Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Laurenwood Nursing And Rehabilitation during CMS and state inspections, most recent first.
Failure to Provide Written Transfer or Discharge Notices: The facility did not give written transfer or discharge notices, with reasons for the move, to three residents or their representatives, and did not send copies to the State LTC Ombudsman. One resident had severe cognitive impairment and was transferred to the hospital twice, another had moderate cognitive impairment and was sent out after a fall and leg pain, and a third had a planned discharge home. The Social Worker and DON stated that only transfer forms or 30-day notices were handled, and the discharge policy did not require written resident notification.
Improper Food Storage and Handwashing Sink Waste Receptacle Use: The facility failed to keep the handwashing sink #1 waste receptacle limited to disposable paper towels, as it also contained used gloves and plastic wrapping. In the dry storage area, multiple canned goods were observed with dents on the seams or sides, and some cans lacked clear received or best-by dates. The DM and DA stated that dietary staff were responsible for labeling and stocking the canned goods, and the facility policy prohibited use of damaged cans.
A facility failed to maintain infection control when one resident being treated under contact isolation for MRSA was roomed with another resident who had invasive devices, and staff gave conflicting explanations about whether isolation was needed. The facility also failed during incontinence care when a CNA continued care with the same gloves and did not perform hand hygiene after glove changes. The residents involved had significant medical needs, including indwelling devices, severe cognitive impairment, and dependence on staff for care.
A resident with bipolar disorder, schizophrenia, and psychotic symptoms was not referred for PASSR Level II review after a significant change in status. The MDS Coordinator said she received the PASSR Level-I screening but did not submit a new one, and the DON said she did not know the process to follow if the screening was inaccurate. The resident’s MDS did not include PASSR status, and the on-file Level-I screening incorrectly stated the resident did not have mental illness or dementia.
The facility failed to protect resident privacy and confidentiality by placing an "Elopement Binder" containing full admission records, including names, dates of birth, SSNs, Medicare/Medicaid numbers, addresses, and contact phone numbers, on a table by the front door. This binder, intended for residents identified as having elopement potential, was accessible to anyone entering or exiting the building. The DON acknowledged that such personal information is protected under HIPAA and should not be left where it can be accessed by unauthorized individuals, while the ADON reported she had continued an existing practice of maintaining the binder. The Administrator stated that only limited staff, such as business office, social worker, and IDT members, should have access to this level of information, and facility policy required reasonable measures to safeguard protected health information from unauthorized release.
A resident with dementia and hypertension was diagnosed with pneumonia and started on antibiotic therapy, but the care plan was not updated to include the pneumonia diagnosis or related interventions. Interviews with the DON and Administrator revealed uncertainty about the omission, despite facility policy requiring care plans to be revised with changes in condition.
A resident with multiple comorbidities was diagnosed and treated for pneumonia and sepsis during a hospital stay, but upon return, the DON did not add the infection to the facility's infection control log. The DON stated that only infections identified at the facility were logged, and there was no specific policy guiding this process. The administrator was also unsure about the documentation requirements for such cases.
Staff failed to disinfect a blood pressure cuff between use on two residents and did not follow proper glove use or hand hygiene during incontinent care for two other residents. These lapses occurred despite recent in-service training and clear facility policies requiring such infection control measures.
Surveyors found that staff failed to separate dented cans from regular food storage and did not label or date food and drink items as required. Kitchen staff and the DM confirmed that all staff were responsible for these tasks, and acknowledged the risks of not following proper procedures.
A resident with severe cognitive impairment was found on the floor after an unwitnessed fall and later diagnosed with a hip fracture. Initial assessments did not identify injuries, and the incident was not thoroughly investigated or reported to the administrator or state agency as required. Staff interviews revealed gaps in reporting procedures and lack of awareness among interim leadership, resulting in a deficiency related to the facility's response to potential abuse or neglect.
Two residents with moderate cognitive impairment and complex medical histories were given nutritional supplements by a medication aide without physician orders or proper documentation. Staff interviews and facility policy confirmed that such supplements require a physician's order specifying type, amount, and frequency, which was not obtained in these cases.
