Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Mildred & Shirley L. Garrison Geriatric Educat during CMS and state inspections, most recent first.
Cell Phone Use During Resident Care: Multiple confidential residents stated CNAs used personal cell phones while assisting with showers, peri-care, and other care, as well as while walking in hallways, at the nurses' stations, and in the dining area. Residents reported feeling ignored, embarrassed, and that their privacy was violated. The DON and ADM stated staff should give residents full attention during care and that personal cell phone use is not allowed in patient care areas.
A facility failed to ensure meals were palatable and served at proper temperatures. Several residents reported that food was cold or could be warmer, and 15 confidential residents said meals were cold most of the time across all meal forms. During a test tray observation, 6 of 8 sampled items were cold, and staff stated the plate warmer was not functioning correctly and that meal temperature depended on how quickly trays were handled and served.
Food Storage and Kitchen Sanitation Deficiencies: Surveyors observed a leaking ice machine drainage pipe, dirty ceiling vents, and multiple unlabeled or undated food items in the freezer and refrigerator, including items with expired dates. The DA, DM, RD, and ADM each stated kitchen staff were responsible for labeling, dating, discarding expired food, and monitoring sanitation tasks, while the facility policies required foods to be covered, labeled, dated, and checked for safe use-by dates and required a cleaning schedule for food service areas.
Improper dumpster waste disposal and open dumpster doors were cited after surveyors observed two commercial dumpsters with their doors left open and an improperly trashed recliner chair left on the ground behind them. The HKS, MM, and ADM each described responsibility for keeping the area clean and closing the doors, and the facility policy required waste to be placed fully inside the dumpster and doors or lids to remain closed when not in use.
Incomplete DNR forms were found for two residents with DNR status. One resident with chronic respiratory failure, heart failure, and type 2 diabetes had a DNR form with the resident’s signature on the wrong line and an undated physician signature, and another resident with renal disease and type 2 diabetes had the resident’s signature on the wrong line with the Person’s Signature line left blank. The DON and SW both verified the missing information and stated the forms were not completed correctly.
Loose Pills Found in Medication Carts: The facility failed to keep medications properly stored in 2 medication carts after a loose trazodone tablet was found in the Oak cart and two loose tablets, identified as losartan and clopidogrel, were found in the Sage cart. Staff stated carts are checked at shift start or throughout the shift for cleanliness, expired meds, and loose pills, and the DON and ADM confirmed the carts should be free of loose medication.
A resident with multiple comorbidities and severe cognitive impairment had elected full code status with orders for CPR and AED use. When the resident was found unresponsive and pulseless, an RN, an LVN, and CNAs initiated a code response with the crash cart and AED, and chest compressions were started. Staff were unable to promptly locate the Ambu bag on the crash cart, leading one CNA to leave the room to obtain another bag from the supply room while compressions continued. Another CNA later found an Ambu bag in the cart after several rounds of compressions, but rescue breaths were not provided in a timely manner and mouth-to-mouth was not used; significant emesis and secretions further interfered with use of the Ambu bag. EMS assumed care upon arrival and the resident was pronounced deceased, and leadership later confirmed that facility policy and expectations required CPR with rescue breaths for full-code residents.
A resident with severe cognitive impairment and multiple comorbidities had a care plan and physician order for Full Code status, including CPR and AED use. During a code, an RN and an LVN could not promptly locate an Ambu bag on the shared crash cart for two halls, delaying rescue breaths. After the event, the same crash cart was found contaminated with used suction equipment containing green fluid and used AED pads still attached, and several required items such as an O2 mask, suction canister, suction tubing, Yankauer, and AED pads were missing. Review of crash cart checklists showed many days without documented daily audits, despite policy requiring daily checks and restocking after each use.
A resident with dementia, prior stroke, right-sided weakness, and an indwelling central line receiving IV meds had an active order for Enhanced Barrier Precautions requiring PPE for high-contact care. During observed central line flushing, an LVN did not wear a gown despite posted EBP signage and available PPE. The LVN later acknowledged she should have worn a gown and had previously received EBP training. Facility policies required gown and glove use for high-contact device care, including central vascular lines, and leadership stated they expected staff to follow these precautions.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found that staff were not adequately trained or informed about protocols, and there was a lack of clear written procedures, leaving residents insufficiently protected.
