Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Rio At Mission Trails during CMS and state inspections, most recent first.
Incomplete MAR Documentation for Wound Care Treatments: The facility had blank MAR entries for wound care treatments for multiple residents with complex conditions, including severe cognitive impairment and several pressure injuries. The records did not show whether the treatments were completed, refused, held, or unavailable, and an LVN stated wound care coverage had been sporadic and he could not confirm whether the blank entries reflected completed care. The DON acknowledged that blank documentation could occur when staff were distracted and stated that if it is not documented, it did not happen.
Improper Hand Hygiene During Wound Care: An LVN failed to maintain proper hand hygiene and aseptic technique while providing wound care to a resident with a Stage 4 sacral pressure ulcer and severe cognitive impairment. During the procedure, the LVN touched the curtain and bed remote with gloved hands, touched the wound bed while measuring it, repeatedly removed and reapplied gloves, and handled wound care items after touching non-clean surfaces. The same brief with visible blood and skin was then placed back on the resident.
A resident with dysphagia, NPO status, and severe cognitive impairment required occasional oral suctioning, which was being performed by nursing staff based on clinical judgment and the presence of suction equipment in the room. However, review of the MDS, physician orders, and the comprehensive care plan showed no documented order or care plan interventions for suctioning. An LVN and an RN confirmed they had provided oral suctioning, while the MDS nurse stated she did not include suctioning in the care plan because there was no physician order, and the new DON was unaware of the resident’s suctioning needs. This resulted in the resident’s oral suctioning needs not being incorporated into the comprehensive, person-centered care plan as required by facility policy.
A resident with dysphagia, an NPO order, and severe cognitive impairment was receiving occasional oral suctioning without a corresponding physician’s order or care plan interventions. Staff, including an LVN and an RN, reported performing or recognizing the need for oral suctioning based on the resident’s condition and the presence of suction equipment, but both were unsure whether an order existed. The DON was unaware the resident required suctioning and acknowledged an order should have been in place, despite facility policy stating suctioning is prescribed for residents unable to clear their airway by coughing.
A resident admitted with multiple diagnoses, including osteopenia, had hospital documentation of osteopenia prior to admission and an admission MDS showing severe cognitive impairment, yet the comprehensive person-centered care plan did not include any problem, goals, or interventions for osteopenia. The responsible party expected staff to know and address this diagnosis, while the DON and MDS Coordinator acknowledged that the care plan should identify needed care and services but could not explain why osteopenia was omitted, suggesting it was overlooked, despite a facility policy requiring individualized care plans that incorporate all identified problem areas and associated risk factors.
Failure to Process Resident Council Grievances: The facility did not follow its grievance process for concerns raised in Resident Council. Monthly minutes documented complaints that staff were using personal cell phones while providing care or in resident common areas, but no grievance forms were completed or found in the grievance log. An Activity Director said she only brought the concerns to stand-up, and the Administrator said the issue had been addressed, though no specific cell phone in-service was provided and the Resident Council policy was not produced.
RN coverage was not provided for at least 8 consecutive hours on multiple reviewed days, and the facility also lacked a designated DON for an extended period. Record review showed several days with less than 8 hours of RN presence, including days where RN hours were split between two nurses or limited to only 2 hours. Interviews confirmed the prior DON had left, staff were unsure who their supervisor was, and a corporate nurse was only coming in intermittently without clocking in or out.
Medication administration errors resulted in an 8% error rate, with two errors found during review of 25 opportunities. One LVN gave insulin aspart without priming the pen injector for a resident with DM2 and moderate cognitive impairment, and another LVN withheld ordered insulin glargine for a resident with DM2 based on an assumed standing order to hold it when BG was below 70. The RN stated meds were to be given per MD orders and manufacturer instructions, and that no standing order existed to hold the long-acting insulin.
Medication Parameter Errors: Staff failed to follow BP medication parameters for multiple residents. An LPN, MA, or LVN either gave meds when SBP was above the hold parameter or failed to give PRN hydralazine when SBP or HR met the ordered threshold. The affected residents included one with a trach/vent and mild cognitive impairment, one with severe cognitive impairment, and others with HTN and intact cognition. Interviews confirmed the expectation to follow physician orders and clarify them if needed.
