave a urethral catheter in place if residual was greater than 250 mL. A nursing progress note documented that the residual was greater than 250 cc and that a Foley catheter remained in place with the balloon inflated. Documentation survey reports for July and August 2025 showed the resident had an indwelling urinary catheter from 07/15/2025 until she went to the hospital on 08/04/2025. On observation on 08/24/2025, the resident was in bed with a covered urinary drainage bag hanging on the side of the bed frame. Resident #55’s admission MDS assessment with an ARD of 07/24/2025 also did not code an indwelling urinary catheter, despite the physician order dated 07/18/2025 for a Foley catheter 16 French, 10 milliliters, to be changed monthly and as needed. The resident’s care plan identified that she required a catheter and catheter care, and on observation on 08/26/2025 she was in bed with an indwelling urinary catheter hanging to the bed frame. Resident #34’s annual MDS assessment with an ARD of 07/25/2025 did not reflect opioid use in section N0415, even though the active orders showed Tylenol with Codeine #3, 300-30 mg, ordered every 6 hours as needed for severe pain. The MAR showed she received Tylenol with Codeine on 07/21/2025 for pain rated 6, and the resident stated she sometimes had pain in her back and joints and took pain medication.
Care Plans Did Not Reflect Required Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that reflected identified needs for three residents. For one resident with diagnoses including myopathy, acute respiratory failure with hypoxia, epilepsy, suicidal ideations, and major depressive disorder, the care plan noted use of a call light and later referenced a call bell, but the resident was observed in his room with the call light cord and button wrapped around the armrest of a tall chair and not within reach. The resident stated he could not reach and use the call light and demonstrated pressing a call light button. The charge nurse stated the call light was not within reach and acknowledged it was important for him to have a call bell within reach because he had been noted to chew on the call light. For another resident with diagnoses including muscle wasting and atrophy, pain due to internal orthopedic prosthetic devices, diabetes mellitus, osteoporosis, post viral fatigue syndrome, and dementia, the quarterly MDS reflected an indwelling urinary catheter during the relevant period, and records showed a physician order for urethral catheterization with the Foley catheter left in place when residual was greater than 250 ml. Nursing documentation stated the Foley catheter remained in place with the balloon inflated, and survey records and hospital notes reflected the resident had a chronic indwelling Foley catheter. The resident was observed in bed with a covered urinary drainage bag hanging on the side of the bed frame, yet the comprehensive care plan continued to reflect self-care deficits, bladder incontinence, and bowel incontinence without identifying the indwelling urinary catheter. For a third resident with diagnoses including arthritis, COPD, muscle wasting and atrophy, and heart failure, the MDS indicated moderate cognitive impairment and that the resident was receiving oxygen therapy. The physician order specified oxygen at 3 to 5 liters per minute via nasal cannula as tolerated for COPD, and the resident was observed on the bed receiving oxygen at 4 liters per minute via nasal cannula. However, the comprehensive care plan did not address oxygen therapy. Facility staff confirmed that the care plan did not reflect the resident's oxygen therapy, and the facility policy stated care plans are to include measurable objectives to meet residents' medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment.
Medication Availability and Insulin Storage Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring timely access to ordered medications and by not ensuring an insulin pen was within the proper use period. The report identified three residents affected during review of pharmacy services: one resident with diabetes, hypertension, and heart failure; one resident with anemia, glaucoma, and muscle wasting; and one resident with diabetes, COPD, and hypertension. For the resident with diabetes, the physician ordered Janumet 50-500 mg twice daily. The MAR showed the medication was scheduled for 8:00 a.m. and 5:00 p.m., but during observation the LVNN could not find the medication in the cart and also could not obtain it from the emergency medication cart. The LVNN reported the issue to the DON and the primary care physician. The DON stated the facility pharmacy was contacted and staff would pick up the medication, and the physician said the nurse could administer it when available. The DON later stated the resident received the Janumet at 6:00 p.m. after facility staff picked it up from the pharmacy. For the resident with glaucoma and dry eyes, the physician ordered Carboxymethylcellulose Sodium Ophthalmic Solution 0.5% to be instilled in both eyes four times daily. During observation, the LVNO did not administer the eye drops because the medication was not available. The LVNO did not report the missing medication to the DON or the primary care physician and continued to the next resident. The LVNO stated she did not report it because she was busy passing medications to other residents. The DON stated the physician was informed and said it was fine to administer the medication when available, and also stated the medication should have been reordered before it ran out. For the resident with diabetes receiving sliding-scale Humalog insulin, observation showed the insulin pen stored in the 200-unit C-hall nursing cart had been opened on a prior date and was still in use. The LVNP stated she had used the pen earlier that morning and believed it was acceptable because she was confused about when it should be discarded. The DON stated staff were responsible for checking carts and that the insulin pen should have been discarded 28 days after opening. The report also noted the facility did not have a specific policy for when to discard an insulin pen and referenced professional guidance stating Humalog/insulin lispro pens expire 28 days after first use.