A resident with severe cognitive impairment and multiple health issues experienced an unwitnessed fall that was not reported to authorities as required, despite later being diagnosed with a hip fracture. Staff conducted internal monitoring and communicated with family and facility leadership, but did not follow mandated reporting procedures due to lack of training and unclear leadership during the administrator's absence.
A resident with dementia and a wander guard eloped from the facility unsupervised. The alarm system failed to alert staff, and the resident was found outside shortly after leaving the dining room. The resident's care plan identified them as an elopement risk, but staff did not effectively monitor the wander guard. The alarm volume was low, and staff were occupied with dining duties, leading to a lapse in supervision.
A resident under hospice care sustained an injury of unknown origin, and the facility failed to promptly notify the responsible party. The LVN assumed hospice would inform the family, which did not happen, leading to a delay in the family being aware of the resident's condition. The facility's policy required direct notification, which was not followed.
A resident with Alzheimer's disease was physically abused by a CNA, who was caught on video slapping and hitting the resident. The resident, who required total assistance and was nonverbal, was repositioned aggressively, leading to the involvement of law enforcement and the CNA's arrest. The facility's DON confirmed the incident and the lack of witnesses.
A resident with severe cognitive impairment eloped from a facility, crossing a busy street in a wheelchair to reach a fire station. The resident's care plan did not address the risk of elopement until the day of the incident, and previous assessments inaccurately indicated no risk. Staff were unaware of any exit-seeking behavior, and the resident's increased anxiety prior to the incident was not linked to elopement risk.
A facility failed to ensure a CNA maintained a current certification while providing care to residents. Despite being informed of her certification's impending expiration, the CNA continued to work multiple shifts without renewal. The HR department did not follow up on the renewal status, and the facility lacked a policy for registry verification. This oversight could result in residents receiving care from unverified staff.
A resident with severe cognitive impairment and multiple dependencies did not have her need for dining assistance accurately reflected in her care plan, leading to inconsistent meal consumption. Additionally, her bed was not maintained in the lowest position as required, resulting in a fall and shoulder injury. Despite regular care plan meetings, there was a disconnect between documentation and actual care, with staff unaware of the resident's fall risk and dining needs.
A resident with Alzheimer's and mobility issues was not provided a safe environment, as her bed was not kept in the lowest position despite being at risk for falls. The facility's staff had inconsistent views on the resident's fall risk, leading to multiple falls and a deficiency noted by surveyors.
A resident with Alzheimer's and a history of falls experienced a delay in treatment due to the facility's failure to promptly notify the physician of x-ray results indicating a shoulder dislocation. The x-rays were completed, but the results were not reviewed in a timely manner, leading to a delay in arranging hospital transfer. Interviews revealed confusion among staff about responsibility for checking and reporting results.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, as expired food items were found in the refrigerator on two separate occasions. Staff interviews revealed awareness of the requirement to discard food by the use-by date, but this was not followed. The Administrator was unaware of the outdated foods, and the facility's policies emphasize the importance of discarding expired food.
Failure to Provide Written Transfer or Discharge Notices
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing, in a language and manner they understood, of transfer or discharge and the reasons for the move, and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for three residents reviewed for discharge planning. The deficiency involved Resident #7, Resident #8, and Resident #77. Resident #7 was a female resident with diagnoses including NSTEMI, cognitive communication deficit, COPD, acute respiratory failure with hypoxia, and paranoid personality disorder. Her quarterly MDS showed a BIMS score of 3/15, indicating severe cognitive impairment. Progress notes documented that she was transferred to the hospital on 12/09/2025 for chest pain and shortness of breath, and again on 12/28/2025 for abnormal vital signs, altered mental status, and increased confusion. The record contained no evidence that a written transfer or discharge notice was provided to Resident #7 or sent to the State LTC Ombudsman. During interview, Resident #7 stated she did not remember receiving a written letter when sent to the emergency room and said she would have liked to receive one to give to her family member. Resident #8 was a female resident with diagnoses including COPD, type 2 diabetes mellitus without complications, morbid obesity, and chronic hypoxic respiratory failure. Her MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and she required mostly substantial to maximal assistance with care. Progress notes documented that after a fall and complaint of leg pain, she was not willing to wait for the facility mobile x-ray, called 911, and was taken to the hospital. There was no evidence that a written transfer or discharge notice was provided to Resident #8 or sent to the State LTC Ombudsman. During interview, Resident #8 stated she had never received a written letter when sent to the hospital and said written information would have allowed her to review the details more carefully later. Resident #77 was a female resident with diagnoses including cognitive communication deficit, muscle wasting, hypokalemia, and diaphragmatic hernia. Her admission MDS showed a BIMS score of 11/15, indicating moderate cognitive impairment, and she required mostly setup or clean-up assistance. Progress notes documented a planned discharge home on 04/02/2026, and there was no evidence that a transfer or discharge notice was provided to the State LTC Ombudsman. The Social Worker stated she had not provided written notification to residents or their representatives regarding transfer or discharge, including the reason for the transfer or discharge, and said the only list sent to the State LTC Ombudsman was 30-day notices. The DON stated nursing staff only provided a transfer form to the hospital and that she did not send a list of discharged residents to the State LTC Ombudsman. The facility's discharge policy did not contain requirements for written notification to the resident or representative regarding discharge.
