Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Lennwood Nursing And Rehabilitation during CMS and state inspections, most recent first.
Missing Discharge Summaries for Four Residents: The facility failed to complete discharge summaries for four residents who were discharged to an acute care hospital or home. The residents had significant diagnoses including CKD, HF, sepsis, metabolic encephalopathy, rhabdomyolysis, cerebral atherosclerosis, and DM2. Record review showed no completed discharge summary in the EHR for any of the four residents, and interviews confirmed nursing staff and the SW were responsible for the discharge summary process, with the nurse on duty expected to complete it at discharge.
An unsecured mechanical lift was observed parked in a hallway between resident rooms on the 300 Hall during repeated checks. CNA B said she was assigned to the hall, did not know the lift was left unlocked, and typically did not verify whether parked lifts were secured. LVN C and the ADON also stated they were unaware of the lift being left in the hallway, and record review showed the facility policy for mechanical lifting machines did not address lift safety and storage hazards.
Call lights were not accessible for several residents, including in shared toilet areas where pull strings were too short or tangled, and two residents did not have call lights within reach at all. In one room, a resident with cancer and moderate cognitive impairment was sweating in bed because the AC was not working, and the room temperature was measured at 82 degrees. Staff and the Maintenance Director acknowledged the call light and temperature problems, and the residents’ care plans and facility policy required accessible call lights and a comfortable room environment.
A facility failed to ensure two residents with CVA-related left-sided contractures received ordered ROM/splinting support. One resident had impaired LUE ROM, no splint or ROM task on the CNA list, and was observed with a contracted left hand and no device in place; staff said they had not been instructed on splint use. The second resident had an active order for a left UE splint for 8 hours daily, but no device was in place, the CNA task list did not include splinting or ROM, and staff stated they were unsure whether the resident ever received the splint.
Failure to Monitor Wanderguards and Elopement Risk: The facility did not consistently identify or document wandering/elopement risk for three residents, and shift-by-shift wanderguard checks were missing from the TARs. One resident with dementia and moderate cognitive impairment was observed without a wanderguard despite a current order for one, while two other residents with cognitive impairment had wanderguards in place but no documented monitoring. Care plans and Kardex entries did not consistently reflect elopement risk, and staff interviews showed confusion about which residents were at risk and where that information was located.
A resident with severe cognitive impairment had Econazole Nitrate Cream, 1% left on the nightstand in his room with a non-facility pharmacy label and no physician order on the medication record. The LVN said the ointment should not have been left at the bedside, and the DON and Administrator stated medications should be stored securely and not kept at the bedside.
Incomplete Elopement Care Plans and Missing Kardex Information: The facility failed to ensure that multiple residents with dementia, cognitive impairment, or other neuropsychiatric conditions had complete, person-centered care plans and Kardex entries for wandering/elopement risk and wander guard use. Several residents had blank or incomplete elopement assessments, and some had physician orders for wander guards that were not reflected in the care plan or Kardex. One resident was observed with the wander guard on the wrong ankle, and staff stated the Kardex should show elopement risk and device status.
A facility failed to ensure needed nail care for four residents who required staff help with ADLs. Residents with conditions including CVA, hemiplegia, weakness, lack of coordination, and cognitive impairment were observed with fingernails that were long, jagged, and in some cases dirty with debris underneath. Staff, including CNAs, an LVN, the DON, and the Administrator, acknowledged the nails needed to be cleaned and trimmed and stated nail care was part of resident hygiene.
Expired eye drops and artificial tears were found on a medication cart, including multiple opened glaucoma drops and artificial tears past the expected discard timeframe. An LVN stated nurses were responsible for checking carts at the start of each shift, and the DON confirmed liquid meds should be labeled with the open date and discarded no later than 28 days after opening. The facility policy stated outdated or deteriorated meds are to be immediately removed from stock and disposed of accordingly.
Hand Hygiene and Glove Changes Not Performed During Incontinent Care: A CNA provided incontinent care to a resident with HTN, DM2, CVA, and severe cognitive impairment but did not perform hand hygiene or change gloves when moving from a contaminated body site to a clean body site and when handling the dirty brief. The CNA acknowledged the expected hand hygiene steps, and the DON stated staff were to complete hand hygiene before and after care and change gloves during incontinent care.
A resident with cancer, muscle weakness, lack of coordination, and moderate cognitive impairment was found lying in bed in a hot room with sweat on his face. He said the AC unit under the window had not worked for about a month, and the room temperature was measured at 82 degrees, above the facility’s stated range of 71 to 81 degrees. The Maintenance Director found the unit had no power at the outlet, and the DON said he was not aware of the issue.
A resident with severe cognitive impairment and a history of elopement was able to leave the facility undetected, despite wearing a Wanderguard device. The facility did not complete an elopement assessment prior to the incident, and staff were unaware of the resident's exit until notified by someone outside the facility. The resident was later found at a nearby location with minor injuries.
A resident with severe cognitive impairment and a history of wandering eloped from the facility undetected, despite having a Wanderguard device in place. The incident was not reported to the State Survey Agency within the required timeframe, and documentation of the event and device checks was incomplete. Staff and administration failed to ensure timely and proper reporting of the incident as required by facility policy and regulation.
A facility failed to provide adequate pharmaceutical services, resulting in the loss of 26 tablets of Acetaminophen-Codeine #3 for a resident. An LVN signed for the medication delivery but could not recall receiving it, leading to its disappearance. The resident, with a history of transient cerebral ischemic attack and rheumatoid arthritis, was at risk of unrelieved pain due to the missing medication.