Kitchen Food Storage and Personal Hygiene Lapses
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation, surveyors found a tray of lettuce, sliced tomato, sliced onion, and cheese in the walk-in refrigerator that was unlabeled, an open bag of lettuce that was unlabeled, and three drink dispensers containing liquids that were also unlabeled. The report also noted that prepared items in the walk-in refrigerator were not labeled and dated with a use-by date. Surveyors observed Dietary Aide A at the steam table without a facial hair restraint over his facial hair, and Dietary Aide B wearing a hair restraint that did not cover all of the hair on his head. On a later observation, Dietary Aide A was again seen in the kitchen without a facial hair restraint over his facial hair. The dietary staff interviewed stated that hairnets and facial hair restraints were to be worn to cover all hair while in the kitchen and that it was the responsibility of all staff to ensure they were worn correctly. Surveyors also observed 9 trays of wet bowls and 3 trays of wet mugs stored in a way that did not allow air flow. Staff interviews stated that dishes should be stored dry or in a way that allows air to dry, and that all staff were responsible for ensuring proper drying. Facility policy and the Food Code cited in the report required refrigerated foods to be dated and labeled, clean utensils to be stored in a self-draining position that allows air drying, and food employees to wear effective hair restraints, including beard restraints.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program for three residents during observed care and record review. Resident #9 had diagnoses including infection following a procedure and a stage 4 sacral pressure ulcer, and the care plan and physician orders indicated Enhanced Barrier Precautions (EBP) were to be practiced. During observation, the resident’s room had an EBP sign posted, and the resident stated staff did not wear a gown when performing care. When the surveyor observed an LVN administering a suppository, the LVN was not wearing a gown while providing care and later stated she should have been wearing a gown and gloves for Resident #9 because of the EBP requirement. Resident #17 was observed during incontinent care by two CNAs. The resident was incontinent of urine and had feces present in the shower area and around the anal and rectal area. The CNAs cleaned the penis, scrotum, and upper legs, but the surveyor requested that they clean the buttocks and anus/rectal area because feces remained present. The CNAs also left the resident’s nonskid socks on while they were lying on urine-soaked bedding and then onto clean bedding. One CNA stated she did not remember to remove the socks and did not spread and clean the rectum and anus. The DON stated the resident should have been checked for wetness or soiling, soiled clothing should not have been left in the room, and the anal and rectal area needed to be cleaned as part of incontinent care. Resident #105 had diagnoses including cerebral ischemia, muscle wasting and atrophy, hypertension, muscle weakness, and pleural effusion. During observation, an LVN exited another resident’s room with a blood pressure cuff and then entered Resident #105’s room and measured the resident’s blood pressure without cleaning the cuff. The LVN acknowledged she had not cleaned the cuff before using it on Resident #105 and stated she should have cleaned it to prevent possible infection. The DON stated the cuff should have been cleaned before use and noted there was no specific policy for cleaning a blood pressure cuff.
Failure to Maintain Resident Dignity During Care and Medication Administration
Penalty
Summary
The facility failed to treat residents with respect and dignity for two residents observed during survey. One resident had diagnoses including myopathy, acute respiratory failure with hypoxia, epilepsy, suicidal ideations, and major depressive disorder, and his MDS showed severe cognitive impairment, dependence for ADLs except eating, and bowel and bladder incontinence. During incontinent care, two CNAs found him lying in bed with his pants and the back of his shirt wet with urine, and the bed sheet beneath him had a large ring of wet urine extending to his curled-up legs and anti-skid socks. After peri-care was completed, the CNAs pulled a clean brief up on the resident but did not remove the socks that were lying on the urine-soaked sheet. A second resident was receiving G-tube medications when an LVN entered the room without knocking first. The report states the LVN did not knock on the resident’s door prior to entering to administer the medications. Interviews with staff confirmed the events, including one CNA stating the wet socks could affect the resident’s self-esteem and dignity, and the charge nurse stating the resident had been dry when placed in bed earlier. The deficiency was cited for failure to maintain dignity and respect for these two residents.
Call light not within reach for resident with severe cognitive impairment
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences for one resident who required assistance with ADLs. Resident #17 had diagnoses including myopathy, acute respiratory failure with hypoxia, epilepsy, suicidal ideations, and major depressive disorder. His quarterly MDS showed he could usually be understood and understand others, but his BIMS score was 06 of 15, indicating severely impaired cognition. He was dependent for ADL care except eating, where he required set-up assistance, and he was always incontinent of bowel and bladder. His care plan included that he had been noted to chew on the call light-bell and that the call bell should be kept within reach. During observation, Resident #17 was lying on a low bed with a mat on the floor and was reaching out as if trying to get someone's attention. When asked if he could reach and use his call light, he stated no and demonstrated pressing a call light button. His call light cord and button were located approximately three feet from the bed and wrapped around the left arm rest of his tall wheelchair. The room also had an odor of stale urine. The charge nurse stated she had not noticed the call bell was not within reach, and the DON stated the resident should have had a call bell because he chewed on the call light, but she did not know why he did not have one.
Missing catheter order and diagnosis for resident with chronic Foley
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling urinary catheter when the resident had no active diagnosis or physician order for the catheter in August 2025. Resident #41 was a female with diagnoses including muscle wasting and atrophy, pain due to internal orthopedic prosthetic devices, diabetes mellitus, osteoporosis, post viral fatigue syndrome, and dementia. Her quarterly MDS reflected she was severely cognitively impaired, dependent on staff for ADLs except eating, and always incontinent of bowel and bladder. Her care plan addressed self-care deficit, weakness, debility, and incontinence, but did not reflect an indwelling urinary catheter. Record review showed the resident received a urinary catheter on 07/15/2025 after a physician order for PVR urethral catheterization, with the catheter to remain in place if residual was greater than 250 ml. A nursing progress note documented that urine was collected, residual was greater than 250 cc, and the Foley catheter remained in place with the balloon inflated with 10 cc NS. Facility documentation reflected the resident had an indwelling urinary catheter from 07/15/2025 to 08/04/2025, when she went to the hospital for a change in condition. Hospital notes dated 08/14/2025 reflected ESBL E. coli and a chronic indwelling Foley catheter that had been replaced in the ED on 08/04/2025. The resident returned to the facility with the indwelling urinary catheter, but the EMR did not show updated physician orders or a diagnosis for the catheter. During interview, the DON stated the catheter was related to urinary retention and confirmed that the diagnosis, catheter, and catheter care orders were not in the August 2025 physician orders. The DON also stated the resident was on hospice and that not having the orders or diagnosis did not meet professional standards for having an indwelling urinary catheter.