Improper Food Storage and Handwashing Sink Waste Receptacle Use
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its kitchen. During observation of handwashing sink #1, the garbage receptacle contained items other than disposable paper towels, including used gloves and plastic wrapping. During observation of the dry storage room, multiple canned goods were found with dents, including several cans of fruit cocktail, one can of crushed pineapple, and one can of vegetarian beans; some of the cans also had written received dates, while others had no written received date or best by date. The facility's DM stated that the date written on canned goods was the date the facility received the item and that dietary aides were responsible for stocking the shelves and ensuring products were properly labeled. During interview, the DA stated she was responsible for writing the date on all canned goods and that the date reflected when the facility received the items. She also stated that if she noticed a dent while stocking canned goods, she would remove the can from the storage area and place it in the DM's office. The facility's Food Safety and Sanitation policy stated that bulging or leaking cans, cans with severe dents on the seam, or broken containers of food would not be used, and that canned and dry foods without expiration dates should be used within six months of delivery or according to the manufacturer's guidelines. The U.S. FDA Food Code 2022 was also cited regarding waste receptacles at handwashing sinks and food receiving and storage requirements.
Infection Control Failures During Room Cohorting and Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents. Resident #4, who had severe cognitive impairment, a tracheostomy, feeding tube, and indwelling catheter, was housed in the same room with Resident #19 while Resident #19 was being treated under contact isolation for MRSA found in the urine. Resident #19’s record reflected a urine culture with greater than 75,000 CFU/ML of MRSA, an order for strict contact isolation, and a plan for all services to be provided in the room, but the care plan did not include MRSA or isolation precautions. Facility staff stated they believed the two residents could be roomed together, and the DON stated Resident #19 did not have an active infection and did not need strict isolation. During observation, Residents #4 and #19 were seen together in the same room with a contact isolation sign posted and PPE available. Interviews with the infection control nurses, DON, FNP, hospice RN, and physician showed differing views about whether Resident #19 had an active MRSA infection and whether Resident #4 was at risk. The facility policy on multidrug-resistant organisms stated that a resident with an MDRO may need to be separated from a roommate who has invasive devices, wounds, or significant immunosuppression, and it also described possible room placement options depending on the situation. The facility also failed during incontinence care for Resident #42, who had an indwelling catheter, was always incontinent of bowel movement, and was dependent on staff for toileting hygiene. During observation, CNA A cleaned the resident and then continued care without changing gloves or performing hand hygiene, including applying barrier cream, placing a clean brief, and straightening the sheets with soiled gloves. CNA A stated she had been trained to perform hand hygiene after changing gloves and acknowledged the lapse could lead to contamination, germs, and infection. The DON stated hand hygiene was required after glove changes and that residents were at risk for spread of infection if it was not performed.
