Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Lev At Town Park during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of stroke experienced significant knee pain and swelling, which staff failed to promptly assess, document, or report to the physician. Despite severe pain and a later x-ray revealing a femoral fracture, there were delays in both medical notification and hospital transfer, resulting in prolonged pain and delayed emergency surgery.
A resident with severe cognitive impairment and a history of stroke experienced escalating pain and swelling in the left knee, which was not promptly assessed or reported by nursing staff. Despite repeated complaints and a family member's concerns, staff delayed in notifying the physician and obtaining diagnostic imaging. After an x-ray revealed a displaced femoral fracture, there was a further delay of approximately 13 hours before the resident was sent to the hospital for emergency surgery, with inadequate pain management and monitoring throughout the incident.
A medication aide left a computer unlocked and unattended, displaying multiple residents' photos and names, making confidential medical information accessible. The aide admitted to forgetting to lock the computer and acknowledged this as a privacy violation, despite having received prior training on protecting resident records. The facility's policy requires all personal and medical records to be kept secure and confidential, and the administrator confirmed that staff must always protect resident information.
Three residents did not have comprehensive care plans addressing their specific needs, including exit-seeking behavior, use of oxygen and anticoagulants, and DNR status. Staff and documentation confirmed that these care plans were missing despite clear evidence of the residents' conditions and physician orders.
A resident with cognitive impairment and physical limitations was not provided timely assistance with the removal of unwanted facial hair, despite expressing a desire for this care and being unable to perform it independently. Staff interviews and observations confirmed that grooming assistance was not consistently provided as required by the resident's care plan and facility policy, resulting in the resident feeling unclean.
Multiple staff members failed to follow infection control protocols, including improper handling of linens and care items, lack of PPE use during direct care for residents on Enhanced Barrier Precautions, and missing infection control signage. These actions involved two residents with significant medical needs and resulted in increased risk of cross-contamination and infection.
Surveyors found expired medications on two medication carts, including Tramadol, Hyoscyamine Sulfate, and Haloperidol, which were not removed despite facility policies and recent in-services on medication management. Nursing staff acknowledged missing the expired medications during routine checks, and records showed that the affected residents had not received these medications in recent months.
A CNA placed a resident's Foley catheter drainage bag on the bed during catheter care, instead of keeping it below bladder level as required by facility policy and infection control standards. This action was observed and acknowledged by staff as improper, given the resident's medical history and care plan directives.
A nurse failed to verify the placement of a gastrostomy tube before administering medications to a resident with severe cognitive impairment and multiple medical conditions. Instead of following facility policy to confirm tube placement, the nurse only checked for residual contents and proceeded with medication administration. Staff interviews revealed inconsistent practices and understanding of proper tube placement verification, which did not align with facility policy.
A resident with moderate cognitive impairment and significant care needs was unable to summon staff assistance due to a non-functional call light system. The issue was discovered when the resident reported unanswered calls and the call light failed to activate during testing. Staff later found the cords unplugged, and the system only worked after being re-inserted, indicating a lapse in monitoring and ensuring call light functionality.
A resident with a history of yelling, cursing, and verbal abuse toward staff and family members was not accurately coded for behavioral symptoms on the quarterly MDS. Despite multiple nurse's notes and staff interviews documenting these behaviors, the staff member completing the MDS did not review available documentation or consult with other staff, leading to an incomplete assessment.
The facility had an 18% medication error rate, involving three residents who did not receive their medications as prescribed. Errors included administering medications without food, incorrect dosage measurement, and not following medication label instructions. Staff failed to adhere to proper medication administration procedures despite training.
The facility failed to maintain proper temperatures for leftover breakfast food and to safely thaw frozen food, placing residents at risk of foodborne illness. Scrambled eggs and hard-boiled eggs were stored at unsafe temperatures, and frozen pork was thawed in stagnant water at temperatures above the recommended level.
The facility failed to maintain an effective infection control program, as evidenced by a CNA not performing hand hygiene between glove changes during incontinent care and an LVN not maintaining sterile technique during tracheostomy care. These deficiencies were observed during direct care activities and confirmed through staff interviews.