PASRR screening was not completed accurately for two residents. One resident had diagnoses including schizophrenia, bipolar disorder, and vascular dementia, but the chart did not contain a PASRR Level II evaluation or a revised PL1 using the current form. Another resident had schizophrenia, Huntington’s disease, depression, anxiety, hydrocephalus, and altered mental status, yet the referring entity’s PL1 marked no evidence of mental illness and the facility did not verify the screening against the hospital record.
An LVN administered scheduled meds to two residents with complex medical needs, including tracheostomy and gastrostomy tube dependence, but did not immediately document the administrations in the MARs. One resident had COPD, CHF, HTN, and severe cognitive impairment; the other had spastic quadriplegic cerebral palsy, seizure disorder, and multiple sclerosis. The facility policy and RN interview stated meds should be documented at the time they are given.
Unsecured Medication Cart Left Unattended: An LPN left the 400-hall med cart unattended and unlocked while she went to retrieve PPE supplies, and the cart remained unsecured for more than 9 minutes. The cart was observed at the end of a hall occupied by more than 14 residents, with the drawers facing out toward the hall. The LPN later acknowledged she knew the cart should have been locked, and facility leadership stated staff were expected to secure med carts whenever they were not in use.
Incomplete and Inaccurate Resident Medical Records: A resident’s medical record was not consistently accurate, with schizophrenia and bipolar disorder not properly documented in the diagnosis list and MDS for a period of time. The record also lacked updated PASRR documentation, including the revised PL1 form and a PASRR level II evaluation, while the care plan referenced cognitive impairment related to bipolar disorder, vascular dementia, and schizophrenia.
Call Light System Not Working in Available Resident Room: A room marked ready for move-in had a call light issue when the hallway indicator flashed but the nurse call panel did not activate or ring for that room. An LVN could not explain the mismatch, another LVN reported housekeeping had activated the light in the empty room and could not turn it off, and the call light box was observed hanging from the wall with wires exposed. The room was listed as ready for move-in on the bed classification report.
A resident with multiple chronic conditions, including respiratory failure, morbid obesity, diabetes, and tracheostomy status, was care planned and ordered for a regular diet with regular texture and consistency, and was observed receiving and reporting a regular diet. However, the significant change MDS assessment inaccurately coded the resident as receiving a mechanically altered diet, and MDS staff also acknowledged missing CPAP use under non-invasive mechanical ventilator. Facility leadership and clinical staff confirmed the resident’s regular diet and stated that MDS accuracy is essential to reflect needed care, consistent with facility policy and CMS RAI requirements.
A resident with multiple complex conditions, including MRSA, a stage 4 sacral pressure ulcer, diabetes, tracheostomy, and gastrostomy, required total assistance with ADLs and had a care plan for perineal care after bowel incontinence. During observed incontinent care, an LVN wiped feces from the anal area, then continued to handle the soiled brief and place a clean brief under the resident without removing soiled gloves, performing hand hygiene, or donning clean gloves, completing care with the same contaminated gloves. This practice did not follow facility policies on perineal care and hand hygiene, which require glove removal and hand hygiene after contact with body fluids or excretions.
A resident with complex medical needs accused an RT of yelling during care, but the RT failed to report the allegation to the Administrator as required by facility policy. The incident was only discovered two days later during a review of progress notes, resulting in delayed reporting to the State Agency.
A resident with complex medical needs accused an RT of yelling during care. The RT documented the allegation in the progress notes but did not report it to the Administrator or state agency as required. The incident was only discovered and reported two days later during a review of documentation, resulting in a delay in addressing the abuse allegation.
A resident with a tracheostomy was left unmonitored during a capping trial, leading to unresponsiveness and eventual death. The facility lacked a policy for capping trials, and staff were not required to be present during the procedure. Despite assurances to the family, the resident was left alone, and the oximeter used did not have an audible alarm. The resident's co-morbidities were cited as contributing factors, but the absence of continuous monitoring and a clear policy resulted in neglect.
