Average — CMS composite of the measures below.
The next survey window likely opens 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 Harrison At Heritage during CMS and state inspections, most recent first.
A resident with an open right elbow lesion and diagnoses including repeated falls and rhabdomyolysis had a physician order and care plan for daily-shift wound care with cleansing and dry dressing. Review of treatment records showed that the ordered elbow treatment was not documented on multiple weekend days, and the resident reported not receiving treatments on weekends. The weekday WCN stated she completed all treatments during the week and relied on charge nurses to perform weekend wound care, with only a brief Friday meeting for communication and no follow-up when dressings were found missing. An LVN caring for the resident on one of the missed days acknowledged not performing elbow treatment and was unaware of the order, while leadership staff, including the former DON, ADON, administrator, and weekend supervisor, each described that charge nurses were responsible for weekend wound care but confirmed there was no active verification of treatment administration records, despite a facility policy requiring wound treatments to be provided and documented per MD orders.
Two residents did not have full visual privacy due to incomplete or improperly installed bed curtains. One resident's curtain only partially covered the bed, and another's left the foot of the bed exposed. Staff were unaware of the deficiency and had not reported it, and there was no specific policy addressing privacy curtains.
A resident was prescribed PRN Alprazolam for anxiety without a required 14-day stop date, contrary to facility policy. The medication order was entered after hospital readmission, but neither the admitting nurse nor subsequent reviews by the DON and ADON ensured compliance with the 14-day limitation. The resident's care plan did not reflect the use of this medication, and no doses were administered during the review period.
A resident with end-stage renal disease receiving regular dialysis did not have her dialysis treatment accurately coded in the MDS assessment, despite documentation and interviews confirming her ongoing treatment. The MDS Coordinator acknowledged missing this information, and the DON confirmed the expectation for accurate and timely assessments.
A resident with multiple fractures and functional limitations was not provided with a comprehensive care plan that included the use of a back brace and bilateral foot protectors, despite these being necessary interventions. Staff interviews revealed uncertainty about care planning responsibilities, and the omission was not identified until the survey, contrary to facility policy requiring all assessed needs and interventions to be care planned.
A resident admitted with a back brace and bilateral foot protectors did not have physician orders for these devices, despite their use being confirmed by the resident and staff. The care plan did not address the use of the braces, and staff interviews revealed uncertainty about the existence of necessary orders. The deficiency was identified when it was found that required physician orders had not been obtained or documented in accordance with facility policy.
A resident with severe cognitive impairment and a history of stroke received tube feedings at a rate higher than the physician-ordered 55 ml/hour, with staff administering 60 ml/hour and failing to update or clarify the order in the system. Nursing staff and management acknowledged the discrepancy, and facility policy required adherence to physician orders for enteral nutrition administration.
Two residents receiving dialysis did not have physician orders in place for their dialysis treatments or for pre- and post-dialysis vital sign monitoring, despite care plans indicating the need for such care. Staff interviews and record reviews confirmed the absence of these orders, and management was unaware until an audit revealed the deficiency.
A nurse prepared morning thyroid medications for a resident with severe cognitive impairment but left the medication cup unattended on a hallway handrail after being distracted by another resident. The nurse failed to return and administer the medications, which were later found by another nurse. This incident resulted in the resident missing prescribed doses and violated facility policy requiring proper medication administration and observation.
A resident with moderate cognitive impairment and a history of anxiety and stroke was found with a call light cord around his neck after expressing suicidal statements. Staff intervened, removed potential hazards, and arranged for psychiatric evaluation, but the incident was not reported to the State agency as required by facility policy.
A resident with moderate cognitive impairment and a history of anxiety and stroke was found with a call light cord around his neck, expressing suicidal ideations. Staff intervened promptly to ensure safety and arranged for psychiatric evaluation, but the required reporting of the incident to the State Survey Agency was not completed as mandated by facility policy and state law.
A nurse failed to treat a resident with dignity and respect by raising her voice and scolding the resident for repeatedly using the call light, despite the resident's severe cognitive impairment and need for assistance. Video evidence and interviews confirmed the nurse's inappropriate behavior, which did not align with the facility's policy on resident rights and respectful treatment.
Staff failed to wear required gowns while providing direct care to a resident on enhanced barrier precautions, despite clear signage and policy. Interviews revealed gaps in staff knowledge and training, and records showed the involved staff had not attended EBP training.
A resident was transferred to the hospital without receiving written notification of the transfer, reasons, or appeal rights, and the Ombudsman was not informed. The resident, with intact cognition, was transferred due to altered mental status, but no written documentation was provided. Facility staff were unaware of the requirement for written notices, despite policy guidelines.
A resident requiring substantial assistance for transfers was left unsupervised in a mechanical lift by a CNA who failed to obtain the required assistance from another staff member. The resident, with intact cognition and multiple diagnoses, was left suspended in the lift sling while the CNA sought help, contrary to the facility's policy requiring two staff members for such transfers.