Failure to Refer Resident With Mental Illness for PASSR Level II Review
Penalty
Summary
The facility failed to refer a resident with mental illness for Level II resident review after a significant change in status assessment. Resident #12’s quarterly MDS assessment documented a BIMS score of 8, indicating moderately impaired cognitive skills for daily decision making, and listed diagnoses of bipolar disorder and schizophrenia. The resident’s comprehensive care plan also identified unspecified psychosis, schizoaffective disorder, and bipolar disorder, with a note that the resident could see and hear people in her room trying to rape her. However, the MDS did not include PASSR status, and the resident’s PASSR Level-I screening on file stated that she did not have mental illness and did not have dementia. During interview, the MDS Coordinator said she received the resident’s PASSR Level-I screening and did not submit a new one. She stated she was not supposed to correct the PASSR Level-I screening and did not know the effect it could have on the resident if it was incorrect. The DON said PASSR was data entry and that she reviewed Level-I screenings to ensure they were entered correctly in SIMPLE, but she did not know the process to follow if the Level-I screening was inaccurate. The facility policy stated that the Level I screen should be reviewed at least quarterly and that the appropriate state designated agency should be contacted for any resident requiring a Level II screen upon learning of an SMI/ID diagnosis that was previously unknown or undetermined.
Failure to Safeguard Resident Protected Health Information in Elopement Binder
Penalty
Summary
The facility failed to ensure residents’ right to personal privacy and confidentiality of personal and medical records for four residents identified as having elopement potential. Surveyor observation revealed a yellow notebook labeled “Elopement Binder” placed on a table by the front door. In addition to elopement policies and procedures, this binder contained full admission records for four residents, including their names, dates of birth, Social Security numbers, Medicare and Medicaid numbers, home addresses, and contact phone numbers. The binder was intentionally placed at the front door, as well as at each nurse’s station, so it could be easily located in the event of an elopement. During interviews, the DON stated that residents in the Elopement Binder had been determined to have the potential to leave the facility without notice and acknowledged that resident personal information is protected information with restricted access under HIPAA and should not be left where anyone could access it. The DON reported that the ADON was responsible for maintaining the binder and that she was unaware that full admission records were included. The ADON stated she had not initiated the Elopement Binder but continued the existing practice and confirmed that the front-door binder should not have contained residents’ personal information, only the binders at the nurses’ stations. The Administrator stated that resident personal information was restricted to a limited number of staff, such as the business office, social worker, and other IDT members, and that such information should not be left out where anyone could access it. Review of the facility’s policy on safeguarding and storing protected health information indicated the facility’s policy was to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of residents’ identifiable information and to safeguard against unauthorized release of information and records.
Care Plan Omission for Pneumonia Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting the diagnosis of pneumonia for one resident. The resident, an elderly female with a history of dementia and secondary hypertension, was readmitted to the facility and subsequently diagnosed with pneumonia, as documented in the Infection Surveillance Monthly Report. Despite the confirmed diagnosis and the initiation of antibiotic therapy (Levaquin), the resident's care plan did not reflect the pneumonia diagnosis or related care interventions. Interviews with the DON and Administrator revealed uncertainty as to why the pneumonia diagnosis was not included in the care plan. The DON indicated that she would typically be notified of changes in a resident's condition through central intake, floor nurses, or audits, which would prompt an update to the care plan. However, in this instance, the care plan was not updated to address the pneumonia, resulting in a missed need for the resident. The facility's policy requires that care plans incorporate all identified problems and risk factors, and be revised as residents' conditions change, which was not followed in this case.
Failure to Document Hospital-Treated Pneumonia on Infection Control Log
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program by not including a resident diagnosed with pneumonia on the infection control log. The resident, a male with a history of Alzheimer's Disease, COPD, and acute respiratory failure, was admitted to the facility, sent to the hospital after a chest x-ray indicated possible pneumonia, and subsequently diagnosed with pneumonia and sepsis at the hospital. Upon return to the facility, the resident was not added to the infection control log, despite the diagnosis and treatment for pneumonia. The Director of Nursing, who also served as the infection preventionist, acknowledged awareness of the resident's pneumonia diagnosis and hospital treatment but did not update the infection control log, stating that infections identified and treated outside the facility were not logged. The facility did not have a policy specifying requirements for the infection control log, and the infection control policy provided only general guidelines for nursing procedures. The administrator deferred to the DON for infection control log procedures and was unsure about the requirements for documentation of infections diagnosed during hospital stays.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices by staff members during resident care. Specifically, a medication aide did not disinfect a blood pressure cuff between use on two different residents during medication administration. The aide admitted to not being aware of the need to clean the equipment between residents, although she did perform hand hygiene between uses. Both residents involved had significant medical conditions, including schizophrenia, hypertension, cerebrovascular accident, and cognitive impairment, and required staff assistance for activities of daily living. Additionally, a certified nursing assistant did not follow proper glove use and hand hygiene protocols during incontinent care for two residents. The CNA failed to change soiled gloves and did not perform hand hygiene at any point during or after providing care, despite handling soiled briefs, personal care items, and resident belongings. The CNA continued to assist the residents with dressing, grooming, and repositioning while wearing the same soiled gloves, and left the resident rooms without washing hands or using hand sanitizer. Both residents receiving care were incontinent and had complex medical histories, including diabetes, end stage renal disease, and peripheral vascular disease. Interviews with the staff involved revealed a lack of understanding or recall of proper infection control procedures, despite recent in-service training on these topics. The Director of Nursing, who also served as the infection control preventionist, confirmed that staff were expected to clean equipment between residents and to change gloves and perform hand hygiene during resident care. Facility policies reviewed also required these infection control practices, but observations and staff interviews demonstrated that these procedures were not consistently followed.