The facility failed to provide adequate care for residents with pressure ulcers, as observed in three cases. A resident developed an unstageable pressure ulcer, and wound care was not consistently provided. Another resident's stage 4 ulcer was not properly dressed, and the low air loss mattress settings were incorrect. A third resident's mattress was not turned on, and staff did not adjust settings according to residents' weights, impacting pressure ulcer prevention and treatment.
Two residents in the facility experienced inadequate catheter care, leading to potential risks of catheter-associated urinary tract infections. One resident with a suprapubic catheter had no urine output documented, and the care plan lacked specific interventions. Another resident's catheter showed cloudy urine with sediment, which was not addressed by staff. Interviews revealed inconsistencies in monitoring and reporting, highlighting deficiencies in adhering to catheter care protocols.
A facility failed to administer blood pressure medication, Midodrine, according to physician orders for a resident with multiple health conditions. The resident's blood pressure was not recorded before administering the medication on several occasions, contrary to the facility's policy. This oversight could lead to the resident not receiving the correct dosage of medication.
The facility failed to maintain complete and accurate medical records for three residents with pressure ulcers and non-pressure wounds. Documentation gaps were found in the treatment administration records (TARs) for these residents, with numerous instances of undocumented wound care. Interviews revealed that wound care responsibilities were sometimes delegated to charge nurses, but there was a lack of consistent documentation and oversight to ensure treatments were completed and recorded.
A facility failed to obtain necessary hospice documentation for a resident admitted to hospice care, including nursing documentation, plan of care, and physician orders. The resident, with a life expectancy of less than six months, required substantial assistance for daily activities. Staff changes and the absence of a designated hospice coordinator contributed to the oversight.
A LTC facility reported a 29% medication error rate involving two residents. One resident received crushed extended-release medications, while another had medications improperly administered via a G-tube. Staff failed to follow physician orders and facility policies, leading to potential medication interactions and ineffective treatment.
A medication aide in a facility failed to follow infection control protocols while providing peri care to a resident, as they did not change gloves or perform hand hygiene after cleaning the resident. This oversight was compounded by a lack of training and awareness, as the aide had not been in-serviced on proper procedures. Interviews with staff confirmed the expectation of changing gloves and performing hand hygiene to prevent cross-contamination, but there was no evidence of the aide receiving necessary training.
The facility failed to notify physicians of significant changes in two residents' conditions, leading to their unexpected deaths. One resident had a dangerously low blood sugar level, and another had severe pulmonary edema or pneumonia, but neither physician was informed promptly. This lack of communication prevented timely medical intervention.
Two residents in a facility were not properly monitored or treated for changes in their conditions, leading to their deaths. One resident with diabetes experienced a dangerously low blood sugar level, but there was no documented follow-up or intervention after the initial shift. Another resident with multiple health issues had abnormal chest x-ray results indicating severe pulmonary edema or pneumonia, but the findings were not communicated to the medical team. These deficiencies highlight a lack of adherence to care protocols and communication failures within the facility.
A resident with multiple health conditions did not receive prescribed medications during several morning shifts due to refusals documented by a medication aide, MA G, without proper follow-up or notification to nursing staff. The facility failed to record necessary blood pressure readings to assess medication needs, and the charge nurse was unaware of the refusals, indicating a breakdown in communication and protocol adherence.
A resident with multiple medical conditions did not receive scheduled showers or bed baths according to her preferences for May and June 2024. Despite having a system for tracking showers, inconsistencies in documentation and execution were found. Staff interviews revealed gaps in following the facility's policy, contributing to the deficiency in providing adequate personal hygiene care.
The facility failed to provide necessary wound care for three residents with pressure ulcers on multiple occasions, as prescribed by their physicians. This lapse in care was due to confusion and lack of clarity regarding wound care responsibilities among staff, particularly on weekends.
The facility failed to document wound care for three residents on specified dates, despite having active wound care orders. Staff interviews revealed that the care was performed but not recorded, violating the facility's documentation policies.
Missing Discharge Summaries for Four Residents
Penalty
Summary
The facility failed to complete discharge summaries for 4 residents who were discharged from the facility. Record review showed that Resident #1 was discharged to an acute care hospital, Resident #2 was discharged to an acute care hospital, Resident #3 was discharged to an acute care hospital, and Resident #4 was discharged home, but each resident’s electronic health record did not contain a completed discharge summary. The report states that the discharge summary was expected to include an accurate and current description of the resident’s clinical status and individualized care instructions to support safe transition to another setting. Resident #1 was an older female with diagnoses including lack of coordination, chronic kidney failure, and heart failure. Resident #2 was an older male with diagnoses including metabolic encephalopathy, rhabdomyolysis, extrarenal uremia, acute kidney failure, and chronic kidney disease. Resident #3 was an older male with diagnoses including sepsis and stage 3 chronic kidney disease. Resident #4 was an older male with diagnoses including cerebral atherosclerosis, heart failure, and type 2 diabetes. For each of these residents, the record review found that a discharge summary had not been completed after discharge. During interview, the MDS Coordinator stated nursing staff and the Social Worker were responsible for opening and closing discharge summaries, and that if she did not open the discharge summary, the IDT would not receive a notification to complete its part. She confirmed Resident #2 did not have a discharge summary and stated LVN A should have completed it. The Administrator stated she was not aware the discharge summaries were missing and said the nurse on duty during discharge should complete them. She also stated the facility had a vacant Social Worker position and nursing staff had been directed to complete discharge summaries. The facility policies reviewed stated that a discharge summary and post-discharge plan would be developed and that the nurse caring for the resident at discharge was responsible for ensuring the discharge summary was complete, including diagnoses, course of illness or therapy, medication reconciliation, and a post-discharge plan of care.