Respiratory Equipment Not Covered When Not in Use
Penalty
Summary
Resident #174, a 70-year-old male admitted with diagnoses including lack of coordination, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and acute respiratory failure, had a baseline care plan addressing shortness of breath and breathing treatments as ordered. A physician order dated 08/16/2025 directed Levalbuterol inhalation nebulization solution 0.31 mg/3 mL via nebulizer four times daily for COPD. On 08/24/2025 at 10:32 a.m., the resident was observed sleeping in bed while the tubing and mask attached to the nebulizer were on the nightstand and not covered in a plastic bag. During interview, the LVNM stated the tubing and mask should have been covered in a plastic bag when not in use to prevent possible infection, and the DON later stated the same. The facility policy titled Respiratory Tubing/Equipment Management states that clean equipment and tubing bottles and masks are maintained to decrease the potential for the spread of infection.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with a documented rate of 7.41% based on 2 errors out of 27 opportunities involving one resident reviewed for medication errors. Resident #150 was a 91-year-old male admitted with anemia, glaucoma, and muscle wasting and atrophy. His baseline care plan identified him as at risk for vision loss/impairment and included medications as ordered. His physician orders included Carboxymethylcellulose Sodium Ophthalmic Solution 0.5% for dry eyes, to be given 1 drop in both eyes four times daily, and Timolol Maleate Gel Forming Solution 0.5% for glaucoma, to be given 1 drop in both eyes every 12 hours at 8:00 a.m. and 8:00 p.m. During a medication pass observation, LVNO did not administer the Carboxymethylcellulose Sodium Ophthalmic Solution because the medication was not available, and she did not report it to the DON or primary care physician at the time. The same observation showed LVNO administered the Timolol Maleate eye drops at 4:39 p.m. instead of the ordered 8:00 p.m. time. In interview, LVNO stated she was confused about the time and acknowledged the timing error, and the DON later stated both events were medication errors. The facility policy required medications to be administered accurately, safely, timely, and as ordered by the physician.
Unsecured Medication Cart and Unapproved Chest Rub at Bedside
Penalty
Summary
Drugs and biologicals were not stored in locked compartments as required when a treatment cart was found unlocked and unattended on the 300-unit B-hallway during observation. The surveyor was able to open all drawers of the cart and see multiple medications, ointments, scissors, and bottles of medications. The wound care nurse stated she had left the cart unlocked and unattended and acknowledged that it should have been locked at all times for resident, visitor, and staff safety. The DON also stated the cart should not have been unlocked and that a resident with dementia or another person could have opened it and taken medications. The facility also failed to remove a jar of medicated chest rub from Resident #34’s nightstand. Resident #34 was an older female with diagnoses including muscle wasting and atrophy, COPD, pain, and major depressive disorder. Her MDS reflected intact cognition, and her care plan addressed pain management. Observations showed the chest rub on her nightstand on two separate occasions, and the resident stated she used it on her lips at night and did not remember when or how she got it. The label identified camphor, eucalyptus oil, and menthol and warned for external use only and not to use by mouth, in nostrils, wounds, damaged skin, or lips. The charge nurse stated she had not seen the jar in the room and would have removed it, and the DON stated she was unaware the resident had the medication and that it could be harmful if used inappropriately.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post daily staffing and census requirements on a daily basis for 5 days, affecting one of one facility. On 08/24/2025 at 08:50 am, surveyors observed that the daily staffing sheet dated 08/19/2025 was posted in a hard plastic display frame on the first nurses station counter. During an interview on 08/27/2025 at 09:36 am, the DON stated that the person who normally posted the staffing was out and the posting was missed from August 19, 2025, up to August 24, 2025. The DON stated that the purpose of posting nursing staff was to show how many staff were available in case of emergency and for needed care. Record review of the facility policy titled Nursing Services, revised January 2023, stated that the community maintains and posts continuous time schedules showing the number and classification of nursing personnel, including relief personnel, who are scheduled or who worked in each unit during each tour of duty, and that the schedules are maintained for the period specified by community policy or for at least two years following the last day in the schedule.
Late Transmission of Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit an encoded, accurate, and complete MDS assessment to CMS within the required timeframe for one resident. Resident #70 was admitted with diagnoses including alcohol dependence with withdrawal, cyst of kidney, alcoholic hepatitis without ascites, other specified anemias, fatty liver, acute metabolic acidosis, anxiety disorder, and acute and chronic respiratory failure with hypoxia. The resident’s discharge MDS assessment was completed and signed by the MDS SS, but the assessment was not transmitted to CMS until months later, and the record showed it had not been transmitted as of the survey review. During interviews, staff gave differing accounts of who was responsible for completing and transmitting MDS assessments and how long they had to submit them. The NAS stated she was not responsible for transmitting anything and believed the MDS had to be transmitted within 14 days after it was signed and completed, though she was not sure. The DOCR stated the facility had 14 days from the ARD to complete the MDS and then 14 days to transmit it, and said the resident’s discharge MDS was late but she did not know why. The MDS SS stated she believed she completed the discharge MDS on Monday morning and said the assessment got missed. The facility policy stated that within seven days after completion of a resident’s assessment, the community will transmit the MDS information to the state, and that MDS data are transmitted at least monthly.
Failure to Administer Prescribed Medication Due to Unavailable Stock
Penalty
Summary
A deficiency occurred when a nurse failed to administer a prescribed dose of Famotidine (Pepcid) 10 mg to a resident with dementia and GERD, as ordered for indigestion. The medication was not found in the medication cart during the scheduled administration time, despite being present the previous day. The nurse searched both the medication cart and the medication room but was unable to locate the medication. She subsequently ordered the medication from the pharmacy and informed the resident that it would be delivered later, but the dose was missed for that day. Further review revealed that the medication was listed as an over-the-counter (OTC) drug, which contributed to it not being refilled in a timely manner. The following day, another nurse located an opened box of the medication in the medication cart and administered it as ordered. The facility's policy requires medications to be administered accurately and as ordered by the physician, but this process was not followed, resulting in the resident missing a scheduled dose.