A resident with a history of hypertension and post-surgical infection did not receive prescribed furosemide for 12 days after readmission due to a failure in the medication reconciliation process. The omission was discovered during a wound care appointment, and staff interviews revealed that the medication order was not properly entered or verified in the system, resulting in the resident missing doses despite remaining clinically stable.
The facility failed to provide adequate privacy for residents during showers, as shower curtains were either too small or missing, leaving residents exposed. A resident with severe cognitive impairment reported feeling ashamed due to the lack of privacy, while another with mild cognitive impairment had similar past experiences. Observations confirmed insufficient curtain coverage, and staff interviews revealed a long-standing issue with inadequate reporting and resolution. The facility's policy on resident rights was not upheld, affecting residents' dignity.
A dietary staff member failed to follow proper hand hygiene and glove use protocols while serving food, as observed during a survey. The staff member did not change gloves or wash hands after handling various items, including dirty dishes, before returning to serve food. Interviews revealed a lack of awareness of the facility's policy on glove use and handwashing, despite having completed infection control training.
The facility failed to prepare pureed meat to a smooth, uniform texture, posing a choking risk to residents on a pureed diet. During an observation, the pureed meat contained small pieces, and the Dietary Manager confirmed it was not properly processed. The staff member responsible cited an old processor blade as the issue, despite processing the meat for 20 minutes.
The facility failed to implement its policies to prevent abuse and neglect for two residents. A family member reported verbal abuse involving a resident and a CNA, but the LVN did not report or investigate it. Another CNA reported concerns about potential exploitation involving a resident's coffee, but no investigation was conducted. The ADM and DON were unaware of these allegations, highlighting a lack of communication and reporting within the facility.
Two residents in the facility experienced unsanitary conditions due to a mice infestation, with droppings found in their rooms. Despite reports from residents and family members, the issue persisted, with mice seen running across rooms and droppings not consistently cleaned. Staff interviews revealed awareness of the problem, attributed partly to the facility's location, but efforts to control the infestation were insufficient.
The facility failed to maintain an effective pest control program, leading to a mice infestation in two resident rooms. Observations and interviews revealed mice droppings in various locations, and residents reported sightings of mice, including one running across a resident's chest. Staff were aware of the issue, but there was no follow-up or resolution communicated to residents or families. The facility lacked a formal pest control policy, relying instead on a service agreement with pest control services.
A resident with severely impaired cognition and multiple health issues did not receive regular denture cleaning, as required by their care plan. Despite family grievances and staff in-service training on oral care, the resident's dentures were often found unclean, indicating a failure in maintaining proper hygiene.
The facility failed to maintain a sanitary and comfortable environment in Hall 200, which had a pervasive foul urine odor. Observations and interviews with residents, staff, and family members confirmed the presence of the odor, which persisted despite cleaning efforts. The carpet in Hall 200 had not been replaced since 2001, and the odor was likely trapped between the carpet and the concrete.
The facility failed to notify a resident's physician and representative when the resident reported feeling something stuck in her throat. Despite the resident's history of cognitive and swallowing disorders, staff did not take immediate action, leading to a delay in medical intervention. The issue was only addressed after the speech therapist and family intervened, resulting in the resident being taken to the emergency room.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and care in a manner and environment that promotes quality of life and recognizes each resident's individuality. Based on interviews with 12 confidential residents, they stated that CNAs used personal cell phones while providing care, including assisting with showers and performing peri-care. The residents said this happened on every shift and that staff also texted and talked on their phones while walking in hallways, at the nurses' stations, and in the dining area during meals. The residents reported feeling ignored, not a priority, embarrassed, and concerned that a CNA could make a mistake because of distraction from the cell phone conversation; they also stated their privacy was violated. The 15 residents said they did not know the names of the CNAs who used their cell phones while providing care. During interviews, the DON stated residents should receive privacy and staff should provide full attention during care, and that staff were trained on privacy, resident rights, dignity, and cell phone use during orientation and ongoing education. The DON stated cell phones should never be used in patient care areas or anywhere residents are visible, and that staff were monitored through sporadic rounds by the DON and ADON. The ADM stated staff should provide undivided attention during care, that personal calls were not allowed while performing care or in patient care areas, and that cell phones should be kept in breakroom lockers. The facility policy titled Resident Rights and Responsibilities stated residents are to be informed of their rights and that copies of rights and rules may be posted in a prominent area of the facility.
