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 Heights At Medical Center during CMS and state inspections, most recent first.
A resident with intact cognition and diagnoses including acute respiratory failure, sleep apnea, and COPD reported that his room window was screwed shut and he wanted to open it for fresh air. Surveyors observed a screw in the window, and later found a hole and metal shavings where the screw had been removed. Staff stated windows had been secured for safety, but the DNS and Administrator acknowledged the window should not have been screwed totally shut and that the resident should have been able to open it partially.
Two residents had inaccurate MDS coding. One resident with intellectual disability was receiving PASRR Level II services, but the annual MDS stated he was not PASRR positive. Another resident with sleep apnea used CPAP nightly per care plan and MD order, but the quarterly MDS did not code non-invasive mechanical ventilator use. The DCR confirmed both assessments were coded incorrectly.
Incontinence and peri care were not completed correctly for two residents with severe cognitive impairment. A female resident who was always incontinent of bowel and bladder was cleaned without separating the labia, and a male resident with a urinary catheter and bowel incontinence was cleaned without cleaning the entire scrotum. The CNA involved in each observation acknowledged the missed steps, and the DNS stated the facility used skill check-off sheets that did not include those specific peri care steps.
Oxygen Tubing and Filter Not Maintained as Ordered: A resident with shortness of breath, HTN, and moderate cognitive impairment was receiving O2 via nasal cannula. Staff observed the O2 tubing was overdue for change and the concentrator filter was dirty with gray dust, despite MD orders for weekly tubing changes and weekly filter checks/cleaning/replacement. Interviews with an LVN and the DNS confirmed the ordered care had not been completed.
Improper Hair and Beard Restraints in Kitchen Food Prep Area: A Cook was observed in the food prep area without a beard restraint covering facial hair, and a Dietary Aide was observed without a hair restraint covering all hair. Interviews confirmed staff had been trained that all hair, including facial hair, must be fully restrained while working in the kitchen, and facility policy and the Food Code required effective hair restraints to prevent hair from contacting food and food-contact surfaces.
An LVN administered medications via a resident’s gastrostomy tube while wearing gloves only and not a gown, despite the resident being on EBP and a door sign directing staff to wear gown and gloves for high-contact care such as feeding tube use. The resident had severe cognitive impairment, an enteral feeding tube, and care plan directions for feeding tube care, infection monitoring, and EBP. The LVN acknowledged forgetting the gown, and the DNS confirmed a gown should have been worn per EBP and facility policy.
Failure to submit discharge MDS timely: A resident with orthopedic aftercare following surgical amputation, osteomyelitis of the left ankle and foot, and type 2 DM was discharged, but the discharge MDS was not completed or transmitted to CMS within the required timeframe. The MDS Coordinator acknowledged the omission, and the DNS and Administrator confirmed the discharge assessment should have been completed for the resident.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to proper transition planning.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards for individualized resident support.
The facility failed to employ sufficient staff with the necessary competencies in the food and nutrition service, lacking a full-time dietitian or certified dietary manager since April 2024. The Head Cook/Supervisor in Training confirmed the absence of a Dietary Manager for four months, and the Administrator acknowledged the risk to residents' nutritional needs due to this staffing deficiency.
The facility failed to ensure call lights were accessible for three residents, including a cognitively intact female with Parkinson's and two males with severe cognitive impairments. Observations revealed call lights on the floor or behind furniture, preventing residents from obtaining assistance. Staff interviews confirmed the importance of accessible call lights for safety and communication, highlighting a gap between policy and practice.
The facility failed to maintain a clean and safe environment for residents, with observations revealing cracked floors, dirty air conditioning units, and stained surfaces in several rooms and the shared shower room. Housekeeping staff admitted to inconsistencies in cleaning practices, and the Maintenance/Housekeeping Director acknowledged foundational issues contributing to the damages. The Administrator was aware of these issues but expected housekeeping to maintain cleanliness throughout the facility.
The facility failed to ensure proper labeling and dating of food items in the kitchen, including the refrigerator, freezer, and dry storage areas, leading to potential contamination risks. Additionally, the ice machine was found to be inadequately cleaned. The Head Cook/Supervisor in Training acknowledged these issues, and the facility had been without a Dietary Manager for several months.
A resident with Type 2 diabetes and severe cognitive impairment experienced a breach of privacy when an LVN attempted to check her blood sugar in the dining area. Despite being advised to perform the procedure in the resident's room, the LVN initially intended to proceed in the dining area, and later failed to close the door when conducting the procedure in the room. Interviews with staff confirmed that procedures should be conducted in private, with the door closed.
Two residents in the facility had inaccurate MDS assessments that failed to reflect their current conditions, including the presence of g-tubes and impairments. One resident's assessment did not indicate a g-tube despite its presence and related care needs, while another resident's assessment missed both a g-tube and a hand impairment. These inaccuracies could lead to inadequate care, as the assessments did not align with the residents' actual needs.