A resident with a tracheostomy was left unmonitored during a capping trial, resulting in the resident becoming unresponsive and later dying in the hospital. The facility lacked a policy for capping trials and did not have staff present during the trial, despite assurances to the family. The resident had a history of multiple health issues, and the absence of monitoring equipment and staff contributed to the incident.
The facility failed to ensure call lights were within reach for three residents, including an 89-year-old with osteoporosis and diabetes, a resident with schizophrenia, and another with end-stage renal disease. All were found with call lights on the floor, risking their ability to call for help. The DON acknowledged the absence of a policy on call light accessibility.
A facility failed to accurately reflect a resident's anxiety diagnosis in their MDS assessment. Despite being prescribed Ativan for anxiety and having the diagnosis listed in progress notes, the MDS did not include it. Interviews with the DON and Administrator revealed a possible system breakdown in medical records, leading to the omission.
A facility failed to include a resident's anxiety disorder and related medication in their comprehensive care plan, despite the resident having a diagnosis of depression and anxiety disorder, and being prescribed Ativan for anxiety. The omission was due to the diagnosis being noted in progress notes but not transcribed into the care plan by the MDS LVN, as confirmed by the DON.
The facility failed to properly store medications, as observed in the 200 Hall Nurse Medication Cart, where seven loose pills were found. CMA D confirmed the pills likely dropped during a medication pass. The DON stated that medication carts should not have loose medications and are the responsibility of the medication aide. Facility policy requires carts to be clean.
The facility failed to properly store and label a container of thawed frozen strawberries in the walk-in cooler, as it lacked a date indicating when it was opened or a use-by date. This oversight was confirmed by a dietary aide and could potentially lead to foodborne illness, as it did not comply with the facility's food storage policy and the U.S. FDA Food Code.
The facility failed to maintain accurate medical records for two residents, leading to potential risks of improper care. One resident's advance directive was not readily accessible in the EHR, while another resident had conflicting diet orders. The DON acknowledged these issues, and the facility's policy on order accuracy was not followed.
A resident with cerebral palsy and moderate cognitive impairment was allegedly verbally and physically abused by an LPN. The incident was reported by the resident's family to another LPN, who failed to report it to the Administrator or DON as required. The facility's policy mandates immediate reporting of such allegations, but the grievance was not communicated to the necessary authorities, risking further abuse.
A resident's right to retain personal possessions was violated when staff removed his off-loading boots, which he used to prevent foot drop. Despite being fully capable of making daily decisions, the resident's boots were taken without a medical order, and concerns about pressure wounds were cited. The facility's policy on resident rights was not followed, and the resident was left with ineffective alternatives.
A resident with multiple health conditions requiring assistance for daily living activities did not receive scheduled showers, leading to poor hygiene. Discrepancies in documentation and execution of the shower schedule were noted, with a non-certified aide incorrectly documented as providing care. The facility's policy on bathing was not adhered to, and claims of the resident refusing showers were undocumented.
A resident with a history of respiratory failure and neuropathy was not evaluated for foot drop and a possible brace, despite a physician's order. The resident, who required PT services, was found without assistive devices, and both feet were in a dropped position. Interviews revealed staffing challenges and a communication gap, as the facility had only one PT with limited availability, and the Administrator believed the evaluation had already been completed.
A facility failed to maintain an effective pest control program, resulting in a resident's heel wound becoming infested with maggots. The resident, with multiple pressure injuries, was found to have maggots in the wound upon hospital admission. Observations revealed flies throughout the facility, and interviews indicated inadequate pest control measures and staff awareness, contributing to the infestation.