The facility failed to ensure accurate narcotic logs and remove expired medications, leading to discrepancies in medication counts for several residents. Nurses admitted to not signing off on narcotic administration records, and expired medications were found in the Central Supply cabinet. The ADON and DON acknowledged the importance of proper documentation and oversight but lacked evidence of recent corrective actions.
The facility failed to provide palatable and appetizing food during a lunch meal, with observations revealing flavorless pureed vegetables and bland grilled chicken. Despite resident feedback indicating food was often cold and tasteless, the Dietary Manager and Regional Dietitian reported no prior complaints. The facility's policy on maintaining appetizing food was not followed.
The facility failed to properly label and date food items in the freezer and refrigerator, risking food contamination. Additionally, the ice machine in the 300-hall nutrition room had a brown substance on a flap touching the ice, indicating a lack of cleanliness. These deficiencies could lead to foodborne illnesses among residents.
A facility failed to update a resident's care plan to reflect current diet orders, leading to a mismatch between the care plan and the actual diet provided. The resident, with severe cognitive impairment and multiple health issues, had a diet order that was not accurately documented in the care plan. Staff interviews revealed a lack of communication and responsibility in ensuring care plans matched diet orders, despite the facility's policy requiring such updates.
A resident with multiple health conditions was not provided with scheduled showers, resulting in a disheveled appearance and soiled bedding. Staff interviews revealed a lack of documentation and accountability for the resident's hygiene care, despite facility policies requiring consistent care and documentation. This failure placed the resident at risk of infection.
A facility failed to ensure proper labeling of IV medication bags and tubing for a resident, leading to potential medication errors. The resident, who was receiving IV medication through a PICC line, had unlabeled IV bags and tubing, contrary to facility policy. An LVN admitted to not labeling the equipment despite being aware of the requirement, and the DON confirmed the expectation for labeling to prevent errors.
A facility failed to maintain accurate clinical records for a resident regarding catheter care. Despite orders to discontinue the catheter, progress notes inaccurately documented its presence. Observations and interviews confirmed the absence of a catheter, highlighting discrepancies in documentation. The facility's policy requires accurate records, which was not followed, potentially leading to miscommunication about the resident's care.
A resident with chronic pain and opioid dependence was not allowed to choose a new pain management provider despite expressing dissatisfaction with the current NP. The resident reported his concerns to an LVN, but facility policy was cited as a barrier to changing providers. The interim DON and administrator were aware of the issue but did not take timely action, leading to a deficiency in honoring the resident's rights.
A resident with a history of dementia and other medical conditions was left unsupervised in 96-degree heat for about two hours, resulting in unresponsiveness, second-degree burns, and heat stroke. The facility failed to implement a comprehensive care plan addressing the resident's behavior of wanting to sit outside, leading to severe consequences.
A resident with a history of dementia and other medical conditions was left unattended in 96-degree heat for about two hours, resulting in unresponsiveness, second-degree burns, and heat stroke. Despite being cautioned about the heat, the resident was left unsupervised on the patio, leading to hospitalization. The facility failed to document staff checks or interventions, highlighting a lack of supervision and adherence to care plans.
A facility failed to secure medications properly, leading to a deficiency in medication storage practices. An LVN left a resident's IV and injection medications unattended on a medication cart in the hallway, with the cart unlocked and accessible to unauthorized individuals. The resident required insulin and IV antibiotics for conditions including cellulitis and diabetes. The DON and ED confirmed that the facility's policy mandates securing medications in locked carts, which was not followed in this instance.
A medication cart in the facility was left unlocked and unattended by an LVN, allowing two residents to pass by it. The LVN admitted the cart should have been locked to prevent unauthorized access. Interviews with the DON and ED confirmed the expectation for carts to be locked at all times, but the facility could not provide a specific policy on medication security.
A resident with cognitive impairment and an unsteady gait was left alone in her room by a hospice aide, resulting in a fall that caused multiple lacerations and a wrist injury. Despite being identified as a high fall risk and having specific care plan interventions, the resident was not adequately supervised, leading to the incident.
Failure to Provide and Document Ordered Wound Care on Weekends
Penalty
Summary
The deficiency involves the facility’s failure to provide wound treatment to a resident’s right elbow as ordered by the physician and as outlined in the care plan. The resident was admitted in April with diagnoses including repeated falls and rhabdomyolysis. The physician’s order, effective mid-April, directed that the right elbow wound be cleansed with normal saline or skin cleanser, patted dry, and covered with a dry dressing every day shift. The resident’s care plan identified an open lesion on the right elbow and included an intervention to perform treatments per order. However, review of the Wound Care Treatment Administration Record for April showed that the ordered elbow treatment was not documented as provided on three specific dates. During observation and interview, the resident was found in bed wearing a long-sleeved shirt and was unsure of the exact frequency of her elbow treatments, stating that the wound care nurse (WCN) performed treatments during the week but that she did not receive treatments on weekends. The WCN confirmed she worked Monday through Friday and completed all resident treatments on weekdays, while charge nurses were responsible for treatments on weekends. The WCN stated there was a Friday meeting to communicate with weekend staff about treatments but no other communication, and acknowledged that she sometimes found dressings missing on Mondays without following up with weekend staff. She also stated that all staff had access to the treatment cart and that completion of treatments should be documented on the wound care treatment administration record. Interviews with other staff revealed inconsistent understanding and oversight of weekend wound care responsibilities. An LVN who cared for the resident on one of the missed-treatment dates reported he did not provide any elbow treatment, was unaware of the elbow treatment order, and stated that on weekends responsibility for treatments varied based on informal staff decisions and conversations. The previous DON and ADON both stated they were not aware that treatments were not being completed on weekends; the ADON reported she had not recently reviewed treatment administration records. The administrator and weekend supervisor each stated that charge nurses were responsible for completing wound care on weekends, and the weekend supervisor acknowledged she did not check treatment administration records to ensure completion. The facility’s wound treatment management policy required that wound treatments be provided in accordance with physician orders and documented on the treatment administration record, which did not occur for this resident on the identified dates.