The facility failed to update care plans for two residents with severe cognitive impairment and dysphagia, who had gastrostomy feeding tubes (g-tubes) that were no longer used for nutrition. Despite the presence of these g-tubes, the care plans did not include necessary maintenance or monitoring, potentially leading to complications. Observations and interviews confirmed the lack of comprehensive care plans, contrary to facility policy requiring updates to reflect specific resident care needs.
Two residents requiring ADL assistance did not receive their scheduled showers over a 30-day period. Despite being scheduled for three showers a week, both residents reported not receiving them. Facility staff admitted to lapses in documentation and monitoring, with a CNA forgetting to complete shower sheets and LVNs failing to ensure proper oversight. The ADON was aware of the missing documentation but believed the showers were provided. This lack of documentation and oversight risked the residents' personal hygiene.
A resident with a history of incontinence was observed receiving improper incontinent care from a CNA, who wiped from back to front instead of the recommended front to back technique. This action, contrary to the facility's perineal care policy, posed a risk of urinary tract infection due to potential cross-contamination.
A facility failed to provide appropriate care for a resident with a gastrostomy tube, as there were no physician orders to observe, flush, or check the placement of the tube. Despite the resident's severe cognitive impairment and diagnosis of dysphagia, the necessary orders for g-tube management were missing, which could lead to complications. The DON confirmed the need for such orders to maintain tube patency, as per facility policy.
A resident with a history of respiratory issues was found with an unbagged CPAP mask and an oxygen concentrator without water in the humidifier. The facility staff, including an LVN, failed to ensure proper storage of the CPAP mask and maintenance of the humidifier, which are necessary to prevent cross-contamination and irritation. Interviews with the DON, ADON, and Administrator confirmed these oversights, highlighting a deficiency in respiratory care procedures.
A resident with severe cognitive impairment and denture use did not receive timely dental care despite requests from the responsible party. The facility faced issues with scheduling due to a change in dentists and a canceled appointment, leading to a delay in addressing the resident's dental concerns.
A resident with severe cognitive impairment and sepsis did not receive proper infection control during incontinent care. LVN B and RA F failed to change gloves and perform hand hygiene after cleaning the resident and before handling a new brief, risking cross-contamination. Interviews with facility leadership confirmed the expectation for proper hand hygiene and glove-changing procedures, which were not followed according to facility policies.
Two residents experienced privacy breaches during wound care procedures. One resident was left exposed when an LVN left the room without closing the privacy curtain, while another resident's privacy curtain was not fully drawn by an RN during care. Both residents had cognitive impairments and required specific wound care. Staff acknowledged the importance of maintaining privacy for resident dignity.
A medication cart in the 100-hallway was found unlocked and unattended near the nurse's station, containing various medications and glucose monitoring paraphernalia. The DON confirmed the cart should have been locked and was unsure of the responsible nurse's location. Facility policies require carts to be locked when not in use and accessible only to authorized personnel.
A facility failed to maintain an effective infection control program when an RN did not perform proper hand hygiene during wound care for a resident. The RN washed hands for only a few seconds at various stages, contrary to the facility's policy of at least 15 seconds. Interviews confirmed awareness of the hand hygiene standards, yet the RN did not comply during the observed care.
A resident with moderate cognitive impairment fell twice in one night, resulting in injuries, but the facility failed to immediately notify the physician and responsible party. The resident was found on the floor by staff, who assisted her back to bed without taking further action. The deficiency was identified after the resident's family raised concerns, revealing that the LVN did not notify the physician or family after the first fall, leading to a delayed response after a second fall caused a hip dislocation.
A resident with moderate cognitive impairment experienced two falls in a facility, resulting in significant injuries due to inadequate care and delayed medical intervention. The first fall was not properly addressed by the staff, leading to a second fall with severe consequences. The facility failed to notify the physician or the resident's family promptly, violating professional standards and fall prevention policies.
A resident with a history of PTSD and mood disorders eloped from the facility due to inadequate supervision and security measures. The resident, who had been attempting to elope and had removed his wanderguard, was found outside at a local fast-food restaurant. The incident occurred during a night shift with low staffing levels, and the front door alarm did not activate. Staff interviews revealed that the door was not always secured, and the facility's elopement prevention policies were not effectively implemented.
The facility restricted residents' visitation rights by enforcing visiting hours from 7:00 AM to 7:00 PM, contrary to its policy of 24-hour access. A resident's family member was unaware of the right to visit at any time, and the administrator cited security concerns for the restricted hours. The facility's policy allowed 24-hour visitation, but this was not practiced.
The facility failed to update a resident's comprehensive care plan to reflect the discontinuation of a foley catheter. Despite the resident not having a foley catheter since returning from the hospital, the care plan still indicated its presence. Interviews and observations confirmed the discrepancy, and the care plan was not revised until it was brought to the attention of the MDS nurse.
The facility failed to coordinate hospice care and maintain required documentation for a resident receiving hospice services. Interviews and record reviews revealed that the necessary hospice forms were not properly managed, and staff had differing accounts of responsibility for hospice documentation. This lack of coordination and communication could potentially place residents at risk of inadequate end-of-life care.