Failure to Accurately Document Bathing Care in Resident Medical Records
Penalty
Summary
The facility failed to ensure that medical records were maintained in accordance with accepted professional standards and practices, specifically regarding the documentation of bathing or showering for four residents. For each of these residents, there were multiple instances over a one-month period where it was not documented whether a bath or shower was given or refused, despite scheduled bathing days and care plans indicating the need for 2-3 showers per week. The lack of documentation was identified through review of electronic clinical records, care plans, shower schedules, and nurses' notes, which did not reflect either the provision of care or resident refusals on numerous scheduled days. Resident records reviewed included individuals with significant medical conditions such as heart failure, stroke, hemiparesis, hemiplegia, high blood pressure, memory deficits, vascular dementia, morbid obesity, cognitive communication deficits, atrial fibrillation, kidney failure, lymphedema, and muscle wasting. These residents were all dependent on staff for bathing or showering, as indicated by their care plans and Minimum Data Set (MDS) assessments. Despite this dependency, the documentation in the electronic clinical record was incomplete, with several scheduled bathing days lacking any record of care provided or refusals, and no corresponding notes in the nursing progress records. Interviews with the DON revealed that, upon inquiry, CNAs reported having provided baths or showers or having received refusals from residents on the undocumented days. However, these actions or refusals were not entered into the electronic Point of Care Tasks or nursing notes as required by facility policy. The administrator confirmed that the absence of such documentation resulted in inaccurate medical records. The facility's policy, revised in January 2023, requires that a medical record be maintained for every resident, including documentation of services provided, in accordance with professional standards.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas within the kitchen. The Certified Dietary Manager (CDM) was observed wearing a hair restraint that did not cover all his hair, which is against the facility's policy and the U.S. Food Code requirements. Additionally, in the freezer, raw beef was improperly stored above fully cooked frozen pies, posing a risk of cross-contamination. In the walk-in cooler, there were uncovered trays of pie desserts, bowls of fruits, and plates of salad, as well as improperly stored cheese. The CDM admitted to not labeling prepared foods with a discard date, which is a violation of the facility's food storage policy and the U.S. Food Code. The dishwashing machine's temperature log was found to have incorrect temperatures recorded, with the machine's operational requirements not being met. The CDM revealed that the dishwasher staff recorded temperatures before the machine started, which did not reflect the actual temperature. This discrepancy could lead to contamination if the dishwashing machine does not reach the required temperature for sanitization. Furthermore, during a lunch service, the temperatures of fortified shakes and yogurt were taken incorrectly by touching the thermometer to the outside of the containers instead of inserting it into the food, contrary to the facility's policy. The facility also failed to monitor refrigerator temperatures adequately, as logs showed only one temperature check per day, despite the policy requiring checks once on the day shift and once on the night shift. This lack of monitoring could result in food spoilage if the refrigerators do not maintain the appropriate temperature. These deficiencies collectively indicate a failure to store, prepare, distribute, and serve food in accordance with professional standards, potentially placing residents at risk for foodborne illness.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Diltiazem HCl Oral Tablet 30 MG. The medication was prescribed to be given three times a day with specific parameters to monitor blood pressure and heart rate, holding the medication if systolic blood pressure was less than 110 or heart rate was less than 60 bpm. However, the medication was administered outside of these parameters on multiple occasions, and there were instances where the medication administration record was left blank, indicating potential missed doses. The resident involved was a female with a history of paroxysmal atrial fibrillation and essential hypertension, conditions that require careful management of heart rate and blood pressure. The resident's medical records showed several instances where the medication was given despite blood pressure readings being outside the prescribed parameters, and there were also times when the blood pressure was not documented at all. This inconsistent medication administration could have contributed to the resident's hospitalization for atrial fibrillation with rapid ventricular rate. Interviews with facility staff, including the Assistant Director of Nursing and a registered nurse, confirmed the discrepancies in medication administration. The staff acknowledged that the medication was given outside of the prescribed parameters and that this practice was unacceptable. The facility's policy on medication administration emphasized the importance of administering medications as ordered by the physician and documenting vital signs accurately, which was not adhered to in this case.