A facility failed to ensure proper catheter care and hand hygiene for a resident with multiple medical conditions, including a history of UTIs. CNA A did not follow correct procedures for cleaning the Foley catheter and hand hygiene, which was acknowledged by the CNA and confirmed by the DON. The resident had recently been hospitalized for a UTI, and the facility lacked a documented policy for incontinent and Foley catheter care.
A facility failed to provide proper respiratory care for a resident with a tracheostomy, including not using sterile techniques during suctioning and not maintaining the prescribed oxygen levels. The resident, who has multiple medical conditions, was observed with moist breath sounds and foam at the mouth, indicating potential respiratory distress. The LVN admitted to not following proper procedures, and the DON acknowledged the need for updated training.
A facility failed to ensure accurate medication administration when a medication aide administered Minocycline along with a multi-vitamin and iron tablet to a resident, despite warnings against such combinations. The resident, who had multiple diagnoses and intact cognition, complained about the number of medications. The aide admitted to not reading the medication label, and the DON and Administrator emphasized the importance of following physician orders.
A resident with a complex medical history was allegedly slapped by a CNA during a night shift, leading to feelings of unsafety and distress. The incident was reported, and the CNA was terminated following an investigation. The resident had moderate cognitive impairment but was able to communicate her needs and had previously reported issues to the administration.
A resident's right to privacy and dignity was compromised when a CNA entered their room without knocking. Despite being trained on resident rights, the CNA failed to adhere to the protocol of knocking and introducing themselves. The resident, who was cognitively intact, reported frequent occurrences of staff entering without knocking. The facility's policy emphasizes maintaining resident dignity and privacy, which includes knocking before entering a room.
Two residents with severe cognitive impairment were left soiled and unattended, failing to receive necessary incontinence care. A CNA admitted to not changing the residents before leaving the shift, and the facility's policies on resident dignity and neglect were not followed. The incident was reported to the Administrator, highlighting a lapse in care for residents dependent on staff for daily living activities.
A resident in an LTC facility was found using a space heater in his room, despite knowing it was against policy due to fire safety concerns. The resident, who felt cold due to heat intolerance, repeatedly acquired space heaters, which were removed by staff only for him to replace them. The Maintenance Director, responsible for temperature adjustments and safety checks, was unaware of the heater's presence during his rounds, indicating a lapse in monitoring and enforcement of safety policies.
Failure to Immediately Notify Physician and Act on Change in Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify appropriate parties when there was a significant change in the resident's condition. The resident, who had severe cognitive impairment, non-Alzheimer's dementia, a history of stroke, and was dependent on staff for all activities of daily living, began experiencing pain and swelling in the left knee. Despite complaints of pain and visible swelling, nursing staff did not promptly assess, document, or notify the physician or nurse practitioner of the change in condition. Pain assessments and administration of PRN pain medications were delayed, and there was a lack of timely documentation and follow-up regarding the resident's ongoing pain and swelling. On multiple occasions, the resident reported severe pain (rated 8 out of 10) and swelling in the knee, but staff failed to immediately notify the physician or seek medical guidance. The resident's family member also reported the pain and swelling to staff, but the response was inadequate, with staff either not documenting the incident or not escalating the issue appropriately. When an x-ray was eventually ordered and revealed a displaced distal femoral shaft spiral fracture, there was a significant delay—approximately 13 hours—before the resident was transported to the hospital for emergency surgery. During this period, the resident continued to experience severe pain without appropriate intervention or escalation. Interviews with staff and review of records confirmed that there were lapses in assessment, documentation, and communication regarding the resident's change in condition. Staff failed to recognize the significance of the resident's symptoms, did not follow the facility's policy for notification of changes, and did not act promptly on critical diagnostic information. The delay in seeking medical attention and transporting the resident to the hospital after the fracture was identified resulted in prolonged pain and delayed treatment for the resident.
Removal Plan
- DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition.
- Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification.
- Charge nurses were instructed to conduct and document a Pain Assessment.
- Notify the PCP immediately when a resident exhibits new or worsening pain or when it contributes to a suspected change in condition.