Failure to Provide Full Visual Privacy Due to Inadequate Bed Curtains
Penalty
Summary
The facility failed to ensure that each bed had ceiling-suspended privacy curtains that provided total visual privacy for two residents. Observations revealed that one resident's curtain only partially covered his bed, leaving more than half exposed, and the resident expressed concern about being seen during incontinence care. The curtain had been insufficient since the resident's admission. Another resident's curtain separated his bed from his roommate but left the foot of the bed exposed, and staff interviews confirmed that privacy was not fully maintained during care. Staff, including CNAs, housekeeping, and maintenance, were unaware of the need for additional or adjusted curtains and had not reported the issue. The DON confirmed that privacy curtains should provide full coverage and that staff were responsible for notifying the appropriate departments if curtains needed to be changed or installed. There was no specific policy addressing privacy curtains, only a general policy on maintaining a safe and homelike environment.
PRN Psychotropic Medication Ordered Without Required 14-Day Stop Date
Penalty
Summary
A deficiency occurred when a resident was prescribed a PRN psychotropic medication, Alprazolam, for anxiety without a required 14-day stop date. The medication order was initiated upon the resident's readmission from the hospital and entered into the facility's system without specifying a stop date, as required by facility policy and regulatory guidelines. The resident's care plan did not reflect the use of this anti-anxiety medication, and medication administration records showed that the resident had not received any doses of the PRN Alprazolam during the review period. Interviews with nursing staff and the Director of Nursing (DON) confirmed that all PRN psychotropic medications must have a 14-day stop date to allow for reassessment and reevaluation of the medication's appropriateness. The admitting nurse did not ensure the stop date was included, and subsequent checks by the DON and ADON did not identify the omission. The facility's policy clearly stated the requirement for a 14-day limitation on PRN psychotropic orders unless specifically extended by the prescriber, but this was not followed in this instance.
Failure to Accurately Code Dialysis in MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident who was receiving dialysis treatment. Specifically, the MDS for a female resident with end-stage renal disease and hypertension did not indicate that she was undergoing dialysis, despite her care plan and interviews confirming that she received dialysis three times a week. The resident's care plan included multiple interventions and monitoring related to her dialysis treatment, and the resident herself confirmed her ongoing dialysis schedule and the facility's involvement in her care. Interviews with the MDS Coordinator revealed that dialysis treatment was not coded in the resident's MDS assessment due to an oversight, and the Coordinator acknowledged responsibility for the error. The Director of Nursing confirmed that MDS Coordinators are expected to complete assessments accurately and on time, and recognized that missing information in the MDS could result in incomplete capture of the resident's care needs. The facility's policy required comprehensive assessments using the current RAI, including special treatments and procedures such as dialysis.
Failure to Include Back Brace and Foot Protectors in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with a back brace and bilateral foot protectors. The resident's admission assessment documented multiple fractures, muscle weakness, and functional limitations in both upper and lower extremities, with an intact cognitive status. Despite these needs, the care plan did not address the use of the back brace or foot protectors, even though the resident required the back brace when out of bed and the foot protectors while in bed. Observations confirmed the resident was using these devices as part of his care, and interviews with the resident and staff indicated that staff assisted with their application as needed. Interviews with nursing staff, the MDS Coordinator, the Unit Manager, and the DON revealed a lack of clarity regarding responsibility for updating care plans and whether such interventions should be included. The MDS Coordinator and DON both acknowledged that the back brace and foot protectors should have been included in the care plan, as they were interventions provided by the facility. However, the omission was not identified until the survey, and the facility's policy required all services identified in the comprehensive assessment to be included in the care plan with measurable objectives and timeframes.