Failure to Implement Food Storage Policy in Resident Refrigerators
Penalty
Summary
The facility failed to implement a policy regarding the use and storage of foods brought to residents by family and other visitors, leading to unsanitary conditions in personal refrigerators for several residents. Resident #29's refrigerator was found to be dirty with old and brown-colored food debris, which was confirmed by both the resident and LVN O. Despite the nurse's responsibility to check and clean the refrigerators, the debris was not cleaned due to the nurse being busy. The Director of Nursing (DON) confirmed that the refrigerator should have been cleaned to prevent potential food-borne illness. Resident #228 had undated soup with rice in his personal refrigerator, which was brought by his wife. The resident forgot to consume it, and the assigned nurse, LVN A, acknowledged that the undated food should have been discarded by the nursing staff. The Assistant Director of Nursing (ADON) G, responsible for overseeing personal refrigerators, confirmed the risk of food-borne illness from consuming undated food. Similarly, Resident #2's refrigerator had a broken door, causing improper closure and water leakage, along with an unlabeled and undated opened food container. The ADON RN I confirmed these issues and acknowledged that the facility nurses should have labeled and dated opened foods. Resident #100's refrigerator contained undated fried chicken brought by a friend, and the resident could not recall when it was brought. LVN A confirmed that the undated food should have been discarded. ADON G reiterated the risk of food-borne illness from undated food. Lastly, Resident #4's refrigerator contained expired foods, including Danishes and brownies, which were brought by a family member. LVN S confirmed that nursing staff should have checked and disposed of expired foods to prevent illness. The facility's policy required routine checks of personal refrigerators to ensure safe food storage, which was not adequately followed, leading to these deficiencies.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents received services with reasonable accommodation of their needs, specifically regarding the placement of call lights. Two residents were affected by this deficiency. Resident #4, who has moderate cognitive impairment and requires assistance with all activities of daily living (ADLs) except eating, was observed with her call light out of reach and out of sight, placed on top of the nightstand behind her. This was confirmed by LVN S, who acknowledged that the call light should have been within Resident #4's reach as she regularly used it to request assistance. Similarly, Resident #49, who has severe cognitive impairment and requires substantial assistance with ADLs, was observed with her call light pinned to her bed cover, making it inaccessible while she was seated in her wheelchair. CNA W confirmed that the call light was not within reach and adjusted its placement. Interviews with the ADON and DON revealed that all staff were responsible for ensuring call lights were within reach, and the facility's policy emphasized the importance of timely response to call lights and their placement within easy reach of residents.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care documentation. For one resident, the Quarterly MDS assessment did not reflect the therapeutic diet prescribed, despite the resident being on a regular soft and bite-sized diet with large protein portions due to conditions like type 2 diabetes mellitus, dysphagia, and protein-calorie malnutrition. The MDS coordinator acknowledged the error, stating the importance of accurate MDS assessments for care provision and billing purposes. Another resident's discharge MDS assessment inaccurately recorded the discharge status as to a short-term general hospital, while the resident was actually discharged to home with home health services. This discrepancy was confirmed by the MDS RN and LVN, who admitted the mistake and indicated the need for modification. The facility's policy and CMS MDS 3.0 Manual emphasize the necessity of accurate resident assessments, which were not adhered to in these cases.
Inaccurate PASRR Screening for Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment. Specifically, the PASRR Level I assessment for a resident did not accurately capture the resident's diagnosis of mental illness. The resident, a female admitted to the facility with diagnoses including Post Traumatic Stress Disorder (PTSD), had a PASRR Level I screening that incorrectly indicated no evidence of mental illness. This oversight was acknowledged by the MDS Coordinator, who stated that the resident's PASRR screening should have been marked as positive. Additionally, the Director of Nursing (DON) admitted to overseeing PASRRs and monitoring them at random, which may have contributed to the missed assessment. The facility's policy on comprehensive assessments emphasizes coordination to maximize the resident assessment process, yet the failure to accurately complete the PASRR Level I assessment for the resident with PTSD indicates a lapse in this process. The resident risked missing out on potential services due to the inaccurate PASRR screening.
Failure to Provide Adequate ADL Care for a Resident
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADL) to a resident with severe cognitive impairment and dependency on staff for all ADLs. The resident, who had a traumatic brain injury and other medical conditions, was observed with long fingernails, dry patches on the face, and cracked lips with residue. These observations were made over several days, indicating a lack of consistent personal and oral hygiene care by the nursing staff. Interviews with staff, including a charge nurse and an occupational therapist, revealed that the resident was not well-groomed and that the responsibility for ADL care was assigned to the CNAs. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the nursing staff was responsible for maintaining the resident's grooming, including cutting nails. However, the DON stated she had not observed the resident's poor condition, suggesting a lack of oversight and communication among the staff.
Incorrect Water Flush Rate for Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was provided with the appropriate treatment and services to prevent complications. Specifically, the facility did not administer the correct rate of water flush as prescribed by the physician for a resident with a gastrostomy tube. The resident, who had intact cognition, was supposed to receive a water flush of 275 milliliters every four hours, as per the physician's order. However, observations revealed that the water flush was set to 175 milliliters every four hours, which was confirmed by the LVN responsible for the resident's care. The LVN admitted to not checking the physician's order due to nervousness, leading to the incorrect setting of the water flush rate. The Director of Nursing confirmed that the resident should have received the prescribed 275 milliliters of water flush every four hours. This oversight could potentially lead to dehydration, as the resident was not receiving the proper hydration requirements as prescribed.
Improper Storage and Dating of Nebulizer Mask
Penalty
Summary
The facility failed to provide proper respiratory care for a resident, specifically in the management of a nebulizer mask. The resident, who had a history of asthma and other medical conditions, was observed with a nebulizer mask that was not properly stored or dated. The mask was found on the nightstand without being bagged, and there was no indication of when it was last changed. This oversight was confirmed by both the resident and a Licensed Vocational Nurse (LVN), who acknowledged that the mask should have been covered and dated according to facility policy. Interviews with the LVN and the Director of Nursing (DON) further confirmed that the facility's policy required nebulizer masks to be changed weekly and stored in a plastic bag when not in use. The lack of proper storage and dating of the nebulizer mask could potentially lead to respiratory infections, as noted by the staff. The facility's policy on respiratory equipment management, revised in January 2022, mandates weekly changes and proper storage of respiratory tubing and equipment, which was not adhered to in this instance.