Cold Food Served to Residents
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for residents reviewed for food palatability. Residents #10, #30, #80, and #93 each voiced concerns that the food was cold or could be warmer. In addition, 15 confidential residents stated in interview that the food was cold for all three meal forms approximately 85% of the time, including food served in the dining area and in resident rooms. During a test tray observation, six of eight sampled food items were cold, including mechanical corn/peas, mechanical meat/spaghetti, mechanical mixed vegetables, puree Italian vegetables, puree meat/spaghetti, and puree bread. The DM was informed of a request for a test tray, and the survey team observed the sample trays delivered to the survey room. In interviews, the DA, DM, RD, and ADM stated that kitchen staff were responsible for monitoring meal palatability and that cold food could occur if tray transportation took too long, if meals were not served quickly enough, or if the plate warmer was not functioning correctly; the DM stated the plate warmer was not functioning correctly and was being replaced. The facility policy stated that food shall be served at proper temperatures, with hot foods hot and fresh and cold foods appropriately chilled.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During a kitchen tour on 06/02/2026, surveyors observed a leaking drainage pipe from the ice machine next to the prepping table and dirty, dusty ceiling vents. In the walk-in freezer, items that resembled garlic bread, corn filters, and noodles were found in different clear plastic bags with no labels and no use-by dates. In the walk-in refrigerator, items that resembled pork, lettuce, grapes, American blend lettuce, and strawberries were found in different clear plastic bags with expired dates. Additional items that resembled cheese, pork, and chicken thighs were found in different clear plastic bags with no labels and no use-by dates. The facility policy required refrigerated and frozen foods to be covered, labeled, dated, and checked to ensure they were used by their safe use-by dates or discarded. During interviews, the DA, DM, RD, and ADM each stated that kitchen staff were responsible for labeling, dating, and discarding expired food items. The DA stated he had brought the leaking ice machine drainage pipe to the DM's attention but did not know what happened afterward, and he was not certain who was responsible for cleaning the dirty vents because the kitchen staff had no tall ladder. The DM stated MM was responsible for the leaking ice machine drainage pipe and the dirty dusty vents, and the ADM stated the issue had not been brought to his attention. The facility's cleaning and sanitation policy required the director of food and nutrition services to determine cleaning tasks, post a cleaning schedule, and hold staff accountable for cleaning assignments.
Improper Dumpster Waste Disposal and Open Dumpster Doors
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed the facility’s dumpster area next to the loading dock with commercial-size dumpsters #1 and #2 left with their doors open. Surveyors also observed an improperly trashed recliner chair on the ground behind both dumpsters. The observation was made during the survey visit, and the report identified the condition in 2 of 2 dumpsters reviewed. During interviews, the HKS stated that the MM was responsible for keeping the dumpster area clean and closing the doors, and that she helped sometimes, while the MM was responsible for monitoring those tasks. The HKS said the doors may have been left open because the MM forgot to close them or because the dumpsters may have been full, and she stated she had not received training on the task and had not come across the waste disposal policy. The MM stated he was responsible for properly disposing of the recliner chair and closing both dumpster doors, and that he was also responsible for monitoring the task. The ADM stated that anyone who throws away trash is responsible for keeping the dumpster area clean and closing the door, while the MM monitors the task, and he was not sure why the recliner was left on the ground or why the dumpster doors were left open. Record review showed the facility policy required waste to be placed fully inside the dumpster, doors or lids to remain closed when not in active use, and maintenance or environmental services to inspect dumpster areas routinely for cleanliness and compliance.
Incomplete DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with DNR status had completed DNR forms with all required information. Resident #9, a male with chronic respiratory failure, heart failure, and type 2 diabetes, had a DNR order on the physician order summary and a care plan for DNR, but the DNR form showed the resident’s signature on the line for Guardian/Agent/Proxy/Relative Signature, the Person’s Signature line was blank, and the physician’s signature was not dated. Resident #35, a male with renal disease and type 2 diabetes, also had a DNR order and a care plan for DNR, but the DNR form showed the resident’s signature on the line for Guardian/Agent/Proxy/Relative Signature and the Person’s Signature line was blank. During interviews, the DON stated the DNR was not valid if it was not filled out correctly and verified the missing information on the forms for Residents #9 and #35. He stated the SW was responsible for making sure the DNR was completed accurately and that quarterly audits of DNRs were completed for accuracy. The SW also verified the missing information on the DNR forms for both residents and stated she and the resource nurses were responsible for ensuring DNRs were completed correctly. The facility’s Social Services policy stated advance directives would be recognized and respected and that the facility would implement residents’ decisions and directives in compliance with state and federal law and facility policy.