Failure to Obtain Physician Orders for Orthopedic Devices
Penalty
Summary
A deficiency occurred when a resident with a history of multiple fractures, including an unspecified fracture of the third thoracic vertebra and muscle weakness, was admitted to the facility with a back brace and bilateral foot protectors. The resident was cognitively intact and required the back brace when out of bed and foot protectors while in bed, as confirmed by both the resident and staff. Despite this, the resident's care plan did not address the use of these devices, and there were no physician orders for either the back brace or the foot protectors in the resident's medical record at the time of review. Staff interviews revealed that both CNAs and nurses were aware of the resident's need for the back brace and foot protectors, and assisted the resident with their use. However, staff were unsure about the existence of physician orders for these devices. The nurse assigned to the resident and the unit manager both confirmed that physician orders should have been present, but were not found in the system until the unit manager entered them during the survey process. The Director of Nursing also confirmed that physician orders were required and that it was the responsibility of the admitting nurse and nurse management to ensure all necessary orders were obtained and documented. The facility's policy required that written and/or verbal orders for immediate care and needs, including treatment and routine care orders, be obtained upon admission to allow staff to provide essential care. The absence of physician orders for the back brace and foot protectors meant that staff did not have formal guidance for their use, which was inconsistent with professional standards of practice and the facility's own policies.
Failure to Administer Tube Feeding per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via feeding tube was administered the correct feeding rate as per physician orders. The resident, a male with a history of aphasia, stroke, hemiplegia, and severe cognitive impairment, was dependent on staff for eating and required tube feedings due to dysphagia. Physician orders specified a continuous feeding rate of 55 ml/hour, but observations and interviews revealed that the resident was instead receiving feedings at a rate of 60 ml/hour on multiple occasions. Family members and staff noted the discrepancy in the feeding rate, with the feeding pump and formula bag both indicating a rate of 60 ml/hour. Nursing staff, including an LVN, acknowledged administering the higher rate and stated that there was confusion regarding whether the physician order had been updated to reflect the new rate. However, the order in the system had not been updated, and the resident continued to receive feedings at the incorrect rate. The LVN and Unit Manager both confirmed that nurses were responsible for entering and updating physician orders, and that the Unit Manager was responsible for reviewing all orders for accuracy, but these processes were not followed in this case. The Director of Nursing (DON) confirmed that the resident was receiving a feeding rate inconsistent with the documented physician order and stated that nurses were responsible for following the orders as written. Facility policy required that feeding tubes be managed according to physician orders, including the specific rate and type of feeding, and that administration be periodically evaluated for consistency with those orders. The failure to administer the feeding at the prescribed rate constituted a deficiency in care for residents receiving enteral nutrition.
Failure to Obtain Physician Orders for Dialysis Care
Penalty
Summary
The facility failed to ensure that two residents requiring dialysis had appropriate physician orders for their dialysis treatments. Both residents had documented diagnoses of end-stage renal disease and were receiving dialysis, as reflected in their care plans and through staff interviews. However, a review of their electronic health records and physician orders for multiple months revealed that there were no orders for completing dialysis or for obtaining and documenting vital signs before and after dialysis sessions. Despite the care plans outlining specific interventions related to dialysis care, such as monitoring for complications, checking the access site, and encouraging attendance at scheduled dialysis appointments, these interventions were not supported by corresponding physician orders. Nursing staff and management interviews confirmed that the admitting nurse was responsible for entering these orders, but the orders were not present in the system. Staff were unaware of the missing orders until an audit was conducted, and both the unit manager and DON acknowledged the oversight. The facility's own hemodialysis policy required detailed physician orders for dialysis, including the type and location of access, dialysis schedule, nephrologist and facility contact information, transportation arrangements, and medication or fluid restrictions. The absence of these orders meant that staff relied on care plans and communication forms but lacked the formal physician directives necessary for consistent and safe dialysis care.
Failure to Administer and Secure Medications as Ordered
Penalty
Summary
A deficiency occurred when a nurse prepared morning medications for a resident with severe cognitive impairment and multiple diagnoses, including hypertension and hypothyroidism, but failed to administer them. The nurse placed the medication cup, containing a pink and a white pill, on the hallway handrail after being distracted by another resident attempting to get out of bed. The nurse did not return to retrieve or administer the medications to the intended resident. The missed medication was discovered later by another nurse, who found the cup labeled with the resident's room number on the hallway handrail. Upon review, it was confirmed that the resident had not received her prescribed doses of Levothyroxine and Liothyronine, which were ordered for her thyroid condition. The nurse who found the medication noted that he had not been informed of any missed doses and recognized the risk posed by the unattended medication. Interviews with facility staff, including the Unit Manager and DON, confirmed that the nurse responsible for the missed administration acknowledged the error. The nurse stated that he should have returned the medication to the cart before assisting the other resident but failed to do so. Facility policy requires that medications be administered according to the six rights of medication administration and that staff observe residents taking their medications, which was not followed in this instance.
Failure to Report Incident of Resident Self-Harm Attempt
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property, for one resident reviewed for abuse and neglect. Specifically, the facility did not report an incident in which a resident was found with a call light cord wrapped around his neck, an event that met the facility's definition of an adverse event and neglect. The facility's Abuse Prohibition Protocol required immediate reporting of such incidents to the State agency and other authorities within two hours, but this was not done. The resident involved was an older male with a history of anxiety disorder, cerebral infarction, and hemiplegia, and had moderate cognitive impairment. Prior to the incident, there was no documentation or indication of suicidal ideation or behaviors in his medical record or care plan. On the day of the incident, the resident was found agitated, refused care, and wrapped the call light cord around his neck, expressing suicidal statements. Staff responded by removing the cord, notifying medical providers, and placing the resident on one-on-one supervision until he was transported to the hospital for psychiatric evaluation. Assessments showed no physical harm or marks on the resident. Interviews with staff confirmed that the resident had not previously expressed suicidal ideation and that the incident was promptly managed in terms of resident safety and medical response. However, the Administrator, who was responsible for reporting such incidents, did not report the event to the State agency, as required by facility policy and regulation. The failure to report the incident constituted a violation of the facility's abuse prevention and reporting protocols.