Failure to Periodically Assess Bed Rail Safety
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of residents using bed rails, which could lead to potential safety risks such as entrapment. Specifically, two residents, identified as Resident #4 and Resident #33, were not periodically assessed for the risk of entrapment from bed rails as per the facility's policy. Resident #4, who has a history of aphasia following cerebral infarction and moderate cognitive impairment, was observed using side rails for repositioning and assistance during care. However, the last documented consent for side rail use was dated over a year prior, and the side rail review tool was last updated several months before the observation. Resident #33, diagnosed with muscle wasting, atrophy, lack of coordination, and dementia, also used side rails as an enabler. Despite her moderate cognitive impairment and dependency on staff for daily activities, her consent for side rail use was dated several years prior, with the last update to the side rail review tool occurring months before the observation. Interviews with staff, including the ADON and DON, revealed inconsistencies in the understanding and implementation of the facility's policy regarding the frequency of side rail assessments, with some staff unsure of the specific timeframe for updates. The facility's policy on restraints and entrapment risk emphasizes the need for informed consent, regular assessments, and monitoring to ensure resident safety and prevent the use of restraints as a convenience. However, the lack of periodic assessments and unclear guidelines on assessment frequency contributed to the deficiency, potentially affecting any resident using side rails and increasing the risk of entrapment incidents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly secured for a resident, leading to a deficiency in medication storage practices. Specifically, a bottle of Ciprofloxacin ophthalmic eye drops was observed on the bedside table of a resident who did not have an order to self-administer medications. The resident, who had intact cognition as indicated by a BIMS score of 15, confirmed that the nurse had left the eye drops for him to use after breakfast. However, there was no documented order or assessment allowing the resident to self-administer the medication. Interviews with the LVN responsible for the resident and the Director of Nursing (DON) revealed that the LVN had left the medication on the nightstand without a self-medication assessment or a signed physician order. The DON acknowledged that this practice was against the facility's policy, which requires a self-medication review by the clinical team if a resident wishes to self-administer medication. The facility's policy, revised in January 2023, emphasizes the need for such assessments to prevent residents from taking more than the prescribed dosage.
Failure to Follow Menu and Update Residents on Meal Changes
Penalty
Summary
The facility failed to adhere to the planned menu for residents on regular and modified diets during a lunch meal. On the specified date, the menu was supposed to include lemon pepper chicken, buttered corn, and roasted broccoli. However, the facility served mixed vegetables and rice instead of corn and broccoli, and a resident's meal tray lacked protein. This deviation from the menu was not communicated to the residents, and the menu displayed was not updated to reflect the changes. A resident, who was at risk for nutritional deficits due to muscle wasting, atrophy, and mild protein-calorie malnutrition, did not consume the meal provided because it did not include the items he preferred and expected based on the posted menu. The resident expressed dissatisfaction with the meal provided, which led to him being offered peanut butter and jelly sandwiches as an alternative. Interviews with staff revealed that the kitchen ran out of corn and broccoli, and the Certified Dietary Manager (CDM) was aware of the shortage but did not update the menu. The Registered Dietitian (RD) confirmed the importance of updating the menu to ensure residents are informed and can adjust their meal choices accordingly.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to accommodate the dietary needs and preferences of two residents, leading to deficiencies in their care. Resident #79, who was at risk for nutritional deficits due to muscle wasting and mild protein-calorie malnutrition, did not receive an appropriate protein source during a lunch meal. Despite having a documented dislike for chicken, the resident was served a meal without any protein, and the staff incorrectly identified greens as a protein source. The resident expressed that he had not received a proper protein for a long time, and the dietary manager admitted difficulty in finding suitable protein options for him. Resident #35, who had a documented allergy to fish and seafood, was served fish for lunch, contrary to her medical record and cardiology prescription. Despite her moderate cognitive impairment, she was aware of her dietary restrictions and expressed frustration when served fish. The dietary staff and nursing staff failed to update her meal ticket to reflect her allergy, and the registered dietitian had not reviewed her cardiologist's note regarding her dietary needs. The resident's main entree was removed after she refused to eat the fish, highlighting a lapse in communication and adherence to dietary protocols. The facility's policies on menu substitutions and honoring food preferences were not followed, contributing to these deficiencies. The policy stated that menus should be served as planned unless an emergency arises, and substitutions should ensure a well-balanced meal. However, the facility did not adhere to these guidelines, resulting in inadequate nutrition and potential health risks for the residents involved.
Infection Control Breach in EBP Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving residents under Enhanced Barrier Precautions (EBP). In the first incident, a Licensed Vocational Nurse (LVN) entered the room of a resident with multiple medical conditions, including muscle wasting, type 2 diabetes, and a pressure ulcer, without donning a gown as required by EBP protocols. The LVN applied a cream to the resident's legs, which had skin abrasions, without wearing a gown, potentially risking contamination. The LVN later acknowledged forgetting to wear a gown due to nervousness, and the Director of Nursing (DON) confirmed the breach in protocol. In the second incident, the Assistant Director of Nursing (ADON) entered the room of another resident, who had a traumatic brain injury and was on EBP due to a gastrostomy tube, without washing or sanitizing her hands or wearing a gown. The ADON handled the resident's G-tube without following proper hand hygiene or gowning procedures, despite the posted EBP sign on the resident's door. The ADON admitted to not being sure about the gown requirement and acknowledged the importance of following EBP and hand hygiene to prevent cross-contamination. Both incidents highlight the facility's failure to adhere to its own infection prevention and control policies, specifically regarding the use of gowns and hand hygiene during high-contact resident care activities. The facility's policy, revised in April 2024, clearly outlines the need for gloves and gowns during such activities, yet these protocols were not followed, potentially placing residents at risk for infections.