Unsecured Mechanical Lift Left in Hallway
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible on the 300 Hall when an unlocked and unsecured mechanical lift was observed parked in the hallway between residents’ rooms. The lift was seen in the hallway during multiple observations, and no residents were observed in the hallway at those times. During interview, CNA B stated she was assigned to the 300 Hall and was unaware that the mechanical lift had been left unlocked and unsecured in the hallway. She stated that she had received in-service training on mechanical lift usage, safety, and storage, and that lifts were to be locked when not in use and placed in a storage area rather than left in the hallway. She also stated she typically did not check parked mechanical lifts to verify whether they were locked and secured. LVN C stated she was also assigned to the 300 Hall and was unaware of the unsecured lift in the hallway. She stated that mechanical lifts should always be locked and secured when not in use and should never be placed in the hallway. ADON A stated she was unaware the lift had been left unlocked and unsecured during the observations and stated that all mechanical lifts were expected to be locked when not in use and stored in a safe place. Record review showed the facility’s policy for Accidents and Supervision required the resident environment to remain as free of accident hazards as possible, but the facility’s policy for Using a Mechanical Lifting Machine did not address accidents and hazards related to mechanical lift safety and storage.
Call lights inaccessible and room temperature not maintained
Penalty
Summary
The facility failed to maintain a comfortable room temperature for a resident with cancer, muscle weakness, lack of coordination, and moderate cognitive impairment. The resident was observed lying in bed in a hospital gown with a damp face from sweating and stated that his room was hot because the air conditioning unit under the window was not working. He reported that the problem had been ongoing for about a month and that he had told aides about it. Later that day, the Maintenance Director checked the room temperature and found it to be 82 degrees Fahrenheit. He also found that the air conditioning unit would not turn on until he unplugged it, tested the outlet, and then plugged it back in, after which it started working. The facility also failed to keep call light systems accessible in shared resident toilets and at residents’ bedsides. In the shared toilets inside resident rooms, the call light pull strings were observed intertwined on a grab bar, short, and about two feet from the floor, making them difficult to reach. These conditions were observed for multiple residents in different rooms. The Maintenance Director stated the call light strings were too short and needed to be within reach of a resident who was on the floor, and he identified the risk as residents falling and not getting help. In addition, two residents did not have their call lights within reach. One resident with stroke, left-sided paralysis, and severe cognitive impairment had his call light on a chair underneath gift bags and birthday decorations and stated he was not sure where it was. A CNA found the call light and stated it should have been within reach on the bed. Another resident with sepsis, hypertension, diabetes, stroke, moderate cognitive impairment, and substantial/maximal assistance needs had her call light on the floor about three feet away from her wheelchair and stated she could not reach it. A CNA then attached the call light to her clothing so it would be within reach. The residents’ care plans and the facility policy both reflected that call lights were to be within reach and accessible for assistance.
Failure to Provide Splinting and ROM Support for Residents with Left-Hand Contractures
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to maintain or improve range of motion for two residents with left-sided contractures. Resident #34 had diagnoses including CVA and hemiplegia/hemiparesis affecting the left nondominant side, a BIMS score of 14, and MDS coding showing impairment in range of motion on one side. His care plan addressed hemiplegia/hemiparesis and included therapy evaluation and treatment, but the CNA task list did not show splint placement or range of motion for the left hand, and the order summary did not show a physician order for a left hand splint or ROM on the survey date. Resident #34’s OT evaluation documented impaired left upper extremity ROM and noted the resident was at risk for further decline in function and falls. During observation, he was lying in bed with his left hand contracted and unable to open it on command, and no contracture management device was in place. He stated he had a stroke, could not use his left hand, and had never had a splint or support for it. A CNA later opened the hand and noted the nails extended about 0.8 cm from the fingertips, with no skin breakdown on the palm. The CNA stated she had not been instructed on splint placement or use of a carrot splint and that it was not on the task list for splinting or ROM exercises. Resident #45 had diagnoses including CVA, weakness, lack of coordination, and hemiplegia/hemiparesis affecting the left nondominant side, with a BIMS score of 08 and MDS coding showing impairment in range of motion on one side. His care plan addressed impaired physical mobility related to contractures and included referral to therapy, and the order summary showed an active physician order for a left upper extremity splint for 8 hours per day with monitoring for redness, edema, or skin breakdown. However, the CNA task list did not indicate splint placement or ROM for the left hand, and during observation the resident was in a wheelchair with the left hand contracted and no contracture management device in place. He stated he had a stroke, could not use his left arm and hand, and had never had a splint or support for it. A CNA opened the hand and noted the nails extended about 0.6 cm from the fingertips, with no skin breakdown on the palm. Staff interviews showed the CNA had not been instructed on splint placement, the LVN did not know if the resident ever received a splint, and the PT Director stated the splint order had been entered but she had no documentation that the splint was given to the resident.
Failure to Monitor Wanderguards and Document Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were in place and monitored for residents at risk for wandering and elopement. Resident #14 had dementia, moderate cognitive impairment, and was identified in nursing notes as a wanderer and high risk for elopement, yet the elopement assessment was incomplete, the care plan did not reflect elopement risk or wanderguard use, and the Kardex did not identify him as an elopement risk. Although a physician order dated 09/04/25 required a wanderguard on the right ankle with placement and proper working function checked every shift, the September 2025 MAR/TAR contained no shift-by-shift monitoring documentation. During observation on 09/23/25, staff checked both ankles and could not locate a wanderguard on Resident #14. Resident #6 had encephalopathy, schizoaffective disorder, moderate cognitive impairment, and required supervision for transfers and ambulation. Her care plan identified her as a risk for elopement and included interventions such as distraction and structured activities, and a physician order required a wanderguard on the right ankle with placement and proper working function checked every shift. However, her Kardex did not identify her as an elopement risk, and her TAR contained no documentation of wanderguard monitoring for September 2025. During observation, a wanderguard was present on her right ankle, but she stated she could not remember whether staff were monitoring it. Resident #30 had dementia, delusional disorder, severe cognitive impairment, and required assistance with transfers and walking. Her care plan stated she was at risk to wander and included a wanderguard intervention, and a physician order required a wanderguard on the left ankle with placement and proper working function checked every shift. Her Kardex did not identify her as an elopement risk, and her TAR contained no monitoring documentation for September 2025. During observation, she was wheeling herself in the hallway and stated she was going to the other side of the building; a wanderguard was observed on her left ankle, and she could not remember whether staff were monitoring it.