Loose Pills Found in Medication Carts
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were stored and maintained in accordance with accepted professional standards in 2 of 4 medication carts reviewed, the Sage medication cart and the Oak medication cart. During observation of the Oak medication cart with an LVN, one loose white scored pill marked with a 3 and L was found in the second drawer without a label. The LVN stated medication carts are checked when staff arrive on shift and are checked for cleanliness, organization, loose pills, and expired medication, and he said he had not seen the pill when he arrived. The DON later identified the loose pill as trazodone. During observation of the Sage medication cart with a CMA, two loose pills were found in the second drawer: one white round pill marked 113 and one tan pill marked 34 on one side and E on the other. The CMA stated medication carts are checked throughout the shift and loose pills are disposed of if found. The DON stated medication carts should be checked at the start of each shift and identified the pills as losartan and clopidogrel. The ADM stated medication carts are checked for cleanliness, expired medication, loose pills, and medication stock, and that loose pills should be brought to the DON for identification and disposal. Record review of the facility policy stated medications are kept and stored in their containers.
Failure to Provide Timely CPR With Rescue Breaths Due to Ambu Bag Unavailability
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff provided basic life support, including CPR with rescue breaths, to a resident who had elected full code status and had corresponding physician orders. The resident was an elderly female with multiple medical diagnoses including a left hip fracture, chronic kidney disease, Type II diabetes, dementia, and anemia, and had a BIMS score indicating severe cognitive impairment. Her comprehensive care plan and physician orders specified Full Code status with interventions including CPR and AED use in the event of cardiac arrest. On the morning of the incident, a staff physical therapist (SP) went to the resident’s room and initially observed the resident breathing but unresponsive, then shortly afterward found her no longer breathing and notified the nurses who were in change-of-shift report. Two nurses, an RN and an LVN, responded to the room with the crash cart designated for the unit, while another nurse called EMS and CNAs also came to assist. The resident was assessed as having no pulse and no respirations and was moved from the bed to the floor. AED pads were applied and chest compressions were started. Multiple staff interviews consistently indicated that when the nurses requested the Ambu bag for rescue breathing, it could not be readily located on the crash cart. One CNA reported searching the cart, not finding the Ambu bag, and running to the supply room to retrieve one, estimating she was gone about two minutes, while the SP estimated the CNA was gone approximately four to five minutes. Another CNA later reported that during this period she searched the crash cart drawers and found an Ambu bag on the cart after several rounds of compressions had already been performed. During this time, the nurses and CNAs alternated performing chest compressions, and the resident began to have emesis and greenish-brown secretions from the mouth, requiring suctioning by the RN. Staff reported that mouth-to-mouth breathing was not provided, and that rescue breaths with the Ambu bag were not initiated in a timely manner because the Ambu bag was not immediately available and, once located, could not be effectively used due to the volume of secretions and vomitus. The RN stated that her CPR training included checking responsiveness and pulse, opening the airway, and delivering two rescue breaths with an Ambu bag before starting compressions in a 30:2 ratio, and acknowledged she began compressions without rescue breaths because the Ambu bag was not available. The facility’s written CPR policy specified starting chest compressions, then opening the airway and giving two rescue breaths, and continuing CPR cycles of 30 compressions to 2 breaths. EMS arrived after CPR had been ongoing, took over resuscitative efforts, and the resident was ultimately pronounced deceased at the facility. The administrator and DON later stated their expectation that residents with full code status receive CPR including rescue breaths per policy and protocol, and staff acknowledged that not having essential equipment readily available on the crash cart during an emergency could result in a poor outcome.
Removal Plan
- Medical Director notified of the Immediate Jeopardy by the Executive Director.
- Crash cart for Magnolia/Sage hall cleaned, replenished, and verified by ADON-1, ADON-2, and Clinical Resource.