Window Screwed Shut Prevented Resident From Opening It for Fresh Air
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for Resident #54 by allowing his room window to remain screwed shut so it could not be opened for fresh air. Resident #54 was admitted with diagnoses including acute respiratory failure, sleep apnea, and COPD, and his MDS assessment showed a BIMS score of 15, indicating intact cognition. During a resident group interview, he stated his room window was screwed shut and asked whether it could be opened so he could use it when he wanted fresh air. An observation shortly afterward confirmed a screw in the window. Maintenance staff stated screws had been placed in windows after residents had tried to go out through them, and the Maintenance Supervisor said the facility now had locks to limit how far windows could open if needed. On later observation, the window showed a hole and metal shavings where a screw had been removed, and Resident #54 stated he had not asked for the screws to be removed but that it bothered him that he could not open the window. The DNS stated the windows were supposed to be able to open a small amount and should not have been screwed totally shut, and the Administrator stated the facility’s practice was for windows to open only partially for safety, but Resident #54 should have been able to open his window to get fresh air.
MDS Assessments Did Not Match PASRR Status and CPAP Use
Penalty
Summary
The facility failed to ensure Resident #2’s annual MDS accurately reflected that the resident was receiving Level II PASRR services due to intellectual disability. Resident #2 was a male with a diagnosis of intellectual disability and seizures, and his annual MDS dated 01/07/2025 indicated a BIMS score of 8 out of 15 and stated the resident was not considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. However, the resident’s care plan identified him as PASRR positive due to intellectual disability, and the Local Intellectual and Developmental Disabilities Authorities’ Habilitation Service Plan showed he was receiving PASRR Level II services because he was PASRR Level II positive. The facility also failed to ensure Resident #76’s quarterly MDS accurately reflected CPAP use for sleep apnea. Resident #76 was a male with sleep apnea, and his quarterly MDS dated 05/22/2025 indicated he did not have non-invasive mechanical ventilator use. In contrast, the care plan directed staff to administer CPAP for sleep apnea as ordered, and the physician order required CPAP at bedtime at 10:00 p.m. and removal at 6:00 a.m. Observation and interview showed the resident’s CPAP on the nightstand and the resident stated he used it every night at 10:00 p.m. The Director of Clinical Reimbursement stated both MDS entries were inaccurate and should have been coded yes.
Incontinence and Peri Care Not Completed Correctly
Penalty
Summary
Appropriate care for residents who were incontinent of bowel and bladder, including appropriate catheter care and care to prevent urinary tract infections, was not provided for two residents. Resident #51 was a female with overactive bladder, severe cognitive impairment with a BIMS score of 5 out of 15, and was always incontinent of bladder and bowel. Her care plan directed incontinent care assistance every shift and as needed. During observation, CNA-B removed her dirty brief and cleaned her suprapubic area, groin areas, and genital area, but did not separate the labia while cleaning the middle area of the genitals. Resident #60 was a male with dementia, severe cognitive impairment with a BIMS score of 0 out of 15, a urinary indwelling catheter, and bowel incontinence. His care plan directed incontinent and catheter care assistance every shift and as needed. During observation, CNA-C removed his dirty brief, cleaned the catheter and penis, cleaned the right and left groin areas, and turned him to his side without cleaning the scrotum, including the middle area of the scrotum. During interviews, CNA-B stated she did not separate the labia when cleaning Resident #51 and said she should have done so to prevent infection. CNA-C stated he did not clean the middle area of Resident #60's scrotum and said he should have cleaned the entire scrotum area to prevent possible infection. The DNS stated the facility did not have a specific peri care policy and relied on skill check-off sheets that did not indicate separating the female labia or cleaning the male scrotum, while also stating improper incontinence care might cause infection.
Oxygen Tubing and Filter Not Maintained as Ordered
Penalty
Summary
The facility failed to ensure that Resident #36 received respiratory care as ordered, including tracheostomy-related oxygen equipment care. Resident #36 was a female resident with diagnoses of shortness of breath and hypertension, had a BIMS score of 9 indicating moderate cognitive impairment, was dependent for activities of daily living, and was receiving oxygen therapy. Her care plan directed staff to provide oxygen as ordered and monitor for signs and symptoms of respiratory distress. The physician orders required the nasal cannula/mask and oxygen tubing to be changed every Sunday and as needed, and the oxygen filter to be checked, cleaned, and/or replaced every week on Sunday night shift. During observation, Resident #36 was in bed using oxygen via nasal cannula, the oxygen tubing was dated 08/03/2025, and the oxygen concentrator filter was dirty with gray-colored dust. Staff interviews confirmed the tubing should have been changed and the filter cleaned or replaced on the prior Sunday as ordered, and the DNS stated the same. The facility policy also required tubing to be changed weekly and the air filter to be changed and/or cleaned at least monthly and as needed.