Medication Left at Bedside Without Proper Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and that only authorized personnel had access to them when Econazole Nitrate Cream, 1% was found at the bedside in Resident #53's room. Resident #53 was an [AGE] year-old male admitted and readmitted to the facility with diagnoses of hypertension and Alzheimer's Disease, and his MDS reflected a BIMS score of 00, indicating severe cognitive impairment. Record review of the medication order summary showed no physician order for Econazole Nitrate Cream, 1% on 09/23/25. Observation on 09/23/25 at 1:53 PM showed Resident #53 was not in the room and a box of Econazole Nitrate Cream, 1% with a non-facility pharmacy label was sitting on the nightstand, with a faded date on the package. During interview, the LVN stated he had not noticed the ointment box in the room and said it should not be left at the bedside because it could be used by someone for whom it was not intended. The DON stated the nurse should have removed the ointment from the room, notified the family and primary physician, and determined whether the medication should be incorporated into the resident's regimen. The Administrator stated there should not be any medications at the bedside and that residents' medications should be kept in the medication cart. The facility policy stated medications are to be stored properly and only accessible to licensed nursing personnel, pharmacy personnel, or other staff lawfully authorized to administer medication.
Incomplete Elopement Care Plans and Missing Kardex Information
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans with measurable objectives and timeframes for residents identified as at risk for elopement or wandering. The report identified deficiencies for Residents #14, #8, #6, #29, #30, and #37, including missing or incomplete care plan content and missing Kardex entries related to elopement risk and wander guard use. The facility’s own policies stated that residents at risk for unsafe wandering or elopement should have individualized interventions communicated to staff and included in the plan of care. Resident #14 had diagnoses including dementia, hypothyroidism, hypertension, and age-related cognitive decline, with a BIMS score of 8 and moderate cognitive impairment. Progress notes documented that he wandered at night, required repeated redirection, and was a high risk for elopement with a wander guard in use. However, the elopement assessments were incomplete, with blank sections for wandering behavior questions, goals, interventions, and clinical suggestions. His comprehensive care plan did not reflect elopement risk, wandering behavior, or wander guard placement, and his Kardex did not list elopement or wandering risk. Resident #8 had dementia and later psychiatry documentation described him as a poor historian, forgetful, with bipolar disorder, psychotic disorder with delusions, and a cognitive communication deficit. Although one elopement evaluation said he was not at risk and a later one said he was at risk, both had blank sections for risk and clinical suggestions. His physician orders included a wander guard, but his care plan and Kardex did not include his elopement/wandering risk or wander guard status. Resident #6 had encephalopathy, schizoaffective disorder, diabetes with neuropathy, and moderate cognitive impairment; her care plan noted elopement risk and included diversion interventions, but her Kardex did not reflect elopement risk despite a wander guard order. Resident #29 had stroke, hypertension, diabetes, and aphasia, with moderate impairment in daily decision-making. He had a wander guard order, and the nurse observed that the device was on the wrong ankle; the nurse also stated he was confused and had wandering and exit-seeking behavior at times. Resident #30 had dementia, delusional disorder, diabetes, severe cognitive impairment, and a long-standing care plan noting wandering risk and wander guard use, but her Kardex did not identify her as an elopement risk. Resident #37 had dementia, major depressive disorder, severe cognitive impairment, used a wheelchair, and had a care plan identifying him as an elopement risk with wander guard and diversion interventions, but his Kardex did not reflect wander guard or wandering status, and his elopement evaluation had blank sections for risk and clinical suggestions.
Failure to Provide Needed Nail Care and Personal Hygiene
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received needed assistance with personal hygiene, specifically nail care, for four residents reviewed. Resident #37 had decreased mobility and incontinence and was identified in the care plan as being at risk for impaired skin integrity, with an intervention to keep fingernails short. During observation, his fingernails on both hands were long and jagged, and he stated they were too long and raggedy and that he wanted them trimmed. The LVN stated she was about to trim his nails and noted they were long and jagged, adding that she usually trimmed them weekly but had not worked in over a week. Resident #60 had diagnoses including cancer, muscle weakness, and lack of coordination, with a BIMS score of 10 and a care plan calling for staff participation with personal hygiene and oral care. He was observed lying in bed with fingernails on both hands approximately 0.7 cm long and dirty with black matter underneath. He stated his nails were too long and wanted them cleaned and trimmed. A CNA later observed the nails and stated they needed to be cleaned and trimmed because they looked dirty, long, and jagged, and identified CNAs and nurses as responsible for nail care. Resident #34, who had a history of CVA and left-sided hemiplegia/hemiparesis with intact cognition, and Resident #45, who had diagnoses including CVA, weakness, lack of coordination, and left-sided hemiplegia/hemiparesis with moderate cognitive impairment, were also observed with long, jagged, and dirty fingernails. Resident #34’s fingernails were approximately 0.8 cm long with black substance underneath, and he stated he wanted them cleaned and trimmed. Resident #45 had long fingernails on his contracted left hand and a jagged right thumb nail; he stated he could trim some nails but was unable to trim his right thumb and left-hand nails and wanted them trimmed. CNAs and nurses stated nail care was their responsibility, and the DON and Administrator stated residents’ fingernails should be kept clean, trimmed, and smooth.