Incomplete MAR Documentation for Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 4 of 5 residents reviewed for record accuracy. The deficiency involved blank entries on electronic MARs for wound care treatments, with no initials, coding, or documentation to show whether the treatments were completed, refused, held, or unavailable. The report identified this issue for residents with multiple pressure injuries and other complex medical conditions, including severe cognitive impairment, tracheostomy status, gastrostomy status, respiratory failure, malnutrition, hemiplegia, and dysphagia. For one resident, the record showed a stage 4 sacral pressure injury and an order for daily wound care, but the MAR contained a blank entry for the treatment. For another resident with stage 4 sacral, left heel, and right heel pressure ulcers, the MAR contained blank entries for left heel wound care on multiple days and a blank entry for the right heel and sacral wound care orders on the same date. The MAR also showed that the left heel wound care order was placed on hold during part of the month. For a third resident, the MAR contained blank entries for left heel wound care on two dates, with no documentation indicating whether the treatment was completed or not. For the fourth resident, who had multiple stage 4 pressure ulcers involving the sacrum, left ischium, left outer ankle, left shoulder, and right ischium, the MAR contained blank entries for several wound care orders and also showed a period when the orders were placed on hold. During interview, the LVN stated wound care coverage had been sporadic and he could not say whether the blank entries reflected completed or missed treatments. The DON stated blank entries could occur when staff were distracted and acknowledged that if it is not documented, it did not happen. The facility policy required complete, accurate, timely documentation with each entry dated, timed, and signed.
Improper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when LVN A did not maintain proper hand hygiene and aseptic technique during wound care for a resident with a Stage 4 sacral pressure ulcer. The resident was admitted with multiple complex diagnoses, including hemiplegia and hemiparesis following cerebral infarction, COPD, acute respiratory failure with hypoxia, unspecified protein-calorie malnutrition, aphasia, dysphasia, neuromuscular dysfunction of the bladder, tracheostomy status, gastrostomy status, and chronic kidney disease stage 3. The resident’s annual MDS showed severely impaired cognition with a BIMS score of 3. During wound care observation, LVN A washed his hands, changed the resident’s gown, and put on gloves, but then used a gloved hand to pull the curtain, handed the bed remote to another nurse with a gloved hand, and touched the wound bed while measuring the wound with a paper tape measure. LVN A then removed his gloves, washed his hands, returned to the bedside, moved the curtain with a bare hand, donned new gloves, and cleaned the wound with wet gauze. He again removed his gloves and washed his hands, then returned, moved the curtain with his bare hand, put on new gloves, and handled foam dressing and dry gauze before leaving to wash his hands again. After returning, LVN A used his arm to move the curtain, placed the foam in the wound bed, covered it with an island dressing, and dated the dressing. LVN A and LVN B then secured the same brief back onto the resident even though it had visible blood from the wound and pieces of skin on it. The resident’s care plan identified the Stage 4 sacral pressure ulcer and included wound monitoring and treatment interventions. The facility’s infection control policy stated that hand hygiene is required before and after direct resident contact, before and after invasive procedures and dressing changes, after removing gloves, and that gloves do not replace hand washing.
Failure to Care Plan for Resident’s Oral Suctioning Needs
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s need for oral suctioning. The resident was an elderly female with dysphagia, admitted with an NPO diet order and a quarterly MDS showing a BIMS score of 0 due to inability to be understood. The MDS section for special treatments and procedures did not indicate a need for suctioning at admission, during the stay, or at discharge. Review of the resident’s care plan and order summary showed no physician’s order or care plan interventions related to oral suctioning, despite the resident’s swallowing impairment and NPO status. During interviews, an LVN stated the resident required occasional oral suctioning and that he inferred this need from his experience caring for her and from the presence of suction equipment in the room, but he was unsure whether there was a physician’s order or care plan for suctioning. An RN reported performing oral suctioning on the resident during a recent shift due to her medical history. The MDS nurse explained that suctioning was not included in the care plan because there was no physician’s order, and acknowledged that the treatment should be care planned. The newly hired DON stated she had been unaware the resident required occasional oral suctioning and agreed this intervention should be in the care plan. The facility’s comprehensive care planning policy stated that each resident would have a person-centered comprehensive care plan to address medical, physical, mental, and psychosocial needs, but this was not followed for the resident’s oral suction needs.