- DON or designee (Unit Manager or Administrator) are to be notified of a change in condition.
- Implement and document physician orders in PCC.
- Reassess pain within one hour of pain medication and document effectiveness, if applicable.
- Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred.
- Residents with a change of condition will be noted on the 24-hour report for oncoming shifts.
- DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.
- Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator), Document notification in PCC, Enter any new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.
- Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routine rounding.
- All residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers.
- Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified.
- The facility will provide education regarding reporting recognition of change of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months.
- Charge Nurses, CNA's and Med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.
- The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting.
- The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process.
- Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service.
- Monitoring began including review of all in-service sign-in sheets and staff interviews to validate understanding and compliance.
Delayed Response to Acute Fracture and Change in Condition
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, non-Alzheimer's dementia, and a history of stroke did not receive timely and appropriate care following a significant change in condition. The resident, who was bedbound and dependent on staff for all activities of daily living, began experiencing severe pain and swelling in the left knee. Despite multiple complaints of pain from the resident and reports from family members, nursing staff failed to conduct thorough assessments, document findings, or notify the physician or nurse practitioner promptly. Pain assessments were inconsistently performed, and there was a lack of documentation regarding the resident's pain and condition changes during several shifts. When the resident's pain escalated and was unrelieved by PRN pain medications, staff delayed in escalating care and obtaining necessary diagnostic imaging. An x-ray was eventually ordered and performed, revealing a displaced distal femoral shaft spiral fracture. However, after the facility received the x-ray results indicating an acute fracture, there was a delay of approximately 13 hours before the resident was transported to the hospital for emergency evaluation and surgery. During this period, staff did not immediately notify the physician or nurse practitioner, nor did they reassess or adequately monitor the resident's condition. Interviews with staff and family confirmed that the resident's pain was not effectively managed, and communication breakdowns occurred at multiple points, including failure to document assessments, notify appropriate clinical leadership, and act on critical diagnostic findings. The facility's own Director of Nursing acknowledged that the change in condition should have been recognized and acted upon much earlier, and that the delay in care could have resulted in continued pain and adverse outcomes for the resident.
Removal Plan
- DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition.
- Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification.
- Charge nurses were instructed to conduct and document a Pain Assessment.
- Notify the PCP immediately when a resident exhibits new or worsening pain or when it contributes to a suspected change in condition.
- DON or designee (Unit Manager or Administrator) will be notified of a change in condition.
- Implement and document physician orders in PCC.
- Reassess pain within one hour of pain medication and document effectiveness, if applicable.
- Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred.
- Residents with a change of condition will be noted on the 24-hour report for oncoming shifts.
- DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.
- Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator), Document notification in PCC, Enter any new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.
- Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routine rounding.
- All residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers. Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified.
- The facility will provide education regarding reporting recognition of change of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months.
- This education includes: Completing and documenting Pain Assessments, Notifying the PCP promptly for any unrelieved, new or worsening pain, Documenting PRN pain medication response, Understanding when pain represents a significant change in condition.
- Charge Nurses, CNA's and med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.
- The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting.
- The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process.
- The Administrator will ensure the plan is completed in full.
- Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service.
- All In-service sign-in sheets were requested and reviewed.
- Interviews were conducted on all shifts with staff to verify the in-services and competencies had been conducted and to validate the staff understanding of the information presented to them.