Expired Eye Drops Found on Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when expired medication was found on the 300-400-600-Hall medication cart during observation. The cart contained two boxes of Latanoprost Ophthalmic Solution 0.005% with an open date of 08/09/25, one box of Dorzolamide hcl 2% with an open date of 08/09/2025, one box of Timolol maleate 0.5% with an open date of 08/09/2025, and two boxes of Artificial tears with an open date of 08/13/25. During interview, an LVN stated all nurses were responsible for checking medication carts at the start of their shift for expired medications and supplies, and that liquid medications should be discarded 28 days after opening unless otherwise specified. The DON stated nurses were responsible for checking their carts at the start of shift and that liquid medications should be labeled with the open date and discarded no later than 28 days after opening. The Administrator stated she expected frequent auditing of medication carts to ensure there was no discharged residents' medication and no expired medication in the carts. The facility policy stated outdated, discontinued, or deteriorated medications are to be immediately removed from stock and disposed of accordingly.
Hand Hygiene and Glove Changes Not Performed During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one resident observed during incontinent care. Resident #43 was a female with diagnoses including hypertension, type 2 diabetes, and a cerebrovascular accident, and her Quarterly MDS reflected a BIMS score of 06 indicating severe cognitive impairment. Her record also showed she was frequently incontinent of both urine and bowel, and her care plan directed extensive assistance from one staff member for toilet use and personal hygiene. During observation, CNA M provided incontinent care to Resident #43 but did not perform hand hygiene or change gloves when moving from cleaning the resident’s front area to the buttocks area and when handling the dirty brief. CNA M entered the room, washed hands, put on clean gloves, and began care, but after cleaning the front area removed gloves and put on clean gloves without hand hygiene. CNA M then continued care to the buttocks area, pushed the dirty brief under the resident, and applied the clean brief without hand hygiene or changing gloves. In interview, CNA M stated she was supposed to complete hand hygiene before and after care and after removing the dirty brief, and to sanitize hands each time gloves were removed before putting on clean gloves. The DON stated staff were expected to complete hand hygiene before and after care and to change gloves and use hand sanitizer during incontinent care when taking off the dirty brief before applying the clean brief.
Unsafe Room Temperature and Nonworking AC Unit
Penalty
Summary
The facility failed to maintain a comfortable, homelike environment with safe temperature levels in Resident #60’s room. Resident #60 was an [AGE]-year-old male with diagnoses of cancer, muscle weakness, and lack of coordination, and his Quarterly MDS reflected a BIMS score of 10, indicating moderate cognitive impairment. His care plan included that his rights would be respected and maintained, including the right to live in safe, decent, and clean conditions and be treated with dignity. On observation, Resident #60 was lying in bed wearing a hospital gown, and his face was damp with sweat. He stated that it was hot in his room because the AC unit under the window was not working and said it had not been working for the last month. At the time the Maintenance Director checked the room, the temperature was 82 degrees Fahrenheit. The Maintenance Director was unable to initially turn on the AC unit, found there was no power to the outlet, and later got the unit working. The DON stated he was not aware the AC unit was not functioning and said residents are normally moved to another room or provided a fan until the AC is fixed. The Administrator stated her expectation was that all AC units in resident rooms be in working condition and that the resident should be moved to another room with working AC until the unit was repaired.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of elopement was not provided with adequate supervision, resulting in the resident eloping from the facility. The resident, who had diagnoses including dementia, gout, acute kidney failure, Type 2 diabetes, oropharyngeal dysphagia, lack of coordination, and major depressive disorder, was wearing a Wanderguard device as ordered by the physician. Despite this, the resident was able to exit the facility undetected during the night, and staff did not become aware of the elopement until notified by an external party. The facility's records indicated that the Wanderguard was checked regularly, but there were missing timestamps for the device checks on the day of the incident. The facility failed to complete an elopement assessment for the resident prior to the incident, despite the resident's history of exit-seeking behavior and previous elopement incidents reported by the family. The initial social history and assessment did not document any behavioral concerns, and the family was not asked about prior elopement behaviors during admission. The only elopement evaluation on file was completed after the resident had already eloped, which identified the resident as being at risk for elopement. Staff interviews confirmed that there was no prior knowledge or documentation of the resident's elopement risk before the incident. Facility policy on elopement did not include specific guidance on supervision, accident prevention, or proactive measures to prevent elopement. The incident report and staff interviews revealed that the resident was able to leave the facility through an exit door that did not alarm, and staff were unaware of the resident's absence until contacted by someone outside the facility. The resident was later found at a nearby apartment complex with minor injuries and was subsequently transferred to a secure unit at another facility.