- Completed education/in-service for licensed nurses, certified medication aides, and certified nursing assistants on emergency code names (e.g., Code Blue), crash cart policies and procedures, regular crash cart auditing, and CPR policy requirements.
- Ensured staff complete the training prior to starting work on the floor by having management present at each shift change; staff not allowed to work until training is completed.
- Implemented the same training as part of new hire orientation; new hires not allowed to work the floor until training is completed.
- Held an ad hoc QAPI meeting to review the IJ issues, including CPR policy and crash cart auditing policy/required contents.
- Implemented competency verification for nursing staff (licensed nurses, CMAs, CNAs) via quiz, verified by DON/ADON/designee.
- Implemented crash cart reviews: daily review by licensed nurse floor staff and after each usage, with daily verification by DON/ADON/designee.
- Reviewed summary of IJ and corrective actions by QAPI Committee to ensure ongoing compliance.
Failure to Maintain and Audit Crash Cart Resulting in Delayed Ventilation During Code
Penalty
Summary
The deficiency involves the facility’s failure to ensure that treatment and care were provided in accordance with professional standards, the comprehensive person-centered care plan, and the resident’s Full Code status. An elderly female resident with severe cognitive impairment, multiple chronic conditions including chronic kidney disease, Type II diabetes, dementia, anemia, and a left hip fracture, was admitted with a physician’s order and care plan specifying Full Code status, including initiation of CPR and AED use in the event of cardiac arrest. Despite these orders, the crash cart serving Magnolia and Sage halls, where multiple residents had elected Full Code status, was not maintained in a state of readiness as required by facility policy and the crash cart checklist. On the morning of the medical emergency, a code was initiated for this resident at approximately 6:30 AM. During the resuscitation, RN J and LVN S were unable to timely locate an Ambu bag on the crash cart for Magnolia and Sage halls, resulting in a delay in providing rescue breaths during CPR. Both nurses later stated that all other necessary equipment was present at the time of the code, but the Ambu bag was not readily located. The resident was ultimately pronounced deceased at the facility. Subsequent observation and record review showed that the crash cart used for Magnolia and Sage halls remained in an unusable and contaminated condition after the code. Surveyors observed dirty suction tubing, a suction canister, and a Yankauer suction device containing green fluid, and used AED pads still attached to the AED. An audit of the cart against the facility’s crash cart inventory log revealed missing items, including an O2 mask, suction canister, suction tubing, Yankauer suction device, and AED pads. RN J and LVN S acknowledged that the cart had not been cleaned or restocked after the code and that it would not have been usable in its current condition. Review of the crash cart checklists for January and February showed numerous days without documented daily audits, despite facility policy requiring that crash carts be checked every day and restocked as necessary, and that supplies be re-stocked after each use.
Failure to Follow Enhanced Barrier Precautions During Central Line Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Infection Prevention and Control Program and Enhanced Barrier Precautions (EBP) policy during care of a resident with an indwelling central line. The resident was an elderly female with a history of cerebral infarction, right-sided hemiplegia/hemiparesis, and dementia, who had been admitted and readmitted to the facility and was receiving IV medications. Her orders included EBP with PPE required for high resident contact activities due to an implanted IV access, with a start date of 02/21/26. Facility policy on IPCP and EBP required the use of gown and gloves for high-contact resident care activities, including device care for central vascular lines. On 02/23/26 at 9:35 AM, during direct observation, LVN A flushed the resident’s central line with normal saline without wearing a gown, despite a PPE box and an EBP sign posted outside the resident’s room. During interview, LVN A acknowledged she should have worn a gown when flushing the central line, stated she was not thinking about it and forgot, and confirmed she had last received EBP training around October 2025, with her signature documented on a facility EBP education form dated 12/17/25. The DON and ADM both stated they expected staff to follow EBP for residents on such precautions and identified that the facility had signage and PPE boxes available. The facility’s written policies specified that personnel must conduct care in a way that minimizes the spread of infection and that gown and gloves are required for high-contact activities involving indwelling devices such as central lines.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through surveyor observations and review of facility documentation, which revealed that the required safeguards and protocols were not in place or not consistently followed. As a result, there was insufficient protection for residents against potential incidents of abuse, neglect, or theft within the facility. Surveyors noted the absence of comprehensive written procedures and staff training related to the prevention of these issues. Additionally, interviews with staff indicated a lack of awareness and understanding regarding the facility's expectations and reporting mechanisms for abuse, neglect, and theft.