Failure to Timely Report Alleged Neglect and Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving neglect, including injuries of unknown source, were reported immediately, but no later than two hours after the allegation was made if the events involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. Specifically, the facility did not report an incident involving a resident who was found with a call light cord around his neck and expressing suicidal ideations. The event was not reported to the administrator and the State Survey Agency in accordance with state law and the facility's established procedures. The resident involved was an older male with a history of anxiety disorder, cerebral infarction, and hemiplegia, and had moderate cognitive impairment. Prior to the incident, there were no documented suicidal ideations or behaviors in his medical record, care plan, or hospital records. On the day of the incident, the resident was found agitated, refused care, and wrapped a call light cord around his neck while expressing a desire to die. Staff responded by removing the cord, clearing the room of potentially harmful items, and placing the resident on one-on-one supervision until he was transported to the hospital for psychiatric evaluation. No physical injuries were noted during the head-to-toe assessment. Interviews with staff confirmed that the incident was immediately addressed in terms of resident safety and medical response, but the required reporting to the State Survey Agency was not completed as per regulatory requirements. The administrator, DON, and other staff acknowledged that the administrator was responsible for reporting such incidents, and that the event was not reported because the administrator did not consider it reportable. The facility's current abuse prohibition protocol required all adverse events, including those with risk of serious injury, to be reported, but this protocol was not followed in this case.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
A deficiency occurred when a nurse failed to treat a resident with dignity and respect. The incident involved a nurse raising her voice and scolding a resident who had repeatedly used her call light. Video evidence provided by the resident's family showed the nurse entering the resident's room, speaking in a stern tone, and reprimanding the resident for her actions. The nurse was heard saying, 'I've already helped you... now why are you doing this... you've got to stop this,' and continued to question the resident in a raised voice about her use of the call light and her behavior in bed. The resident involved was an elderly female with multiple diagnoses, including cancer, Alzheimer's disease, stroke, non-Alzheimer's dementia, seizure disorder, anxiety, depression, bipolar disorder, and schizophrenia. She had a severely impaired cognitive status, as indicated by a BIMS score of 3, and required extensive assistance with activities of daily living and transfers. The care plan reflected her need for substantial support, and staff interviews confirmed that she was alert and oriented but experienced moments of confusion and forgetfulness. The resident was known to press her call light repeatedly, sometimes without recalling the reason. Interviews with staff and the resident's family confirmed the incident, with the family noting that the nurse's behavior was 'very ugly' toward the resident. Staff members who worked with the resident stated that she had not reported mistreatment, and the resident herself did not recall the incident when interviewed. The facility's policy emphasized the right of residents to be free from abuse, neglect, and mistreatment, and the incident was documented as a failure to uphold these rights for the resident involved.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident who was on enhanced barrier precautions (EBP). Observations revealed that LVN A, CNA B, and CNA C did not wear gowns while providing direct care, including skin assessments and incontinence care, to a resident with a feeding tube and severe cognitive impairment. The resident's care plan and room signage clearly indicated the need for gown and glove use during all direct care activities, as required by the facility's EBP policy. However, staff were observed wearing only gloves, despite the presence of posted instructions and available PPE supplies. Interviews with the involved staff indicated gaps in knowledge and training regarding EBP requirements. CNA B was unaware that EBP required both gown and glove use and did not recall receiving training on the subject. CNA C believed gowns were only necessary for residents with catheters and did not recall seeing the EBP sign. LVN A admitted to forgetting to wear the gown despite knowing the policy. Review of training records confirmed that these staff members had not attended the facility's EBP training. The DON confirmed the policy and acknowledged uncertainty about staff training attendance, particularly for new employees.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and the resident's representative regarding a transfer to the hospital, including the reasons for the transfer and the right to appeal. Additionally, the facility did not send a copy of the notice to the Office of the State Long-Term Care Ombudsman. This deficiency was identified for one of the three residents reviewed for discharge notices. The resident in question, a male with intact cognition as indicated by a BIMS score of 15, was transferred to the hospital due to altered mental status and other health issues. Despite the transfer, there was no documentation showing that the resident or the Ombudsman were notified in writing about the transfer or the reasons for it. The resident later reported that he was not provided with any transfer or discharge paperwork from the facility, only receiving a 30-day discharge notice upon his return. Interviews with facility staff revealed a lack of awareness regarding the requirement to provide written notices for hospital transfers. The Unit Manager stated that residents and their representatives were notified verbally, and the Administrator admitted to being unaware of the need for written forms. The facility's policy on transfers and discharges, revised in October 2022, specifies that notices should be provided in a form and manner understandable to the resident, but this was not adhered to in this case.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident requiring substantial assistance for transfers. A CNA attempted to transfer the resident using a mechanical lift without the required assistance from another staff member. During the transfer, the CNA left the resident suspended in the lift sling to seek help, leaving the resident unsupervised. This action was contrary to the facility's policy, which mandates that two staff members be present during mechanical lift transfers to ensure safety. The resident involved was a male with intact cognition, diagnosed with conditions including Type 2 diabetes, hypertension, and end-stage renal disease, requiring maximal assistance for transfers. Interviews with staff, including the CNA involved, confirmed that the procedure was not followed correctly, as two staff members are required to be present from the beginning to the end of the transfer process. The facility's policy and staff interviews highlighted the potential risks of leaving a resident unattended in a mechanical lift, such as falls or the lift tipping over, which could lead to injury.