Failure to Use Assistive Device During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident. The resident, a cognitively intact female with a history of muscle wasting, diabetes, cognitive communicative disorder, recurrent depression, a history of a right femur fracture, hyperlipidemia, and dementia, required assistance from one or two staff members with a Total Lift for transfers. On the date of the incident, a nursing assistant (NA E) did not use the required Total Lift when transferring the resident from her bed to a wheelchair, despite the resident's request to use the lift. Instead, NA E used a gait belt and transferred the resident alone, resulting in the resident experiencing pain in her right ankle. The resident reported hearing and feeling a pop in her right ankle during the transfer, and subsequently experienced pain rated at 10/10. An x-ray was ordered, which revealed no fracture. Interviews with other staff members confirmed that the resident's care plan and Kardex indicated the need for a Total Lift during transfers. The Director of Nursing (DON) revealed that NA E admitted to not using the Total Lift because it was faster, despite being trained and in-serviced on safe transfer equipment and resident safety. NA E's competency records showed she had completed training on safe lift and movement, fall prevention, and accessing the Kardex for safety needs.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident diagnosed with Alzheimer's Disease. On two separate occasions, the resident was found outside the facility without supervision. The first incident occurred when the resident was found outside the front doors of the facility, and the second incident happened when the resident was found outside the building in the late evening. Both incidents were not properly documented or reported as elopements, and no new interventions were implemented after the first incident. The resident's care plan indicated that she was at risk for elopement and wandering due to her Alzheimer's Disease. Despite this, the facility did not have adequate measures in place to prevent her from leaving the premises. The front doors of the facility were not locked until 8:00 PM, and there was no locked or memory care unit to provide additional security. Staff interviews revealed that the incidents were not considered elopements, and no elopement assessments or incident reports were completed. The facility's failure to provide adequate supervision and implement appropriate interventions placed the resident at risk of harm. The facility's elopement response policy was not followed, and staff were not adequately trained on elopement prevention. The facility's administration was not fully aware of the incidents, and there was a lack of communication and proper documentation regarding the resident's elopement risk and incidents. This deficiency led to the identification of Immediate Jeopardy, which was later removed after corrective actions were implemented, but the facility remained out of compliance due to incomplete staff training on elopement prevention.
Removal Plan
- Staff immediately re-directed resident #1 from the community's porch, sidewalk area and nursing assessed Resident #1. There were no negative outcomes identified.
- Front entrance lock pad system activated by [company name] to continuously require a code to get in or out at all times.
- Director of Nursing/Designee initiated in-service training to all licensed nurses and direct care team members on utilizing/accessing the Kardex Plan of Care system to identify residents who are at risk for elopement/wandering.
- Director of Nursing / Designee to conduct retraining for all team members as well as agency staffers (nurses/CNAs) prior to assuming next shift. DNS/Designee will ensure that all newly hired team members receive the training as part of the onboarding.
- The 3 residents identified to have a high risk for elopement in the community were provided with a watch like bracelet to identify the risk for wandering/elopement. In-service initiated by Director of Nursing/SW/Designee to all team members on the watch like bracelet placed on residents to identify the risk for wandering and elopement.
- Resident #1 placed on a one to one monitoring to maintain safety.
- Resident #2 placed on q15 minute monitoring to maintain safety.
- Resident #3 placed on q15 minute monitoring to maintain safety.
- Nursing/IDT will continue to monitor resident to ensure resident's safety and wellbeing.
- Nursing notified MD (PCP) and family representative of incident and resident's status.
- VP of Clinical Operations and VP of Operations conducted in-service training to the identified Director of Clinical Operations, Director of Nursing and Administrator regarding identifying and responding to exit seeking and elopement risk or events, implementing appropriate interventions; thus, ensuring the residents' safety and well-being.
- VP of Clinical Operations and VP of Operations conducted in-service training to the identified Director of Clinical Operations, Director of Nursing and Administrator regarding: Missing Person & Elopement / Exit Seeking Response. Additional education provided reviewed the process for reviewing the TXHHSC PL for reporting criteria of missing resident/elopement in order to ensure compliance with state and federal regulations: Preventing, Identifying and Reporting Abuse and Neglect, Facility's process for identifying potential risks of elopement; implementing appropriate interventions and updating the plan of care as indicated.
- Administrator/Social Worker/Director of Nursing/Designee will conduct in-service training to all staff prior to their next shift training regarding: Identifying and responding to missing person, exit seeking and elopement risk and/or incidents, and ensuring that appropriate interventions are implemented to ensure the residents' safety and well-being.
- Director of Nursing/Designee will conduct an audit of all recent new admissions and readmission, reviewing the exiting seeking assessment in order to identify any concerns with exiting seeking or elopement risks and the IDT will review the plan of care to ensure it appropriately reflects potential elopement/exit seeking risks and/or will update the plan of care as indicated.
- Administrator/Social Worker/Director of Nursing/Designee will conduct staff and resident interviews to identify any concerns of exiting seeking / elopement behaviors. If identified the IDT will review the plan of care and/or will update the plan of care as indicated in order to ensure it appropriately reflects potential exiting seeking / elopement risk noted.
- Director of Nursing / Assistant Director of Nursing conducted re-education to the IDT and all licensed nurses regarding the RAI process to include but not limited to completion of a resident centered comprehensive care plan on each resident regarding services to attain or maintain the resident's highest practical level of physical, mental, and psychosocial well-being.
- Director of Nursing / Designee to conduct retraining for all team members as well as agency staffers (nurses/CNAs) prior to assuming next shift. DNS/Designee will ensure that all newly hired team members receive the training as part of the onboarding.
- Director of Nursing / Designee conducted in-service training to all licensed nurses as well as agency staffers (nurses) prior to assuming next shift. DNS/Designee will ensure that all newly hired nurses receive the training as part of the onboarding.
- Ad Hoc QAPI held with Administrator, Director of Nursing and Medical Director to review the concerns and plan of removal implemented.
- ADMIN/DNS/SW/ Designee will conduct random daily rounds on various shifts to validate the safety and well-being of our residents.
- Director of Nursing/Designee will conduct random weekly audits of 1-3 new admission and/or readmissions' initial care plans and comprehensive care plans in order to validate the accuracy of the care plan by ensuring identified elopement risk are noted in the plan of care and appropriate interventions are in place.
- Director of Nursing/Designee will audit and review progress notes, changes in conditions, risk management reports and the nursing 24 hr. report daily during the morning clinical meeting in order to validate appropriate follow up and necessary interventions are in place accordingly.
- Administrator/Director of Nursing/Designee will conduct Elopement / Missing Person Response Drills on random shifts to identify competency of TMs or to identify additional education needs.
- This plan will remain in place and findings will be reported to the QAPI committee during monthly meeting. The QAPI committee will then determine compliance or identify a need for additional training.