Failure to Administer Ordered Medication Following Readmission
Penalty
Summary
A deficiency occurred when a resident did not receive furosemide (Lasix) as ordered by their physician for a period of 12 days following readmission from the hospital. The resident, an older adult with a history of cellulitis, hypertension, and post-surgical infection, was supposed to receive 40mg of furosemide daily. Hospital discharge paperwork included this medication, but it was not entered into the facility's medication administration system upon the resident's return. The lapse was identified when the resident attended a wound care appointment, and the clinic noted the absence of Lasix on the medication list. Review of the medication administration record confirmed that the resident did not receive the ordered furosemide between the dates in question. Interviews with staff revealed that the nurse responsible for entering the orders may have checked off the medication without actually inputting it, possibly due to distraction, and was unsure if a second nurse had verified the orders as required by facility protocol. Throughout the period when the medication was missed, progress notes and staff interviews indicated that the resident remained stable, with no significant changes in condition or complaints. Mild edema was noted, but this was consistent with the resident's baseline and did not worsen. The deficiency was attributed to a failure in the medication reconciliation and verification process during the resident's readmission.
Privacy Deficiency in Shower Rooms
Penalty
Summary
The facility failed to ensure personal privacy for residents during showers, as observed in four shower rooms. The shower curtains were either too small or missing, leaving residents exposed. This deficiency was noted for four residents, including two specific cases where residents expressed discomfort and embarrassment due to the lack of privacy. Resident #1, with severe cognitive impairment, reported feeling ashamed and embarrassed as the shower curtain did not close completely, and staff did not cover her with a towel. Resident #2, with mild cognitive impairment, also experienced similar issues in the past, feeling the need to cover up due to inadequate privacy. Observations of the shower rooms revealed that the curtains were insufficient to cover the openings, leaving gaps that exposed residents. In some cases, there were no curtains on one side, and the existing curtains were too small to provide full coverage. Staff interviews confirmed that the issue had persisted for a long time, with some staff assuming it was the norm. The lack of locks on shower room doors further compromised privacy, as staff would enter without ensuring the room was unoccupied, leading to potential exposure of residents. Interviews with Certified Nursing Assistants (CNAs) and the Director of Nursing (DON) highlighted a lack of reporting and resolution of the issue. CNAs acknowledged the problem but did not report it, either due to uncertainty about the reporting process or previous unresolved maintenance requests. The DON expected staff to report such deficiencies and provide privacy by closing curtains and doors. The facility's policy on resident rights emphasized the importance of personal privacy, which was not upheld in this case, affecting residents' dignity and self-esteem.
Improper Hand Hygiene and Glove Use in Food Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The deficiency involved improper hand hygiene and glove use by a dietary staff member, referred to as [NAME] A, while serving food. Observations revealed that [NAME] A did not change gloves or wash hands after handling various items, including dirty dishes and food scoops, before returning to serve food. This practice was inconsistent with the facility's policy on hand hygiene, which requires staff to wash hands and change gloves after touching different food items or surfaces. During interviews, the Dietary Manager (DM) acknowledged that the staff member did not follow the facility's procedures for hand hygiene and glove use. The DM stated that staff should wash their hands and change gloves after leaving the steam table or serving line and before handling new food items. The DM also noted that [NAME] A should not have used the same gloves after touching dirty items and should not have served food without gloves. The staff member, [NAME] A, admitted to using a dirty food scoop and not being fully aware of the facility's policy on glove use and handwashing. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the facility had provided training on infection control and hand hygiene. However, [NAME] A stated that he had not received specific in-service training on when to wash hands or change gloves. The facility's policy on hand hygiene emphasizes the importance of washing hands at various times, including before and after handling food, and after touching potentially contaminated surfaces. Despite completing a training course on infection control with a perfect score, [NAME] A's actions during the survey did not align with the facility's established procedures.