Lack of Physician Order and Care Plan for Oral Suctioning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required respiratory care received such care in accordance with professional standards and with a valid physician’s order. Record review showed that the resident, an elderly female with dysphagia and an NPO diet order, had no physician’s order for suctioning on the Order Summary Report. Her quarterly MDS did not indicate a need for suctioning, and her care plan contained no interventions related to oral suctioning. The resident’s BIMS score was 0 due to her inability to be understood, and she was unable to participate in an interview because of cognitive and functional decline. Nursing staff interviews confirmed that oral suctioning was being performed without a corresponding physician’s order or care plan interventions. An LVN stated the resident required occasional oral suctioning and that he inferred this need from his experience with her and the presence of suction equipment in the room, but he was unsure whether an order or care plan existed. An RN reported performing oral suctioning on the resident during a recent shift and said she occasionally required it due to her medical history, but he was also unsure if there was a physician’s order. The DON, who was newly in the role, stated she was unaware the resident required occasional oral suctioning and acknowledged the resident should have had a physician’s order, while the facility’s airway suctioning policy specified that suctioning is prescribed for residents unable to clear their airway by coughing.
Failure to Care Plan for Resident Osteopenia Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames for a resident with a known diagnosis of osteopenia. The resident was admitted with multiple diagnoses, including depression, arthritis, diabetes, and osteopenia, as documented in hospital clinical paperwork prior to admission. The admission MDS assessment showed a BIMS score of 3, indicating severe cognitive impairment. Despite this, review of the resident’s comprehensive care plan, last reviewed and revised on 2/10/2026, did not show any care plan problem, goals, or interventions addressing osteopenia. Interviews with the resident’s responsible party indicated an expectation that all nursing staff should know about the osteopenia diagnosis to help care for the resident’s needs. The DON stated that the MDS Coordinator or any nurse was responsible for updating care plans and acknowledged that the comprehensive care plan was essential because it identified the types of care and services residents were supposed to receive, but did not know why a care plan for osteopenia was not completed. The MDS Coordinator confirmed responsibility for developing and revising the comprehensive care plan, stated that it contained information on how to care for the resident and what services were needed, and believed the omission of the osteopenia care plan was likely an oversight. The facility’s own comprehensive care planning policy required individualized care plans with measurable objectives and timetables that incorporate identified problem areas and risk factors, and to be reviewed and updated at least quarterly, but this was not followed for the osteopenia diagnosis.
Failure to Process Resident Council Grievances
Penalty
Summary
The facility failed to implement its grievance process for concerns raised in Resident Council meetings. Record review of Resident Council minutes from 03/2025 through 02/2026 showed that each month the Activity Director documented a complaint that staff were using personal cell phones while providing care or while standing in resident common areas. Record review of the facility grievance logs for the same period showed no grievance forms related to staff cell phone usage, and the facility could not provide a Resident Council policy when requested by surveyors. During an interview on 03/24/2026, 6 residents who wanted to remain anonymous stated they had notified staff about cell phone use and that the issue would improve briefly but remained a concern; they also stated staff began putting earphones in their ears so it was less obvious they were on the phone. The Activity Director stated she did not complete grievance forms for concerns shared during Resident Council and instead brought the minutes to stand-up for discussion. The Administrator stated the facility had addressed the issues and believed there had been in-services regarding cell phone usage, but the in-service records provided did not specifically mention cell phone usage. The facility grievance policy dated 11/21/2016 stated the facility must make prompt efforts to resolve grievances and keep grievance records for at least three years.
RN Coverage and DON Oversight Deficiency
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week on multiple reviewed days, including 2/17/2026, 2/21/2026, 2/23/2026, 2/24/2026, 2/26/2026, 3/3/2026, 3/7/2026, 3/12/2026, and 3/21/2026. Record review showed RN coverage below 8 consecutive hours on those days, including instances where one RN worked 4 hours and another worked 5 hours, one RN worked 7.8 hours and another 7.7 hours, one RN worked 7.6 hours, one RN worked 6.8 hours and another 6.3 hours, one RN worked 2 hours, and on other days one RN worked 2 hours or 7.5 hours with another RN working 2.1 hours. Timecard review showed 11 of 59 days reviewed did not have 8 consecutive hours of RN coverage. The facility also failed to have a designated RN Director of Nursing from 2/14/2026 through 3/24/2026. During interview, the Administrator stated the previous DON left on 2/13/2026 and that the facility had not had a designated DON since then, although a corporate nurse came in 1-2 times a week. RN I stated he was unaware of who his supervisor was because there was no designated DON and that he did not know who the corporate RN was. The Human Resources Coordinator stated the facility was onboarding a new DON and that the corporate nurse did not clock in and out while in the building, so the specific days the nurse was present could not be verified.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent; surveyors identified an 8% error rate based on 2 errors out of 25 opportunities involving 2 residents and 3 staff reviewed for medication administration. One error involved a resident with type II diabetes and moderate cognitive impairment who was ordered insulin aspart before meals on a sliding scale. During observation, an LVN assessed the resident’s blood sugar at 342 and administered 8 units of insulin aspart without first priming the insulin pen injector, and the LVN stated he was not certain whether priming applied to insulin injection pens. A second error involved a resident with type II diabetes who was ordered insulin glargine 20 units subcutaneously twice daily in the morning and evening. During observation, an LVN checked the resident’s blood sugar at 61 and did not administer the prescribed insulin because she believed there were standing orders to hold insulin glargine when blood sugar was below 70, stating she had been taught this by another LVN. The Regional Clinical RN stated nursing staff were to administer medications per physician orders and manufacturer instructions, that insulin pens should be primed before administration, and that there were no standing orders to hold long-acting glargine insulin.