Failure to Timely Report Resident Elopement Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or neglect were reported to the State Survey Agency within the required timeframe. Specifically, an incident occurred in which a male resident with severe cognitive impairment, dementia, and a history of wandering and elopement risk, exited the facility undetected during the night. The resident, who was wearing a Wanderguard device as per physician order, was found at an apartment complex across the street and returned to the facility with minor injuries. Documentation showed that the resident's Wanderguard was checked regularly and was reported to be in working order, but there were missing timestamps for checks on the days surrounding the incident. The facility's records did not indicate that an elopement evaluation had been completed prior to the incident, and the event was not reported to the State Survey Agency within 24 hours as required by policy and regulation. Interviews with staff and the resident's family revealed that the facility was not aware of the resident's prior history of elopement before admission, as this information was not solicited or provided during the pre-admission process. The family was notified of the incident by an outside party, and the facility staff only became aware of the resident's absence after being contacted. The Administrator and ADON were both on leave at the time of the incident, and the DON was responsible for reporting the event. However, there was no confirmation or documentation that the required self-report was made to the State Survey Agency, and the incident report was not uploaded to the TULIP system. The Administrator later acknowledged that she did not follow up to ensure the report was submitted, relying on the DON's verbal assurance. Facility policies required immediate reporting of all alleged violations involving abuse or neglect, including elopement incidents, to the appropriate authorities. The policies also outlined procedures for staff to follow in the event of a missing resident, including notification of the Administrator, completion of incident reports, and documentation in the medical record. Despite these policies, the failure to report the elopement incident within the mandated timeframe constituted a deficiency in the facility's abuse and neglect reporting procedures.
Failure in Pharmaceutical Services Leads to Missing Medication
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, resulting in the loss of 26 tablets of Acetaminophen-Codeine #3, a controlled medication. The incident involved a Licensed Vocational Nurse (LVN) who signed for the delivery of the medication but could not recall receiving it. This discrepancy was discovered during a shift change when the medication was found missing from the medication cart. The LVN was subsequently suspended and tested positive for marijuana. The resident involved was an elderly female with a history of transient cerebral ischemic attack, peripheral vascular disease, and rheumatoid arthritis. She was prescribed Acetaminophen-Codeine #3 to manage her pain, with the medication to be administered up to four times daily as needed. The failure to properly receive and account for the medication placed the resident at risk of experiencing unrelieved pain due to the unavailability of her prescribed medication. The facility's investigation revealed that the LVN had signed a manifest form indicating receipt of the medication, but the medication was not present during the subsequent shift. The facility's controlled substances policy required that controlled medications be counted upon delivery by both the receiving nurse and the delivery person, which was not adhered to in this case. This oversight led to the medication's disappearance and the potential risk to the resident's well-being.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as observed in three residents. Resident #1, who was admitted without any pressure ulcers, developed an unstageable pressure ulcer to the sacrum. The facility did not provide wound care on specific dates, and the resident's dressing was found dislodged without being replaced. Additionally, the low air loss mattress settings were not adjusted according to the resident's weight, potentially affecting pressure redistribution. Resident #2, who was readmitted with a stage 4 pressure ulcer, also experienced lapses in care. The facility did not replace the resident's soiled dressing overnight, and the wound was not packed as per physician orders. The low air loss mattress was set to the maximum weight, which was not appropriate for the resident's weight, potentially impacting the effectiveness of pressure relief. Resident #4, who had a history of a stage 4 pressure ulcer, was observed with a low air loss mattress that was not turned on during one observation. The facility staff, including LVN C, LVN B, and RN D, did not consistently check or adjust the mattress settings according to the residents' weights, which is crucial for preventing and treating pressure ulcers. The facility's wound care policy was not adhered to, as evidenced by the lack of proper wound care and mattress setting adjustments.
Inadequate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate catheter care and monitoring for two residents, leading to potential risks of catheter-associated urinary tract infections. Resident #2, a male with a history of urinary retention and other significant health issues, had a suprapubic catheter that was not properly monitored. The comprehensive care plan for Resident #2 did not include specific interventions for the suprapubic catheter, and during an observation, it was noted that the catheter was not draining, and the drainage bag was empty. Despite orders to monitor the catheter and urine output every shift, there was a lack of documentation and follow-up on the catheter's condition, leading to a situation where the resident reported leakage and being wet. Resident #4, a female with a history of pressure ulcers and dementia, also experienced inadequate catheter care. Observations revealed cloudy urine with sediment in the catheter tubing, indicating potential complications. The care plan for Resident #4 included interventions for catheter care, but the facility staff failed to notice or address the abnormal urine appearance during routine checks. The lack of timely reporting and intervention for the observed abnormalities in the catheter care of both residents highlights a deficiency in the facility's adherence to its catheter care policy. Interviews with facility staff, including LVN B and RN D, revealed inconsistencies in the monitoring and reporting of catheter conditions. LVN B admitted to not checking the urine output for Resident #2 after changing the drainage bag and failed to notice the cloudy urine in Resident #4's catheter. The facility's policy on catheter care emphasizes the importance of monitoring urine output and appearance, yet these protocols were not effectively implemented, leading to the identified deficiencies.
Failure to Administer Blood Pressure Medication as Ordered
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident by not administering blood pressure medication, Midodrine, in accordance with physician orders. Specifically, the facility did not obtain the resident's blood pressure prior to administering the medication on seven occasions. This oversight occurred over a period of several days, during which the resident's blood pressure was not recorded as required before administering the medication. The resident involved was an elderly male with multiple complex medical conditions, including encephalopathy, type 2 diabetes, hyperlipidemia, hypertension, atrial flutter, heart failure, end-stage renal disease, and a stage 4 pressure ulcer. The resident had a moderate cognitive impairment and used a wheelchair for mobility. Despite these conditions, the resident's care plan did not include any discussion of his blood pressure medication or related health conditions. The facility's medication administration records and nursing progress notes did not reflect the necessary blood pressure readings prior to administering Midodrine. This lack of documentation and adherence to physician orders could potentially lead to the resident not receiving therapeutic dosages of medication, posing a risk to their health. The facility's policy required obtaining and recording vital signs prior to medication administration, which was not followed in this case.