Pharmaceutical Service Deficiencies in Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by discrepancies in narcotic logs and the presence of expired medications. On two medication carts, the narcotic administration records did not match the actual pill counts for several residents. For instance, Resident #126's narcotic log showed 20 pills remaining, while the blister pack contained only 19 pills. Similarly, discrepancies were noted for Residents #8, #21, and #66, where the narcotic logs did not align with the physical counts of medications like hydrocodone, tramadol, and oxycodone. Interviews with the nursing staff revealed that the discrepancies were due to a failure to sign off on the narcotic administration records after administering medications. LVN G admitted to administering medications to Residents #8, #21, and #66 but forgot to document it, while LVN F also failed to log the administration of tramadol to Resident #126. Both nurses acknowledged the importance of logging medications immediately to prevent errors and discrepancies, yet these lapses occurred. Additionally, expired medications were found in the Central Supply cabinet, specifically two bottles of Vitamin A with an expiry date of April 2024. The responsibility for checking and removing expired medications was shared between the nursing staff and the Central Supply Staff, but interviews indicated a lack of consistent oversight. The ADON and DON acknowledged the importance of proper documentation and regular checks to prevent medication errors and potential drug diversion, but there was no evidence of recent training or audits to address these issues.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable food during a lunch meal, as observed on 09/05/24. The planned menu included soft tacos, refried beans, shredded lettuce, diced tomato, grilled chicken, Brussels sprouts, mashed potatoes, and a brownie. During the observation, the pureed Brussels sprouts, mashed potatoes, and pureed beans were found to be without flavor, and the grilled chicken patty was colorless, bland, and flavorless. Despite these findings, the Regional Dietitian and Dietary Manager did not acknowledge any concerns with the taste of the food and reported not having received any complaints from staff about the bland taste. The Dietary Manager indicated that the cooks were responsible for the taste and presentation of the food. A confidential interview with thirteen alert and oriented residents revealed that food was typically served cold and lacked flavor, both in the dining room and on the halls, when state surveyors were not present. However, the resident council meeting minutes from June 2024 to September 2024 did not document any complaints about the food being cold or flavorless. The Dietitian and Dietary Manager also confirmed that they had not received any complaints regarding the food being cold or bland. The facility's policy on food storage emphasized keeping foods safe, wholesome, and appetizing, which was not adhered to in this instance.
Deficiencies in Food Storage and Ice Machine Cleanliness
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen and the 300-hall nutrition room. In the kitchen, food items stored in the freezer were not properly labeled or dated after being removed from their original packaging. This included bags of breaded chicken patties, meatballs, French fries, and breaded fish. The Dietary Manager acknowledged that these items were leftovers from previous meals and should have been labeled with the name of the food item and the date they were opened. Additionally, a bag of ground meat in the refrigerator was found with a date of 08/11/24 but no end date, and the Dietary Manager could not confirm how long it had been stored. The facility's policy required food items to be covered, labeled, and dated, but this was not consistently followed. In the 300-hall nutrition room, the ice machine was found to have a white flap with a brown substance on it, which was in contact with the ice. The Maintenance Director stated that a contractor cleaned the ice machine about five months ago, and he last checked it a month ago without noticing the brown substance. The DON confirmed that staff were supposed to report any dirtiness in the ice machine to the Executive Director, Maintenance Director, and DON immediately. However, the maintenance logs from July 2024 did not reflect any cleaning needs for the ice machine. These lapses in food storage and equipment cleanliness could potentially place residents at risk for food contamination and foodborne illnesses.
Failure to Update Resident Care Plan with Current Diet Orders
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which did not reflect the current diet orders. The resident, a male with severe cognitive impairment and multiple diagnoses including vascular dementia and diabetes, had a diet order that was not updated in the care plan. The care plan inaccurately listed a mechanically altered diet, while the actual diet order was a regular diet with specific restrictions such as no salt, no orange juice, and no certain fruits and vegetables. This discrepancy was observed during a meal where the resident received a tray consistent with the current diet order, but the care plan had not been updated to reflect these changes. Interviews with facility staff, including an LVN, MDS Coordinator, ADON, and DON, revealed a lack of communication and responsibility in updating the care plan to match the diet orders. The LVN acknowledged the mismatch and noted it was the ADON's responsibility to update care plans. The MDS Coordinator admitted the oversight and emphasized the importance of matching diet orders with care plans to prevent errors, especially since the resident was on dialysis. The ADON and DON both highlighted the collaborative effort required to update care plans and the potential for confusion if discrepancies exist. The facility's policy mandates that care plans must match resident orders, but staff could not recall the last in-service training on this requirement.