Improper Hair and Beard Restraints in Kitchen Food Prep Area
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen observed by surveyors. During observation of the kitchen, a Cook was seen in the food prep area without a beard restraint covering his facial hair, and a Dietary Aide was observed in the food prep area without a hair restraint that covered all of his hair. These observations were made in the facility's only kitchen. During interview, the Dietary Aide stated he had been trained on appropriate hygiene when he started and that hair restraints should cover all hair on top of the head. He stated that hair not contained in the restraint could fall into food and cause foodborne illness, and that it was his responsibility to ensure his hair was fully in the restraint. The Dietary Manager stated staff are trained on appropriate hygiene when they start and that all hair, including facial hair, was to be in a hair restraint when in the kitchen. The Dietary Manager also stated hair not in a restraint could fall into food being prepared and contaminate it. Record review showed the facility policy required hairnets, headbands, caps, beard coverings, or other effective hair restraints to keep hair from food and food-contact surfaces, and the Food Code required food employees to wear hair restraints designed and worn to keep hair from contacting exposed food and related surfaces.
Failure to Use EBP Gown During Feeding Tube Medication Administration
Penalty
Summary
The facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent communicable diseases and infections for one resident reviewed for infection control practices. Resident #60 was a male with diagnoses including dementia, acute respiratory failure, heart failure, and type 2 diabetes mellitus. His MDS assessment showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and that he had an enteral feeding tube. His care plan identified the need for feeding tube care, NPO status, monitoring for infection, and Enhanced Barrier Precautions as clinically indicated. During observation, an LVN entered the resident’s room, sanitized his hands, put on gloves only, and administered morning medications via the resident’s gastrostomy feeding tube without wearing a gown. The LVN then left the room and washed his hands. Later observation showed a sign on the resident’s door directing staff to wear a gown and gloves during high-contact resident care, including feeding tube care. In interview, the LVN stated he forgot to wear a gown and acknowledged he should have worn one because the resident had EBP. The DNS also stated the LVN should have worn a gown when administering medications via the feeding tube because the resident had EBP. The facility policy stated that EBP requires gown and glove use during high-contact resident care activities, including feeding tube care.
Failure to Submit Discharge MDS Timely
Penalty
Summary
The facility failed to transmit an encoded, accurate, and complete discharge MDS assessment to the CMS system for Resident #26 within 14 days of discharge. Resident #26 was a male admitted to the facility and discharged on 04/29/2025 to an assisted living facility, with diagnoses including encounter for orthopedic aftercare following surgical amputation, acute hematogenous osteomyelitis of the left ankle and foot, and type 2 diabetes mellitus with unspecified complications. Record review showed the resident’s Medicare 5-day MDS was completed on 04/01/2025, but no discharge MDS was completed after the resident left the facility. During interview, the MDS Coordinator stated Resident #26 was discharged on 04/29/2025 and a discharge MDS was not completed, and that she was responsible for completing and submitting the discharge MDS within 14 days of discharge. The DNS also stated the MDS Coordinator was responsible for completing the discharge MDS and that it was to be submitted within 14 days. The Administrator stated a discharge MDS should have been completed for all discharged residents and that the MDS Coordinator was responsible for completing it when a resident was discharged.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident-centered care and safe transition planning.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the highest possible level of well-being for each resident, as required by regulatory standards.
Deficiency in Dietary Staffing and Competency
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service. This deficiency was identified through interviews and record reviews, which revealed that the facility had been without a full-time dietitian or certified dietary manager since April 2024. The absence of these key personnel could potentially place residents at risk of not receiving adequate food and nutritional services, impacting their overall nutrition. The Head Cook/Supervisor in Training, who had been at the facility for three years, confirmed that the Dietary Manager had left about four months ago. Although the facility had a dietitian, she was only contracted and visited the facility three or four times a month. The Administrator acknowledged the absence of a full-time dietitian or certified dietary manager and noted that the acting supervisor was in the process of taking courses to become certified. Despite these efforts, the lack of permanent, qualified staff in the dietary department was a significant concern.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents, which could prevent them from obtaining assistance when needed. Resident #9, a cognitively intact female with Parkinson's disease, was found with her call light on the floor behind her side table, making it inaccessible. Despite her statement that she could manage independently, she expressed a preference for having the call light nearby, especially at night. Resident #40, a male with severe cognitive impairment and a history of cerebral infarction and epilepsy, was observed with his call light on the floor behind his bed's headboard. He attempted to use the call light after finishing breakfast but found it stuck. He resorted to using his walker to take his tray to the dining area, indicating the call light's inaccessibility. Similarly, Resident #43, also with severe cognitive impairment and muscle weakness, had his call light under his roommate's bed, rendering it unreachable. Interviews with staff, including CNAs, LVN, DON, ADON, and the Administrator, confirmed the importance of call lights being within reach for resident safety and communication. Staff acknowledged the oversight and the potential risks of falls or unmet needs due to inaccessible call lights. The facility's policy emphasized the necessity of keeping call lights within easy reach, highlighting a discrepancy between policy and practice.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in several rooms and the shared shower room. Observations revealed that multiple resident rooms had issues such as cracked floors, broken tiles, and dirty air conditioning units with dust-laden filters. Additionally, the floors and walls in these rooms had various stains, and the bathroom fixtures were damaged or stained. The shared shower room was found to have blackish and reddish stains, soap scum buildup, and a dead cockroach, indicating a lack of proper cleaning and maintenance. Interviews with housekeeping staff revealed inconsistencies in cleaning practices and a lack of thoroughness in maintaining cleanliness. Housekeeping staff acknowledged their responsibilities, which included cleaning air conditioning units, air filters, handrails, and shower rooms, but admitted that these tasks were not always completed as required. The Maintenance/Housekeeping Director confirmed that the rooms and common areas were supposed to be cleaned daily and acknowledged the foundational problems in the facility, which contributed to the damages observed. The facility's Administrator was aware of the foundational issues and was in the process of obtaining bids for repairs. However, the Administrator expected housekeeping to maintain cleanliness throughout the facility. The facility's policy on maintaining a safe and homelike environment emphasized the importance of cleaning and sanitization, but the observed deficiencies indicated a failure to adhere to these standards, potentially compromising the residents' quality of life.