Incomplete Documentation of Wound Care for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents who were reviewed for pressure ulcers and non-pressure wounds. For one resident, there were twelve occasions in January 2025 where wound care was not documented, despite having an unstageable pressure ulcer to the sacrum. The resident's care plan included specific interventions for wound care, but the treatment administration record (TAR) showed gaps in documentation, and there was no explanation in the nursing progress notes for the missed wound care. Another resident had eight instances of undocumented wound care in January and February 2025. This resident had a stage 4 pressure ulcer and other skin issues requiring treatment. The TARs for this resident also showed gaps in documentation, and the nursing progress notes did not provide reasons for the missed treatments. Despite these documentation gaps, a wound care visit indicated some improvement in the resident's wounds. A third resident had 28 occasions of undocumented wound care in January and February 2025. This resident had venous and arterial ulcers and required specific skin treatments. The TARs showed missing documentation for these treatments, and the nursing progress notes did not address the omissions. Interviews with the facility's wound care nurse and other staff revealed that wound care responsibilities were sometimes delegated to charge nurses, but there was a lack of consistent documentation and oversight to ensure treatments were completed and recorded.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to obtain necessary hospice documentation for a resident who was admitted to hospice care. This included the hospice nursing documentation, the most recent hospice plan of care, the hospice election form, physician certification and recertification of the terminal illness, names and contact information for hospice personnel, hospice medications information, and physician orders. This deficiency was identified for one of the three residents reviewed for hospice services and records. The resident in question had a life expectancy of less than six months and was receiving hospice services due to a diagnosis of congestive heart failure, among other conditions. The resident required substantial assistance for all activities of daily living and was always incontinent of bladder and bowel. Despite these needs, the facility did not have the required hospice documentation in the resident's e-chart or hospice binder at the time of review. Interviews with facility staff revealed that there had been recent changes in staff, and there was no designated hospice coordinator at the time. The facility had been without a social worker for two months, which contributed to the oversight. The Director of Nursing acknowledged the potential harm of incomplete documentation, emphasizing the importance of having accurate hospice binders, especially since many hospice residents were full code.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 29% due to 9 errors out of 31 opportunities. This involved two residents during medication administration. For one resident, extended-release medications were crushed and administered, which is against the prescribed method of administration. The medications included Potassium Chloride ER and Isosorbide Mononitrate ER, both of which should not be crushed as it could lead to ineffective treatment and potential overdose. Another resident, who was severely cognitively impaired and on hospice care, received medications via a G-tube. The LVN administering the medications failed to follow physician orders and facility policy by not checking the tube placement or residual before administration. Additionally, the LVN did not flush the G-tube with water before and after administering the medications, which were all crushed and mixed together, contrary to the facility's guidelines that require each medication to be administered separately with flushing in between. Interviews with the staff involved revealed a lack of awareness and adherence to the facility's medication administration policies. The LVN admitted to not being aware of the requirement to flush the G-tube and to check for placement and residual, which are critical steps to prevent complications such as aspiration. The Assistant Director of Nursing confirmed that the staff did not follow the correct procedures, which could lead to medication interactions and ineffective treatment.
Inadequate Infection Control During Peri Care
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by the actions of a medication aide (MA C) who did not adhere to proper infection control protocols while providing peri care to a resident. During an observation, it was noted that MA C did not perform hand hygiene or change gloves after cleaning the resident, and subsequently applied a clean brief, barrier cream, and touched the resident's linens with the same gloves. This lapse in protocol could lead to cross-contamination and potential infection. Interviews with facility staff revealed a lack of training and awareness regarding infection control procedures. MA C admitted to not having been in-serviced or checked off on providing incontinent care and was unaware of the requirement to change gloves and perform hand hygiene. The Assistant Director of Nursing (ADON) and the infection preventionist confirmed that staff were expected to follow these procedures to prevent cross-contamination. However, there was no evidence that MA C had received the necessary training. The facility's policy, revised in December 2023, emphasized the importance of hand hygiene and stated that glove use does not replace hand washing.
Failure to Notify Physicians of Critical Changes Leads to Resident Deaths
Penalty
Summary
The facility failed to immediately consult with the residents' physicians when there was a significant change in the residents' conditions, leading to the unexpected deaths of two residents. Resident #3 experienced a dangerously low blood sugar level of 40, which was not promptly addressed by notifying the physician. Despite the presence of standing orders for such situations, the necessary medical intervention was not executed in a timely manner. The resident was found unresponsive and later pronounced dead after unsuccessful resuscitation efforts. Resident #4 had an x-ray that revealed severe pulmonary edema or pneumonia, but the physician or physician extender was not notified of these critical findings. The resident was later found unresponsive and died shortly after. The lack of communication regarding the x-ray results prevented timely medical intervention that could have potentially altered the outcome. Interviews with staff revealed a lack of adherence to protocols for notifying physicians of significant changes in residents' conditions. The facility's failure to ensure proper communication and follow-up on critical health changes contributed to the residents not receiving the necessary medical attention, ultimately resulting in their deaths.
Failure to Monitor and Communicate Leads to Resident Deaths
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, leading to significant deficiencies in their care. Resident #3, a male with a history of Type 2 Diabetes Mellitus, was not accurately assessed, monitored, or treated for a change in condition when his blood sugar dropped to 40 mg/dL. Despite the dangerously low blood sugar level, there was no documented evidence of continued monitoring or intervention after the initial shift. The resident later died that night, with the cause of death unknown. Interviews with staff revealed inconsistencies in following protocols for low blood sugar management, including the administration of glucagon and the lack of routine or PRN blood sugar checks. Resident #4, a male with multiple diagnoses including Hypertension and Dementia, was also not properly assessed or monitored for a change in condition. The facility failed to notify the physician or nurse practitioner of abnormal chest x-ray results indicating severe pulmonary edema or pneumonia. The resident was found unresponsive and later died, with no evidence that the x-ray findings were communicated to the medical team. Interviews with staff highlighted a lack of follow-up on lab and radiology results, which contributed to the failure to provide timely medical intervention. These deficiencies demonstrate a pattern of inadequate monitoring and communication within the facility, placing residents at risk for not receiving necessary medical care. The lack of adherence to professional standards of practice and the comprehensive resident-centered care plan resulted in significant lapses in care for both residents, ultimately leading to their deaths.