Unattended Computer Exposes Resident Medical Records
Penalty
Summary
A medication aide (MA) left her computer unattended and unlocked, displaying multiple resident profiles with photos and names visible on the screen. This occurred when the MA stepped away from her medication cart to check for a medication in the medication room, leaving the computer accessible and exposing confidential resident information. The MA acknowledged during an interview that she had forgotten to lock the computer and recognized this as a violation of privacy and confidentiality policies, as well as a potential HIPAA violation. She also confirmed that she had previously received in-service training on protecting resident medical records. The facility's policy on confidentiality, reviewed as part of the investigation, states that all personal and medical records must be kept secure and confidential, regardless of the form or location of storage. The administrator confirmed in an interview that staff are required to always protect resident medical records, and failure to do so places residents at risk of having their privacy invaded. The incident was observed and confirmed through interviews and record review, demonstrating a failure to safeguard resident information as required by facility policy.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to address the medical, mental, and psychosocial needs of three residents. One resident, with diagnoses including schizophrenia and moderate cognitive impairment, exhibited repeated behaviors of pushing on the exit door near her room, as documented in progress notes on multiple occasions. Despite these documented behaviors and staff awareness, there was no care plan in place to address her exit-seeking or wandering behavior until after surveyor intervention. Staff interviews confirmed that the behavior was not initially care-planned, and the resident was only redirected when she attempted to push on the door. Another resident, who had moderate cognitive impairment and required substantial assistance with activities of daily living, was prescribed both oxygen and anticoagulant therapy. However, there were no care plans with interventions to address the use of oxygen or anticoagulants, despite physician orders for both. Staff interviews, including those with the MDS coordinator and DON, confirmed the absence of these care plans and acknowledged that such omissions could result in resident needs not being addressed. A third resident, with advanced directives indicating Do Not Resuscitate (DNR) status, also lacked a care plan to address this directive. Although the resident's DNR status was documented in physician orders and on the DNR form, the care plan did not reflect this critical information. Staff interviews confirmed that the care plan should have included the DNR status to ensure the resident's wishes were respected. The facility's own policies require that care plans include measurable objectives and interventions for all identified needs, but these were not followed for the residents in question.
Failure to Provide Timely Assistance with Grooming and Personal Hygiene
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, Parkinson's disease, muscle weakness, and dementia, who required assistance with personal care and supervision for personal hygiene, was observed to have a moderate amount of unwanted facial hair on her chin and above her top lip. The resident expressed that she was unable to remove the facial hair herself due to hand tremors and stated she would like the hair removed. Multiple observations confirmed the presence of facial hair over several days, and the resident reported not knowing when it was last removed by staff. Interviews with staff, including the DON and a CNA, confirmed that it was the responsibility of CNAs and nurses to ensure residents were groomed, including the removal of unwanted facial hair. The facility's policy emphasized the importance of maintaining resident dignity and grooming according to resident preference. Despite these policies and the resident's care plan, the necessary assistance with grooming was not provided in a timely manner, resulting in the resident feeling unclean and expressing a desire for improved personal hygiene.
Failure to Maintain Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices involving two residents and several staff members. Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) were observed handling potentially contaminated items inappropriately, such as placing a used sheet back on a clean linen cart after providing incontinent care, and carrying used disposable wipes from a resident's room to a medication cart. Additionally, resident care items like wash basins and urinals were found unlabeled, unbagged, and improperly stored in resident bathrooms, contrary to infection control protocols. Staff members providing care to residents on Enhanced Barrier Precautions (EBP), including those with indwelling Foley catheters and feeding tubes, did not consistently wear the required personal protective equipment (PPE), such as disposable gowns and gloves. Observations revealed that EBP signage was missing from the doors of residents who required these precautions, and several staff members, including CNAs and LVNs, were unfamiliar with EBP protocols. The care plans for the affected residents did not include EBP measures, despite physician orders and diagnoses indicating the need for such precautions. Interviews with staff and review of facility policies confirmed a lack of understanding and inconsistent implementation of infection control and EBP protocols. Staff members admitted to not following proper procedures for labeling, bagging, and storing resident care items, and for donning appropriate PPE when providing direct care to residents with wounds, indwelling devices, or artificial openings. These failures were directly observed and acknowledged by staff, placing residents at risk for cross-contamination and infection.
Expired Medications Not Removed from Medication Carts
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the timely removal of expired medications from two medication carts. On Med Cart A, three blister packs of Tramadol 50 mg tablets, totaling 68 tablets and all with the same expiration date, were found. The nurse responsible for the cart acknowledged missing the expired medication during routine checks. The medication administration records showed that the resident had not received Tramadol for several months, and the medication had not been administered during the period in question, despite the presence of a new order. On Med Cart B, a blister pack containing nine tablets of Hyoscyamine Sulfate and another containing one tablet of Haloperidol, both expired, were found. The nurse interviewed stated that nurses and unit managers were supposed to check the carts weekly, but the expired medications remained. The medications were associated with a resident who had not received them in recent months, and one of the medications had been discontinued without a documented end date. The nurse indicated that the medications had come from the resident's hospice and were no longer in use. Interviews with nursing staff and facility leadership confirmed that procedures were in place for checking medication expiration dates, and recent in-services had been conducted on medication management. However, the expired medications were not identified or removed as required by facility policy, which states that expired medications should be reported to the nurse manager. The failure to remove expired medications from the carts was observed directly by surveyors during their review.