Failure to Properly Store and Label Food Items
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, multiple dented cans, including cans of tuna, cream of mushroom, and zucchini tomato juices, were found in the dry storage area rather than being separated as required. Additionally, in the dining room, four large pitchers of unidentified liquid drinks were found without any label description or preparation dates. Interviews with the Dietary Manager (DM) and kitchen staff confirmed that dented cans were supposed to be stored in the DM's office and returned to the vendor, and that all kitchen staff were responsible for labeling and dating food and drinks. Record review showed that the facility's Food Receiving and Storage Policy required unacceptable products such as dented cans to be rejected and labeled food to be dated. The U.S. FDA Food Code also requires proper labeling and segregation of food items to prevent cross-contamination and food-borne illness. The staff acknowledged that failure to separate dented cans and to label and date food items could result in serving expired or spoiled food, potentially causing residents to become sick.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate and report an incident involving a resident who sustained an injury of unknown origin, which was suspicious for abuse or neglect. The resident, an elderly female with severe cognitive impairment, dementia, and total dependence on staff for activities of daily living, was found on the floor in the television room after an unwitnessed fall. Initial assessments by nursing staff did not reveal any injuries or complaints of pain, and neurological checks were performed as per policy. However, two days later, the resident exhibited signs of pain and guarding in her left leg, leading to an x-ray that confirmed a periprosthetic fracture of the left hip. The resident was subsequently transferred to the hospital for further evaluation and care. Despite the presence of a significant injury of unknown origin, the facility did not initiate a thorough investigation into the circumstances surrounding the incident. Interviews with staff revealed that the fall was reported to the DON, ADON, and family, but there was no evidence that the incident was reported to the administrator or to the State Survey Agency as required by facility policy and state law. The administrator was on maternity leave at the time and was unaware of the incident, and interim administrators were not clearly identified. The DON admitted to not being trained on incident reporting procedures and was unaware that the incident had not been properly reported or investigated. The facility's policy required immediate investigation and reporting of all alleged violations, including injuries of unknown source, to the administrator and appropriate authorities. However, documentation and interviews confirmed that these steps were not taken in this case. The lack of a timely and thorough investigation, as well as the failure to report the incident within the required timeframe, constituted a deficiency in the facility's response to potential abuse or neglect.