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. Specific deficiencies included the lack of labeling and dating of food items in the refrigerator, freezer, and dry food storage areas. Observations revealed that a large container of diced pineapples, a small cup of pudding, a tray of beverages, bags of salad, loaves of wheat bread, and hamburger buns were not labeled or dated. Additionally, frozen meat and a large frozen turkey in the freezer were also found without labels or dates. These oversights in food labeling and dating could lead to cross-contamination and foodborne illnesses. Further issues were identified with the cleanliness of the kitchen equipment, particularly the ice machine, which had dust, dirt particles, and a black substance on the inside. The Head Cook/Supervisor in Training, who had been at the facility for three years, acknowledged these concerns and admitted to being responsible for ensuring inventory was labeled and dated, as well as maintaining the cleanliness of the kitchen equipment. The facility had been without a Dietary Manager for several months, and the acting supervisor was in the process of obtaining certification. The Administrator was aware of the findings but was unsure if all concerns had been communicated to her. The facility's policy on food storage, dated June 2019, emphasized the importance of labeling and dating all food items to prevent contamination.
Failure to Ensure Resident Privacy During Blood Sugar Check
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident diagnosed with Type 2 diabetes mellitus, who had a severe cognitive impairment. The deficiency occurred when LVN A attempted to check the resident's blood sugar in the dining area, which was against the facility's expectations for privacy. Despite being advised by LVN C to perform the procedure in the resident's room, LVN A initially intended to proceed in the dining area, potentially compromising the resident's dignity. When LVN A eventually moved the resident to her room to check her blood sugar, she failed to close the door, further neglecting the resident's right to privacy. Interviews with LVN A, LVN C, the DON, and the ADON confirmed that the standard practice should involve conducting such procedures in the privacy of the resident's room with the door closed. The facility's policy on dignity was requested but not provided before the survey exit.
Inaccurate MDS Assessments for Residents with G-tubes and Impairments
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the status of two residents, leading to deficiencies in their care. Resident #40's Quarterly MDS Assessment did not indicate that he still had a gastrostomy feeding tube (g-tube), despite observations and physician orders confirming its presence and the need for care related to it. The resident was observed eating orally and stated that he was no longer using the g-tube, yet the care plan and physician orders still included interventions for the g-tube, indicating a discrepancy in the assessment. Similarly, Resident #43's Quarterly MDS Assessment failed to reflect the presence of a g-tube and an impairment in his right hand. Observations confirmed the presence of a g-tube and a splint on the resident's right hand, which was contracted. Interviews with staff, including a CNA and the DON, highlighted that the resident was dependent on staff for most ADLs and required specific care for his g-tube and hand impairment, which were not accurately documented in the MDS assessment. The discrepancies in the MDS assessments for both residents could lead to inadequate care and services, as the assessments did not align with the residents' current conditions and needs. The facility's policy emphasizes the importance of accurate assessments to describe residents' capabilities and identify significant impairments, which was not adhered to in these cases.
Failure to Update Care Plans for Residents with Unused G-Tubes
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, both diagnosed with dysphagia, who had gastrostomy feeding tubes (g-tubes) that were no longer in use for nutrition. Despite the presence of these g-tubes, the residents' care plans did not reflect the need for specific care related to the g-tubes, such as maintenance or monitoring, which could potentially lead to complications. This oversight was identified through observations, interviews, and record reviews, revealing that the care plans lacked measurable objectives and timeframes to address the residents' medical needs as identified in their comprehensive assessments. Resident #40, a male with severe cognitive impairment, was observed eating breakfast orally, indicating that his g-tube was not being used for feeding. Similarly, Resident #43, also with severe cognitive impairment, was found with a g-tube in place but without a corresponding care plan. Interviews with the Director of Nursing (DON), MDS Nurse, and Assistant Director of Nursing (ADON) confirmed the importance of having comprehensive care plans to ensure appropriate care and prevent potential complications, such as infection at the g-tube site. The facility's policy mandates that care plans be updated to reflect specific resident care needs, which was not adhered to in these cases.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #26 and Resident #63, received their scheduled showers over a 30-day period. Both residents required assistance with activities of daily living (ADLs) due to their medical conditions, including kidney failure. Resident #26, who was cognitively intact, reported not receiving his scheduled showers despite being scheduled for three showers a week. Similarly, Resident #63, who had moderate cognitive impairment, also reported not receiving his scheduled showers. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and Licensed Vocational Nurses (LVNs), revealed inconsistencies in the documentation and monitoring of shower schedules. The CNA responsible for the care of both residents admitted to forgetting to complete the shower sheets, which are required to document whether a shower was provided or refused. The LVNs acknowledged lapses in monitoring and ensuring that the shower sheets were completed correctly, with one LVN admitting to not effectively overseeing Resident #26's showers. The Assistant Director of Nursing (ADON) was aware of the missing shower sheets but believed the residents were receiving their showers, despite the residents' statements to the contrary. The facility's policy on bathing requires documentation of the date, time, and staff involved in assisting with showers, as well as any assessments made during the process. The lack of documentation and oversight placed the residents at risk of not receiving necessary services to maintain good personal hygiene.