Failure to Administer Medications and Monitor Resident
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, identified as Resident #2, by not following current physician orders and failing to administer medications during multiple morning shifts. The medication aide, MA G, did not provide Resident #2 with her prescribed medications on numerous occasions throughout May and June 2024. Additionally, no blood pressure readings were recorded during these shifts to determine if Resident #2 required her blood pressure medication. This lack of medication administration and monitoring could potentially exacerbate the resident's health conditions. Resident #2, a female with a history of heart failure, dementia, major depressive disorder, and other significant health issues, was prescribed several high-risk medications, including antidepressants, diuretics, opioids, and insulin. Despite these prescriptions, the medication administration records (MAR) indicated that Resident #2 refused medications from MA G on multiple dates, with no documented follow-up or intervention from nursing staff. The charge nurse, LVN A, was unaware of these refusals, as MA G did not notify her or other relevant staff members. Interviews with facility staff revealed a breakdown in communication and protocol adherence. MA G claimed to have informed several nurses about the refusals, but there was no evidence of this in the records. The facility's procedure required the medication aide to attempt administration three times before notifying the nurse, who would then contact the physician and family if the resident continued to refuse. However, this protocol was not followed, leading to a lack of appropriate response to Resident #2's medication refusals.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene. Specifically, Resident #1, who had multiple medical conditions including Parkinson's Disease, dementia, and was wheelchair-bound, did not receive scheduled showers or bed baths according to her preferences for May and June 2024. The resident was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays, but records and interviews indicated that she did not receive these services consistently. Interviews with staff, including CNAs and LVNs, revealed inconsistencies in the documentation and execution of the shower schedule. Although the facility had a system in place for tracking showers, there were gaps in the documentation, with some staff failing to complete required shower sheets. The Point of Care (POC) system showed some bathing activities, but these did not align with the resident's scheduled days, and there was no documentation for several days in May and June. The facility's policy required CNAs to notify charge nurses if a resident refused a shower, and alternative options like bed baths were to be offered. However, interviews indicated that this protocol was not consistently followed. The new Assistant Director of Nursing (ADON) acknowledged the importance of reviewing and signing shower sheets to ensure compliance, but the lack of adherence to these procedures contributed to the deficiency in providing adequate personal hygiene care for Resident #1.
Failure to Provide Necessary Wound Care for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, three residents with pressure ulcers did not receive wound care on multiple occasions as prescribed by their physicians. This failure was observed through record reviews, interviews, and direct observations, indicating a significant lapse in care that could lead to worsening of existing pressure ulcers and the development of new ones. Resident #1, a male with vascular dementia, heart failure, and chronic embolism, was readmitted to the facility with an unstageable pressure ulcer to the sacrum. Despite having specific wound care orders, there was no documentation that wound care was provided on two separate dates. Additionally, the resident's baseline care plan did not address the wound, and the resident was later transferred to the hospital due to abnormal labs. Resident #2, a male with type II diabetes mellitus and heart failure, also had an unstageable pressure ulcer to the coccyx. The resident's wound care was not documented on three separate dates, and the wound increased in size over time. Similarly, Resident #3, a female with heart failure, pressure ulcer, and dementia, did not receive documented wound care on one occasion. Interviews with staff revealed confusion and lack of clarity regarding wound care responsibilities, particularly on weekends, contributing to the lapses in care.
Failure to Document Wound Care for Three Residents
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for three residents. Specifically, the staff did not document wound care for Resident #1 on 03/04/24, Resident #2 on 03/16/24, and Resident #3 on 03/06/24. These omissions were identified through record reviews and staff interviews, revealing a lack of proper documentation in the Treatment Administration Records (TAR) for the specified dates. Resident #1, a male with vascular dementia, heart failure, and chronic embolism, had active wound care orders for a sacrum wound. Despite these orders, there was no documentation of wound care being provided on 03/04/24. Similarly, Resident #2, a male with type II diabetes mellitus and heart failure, had wound care orders for a coccyx wound, but no documentation was found for wound care on 03/16/24. Resident #3, a female with heart failure, pressure ulcer, and dementia, also had wound care orders for a sacrococcyx wound, but no documentation was found for wound care on 03/06/24. Interviews with the staff revealed that the wound care was performed but not documented. LVN C mentioned that she performed wound care on 03/16/24 but thought she had documented it. The TN stated she provided wound care on 03/04/24 and 03/06/24 but forgot to document it. The facility's policies and procedures require that all wound care be documented, including the date, time, and the name and title of the individual performing the care. The Administrator emphasized the importance of documentation for ensuring proper care and communication among the interdisciplinary team.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Williamsburg Village Healthcare Campus | 0.6 mi | ★★★★★ | 36 | 5 |
| Duncanville Healthcare And Rehabilitation Center | 0.8 mi | ★★★★★ | 9 | 0 |
| Five Points Nursing And Rehabilitation | 2 mi | ★★★★★ | 6 | 0 |
| The Laurenwood Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 9 | 0 |
| Desoto Nursing & Rehabilitation Center | 3.2 mi | ★★★★★ | 15 | 1 |
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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 August 2026) and official state health department websites.