Failure to Provide Scheduled Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for a resident, specifically in maintaining personal hygiene. Resident #290, an elderly male with diagnoses including hypertension, hyperlipidemia, non-Alzheimer's dementia, and edema, was observed in a disheveled state with greasy hair and unshaven facial hair. His bedding was soiled with dark amber and red stains, and he reported not having received a shower since the removal of a PICC line, despite expressing a desire for one. Interviews with staff revealed a lack of clarity and accountability regarding the resident's care. CNA A, who was not directly responsible for Resident #290, was unable to confirm when the resident last received a shower or bed bath, as there was no documentation of such care since his readmission. LVN B acknowledged the resident's unkempt appearance and soiled bedding, indicating that the resident had not been showered according to the facility's schedule. The DON confirmed that CNAs were responsible for offering showers upon admission and maintaining a regular schedule, but there was no documentation of the resident refusing care. The facility's policy on activities of daily living emphasized consistent assignments and documentation, yet these were not adhered to in Resident #290's case. The lack of proper hygiene care placed the resident at risk of infection, particularly given his recent clearance from isolation for a urinary tract infection and COVID. The failure to provide scheduled showers and maintain hygiene documentation highlights a deficiency in the facility's care practices.
Failure to Label IV Medication Bags and Tubing
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, as observed during a survey. The deficiency involved a resident who was receiving IV medication through a peripherally inserted central catheter (PICC) line. The IV medication bag and tubing were not labeled with the date, time, and initials of the administering nurse, which is a requirement to ensure proper medication administration and prevent errors. This oversight was noted during an observation of the resident in her room, where an unlabeled IV bag and tubing were found hanging on the pole. Interviews with the licensed vocational nurse (LVN) responsible for administering the IV medication revealed that she was aware of the requirement to label the IV bag and tubing but failed to do so. The LVN acknowledged that not labeling the bag and tubing could lead to medication errors, such as overdose or omission of a dose, and infection control issues. The Director of Nursing (DON) confirmed the expectation for staff to label and initial IV bags and tubing to prevent such errors. Despite previous training on IV administration, the facility's policy on labeling IV equipment was not followed, leading to this deficiency.
Inaccurate Documentation of Catheter Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the documentation of catheter care. The resident, a female with a BIMS score indicating no cognitive impairment, had an indwelling catheter that was ordered to be discontinued. However, progress notes inaccurately documented the presence of a catheter on multiple occasions after it was supposed to be removed. Observations and interviews confirmed that the resident did not have a catheter in place at the time of the survey. Interviews with staff, including an LVN and the DON, revealed discrepancies in the documentation process. The LVN confirmed that no catheter care was being provided, and the DON emphasized the importance of accurate documentation. The facility's policy on charting and documentation requires that records be objective, complete, and accurate, which was not adhered to in this case. This failure could lead to miscommunication regarding the resident's care.
Resident's Right to Choose Pain Management Provider Not Honored
Penalty
Summary
The facility failed to honor a resident's right to choose his pain management provider, which is a violation of resident rights. The resident, a male with multiple medical conditions including chronic pain syndrome and opioid dependence, expressed dissatisfaction with the facility's contracted pain management nurse practitioner (NP). Despite his intact cognition and frequent complaints of pain, the resident was not allowed to change his pain management provider after expressing concerns about his current regimen and the NP's approach. The resident reported to a licensed vocational nurse (LVN) that he wanted a new pain management doctor, but was told that facility policy required him to use the contracted provider or leave the facility. The resident was afraid to formally dismiss the NP due to concerns about continuing his pain medication regimen. The facility's staff, including the administrator and interim director of nursing (DON), were aware of the resident's dissatisfaction but did not take timely action to address his request for a new provider. The social worker (SW) only became aware of the issue when the resident threatened to call the state agency. Interviews with facility staff revealed a lack of communication and follow-up on the resident's request. The LVN reported the resident's concerns during a morning meeting, but it was unclear if management took any action. The interim DON acknowledged the resident's dissatisfaction but did not speak to him directly. The administrator admitted to not discussing the resident's rights with him, which contributed to the deficiency in ensuring the resident's right to self-determination and access to preferred medical services.
Resident Left Unsupervised in Extreme Heat
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, leading to severe consequences. The resident, who had a history of vascular dementia, hemiplegia, and other medical conditions, was left unsupervised in 96-degree heat for approximately two hours. This resulted in the resident becoming unresponsive, suffering second-degree skin burns, and experiencing heat stroke, which required hospitalization. The care plan for the resident did not adequately address the resident's behavior of wanting to sit outside in the courtyard, especially during extreme weather conditions. Although the resident was cautioned about the heat and offered water, the staff did not ensure the resident's safety by supervising or documenting interventions when the resident refused hydration and to come inside. The lack of supervision and failure to implement the care plan interventions led to the resident's critical condition. Interviews with staff and other residents revealed that the resident was found unresponsive in a wheelchair on the patio. Despite being warned about the heat, the resident was left outside without proper monitoring. The facility's investigation indicated that there was no documentation of staff checking on the resident or implementing behavior interventions, highlighting a significant oversight in ensuring the resident's safety and well-being.