Nutritional Supplements Administered Without Physician Orders
Penalty
Summary
Staff administered nutritional supplements to two residents who were moderately cognitively impaired and unable to make all decisions for themselves, without obtaining physician orders as required by facility policy. Observations during the morning medication pass showed that a medication aide gave 4 ounces of nutritional supplement to each resident, despite the absence of written physician orders or documentation on the Medication Administration Record for these supplements. Both residents had significant medical histories, including hypertension, diabetes, peripheral vascular disease, and cerebrovascular conditions, and required staff assistance with activities of daily living. Interviews with the medication aide, licensed vocational nurses, and the Director of Nursing confirmed that all nutritional supplements must be given only with a physician's order, and that this protocol was not followed in these cases. Facility policy also specifies that commercial dietary supplements require a physician's order detailing the type, amount, and frequency. The failure to obtain and document physician orders for the administration of nutritional supplements constituted a deficiency in maintaining acceptable parameters of nutritional status for the residents involved.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown source were reported immediately, but not later than two hours after the allegation was made, to the administrator and appropriate authorities. Specifically, a resident with severe cognitive impairment, multiple comorbidities, and a history of being at risk for falls experienced an unwitnessed fall. The incident was not reported to the state agency as required by facility policy and federal regulations, despite the resident later being diagnosed with a periprosthetic hip fracture. The resident was found on the floor by staff, and initial assessments did not reveal any injuries or complaints of pain. Neurological checks and monitoring were conducted per policy, and the resident continued to be observed by various staff members over the following days. It was not until two days after the fall that the resident exhibited signs of pain and guarding of the left leg, prompting an x-ray and subsequent transfer to the hospital for a newly identified hip fracture. Throughout this period, the incident was communicated internally to the DON, ADON, and family, but not reported externally as an injury of unknown origin. Interviews with staff revealed a lack of clarity regarding reporting procedures, especially during the administrator's absence on maternity leave. The DON and interim administrators were unaware of the requirement to report the incident, and the DON admitted to not having been trained on incident reporting. The facility's policy required immediate investigation and reporting of such incidents, but this was not followed, resulting in a failure to meet regulatory requirements for timely reporting of suspected abuse, neglect, or injury of unknown origin.
Resident Elopement Due to Inadequate Supervision and Alarm Failure
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from eloping. The resident, who had unspecified dementia and wore a wander guard, managed to leave the facility unsupervised. The wander guard alarm system did not alert staff, and the resident was found outside between the facility's white fence and a neighboring home, approximately 10-15 feet from the nearest exit door. This incident occurred without any staff noticing the resident's departure or hearing the alarm. The resident had a history of severe cognitive impairment, as indicated by a BIMs score of 3, and was identified as an elopement risk. Despite this, the resident's care plan did not reflect any wandering behavior, and the staff failed to monitor the wander guard effectively. The resident was last seen in the dining room at 8:00 am and was found outside at 8:15 am, indicating a lapse in supervision during this time. Interviews with staff revealed that the alarm system was not heard due to its low volume, and the nurses were away from the nurse's station assisting with dining duties. The facility's elopement policy required staff to report any resident attempting to leave the premises, but this protocol was not effectively followed in this instance. The incident exposed gaps in the facility's supervision and alarm system, which contributed to the resident's unsupervised departure.
Failure to Notify Responsible Party of Resident's Injury
Penalty
Summary
The facility failed to immediately notify the responsible party of a resident when an injury of unknown origin was discovered. The incident involved a resident who was under hospice care with multiple diagnoses, including cirrhosis of the liver, COPD, coronary artery disease, and heart failure. On the evening of January 18, 2025, a Licensed Vocational Nurse (LVN) identified a small scratch on the resident's forehead but did not promptly inform the resident's responsible party. The responsible party only became aware of the injury upon visiting the facility the following day. The resident was later diagnosed with a hematoma on the forehead, and the bruising was noted to have developed overnight. The LVN had notified the hospice but assumed that hospice would relay the information to the family, which did not occur. The facility's policy required the LVN to notify the resident's representative directly, which was not done in this case. The Director of Nursing (DON) confirmed that the LVN should have called the responsible party in addition to notifying hospice. Interviews with hospice staff and the DON revealed that the resident had a history of impulsive behavior and confusion, which contributed to her frequent movements and potential for injury. The DON believed the bruising was delayed from a previous fall on January 15, 2025. Despite the facility's efforts to monitor and manage the resident's condition, the failure to communicate the change in the resident's condition to the responsible party was a significant oversight.
Resident Abuse by CNA Captured on Video
Penalty
Summary
The facility failed to protect a resident from physical abuse by a CNA. The resident, who had impaired cognitive function and was nonverbal, was aggressively repositioned and hit twice in the face by the CNA. This incident was captured on video surveillance installed in the resident's room, which showed the CNA slapping the resident with an open hand and a closed fist, causing the resident to grimace in pain. The resident, an elderly female with Alzheimer's disease and other medical conditions, required total assistance with activities of daily living. On the day of the incident, the resident's representative reviewed the video footage and observed the abuse, prompting her to notify law enforcement. The police arrived at the facility, confronted the CNA with the video evidence, and subsequently arrested the CNA for the offense of injury to an elderly person. The Director of Nursing (DON) and other staff members were informed of the incident after the arrest. The DON confirmed the identity of the CNA from the video footage and acknowledged the lack of witnesses during the incident. The facility's policy on abuse and neglect was reviewed, which defines abuse as the willful infliction of injury or harm, including physical abuse such as hitting and slapping.