Improper Foley Catheter Bag Placement During Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) provided Foley catheter care to a female resident with a history of urinary tract infection, dementia, acute kidney failure, severe sepsis, and neuralgia. The resident had an indwelling Foley catheter as documented in her medical records and care plan, which specified that the catheter drainage bag should be kept below the level of the bladder to prevent backflow of urine. During the observed catheter care, the CNA removed the Foley bag from its proper position and placed it on the resident's bed, contrary to facility policy and standard infection control practices. The CNA later acknowledged awareness of the correct procedure and admitted that placing the Foley bag on the bed could result in urine backflow, increasing the risk of urinary tract infection. The facility's Infection Control Preventionist confirmed that the Foley bag should always remain below the bladder during care. Facility policies reviewed also emphasized the importance of maintaining the drainage bag below bladder level to discourage backflow and ensure quality of care in accordance with professional standards.
Failure to Verify G-Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to verify gastrostomy tube placement prior to administering medications to a resident with a feeding tube, as required by facility policy. The nurse entered the resident's room to administer medications via the G-tube but did not check for tube placement or observe the tube site before proceeding. Instead, the nurse checked for residual contents and, finding none, flushed the tube and administered the medications, followed by another flush. The nurse did not use a stethoscope or other approved method to confirm tube placement, which was inconsistent with the facility's written procedures. The resident involved was an elderly female with severe cognitive impairment, dysphagia, protein calorie malnutrition, cerebral infarction, Alzheimer's disease, gastro-esophageal reflux disease, and a history of adult failure to thrive. She was receiving continuous enteral nutrition and had physician orders for specific medications to be administered via the G-tube. The care plan for this resident included monitoring for signs and symptoms of aspiration, infection, and tube dysfunction, and the facility's policies required verification of tube placement before administering any fluids or medications. Interviews with nursing staff and the DON revealed inconsistent understanding and practices regarding tube placement verification. One nurse stated she was told by the DON that checking for residual was sufficient, while another nurse described using both residual checks and a stethoscope. The DON referenced a change in procedure but could not provide clear guidance consistent with written policy, which specified checking tube length, retention device position, and, if available, pH measurement. This failure to follow established protocols placed the resident at risk for complications associated with improper tube placement.
Non-Functional Call Light System in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be non-functional, preventing the resident from being able to summon staff assistance. The resident, a male with a history of lobar pneumonia and Parkinson's Disease, had moderate cognitive impairment and required significant assistance with activities of daily living, including transfers and continence care. During an observation, the resident reported that his call light had not been answered for the past week. When tested, the call light failed to activate the indicator outside the room, confirming it was not working. The call light cords for both beds were found unplugged and only worked after being re-inserted. Staff interviews revealed that the call light system is considered essential for resident safety and communication of needs. The facility's policy requires that call lights be accessible and functional in all resident areas, including bathrooms and bathing facilities, and that all staff are responsible for monitoring and reporting any issues. Despite these policies, the non-functional call light was not identified or addressed in a timely manner, resulting in the resident being unable to reliably call for assistance.