Resident Left Unattended in Extreme Heat Resulting in Hospitalization
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who was left unattended in 96-degree heat for approximately two hours. This resulted in the resident becoming unresponsive, suffering second-degree skin burns, and experiencing heat stroke, which required hospitalization. The resident, who had a history of vascular dementia, hemiplegia, and other medical conditions, was known to enjoy sitting outside and was assisted to the patio by a CNA. Despite being cautioned about the heat and offered water, the resident was left unsupervised. The resident's care plan indicated a need for total dependence on staff for transfers and supervision during ambulation. However, there was no documentation that staff intervened to ensure the resident's safety or offered hydration while he was outside. The facility's investigation revealed that the resident was found unresponsive in his wheelchair on the patio by another resident, who alerted a nurse. The nurse brought the resident inside and attempted to cool him down with ice and wet towels before calling 911. Interviews with staff and residents indicated that the resident often refused to come inside despite the heat, and there was a lack of documentation regarding staff checks or interventions. The facility's policies on care plans and documentation were not followed, as there was no record of staff monitoring the resident's condition or behavior while outside. The incident highlighted a failure in supervision and adherence to care plans, which placed the resident at risk of harm.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as required by professional principles, which led to a deficiency in medication storage practices. During an observation, it was noted that a Licensed Vocational Nurse (LVN) left a resident's morning intravenous (IV) and injection medications unattended on top of a medication cart in the hallway. The cart was parked outside the resident's room, with the lock in the open position, allowing unauthorized access to the medications. This lapse in protocol was observed when the LVN was inside the resident's room, unable to see the medications from her position, and the medications were visible to anyone passing by. The resident involved had a history of cellulitis, type 2 diabetes with diabetic polyneuropathy, and chronic arterial fibrillation, requiring insulin injections and IV antibiotics. The facility's Director of Nursing (DON) and Executive Director (ED) both acknowledged that the facility's policy required medications to be secured in locked carts at all times to prevent unauthorized access and potential adverse reactions. Despite the facility's policy and previous in-service training on medication security, the LVN admitted to not securing the medications properly, which was a breach of the facility's medication security policy.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. Specifically, the 600 Hall Medication Cart was left unlocked and unattended by LVN C, who was assisting a resident in their room. This oversight was observed when the medication cart was parked outside the resident's room, with no staff present in the hallway, allowing two residents to walk past the unsecured cart. LVN C acknowledged the mistake, stating that the cart should have been locked to prevent unauthorized access to medications. Interviews with the Director of Nursing (DON) and the Executive Director (ED) confirmed that the facility's policy required medication carts to be locked at all times to prevent residents from accessing medications not prescribed to them, which could lead to adverse reactions. Despite the facility's policy on medication security, the Executive Director was unable to provide a copy of this policy when requested during the survey. The facility's policy on medication administration, dated November 2017, was reviewed, but it did not specifically address the security of medication carts.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident with cognitive impairment and an unsteady gait. The resident, who had a history of attempting to get up from her wheelchair unassisted, was left alone in her room by a hospice aide and subsequently fell, sustaining multiple lacerations and a wrist injury that required hospital treatment. The resident was known to be a high fall risk and had specific care plan interventions, including being kept near the nurse's station for closer monitoring, which were not followed at the time of the incident. Interviews with facility staff revealed that the hospice aide, who was aware of the resident's fall risk, left the resident unattended in her room after providing care. The LVN on duty was on a break and not present to ensure the resident was returned to a monitored area. The CNA who discovered the resident on the floor confirmed that the resident had a red bracelet indicating a high fall risk and should have been monitored more closely. The facility's policy on fall management was not adhered to, as the resident was not adequately supervised. The Director of Nursing (DON) and other staff members acknowledged the resident's high fall risk and the need for frequent monitoring. Despite this, the resident was left alone, leading to the fall and subsequent injuries. The facility's failure to implement the care plan and ensure proper supervision directly contributed to the incident, highlighting a significant lapse in the standard of care provided to the resident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 970 citations issued within 25 miles in the last 12 months — including the 41 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legend Oaks Healthcare And Rehabilitation - Fort W | 1.2 mi | ★★★★★ | 11 | 1 |
| Heritage House At Keller Rehab & Nursing | 2 mi | ★★★★★ | 7 | 1 |
| Green Valley Healthcare And Rehabilitation Center | 4.1 mi | ★★★★★ | 4 | 1 |
| North Pointe Nursing And Rehabilitation | 4.2 mi | ★★★★★ | 1 | 1 |
| Discovery Village At Southlake | 5.5 mi | ★★★★★ | 2 | 0 |
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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.