Inappropriate Incontinent Care Technique Observed
Penalty
Summary
The facility failed to provide appropriate incontinent care to a resident, leading to a potential risk of urinary tract infection. The resident, an elderly female with a history of post-COVID-19 condition and pneumonia, was observed to be always incontinent of bowel and bladder. Her care plan required staff assistance for incontinent care every two hours and as needed. During an observation, a CNA was seen providing care to the resident but failed to follow proper wiping techniques. Specifically, after cleaning the front part of the resident, the CNA wiped the resident's bottom from back to front, which is contrary to the recommended practice of wiping from front to back to prevent cross-contamination. The CNA acknowledged the mistake during an interview, stating that he was unaware of the incorrect technique used and recognized the risk of infection it posed to the resident. The facility's policy on perineal care emphasizes the importance of wiping from the base of the labia towards the buttocks to prevent infections. This incident highlights a lapse in adherence to infection control procedures, which could place residents at risk of developing urinary tract infections.
Failure to Ensure Proper Management of Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (g-tube) received appropriate treatment and services to prevent complications associated with enteral feeding. The resident, who was diagnosed with dysphagia and had a severe cognitive impairment, did not have physician orders to observe, flush, or check the placement of the g-tube, even though it was not actively being used. This lack of orders was identified during a review of the resident's records, which showed no instructions for g-tube management, despite the presence of the tube in the resident's abdomen. The Director of Nursing (DON) acknowledged that there should have been orders in place to monitor, flush, and check the placement of the g-tube to maintain its patency and prevent clogging. The facility's policy on maintaining the patency of feeding tubes requires flushing every four to six hours, but this was not being followed for the resident in question. The absence of these orders and the failure to adhere to the facility's policy could place residents with g-tubes at risk for complications.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required CPAP and oxygen therapy. The resident, who was cognitively intact and had a history of pneumonia and acute respiratory failure with hypoxia, was observed with a CPAP mask that was not properly stored. The mask was left unbagged on top of the CPAP machine, contrary to the facility's policy to prevent cross-contamination and infection. Additionally, the resident's oxygen concentrator was found without water in the humidifier, which is necessary to prevent irritation of the nasal passages. The resident was on oxygen therapy at 3 liters per minute via nasal cannula, but neither the resident nor the staff noticed the absence of water in the humidifier. This oversight was confirmed during interviews with the resident and staff members, including an LVN who admitted to not checking the humidifier's water level during her rounds. Interviews with the DON, ADON, and the Administrator revealed a consensus that the CPAP mask should be bagged when not in use and that the humidifier should always contain water. The staff acknowledged the importance of these measures to prevent respiratory infections and ensure the resident's respiratory needs were met. However, these procedures were not followed, leading to the identified deficiency.
Failure to Assist Resident in Obtaining Dental Care
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental care, as requested by the responsible party in March 2024. The resident, a female with severe cognitive impairment and denture use, was care planned to maintain adequate nutritional status and good oral hygiene, which included receiving an oral exam from a dentist. Despite multiple requests from the resident's responsible party, the facility did not schedule a dental appointment in a timely manner. The responsible party expressed concerns about the resident's dentures and gums causing problems, and the facility's social worker acknowledged issues with scheduling due to a change in dentists and a canceled appointment. Interviews with facility staff, including the MDS Nurse, ADON, and Social Worker, revealed a lack of communication and coordination in scheduling the dental appointment. The Social Worker stated that the resident was last seen by a dentist in October 2023 and that an appointment was finally made for July 2024. The Administrator admitted to problems in securing a dentist for the facility and suggested seeing an outside dentist, which the resident refused. The facility's policy on dental services, dated August 2006, indicated that routine and emergency dental services should be available according to the resident's assessment and care plan.