Failure to Accurately Assess and Code Resident Behaviors on MDS
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected his behavioral status. The quarterly Minimum Data Set (MDS) for the resident did not code for any behavioral symptoms, such as yelling, cursing, or verbal abuse, despite multiple documented incidents in the nurse's notes. These notes described repeated episodes where the resident shouted profanities, was verbally abusive toward staff and family members, and exhibited resistance to care. The care plan also identified the resident as being resistive to care and refusing care at times. Interviews with various staff members, including social workers, nurses, and CNAs, confirmed that the resident frequently displayed behaviors such as yelling, cursing, and making delusional statements about animals in his room. Staff consistently reported these behaviors, and the documentation in the nurse's notes supported their accounts. However, the staff member responsible for completing the MDS did not observe these behaviors during her assessment and did not review the nurse's notes or consult with other staff before coding the MDS. The facility's policy requires that all disciplines follow the guidelines in the RAI Manual and use a comprehensive assessment process, including reviewing nurse's notes and CNA documentation. The failure to accurately code the resident's behaviors on the MDS was due to the assessor not consulting available documentation or other staff, resulting in an incomplete and inaccurate assessment of the resident's behavioral needs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate was not five percent or greater, resulting in an 18% error rate based on 6 errors out of 32 opportunities. This involved three residents who did not receive their medications as prescribed. One resident did not receive Metoprolol and Metformin as ordered by the physician, as the medications were administered without food, contrary to the instructions. The resident confirmed that she had not eaten, and the facility's posted menu indicated that dinner was served later than the medication administration time. The medication aide incorrectly stated that the resident had snacks before the medication was given. Another resident received an incorrect dosage of Levetiracetam due to the medication aide's failure to accurately measure the liquid medication. The aide admitted to not placing the medication cup on a flat surface and misreading the calibrated line on the cup. Despite having received training on medication administration, the aide did not follow the correct procedure, leading to the administration error. A third resident was given Minocycline along with a multi-vitamin and iron tablet, despite the medication label indicating that these should not be taken together. The medication aide was unaware of this instruction and did not read the label before administering the medications. The Director of Nursing and the Administrator both emphasized the importance of following physician orders and reading medication labels, but the facility's policy on medication administration was not provided during the survey.
Improper Food Storage and Thawing Procedures
Penalty
Summary
The facility failed to maintain proper temperature for leftover food from the breakfast tray line serving cart and to ensure frozen food was safely thawed. During an observation, it was noted that scrambled eggs stored in the refrigerator since 8:00 AM had a temperature of 72 degrees Fahrenheit, and hard-boiled eggs had a temperature of 49.2 degrees Fahrenheit. These temperatures are within the 'danger zone' where bacteria and other foodborne pathogens can grow quickly. The Dietary Food Service Manager acknowledged the importance of maintaining proper food temperatures for resident safety and wellness. Additionally, an observation of the facility kitchen revealed that frozen pork chops and cubed pork were immersed in stagnant water in the sink, with temperatures ranging from 48 to 69.1 degrees Fahrenheit. The water temperature was 75.6 degrees Fahrenheit, which is above the recommended temperature for safe thawing. The facility's policies and procedures for cooling and heating foods, as well as food preparation and handling, were not followed, leading to these deficiencies.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving staff and residents. In the first incident, a CNA did not perform hand hygiene between glove changes while providing incontinent care for a resident with multiple medical conditions, including severe cognitive impairment and bowel incontinence. The CNA admitted to forgetting to wash hands or use hand sanitizer, despite knowing the importance of this practice to prevent reinfection. The Director of Nursing (DON) confirmed that staff are required to wash hands or use hand sanitizer with each glove change and acknowledged the need for improved skill checks and training. In the second incident, an LVN failed to maintain sterile technique while providing tracheostomy care to a resident with cerebral palsy, tracheostomy status, and other significant medical conditions. The LVN did not wash hands or use hand sanitizer during the procedure and used non-sterile techniques, such as handling sterile equipment with unwashed hands and reusing gloves. The LVN admitted to not following proper sterile procedures and acknowledged the potential risks of infection. The DON noted that the last in-service training on tracheostomy care was several months prior and recognized the need for updated training. These deficiencies were observed during direct care activities and confirmed through interviews with the involved staff and the DON. The lack of adherence to proper infection control practices by the CNA and LVN could place residents at risk for the spread of infection and cross-contamination. The facility's infection control program was found to be inadequate in ensuring a safe and sanitary environment for residents.