Improper Preparation of Pureed Meat
Penalty
Summary
The facility failed to prepare pureed meat to a smooth, uniform texture, which is necessary for residents on a pureed diet to safely consume their meals. During an observation, it was noted that the pureed meat contained small pieces, indicating it was not properly processed. The Dietary Manager (DM) acknowledged that the meat appeared more like mechanically altered meat rather than pureed, which could pose a choking risk to residents requiring a pureed diet. The staff member responsible for preparing the pureed food, identified as [NAME] A, admitted that the consistency of the pureed food should be smooth and pudding-like. [NAME] A noted that the processor blade was old and not sharp, which affected the texture of the meat despite processing it for about 20 minutes. Although [NAME] A tasted the food to check for smoothness and flavor, the deficiency was not corrected before serving. The facility's policy on food sanitary conditions, revised in 2007, was reviewed but did not specifically address the preparation of pureed foods.
Failure to Report and Investigate Allegations of Abuse and Exploitation
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse and neglect for two residents. In the first case, a family member reported an allegation of verbal abuse involving a resident and a CNA. The resident, who had a cognitive communication deficit and dementia, was involved in an incident where he had a bowel movement during a shower and allegedly cursed at the CNA. The family member reported that the CNA had humiliated the resident, but the LVN did not report the incident immediately to the administration or investigate it further. In the second case, a CNA reported concerns about another CNA potentially exploiting a resident by using the resident's coffee. The CNA reported this to the ADONs, but no investigation was conducted, and the issue was not reported to the DON or ADM. The resident involved had a cognitive communication deficit and Alzheimer's disease, but there was no documentation in the progress notes regarding the exploitation allegation. Interviews with staff revealed a lack of communication and reporting of the incidents to the appropriate authorities. The ADM and DON were unaware of the allegations and expected all staff to report any suspicions of abuse, neglect, or exploitation immediately. The facility's policy required immediate reporting and investigation of such allegations, but this was not followed, potentially placing residents at risk.
Mice Infestation in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, as evidenced by the presence of mice droppings in the rooms of two residents. Resident #1, a female with a history of Parkinson's Disease, muscle weakness, anxiety, hypothyroidism, hyperlipidemia, and high blood pressure, was found to have a large number of mice droppings on the floor, including near her slippers, behind the recliner, and at the foot of the bed. The resident and her family had previously reported seeing mice in the room, and the family had even observed a mouse running across the resident's chest while she was sleeping. Despite these reports, the issue persisted, and the resident expressed feeling unclean due to the droppings. Resident #2, a male with diagnoses including an enlarged liver, muscle weakness, high blood pressure, and difficulty swallowing, also experienced similar issues. Mice droppings were found in his bedside table and on the floor by the nightstand. The resident reported seeing mice in his room and had informed the nursing staff on multiple occasions. He expressed his discomfort with the situation, noting that mice are filthy animals and that it was disgusting to have droppings in his drawer and to see mice running across the wall. Interviews with facility staff, including the Charge Nurse, Maintenance Staff, and the ADON, revealed awareness of the mice problem, which had been ongoing for some time. The facility's location in a field was cited as a contributing factor. Despite efforts to control the mice population, such as placing bait boxes outside, the issue remained unresolved. Housekeeping staff were expected to clean the rooms daily, but observations indicated that mice droppings were not consistently removed, contributing to the unsanitary conditions experienced by the residents.
Facility Fails to Control Mice Infestation in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an infestation of mice in two resident rooms. Observations and interviews revealed that mice droppings were found in various locations within the rooms, including on the floor, behind recliners, and in nightstand drawers. Family members and residents reported sightings of mice, including one instance where a mouse was seen running across a resident's chest while sleeping. The issue was reported to nursing staff, but there was no follow-up or resolution communicated to the residents or their families. Interviews with staff, including the Charge Nurse and Maintenance Staff, confirmed awareness of the mice problem. The Charge Nurse noted that mice were likely burrowing inside recliners, as evidenced by droppings falling out when the recliners were shaken. Maintenance staff acknowledged the presence of mice droppings and stated that bait boxes were placed outside the facility, but glue traps were not allowed inside resident rooms. The Maintenance Director admitted to not having a specific pest control policy and relied on a service agreement with pest control services. The facility's pest control efforts were documented in a timeline provided by the Maintenance Director, indicating ongoing issues with mice since February 2024. Despite monthly pest control services and attempts to seal entry points, the problem persisted. The lack of a formal pest control policy and inadequate communication and follow-up with residents and their families contributed to the deficiency, leaving residents at risk of exposure to diseases associated with rodent infestations.