Removal Plan
- Conducted skin assessments on all nonverbal residents
- Conducted safe surveys for every verbal resident
- Educated staff on abuse and neglect and customer service
- Implemented monitoring by all departments completing guardian angel daily rounds
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with severe cognitive impairment, resulting in the resident eloping from the facility. The resident, who was ambulatory with a wheelchair and required assistance for activities of daily living, managed to leave the facility unsupervised and crossed a busy four-lane street to reach a fire station. This incident placed the resident in an Immediate Jeopardy situation, highlighting a significant lapse in the facility's supervision and safety protocols. The resident's medical history included severe cognitive impairment, dementia, and anxiety, with no prior documented behaviors of wandering or exit-seeking. Despite these conditions, the resident's care plan did not address the moderate risk for elopement until the day of the incident. Previous elopement risk assessments had inaccurately scored the resident as having no risk for elopement, indicating a failure in accurately assessing and updating the resident's risk status. Interviews with facility staff revealed that the resident had not exhibited any exit-seeking behavior prior to the incident, and staff were unaware of any potential risk. The resident's anxiety had increased in the weeks leading up to the elopement, and medication adjustments were made, but these changes did not prompt a reassessment of the resident's elopement risk. The facility's failure to recognize and address the resident's increased anxiety and potential for elopement contributed to the incident.
Removal Plan
- An emergency QAPI meeting was held with Medical Director in attendance.
- All residents had a new elopement assessment to identify any current patients that are imminent risk for elopement.
- Elopement assessment will be completed upon admission and quarterly by the charge nurse and/or nurse managers.
- For any resident that triggers an imminent risk for elopement, the elopement response protocol will be initiated.
- Any patient that triggers elopement risk will be placed on 1:1 monitoring until no longer deemed necessary.
- DON will monitor for compliance and then monthly on an ongoing basis.
- Until alternative and/or safe living arrangements are made, they will be placed on one-one-supervision with facility staff.
- The resident's picture and face sheet will be placed in an elopement binder.
- Resident care plans will also be updated.
- The Director of Nursing and/or Nurse Manager will monitor weekly for compliance by completing an audit of the elopement assessments and the elopement binders.
- Audits will be completed weekly and monthly on an ongoing basis.
- The Regional Director of Clinical Services will review the documentation each week for compliance.
- The Executive Director will monitor daily to ensure compliance and will review.
Failure to Verify CNA Certification
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA), identified as CNA F, maintained a current nurse aide certification while employed and actively providing care to residents. CNA F's certification expired, yet she continued to work multiple shifts over several weeks without the necessary documentation of training and competency. This lapse in certification verification was identified during a review of CNA F's personnel file, timecard reports, and the facility's credentialing records. Interviews with the facility's Human Resources (HR) personnel and the Regional Nurse Consultant revealed that the HR department was responsible for conducting background and registry checks prior to hiring and annually thereafter. Although the HR representative was aware of CNA F's impending certification expiration and had informed her, there was no follow-up to ensure the renewal was completed. The facility did not have a policy for nurse aide registry verification, and despite a grace period extension for certification renewal by HHS, the facility failed to provide documentation of a waiver application. This oversight could lead to residents receiving care from staff without verified competencies.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which resulted in unmet needs for dining assistance and fall prevention. The resident, who was severely cognitively impaired and required substantial assistance with eating, did not have her need for dining assistance accurately reflected in her care plan. Despite observations and interviews indicating that the resident could not eat independently, the care plan inaccurately stated that she was independent with eating, requiring only setup assistance and monitoring. This discrepancy was further highlighted by the resident's inconsistent meal consumption records and the acknowledgment by staff that the resident needed assistance with meals. Additionally, the facility did not ensure that the resident's bed was maintained in the lowest position as required by her care plan, which was a critical intervention for her fall risk. The resident, who was fully dependent on staff for bed mobility and transfers, experienced a fall from her bed, resulting in a left shoulder injury. Observations confirmed that the resident's bed was often in a high position, contrary to the care plan's directive. Interviews with staff revealed a lack of awareness and adherence to the care plan's fall prevention measures, with some staff mistakenly believing the resident was not a fall risk. The facility's failure to update and implement the care plan according to the resident's current needs and conditions was evident in the lack of coordination among the interdisciplinary team. Despite regular care plan meetings, there was a disconnect between the care plan documentation and the actual care provided, as evidenced by conflicting statements from staff and the resident's representative. The facility's policy on comprehensive care plans emphasized the need for measurable objectives and timetables, yet these were not effectively applied in the resident's case, leading to significant deficiencies in her care.