Improper Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling Foley catheter, leading to potential infection risks. During an observation, CNA A did not follow proper hand hygiene and catheter cleaning procedures. Specifically, CNA A did not open the labia to clean, did not clean the catheter tubing in a circular motion, and changed gloves multiple times without washing hands or using hand sanitizer. This improper technique was acknowledged by CNA A, who admitted to forgetting the correct procedure despite receiving monthly training on incontinent care and hand washing. The Director of Nursing (DON) confirmed the correct procedure and acknowledged the risk of infection due to deviations from the policy, although no specific policy for incontinent and Foley catheter care was provided during the interview. The resident involved, an elderly individual with multiple medical diagnoses including Type 2 diabetes, dementia, and neuromuscular dysfunction of the bladder, had a history of urinary tract infections (UTIs). The resident had recently been hospitalized for a UTI and had completed a course of intravenous antibiotics. The failure to follow proper catheter care and hand hygiene protocols could have contributed to the resident's recurrent infections. The DON and Administrator both emphasized the importance of proper incontinent care and hand washing to prevent infections, but the facility lacked a documented policy for these procedures.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care, including tracheotomy care and tracheal suctioning, received such care consistent with professional standards of practice and the resident's care plan. Specifically, LVN A did not use sterile technique during tracheotomy suctioning for a resident, which is a critical aspect of preventing infections. The resident's oxygen was also not set per physician orders, as observed on multiple occasions where the oxygen concentrator read 3.5L/min instead of the prescribed 4-6L/min. The resident, a male with multiple medical diagnoses including cerebral palsy, tracheostomy status, and epilepsy, was observed in bed with moist breath sounds and foam coming out of his mouth, indicating potential respiratory distress. LVN A performed tracheotomy care without adhering to sterile procedures, such as not washing hands or using hand sanitizer between glove changes and using non-sterile gloves to handle sterile equipment. This improper technique was acknowledged by LVN A during an interview, where she admitted to not following the correct procedures and recognized the risk of infection. The Director of Nursing (DON) confirmed that the last in-service training on tracheostomy care was conducted in September 2023 and acknowledged the need for updated training. The DON also mentioned that the facility had recently changed companies for respiratory therapy services and was in the process of arranging new in-service training. The failure to follow sterile techniques and maintain the prescribed oxygen levels placed the resident at risk for respiratory infections and other complications.
Failure to Ensure Accurate Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for one resident reviewed for medication administration. Specifically, a medication aide (MA C) administered Minocycline along with a daily multi-vitamin and iron tablet to a resident, despite the medication label warning against taking Minocycline with vitamins or iron within two hours. This error was observed during a medication administration session, where the resident complained about taking too many medications at once. MA C admitted to not being aware of the specific warning and did not read the medication label, despite having received in-service training and being monitored during medication passes. The resident involved was a male with multiple diagnoses, including lymphedema, methicillin-resistant staphylococcus aureus infection, chronic embolism and thrombosis, epilepsy, and chronic venous hypertension with ulcer and inflammation of the lower extremities. The resident's cognition was intact, as indicated by a BIMS score of 15 out of 15. The Director of Nursing (DON) and the Administrator both stated that nursing staff are expected to read the Medication Administration Record (MAR) and medication labels before administering medications to ensure compliance with physician orders. The facility's policy on medication administration was requested but not provided before the survey exit.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving a resident who was physically abused by a CNA. The incident occurred when the CNA allegedly slapped the resident in the face during a night shift. The resident reported feeling unsafe and upset, although no physical injuries were observed. The CNA involved had no prior allegations of abuse or disciplinary actions in her file. The resident involved in the incident had a complex medical history, including conditions such as cellulitis, cerebral infarction, type 2 diabetes, atrial fibrillation, hyperlipidemia, hypertension, paranoid schizophrenia, and chronic ischemic heart disease. The resident also had cognitive deficits, as indicated by a BIMS score suggesting moderate impairment. Despite these challenges, the resident was able to communicate her needs and had previously reported issues to the facility's administration. Interviews with staff revealed that the incident was reported to the facility's administration, and an investigation was initiated. The CNA involved in the incident claimed that the contact was accidental and denied any intention to harm the resident. However, the facility's administration decided to terminate the CNA based on the investigation's findings. The facility had policies in place to prevent abuse, neglect, and exploitation, but the incident highlighted a failure to protect the resident from abuse.