Failure to Administer Medications on Admission
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident, resulting in multiple missed doses of critical medications. Specifically, the resident did not receive Amiodarone, Alprazolam, Latanoprost, Gemtesa, and Loratadine on various dates. The resident's medical history included type 2 diabetes, paroxysmal atrial fibrillation, and acute on chronic combined systolic and diastolic heart failure. The missed doses were due to the medications not being available upon the resident's admission and the failure of the LVN to access the emergency medication kit or seek assistance from other nurses who had access to it. The resident was admitted to the facility from a hospital without medications on hand. The LVN on duty submitted the prescription to the contracted pharmacy but did not see the delivery of the medications, resulting in the resident not receiving the medications on time. The Director of Nursing (DON) confirmed that the facility maintained an emergency kit of medications that nurses could access in such instances, but the LVN did not utilize this resource or contact other nurses for assistance. Interviews with the DON, the Director of Clinical Operations (DCO), and the Administrator confirmed that the LVN's actions were against protocol. The emergency medication kit inventory showed that some of the required medications were available, but the LVN failed to access them. The facility's policy on medication administration emphasized the importance of administering medications accurately, safely, and timely, which was not adhered to in this case.
Failure to Address Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat residents with dignity and respect, as observed in the interactions of LVN A with three residents. LVN A addressed the residents using terms of endearment such as 'honey' and 'sweetheart' instead of their preferred names. This behavior was observed during visits to the rooms of three residents, all of whom had varying degrees of cognitive function. Resident #1, with intact cognition, was addressed as 'honey.' Resident #2, also with intact cognition, was addressed as 'honey' and 'sweetheart.' Resident #3, who was moderately cognitively impaired, was addressed as 'honey.' These observations were made on the same day during different times in the morning. During an interview, LVN A admitted to using terms of endearment and acknowledged that not using the residents' preferred names could diminish their respect and dignity. The Director of Nursing (DON) confirmed that LVN A should not be using such terms to address the residents, emphasizing that it was a respect and dignity issue. The report highlights that this failure could affect residents by making them feel uncomfortable and disrespected, thus failing to protect and promote their rights.
Failure to Report Elopement Incidents
Penalty
Summary
The facility failed to report incidents of elopement involving a resident with Alzheimer's Disease to the appropriate authorities within the required timeframe. On two separate occasions, the resident was found outside the facility, but these incidents were not reported to the Administrator or the State Survey Agency as required by law. The first incident occurred on 02/25/2024, when the resident was found outside the front doors of the facility. The second incident occurred on 04/28/2024, when the resident was again found outside the facility in the evening. Despite these occurrences, the facility staff did not report these incidents as potential neglect to the Administrator or the State Survey Agency. Interviews with staff and record reviews revealed that the facility did not have adequate measures in place to prevent the resident from eloping, especially during times when the front doors were not magnetically locked. The Director of Nursing (DON) and other staff members were aware of the incidents but did not consider them as elopements or potential neglect, and thus did not report them. The Administrator was only aware of the second incident and did not report it to the State Survey Agency, believing it did not meet the criteria for neglect as the resident was found on the sidewalk and not in the parking lot. The facility's failure to report these incidents as required could affect any resident with a high risk for wandering or elopement. The lack of reporting and subsequent investigation into these incidents of elopement indicates a deficiency in the facility's adherence to regulatory requirements for reporting potential neglect. This deficiency could result in similar incidents not being properly investigated or addressed, potentially compromising resident safety.
Failure to Administer Critical Medications Upon Admission
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, Resident #4 did not receive several critical medications, including Amiodarone, Alprazolam, Latanoprost, Gemtesa, and Loratadine, upon admission. The resident, who had a history of type 2 diabetes, paroxysmal atrial fibrillation, and heart failure, was admitted without these medications being administered as ordered by the physician. The medications were not provided until several days after admission, which could have posed a significant risk to the resident's health. The deficiency was identified through a combination of record reviews, observations, and interviews. The resident's medication administration record indicated that the medications were not administered on the dates they were ordered. Interviews with the Director of Nursing (DON) and the Licensed Vocational Nurse (LVN) who admitted the resident revealed that the medications were not available initially and that the LVN did not access the facility's emergency medication kit or seek assistance from other nurses to obtain the medications. Further investigation showed that the facility's emergency medication kit did contain some of the required medications, but the LVN failed to utilize it. The DON confirmed that this was against the facility's protocol and expectations. The facility's policy on medication administration emphasized the importance of administering medications accurately, safely, and timely, which was not adhered to in this case.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection control program, as evidenced by the actions of LVN A during wound care for Resident #14. LVN A prepared wound care supplies and left them unattended in the resident's room, covered only with wax paper. This action posed a risk of cross-contamination. Additionally, during the wound care procedure, LVN A used a single wet gauze to clean the resident's wound, wiping from the top of the wound through to the bottom, which further increased the risk of cross-contamination. Resident #14 had a complex medical history, including acute respiratory failure with osteomyelitis of the vertebra, malignant neoplasm of the thymus, intraspinal abscess, and granuloma. The resident also had an indwelling catheter and ostomy and was cognitively intact. The Director of Nursing (DON) confirmed that LVN A's actions were inappropriate and acknowledged the potential for cross-contamination during wound care.
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.
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What surveyors actually found near you
We read the 1,017 citations issued within 25 miles in the last 12 months — including the 22 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stone Oak Care Center | 1.1 mi | ★★★★★ | 9 | 0 |
| Sonterra Health Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Coronado At Stone Oak | 1.6 mi | ★★★★★ | 2 | 0 |
| San Antonio Wellness & Rehabilitation | 4.9 mi | ★★★★★ | 4 | 0 |
| Castle Hills Rehabilitation And Care Center | 5.9 mi | ★★★★★ | 52 | 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.