Medication Parameter Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication administration errors for 5 of 12 residents reviewed for medications with parameters. The deficiency involved blood pressure medications that were ordered to be given only when specific blood pressure or heart rate parameters were met, but nursing staff either did not administer the medication when the parameters were met or administered it when the parameters were not met. Resident #2 had a diagnosis of hypertension and was ordered hydralazine 25 mg via g-tube every 6 hours as needed for SBP greater than 160 and/or heart rate greater than 90. The MAR showed multiple occasions when staff documented SBP or heart rate above the ordered parameters and did not administer hydralazine, including when the resident had a heart rate of 94, SBP of 165, SBP of 177 with heart rate of 112, and heart rate of 92. Resident #40 had spina bifida, required long term care supports for a tracheostomy and ventilator, and had mild cognitive impairment. The resident was ordered midodrine 10 mg with instructions to hold for blood pressure greater than 110. The MAR showed that midodrine was administered when SBP was 141, 120, 128, and 136, all above the hold parameter, and also not administered when SBP was 107 and 108, which were below the hold parameter. Resident #60 had hypertension and intact cognition and was ordered hydralazine 10 mg every 6 hours as needed for high blood pressure, to be given if SBP was greater than 170. The MAR showed that on two occasions the resident’s SBP was documented as 178 and 173, and hydralazine was not administered as ordered. Resident #68 had hypertension and intact cognition and was ordered hydralazine 25 mg via gastrostomy tube every 8 hours as needed for SBP greater than 160. The MAR showed that when SBP was 162 on three occasions and 164 on another occasion, hydralazine was not administered. Resident #78 had hypertension and severe cognitive impairment and was ordered hydralazine 25 mg by mouth every 6 hours as needed for high blood pressure greater than 170. The MAR showed that on two occasions SBP was documented as 173 and hydralazine was not administered. During interviews, the Medical Director stated staff were expected to follow physician orders and clarify orders if needed. The Administrator and Regional Clinical RN stated the expectation was for nursing staff to administer medications according to physician orders and report to physicians to obtain order clarifications if needed. The facility policy stated medications are to be administered as prescribed and that if a dose is withheld, refused, or given at other than the scheduled time, the physician must be notified.