Failure to Maintain Safe Environment for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents. Specifically, the facility did not maintain the bed of a resident, who was at risk for falls, in the lowest position possible while the resident was lying in bed. This oversight was observed during a survey, and it was noted that the resident had previously sustained falls, including one from her bed. The resident in question was an elderly female with Alzheimer's Disease, an above-the-knee amputation, muscle wasting, and lack of coordination. She was severely cognitively impaired and fully dependent on staff for bed mobility, repositioning, and transfers. Despite these conditions, the resident's bed was observed to be in a high position on multiple occasions, contrary to the interventions outlined in her care plan, which specified that the bed should be in the lowest position possible to mitigate fall risks. Interviews with facility staff revealed inconsistencies in the understanding and implementation of fall prevention measures. Some staff members acknowledged that the resident was a fall risk and that the bed should be in a low position, while others, including the DON, did not consider the resident a fall risk. This lack of consensus and adherence to the care plan contributed to the resident's falls and the subsequent deficiency noted by surveyors.
Failure to Promptly Notify Physician of X-Ray Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of x-ray results that fell outside of clinical reference ranges for a resident who was reviewed for radiology services. The resident, an 81-year-old female with Alzheimer's Disease and an acquired absence of the left leg above the knee, was at risk for falls and required extensive assistance with activities of daily living. After a fall, the resident was ordered to have x-rays of the skull, left arm, and left shoulder. The x-rays were completed, but the results indicating a dislocation were not promptly communicated to the physician. The x-ray results were available on the facility's electronic health record system but were not reviewed by the appropriate staff in a timely manner. The Wound Nurse discovered the results a day after they were available and reported them to the Director of Nursing (DON), family, and physician. However, there was a delay in arranging for the resident's transfer to the hospital for further evaluation, as the initial attempt to secure non-emergency transport was unsuccessful, and emergency medical services deemed the situation non-emergent. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for checking and reporting x-ray results. The DON stated that the facility's policy required the attending physician to be notified of test results, but there was confusion among staff about who was responsible for this task. The delay in notifying the physician and arranging for the resident's transfer to the hospital resulted in a delay in treatment for the resident's shoulder dislocation.
Failure to Discard Expired Food in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility did not discard food in the refrigerator by the use-by date as per the facility guidelines. Observations revealed that on two separate occasions, expired food items were found in the walk-in refrigerator. On one occasion, 12 small cups of cheese with a use-by date of 02/17/2024 were found on a rolling cart. On another occasion, a salad with a use-by date of 02/21/2024 was found among other salads. Interviews with the Dietary Manager and Cook A indicated that staff were aware of the requirement to discard food by the use-by date but failed to do so. The Dietary Manager acknowledged the oversight and mentioned plans to conduct an in-service with all staff. The Administrator was unaware of the outdated foods and referred to the facility's policy, which mandates the daily discarding of outdated products. The facility's policies from 2017 and 2007 were reviewed, both emphasizing the importance of discarding expired food to ensure safety and maintain nutritional quality.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,182 citations issued within 25 miles in the last 12 months — including the 61 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Duncanville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Duncanville Healthcare And Rehabilitation Center | 1.5 mi | ★★★★★ | 18 | 0 |
| The Lennwood Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 4 | 0 |
| Williamsburg Village Healthcare Campus | 2.3 mi | ★★★★★ | 36 | 5 |
| The Villa At Mountain View | 3.6 mi | ★★★★★ | 6 | 0 |
| Five Points Nursing And Rehabilitation | 4 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.