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the resident's right to dignity and privacy, as evidenced by an incident involving a certified nursing assistant (CNA) who entered a resident's room without knocking. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported that staff frequently entered his room without knocking or introducing themselves. This behavior was observed during an interview with the resident when CNA A entered the room unannounced, claiming to check if the lunch tray had been picked up. CNA A, who had been working at the facility since February 2024, acknowledged the mistake and apologized, stating that he was aware of the requirement to knock before entering a resident's room. Despite having received training on resident rights and privacy during onboarding and a recent in-service, CNA A failed to adhere to these protocols. The CNA's supervisor, RN A, confirmed that CNA A had been trained to knock and introduce himself before entering a resident's room and mentioned that CNAs were regularly reminded of this practice. The Director of Nursing (DON) and the facility's administrator reiterated the importance of respecting residents' privacy by knocking and introducing oneself before entering their rooms. Other CNAs at the facility confirmed that they had received similar training and in-services on resident rights, which included the requirement to knock before entering a resident's room. The facility's policy, dated 2022, emphasized the importance of maintaining resident dignity and privacy, including the practice of knocking before entering a resident's room.
Neglect in Incontinence Care for Two Residents
Penalty
Summary
The facility failed to provide necessary services for two residents who were unable to carry out activities of daily living, specifically incontinence care. Resident #3, a male with severe cognitive impairment and multiple health issues including dementia and osteoarthritis, required extensive assistance. On the specified date, he was left soiled and unattended, which was discovered by a CNA coming on shift. The resident's care plan indicated the need for frequent checks and incontinence care to prevent skin breakdown, but these were not adhered to. Resident #4, a female with severe cognitive impairment and conditions such as hypertension and type 2 diabetes, was also left soiled. Her care plan similarly required regular incontinence care and monitoring to prevent pressure ulcers. Observations noted that she was found heavily soiled in urine and feces, indicating neglect in her care. Both residents were dependent on staff for assistance with daily living activities, and the failure to provide timely care compromised their dignity and increased the risk of infections. Interviews with staff revealed that CNA F, who was responsible for the residents during the shift, admitted to falling behind and not changing the residents before leaving. The CNA did not inform the oncoming shift or charge nurse about the residents' conditions. The facility's policies on resident dignity and neglect were not followed, as evidenced by the residents being left in a soiled state. The incident was reported to the Administrator, and it was noted that this was not the first time CNA F had failed to perform required care duties.
Resident's Use of Space Heater Highlights Safety Lapse
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically by allowing a resident to have a working and running electric space heater in his room. This deficiency was identified during observations and interviews with staff and the resident. The resident, who was cognitively intact, had a history of heat intolerance and repeatedly expressed feeling cold, leading him to purchase and use a space heater despite knowing it was against facility policy due to fire safety concerns. The resident's room was observed to be cluttered with various items, including cardboard boxes and plastic lock boxes, which contributed to the potential hazard. Staff interviews revealed that the resident had a pattern of acquiring space heaters, which were removed by staff only for the resident to replace them. The Maintenance Director, who was responsible for adjusting room temperatures and removing space heaters, was not aware of the heater's presence during his rounds, indicating a lapse in monitoring and enforcement of safety policies. Interviews with various staff members, including CNAs, LVNs, and the Maintenance Director, highlighted a lack of consistent communication and action regarding the resident's use of space heaters. Although the facility had a policy in place for maintaining electrical safety, the repeated presence of space heaters in the resident's room demonstrated a failure to effectively implement and enforce this policy, thereby placing the resident and potentially others at risk of harm or injury.
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 696 citations issued within 25 miles in the last 12 months — including the 63 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sharpville Residence And Rehabilitation Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Clarewood House Extended Care Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Treemont Health Care Center | 2 mi | ★★★★★ | 1 | 0 |
| Houston Transitional Care | 2.2 mi | ★★★★★ | 1 | 0 |
| University Place Nursing Center | 2.2 mi | — | 0 | 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.