Failure to Maintain Resident's Oral Hygiene
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living, received the necessary services to maintain good personal and oral hygiene. Specifically, the facility did not regularly clean the dentures of a resident with severely impaired cognition and multiple health issues, including respiratory failure, malnutrition, and muscle weakness. The resident's care plan indicated a need for assistance with personal hygiene and oral care, requiring one to two-person assistance. Interviews and record reviews revealed that the resident's dentures were often not cleaned, as evidenced by pictures showing a cloudy black substance on the dentures. A grievance was filed by the resident's family, expressing concern over the dirty dentures and requesting daily cleaning. The facility's records showed that there were instances where the resident refused denture cleaning, but on other days, the cleaning was documented as completed. The Director of Nursing (DON) and the Administrator were aware of the family's concerns and had seen the pictures of the unclean dentures. Staff interviews confirmed that they had been in-serviced on providing proper oral care, but the deficiency in maintaining the resident's oral hygiene persisted until corrective actions were implemented.
Failure to Maintain a Sanitary and Comfortable Environment in Hall 200
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in Hall 200, which was observed to have a pervasive foul urine odor. Observations on multiple occasions revealed that the odor was present in the hallway and dining area, affecting residents who were sitting in these areas. Interviews with several residents indicated that they were unable to respond clearly to questions about the odor. Staff members, including LVNs, the Director of Nursing, the maintenance supervisor, and the housekeeping supervisor, all confirmed the presence of the foul odor. The maintenance supervisor noted that the carpet in Hall 200 had not been replaced since the facility was built in 2001, and the housekeeping supervisor mentioned that the odor persisted even after cleaning. A technician from a cleaning company indicated that the odor was likely trapped between the carpet and the concrete, and that shampooing would not eliminate it. Family members also reported the strong urine smell in Hall 200, expressing concerns about the cleanliness of the facility. The facility's policy on Resident Rights, which includes the right to a safe, clean, comfortable, and homelike environment, was not upheld in this instance. The report highlights that the carpet in Hall 200 was last shampooed on 09/28/23, but the cleaning did not resolve the odor issue. The Operations Manager acknowledged the problem and mentioned that there were plans to replace the carpet, but no immediate corrective actions were noted in the report.
Failure to Notify Physician and Representative of Resident's Change in Condition
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there was a change in the resident's physical, mental, or psychosocial status. Specifically, the facility did not notify the physician or the resident's representative when the resident reported feeling as if something was stuck in her throat. This failure was observed in one resident who had a history of cognitive communication deficit, aphasia, muscle wasting, cerebral infarction, dysphagia, and esophageal obstruction. The resident had a severe cognitive deficit and signs of a swallowing disorder, as documented in her Minimum Data Set (MDS) and care plan. Despite these documented issues, the facility staff did not take immediate action to address the resident's complaints on 4/24/2024, leading to a delay in appropriate medical intervention. On 4/24/2024, the resident expressed to staff that she felt something was stuck in her throat. This was documented in a video recording and in the progress notes by CMA A. However, the staff did not notify the resident's physician or representative about this change in condition. The resident continued to experience discomfort and was eventually taken to the emergency room on 4/25/2024 after the speech therapist and family member intervened. The emergency room documentation confirmed that the resident had been experiencing throat pain and difficulty swallowing for four days. Interviews with various staff members, including the nurse practitioner, speech therapist, and licensed vocational nurse, revealed that there was a lack of communication and proper reporting of the resident's condition. The facility's policy on significant change in condition requires staff to report any changes in a resident's condition to the licensed nurse or nurse supervisor, who should then assess the resident and notify the physician. Despite this policy, the staff failed to follow the proper procedures, resulting in a delay in addressing the resident's medical needs. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and other staff members highlighted the gaps in communication and reporting that contributed to this deficiency. The failure to notify the physician and the resident's representative in a timely manner could have led to serious health consequences for the resident, given her medical history and condition.
What surveyors are citing around you — mapped
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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 137 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southern Specialty Rehab & Nursing | 1 mi | ★★★★★ | 13 | 2 |
| Lubbock Health Care Center | 1.3 mi | ★★★★★ | 6 | 0 |
| Lakeside Rehabilitation And Care Center | 1.4 mi | ★★★★★ | 7 | 0 |
| The Plaza At Lubbock | 1.4 mi | ★★★★★ | 9 | 0 |
| Mi Casita Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.