Infection Control Deficiency in Incontinent Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of LVN B and RA F during the provision of incontinent care to a resident. The resident, a female with a severe cognitive impairment and diagnosed with sepsis, required staff assistance for incontinent care. During an observation, LVN B and RA F did not adhere to proper infection control protocols. After washing their hands and donning gloves, they proceeded to clean the resident's bottom without changing gloves or performing hand hygiene before handling a new brief. RA F, after cleaning the resident, did not change her gloves before placing a new brief under the resident, and she did not sanitize her hands after changing gloves. Similarly, LVN B touched the trash can with her gloves and then assisted in fixing the resident's brief without changing gloves or sanitizing her hands. Both staff members acknowledged their failure to follow proper hand hygiene and glove-changing procedures, which could lead to cross-contamination and infection. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator confirmed the expectation for staff to perform hand hygiene and change gloves appropriately to prevent infection. The facility's policies on hand hygiene and perineal care were not followed, as they require hand sanitization after glove removal and before touching clean items. This deficiency in infection control practices was observed and documented by the surveyors.
Privacy Breach During Wound Care
Penalty
Summary
The facility failed to ensure personal privacy for two residents during wound care procedures. For Resident #2, the privacy curtain was not completely closed during wound care on June 21, 2024. An LVN left the resident's room to retrieve more gloves, leaving the resident exposed with the privacy curtain open. Resident #2 had severe cognitive impairment and multiple diagnoses, including a sacral ulcer requiring specific wound care. The LVN acknowledged the importance of privacy for dignity but assumed a CNA had covered the resident. Similarly, Resident #4's privacy was compromised during wound care on June 23, 2024, when an RN did not fully draw the privacy curtain before removing the resident's brief. Resident #4 had moderate cognitive impairment and several medical conditions, including a stage 4 wound requiring specific care. The RN admitted the expectation to provide total privacy by closing the door and curtain, acknowledging the importance of maintaining resident dignity. The DON and Administrator emphasized the responsibility of staff to ensure privacy, highlighting the potential for residents to feel embarrassed if privacy is not maintained.
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, and that only authorized personnel had access to the keys for the medication carts. Specifically, the 100-hallway medication cart was found unlocked and unattended in the common area near the nurse's station. This cart contained over-the-counter medications, prescription medications, and glucose monitoring paraphernalia. The surveyor was able to open the drawers without any staff intervention, and non-ambulatory residents were present in the area. During an interview, the Director of Nursing (DON) acknowledged that the cart should have been locked when unattended and expressed uncertainty about the whereabouts of the nurse responsible for the 100-hallway cart at that time. The DON mentioned that he had made rounds within the last five minutes and believed the cart had not been left unlocked and unattended for more than three minutes. The facility's policies on medication storage and security clearly stated that medication carts must be locked when not in use and only authorized personnel should have access, which was not adhered to in this instance.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN A during wound care for a resident. RN A did not perform hand hygiene appropriately, washing hands for only 4 seconds, 3 seconds, and 2 seconds at different points during the procedure, which is below the facility's policy requirement of at least 15 seconds. This inadequate hand hygiene practice was observed during the wound care process, where RN A handled wound care supplies and provided direct care to the resident. Interviews with RN A and the Director of Nursing (DON) revealed that both were aware of the facility's hand hygiene expectations, which include washing hands for 15-20 seconds and performing hand hygiene before and after direct resident care. Despite this knowledge, RN A did not adhere to these standards during the observed wound care. The facility's policy, dated February 2022, clearly outlines the hand hygiene procedures, emphasizing the importance of rubbing hands together vigorously for at least 15 seconds to prevent the spread of infections.
Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to immediately consult with a resident's primary care physician following an incident that resulted in injury and had the potential for requiring physician intervention. The incident involved a resident who fell at 1:30 AM, resulting in bruising to the left hand and a change in skin condition. Despite the fall, the responsible party and the physician were not notified immediately, which was a violation of the resident's rights. The resident, an elderly female with moderate cognitive impairment and a primary diagnosis related to orthopedic aftercare, was dependent on staff for toilet transfers and hygiene. On the night of the incident, the resident was found on the floor by a CNA and an LVN, who assisted her back to bed without notifying the physician or the responsible party. The resident expressed pain, but no immediate action was taken to address her condition or notify the necessary parties. The deficiency was identified when the resident's family member raised concerns about neglect, leading to an investigation. It was discovered that the LVN responsible for the resident's care failed to notify the physician and the responsible party after the first fall. This oversight was compounded by a second fall later that morning, which resulted in a dislocation of the resident's left hip, prompting a delayed notification to the physician and transfer to the ER.
Failure to Provide Timely Care After Resident Falls
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who experienced two falls within a short period. The first fall occurred at 1:30 AM, where the resident was found on the floor by a CNA and an LVN. Despite the resident's cries for help and signs of distress, the LVN did not notify the physician or the resident's family member, nor did they conduct a thorough assessment or provide necessary medical intervention. The resident was placed back in bed without further action, despite expressing pain and needing assistance. The second fall happened at 6:30 AM when the resident attempted to ambulate to the bathroom without assistance. This fall resulted in significant injuries, including a dislocated left hip and fractures. The LVN on duty at that time notified the physician and arranged for the resident to be transferred to the ER for evaluation and treatment. However, the delay in addressing the first fall and the lack of immediate medical intervention contributed to the severity of the resident's injuries. The resident, who had a history of moderate cognitive impairment and was dependent on staff for toilet transfers and hygiene, was left without adequate care and supervision. The facility's failure to adhere to professional standards of practice and its fall prevention policy placed the resident at risk of harm. The incident was reported to the state following concerns raised by the resident's family, highlighting deficiencies in communication and response protocols within the facility.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent the elopement of a resident. The resident, a male with a history of PTSD, MDD, mood disorder, and stimulant abuse, was admitted to the facility and had a known risk of elopement. Despite this, the resident was able to leave the facility unnoticed and was found outside at a local fast-food restaurant. The facility's records indicated that the resident had been attempting to elope and had removed his wanderguard, which was found on the floor of his room. The incident occurred during the night shift when staffing levels were reportedly low, and the front door alarm did not activate. Interviews with staff revealed that the door was supposed to be locked manually, but it was not always secured due to various reasons such as deliveries and staff breaks. The staff on duty were not aware of the resident's absence until a search was conducted, and the resident was found outside the facility. The facility's policies and procedures for elopement prevention were not effectively implemented, as evidenced by the failure to secure the front door and monitor the resident adequately. The staff had not been fully trained on elopement prevention, and there was a lack of communication and coordination among the staff regarding the resident's elopement risk. This deficiency placed the resident at risk of harm due to potential exposure to the elements and other hazards outside the facility.
Violation of Resident Visitation Rights
Penalty
Summary
The facility failed to honor residents' rights to receive visitors of their choosing at any time, as mandated by regulations. Observations revealed a sign at the facility's entrance indicating restricted visiting hours from 7:00 AM to 7:00 PM. Interviews with staff and family members confirmed that these hours were enforced, with announcements made to visitors to leave by 7:00 PM. The receptionist, who was responsible for making these announcements, stated that no administrative staff had questioned the visiting hours policy, and the sign had been in place for an unspecified duration. A resident's family member, who visited daily, was unaware that visiting hours restrictions were prohibited and believed he could only visit during the posted hours. The facility's administrator acknowledged awareness of the visiting hours sign but was unaware of the announcements made by the receptionist. The administrator's rationale for the restricted hours was to prevent unauthorized access and inform visitors of the lack of a receptionist after 7:00 PM. However, the facility's policy, revised in December 2006, stated that residents should have 24-hour access to visitors with their consent, highlighting a discrepancy between policy and practice.
Failure to Update Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure the comprehensive care plan for a resident was reviewed and revised by an interdisciplinary team to reflect the discontinuation of a foley catheter. The resident, a [AGE] year-old female with diagnoses including altered mental status, muscle wasting and atrophy, obstructive and reflux uropathy, and chronic kidney disease, was admitted on [DATE]. Despite the resident not having a foley catheter since her return from the hospital on 04/02/2024, the care plan still indicated the presence of a foley catheter as of 04/18/2024. This discrepancy was confirmed through observations, interviews, and record reviews, revealing that the care plan was not updated to reflect the resident's current condition. Interviews with MDS nurses and CNAs indicated a lack of awareness and communication regarding the resident's current status. The MDS nurses responsible for updating the care plan did not recall the resident having a foley catheter and were unable to provide an exact date of its removal. The CNAs confirmed that the resident did not have a foley catheter upon her return from the hospital and had not had one for a significant period. Despite this, the care plan was not revised until 04/19/2024, during the interview with MDS Nurse E. The facility's policy requires a comprehensive care plan to be developed within seven days of the resident assessment, but this was not adhered to in this case.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified through interviews and record reviews, which revealed that the facility did not maintain the required hospice forms and documentation for the resident. The resident, an elderly female with multiple health conditions including altered mental status, muscle wasting, obstructive and reflux uropathy, and chronic kidney disease, was admitted to hospice services but the necessary documentation was not properly managed or retained by the facility staff. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), Certified Nursing Assistants (CNAs), the Director of Nursing (DON), and the Administrator (ADMIN), indicated a lack of coordination and communication regarding the hospice binder and documentation. The hospice clinical director confirmed that the hospice would have provided the necessary documentation within the first couple of days, but the facility staff could not locate the binder or any hospice documentation for the resident. Staff members had differing accounts of the responsibility for managing hospice documentation, with some believing it was the responsibility of the medical records staff, while others thought it was the responsibility of the DON and Assistant Director of Nursing (ADON). The facility's policy and the Skilled Nursing Facility Hospice Patient Services Agreement required both the nursing facility and the hospice to maintain complete and detailed clinical records. However, the facility failed to adhere to these requirements, resulting in a lack of proper documentation and coordination of care for the resident. This failure could potentially place residents receiving hospice services at risk of inadequate end-of-life care due to the lack of documentation, coordination, and communication of resident needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 939 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wurzbach Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 0 | 0 |
| The Lev At San Antonio | 1 mi | ★★★★★ | 30 | 0 |
| The Atrium Rehabilitation Center | 1 mi | ★★★★★ | 1 | 0 |
| Oak Park Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 25 | 0 |
| Patriot Heights Health Care Center | 1.6 mi | ★★★★★ | 11 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Heights At Medical Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.