PASRR Screening Not Completed Accurately for Two Residents
Penalty
Summary
The facility failed to ensure that residents were screened for Mental Disorder (MD) or Intellectual Disability (ID) before admission for 2 residents reviewed for PASRR. For one resident, the record showed diagnoses including schizophrenia, bipolar disorder, and vascular dementia, with active diagnoses of bipolar disorder and schizophrenia and use of antianxiety and antidepressant medications. The resident’s chart contained prior PASRR Level 1 screenings from 2019 and 2022, but the medical record did not contain a PASRR Level 1 screening using the revised June 2023 form, and it did not contain a PASRR Level II evaluation prior to admission. For that resident, the MDS LVN stated she submitted the CHOW PL1 in 2022 and coded it as negative because dementia was the primary diagnosis, explaining that she was trained to code the mental illness item as no when dementia was the primary diagnosis. The Regional MDS Nurse stated the resident’s primary diagnosis was dementia and that the mental illness diagnosis was secondary, so a PL1 would not be required. He also stated the initial PL1 was sufficient to meet pre-admission screening criteria, even though the resident had diagnoses of schizophrenia and bipolar disorder and the revised June 2023 PL1 form was available. For the second resident, the record showed diagnoses including schizophrenia, Huntington’s disease, depression, anxiety, hydrocephalus, and altered mental status. The admission MDS reflected schizophrenia and a BIMS score of 02, and the care plan documented use of an antipsychotic for schizophrenia, an anti-anxiety medication for anxiety, an antidepressant for depression, and impaired cognitive function related to Huntington’s disease. The referring entity’s PL1, completed before admission, marked no evidence of mental illness in section C0100, and the facility chart did not contain a secondary Level 1 PASRR assessment to confirm the accuracy of that negative screening despite the diagnosis information received from the referring facility. The MDS LVN stated she did not double check the PL1 against the hospital paperwork, and the Regional MDS Nurse stated the facility entered what the referring entity marked.
Medication Administration Not Documented for Two Residents
Penalty
Summary
The facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for 2 of 8 residents reviewed for medication administration and documentation. On 3/24/2026 at 7:34 AM, LVN C stated she had administered medications to Resident #51 and Resident #94 but had not documented the administrations in either resident’s medication administration record at the time she was observed documenting at the medication cart. Resident #51 was admitted on 1/24/2026 and had diagnoses including COPD, tracheostomy, and a gastrostomy tube. The resident’s quarterly MDS described severe cognitive impairment with a BIMS score of 6 and unclear speech related to the tracheostomy. The care plan included CHF, emphysema/COPD, hypertension, enhanced barrier precautions, chronic pain syndrome, osteoarthritis of both knees, and use of anti-anxiety medications. Physician orders dated 3/25/2026 showed multiple morning medications to be given by gastrostomy tube, including cyanocobalamin, furosemide, empagliflozin, multivitamin, pantoprazole, spironolactone, thiamine, aspirin, buspirone, metoprolol, quetiapine, and calcium carbonate. Resident #94 was admitted on 3/9/2025 and had diagnoses including spastic quadriplegic cerebral palsy, tracheostomy, and gastrostomy tube. The quarterly MDS described unclear speech related to the tracheostomy and a BIMS score of 99 indicating the resident could not complete the interview. The care plan included seizure disorder, multiple sclerosis, fungal-related skin condition, and enhanced barrier precautions. Physician orders dated 3/25/2026 showed multiple morning medications to be given by gastrostomy tube, including carbamazepine, cholecalciferol, famotidine, ascorbic acid, clonazepam, UTI stat, lactulose, oxybutynin, and triamcinolone acetonide cream to the face. The Regional Clinical RN stated the standard was to administer medications and then immediately document each administration, and the facility policy stated medications are to be documented at the time they are given.
Unsecured Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the medication cart keys for 1 of 6 medication carts reviewed, the 400-hall medication cart. During an observation on 3/22/2025 at 9:35 AM, the 400-hall medication cart was seen stationed at the end of the 400-hall, which was occupied by more than 14 residents. The cart was unattended, unsupervised, and unlocked, with the drawers facing out toward the hall. During an observation and interview on 3/22/2026 at 9:44 AM, LVN A returned with PPE supplies and recognized that she had left the cart unlocked, then locked it. LVN A stated she had gone to the 200-hall supply room to retrieve PPE supplies and could not see the cart from there. She stated she knew she should have locked the cart and that medications such as high blood pressure medications, insulins, and others could have been taken from the cart if it was left unlocked. During a joint interview on 3/25/2026 at 4:24 PM, the Administrator and Regional Clinical RN stated the expectation was for nursing staff to secure medication carts whenever they were not in use and whenever the nurse needed to be away from the cart. A record review of the facility policy stated that medications are administered as prescribed and that when preparing PRN medications away from the medication pass, the cart is to be left locked and secured.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident in the sample, Resident #4. Review of the resident’s admission and diagnosis records showed diagnoses including schizophrenia, bipolar disorder, and vascular dementia, but the medical diagnosis list and MDS documentation were not consistently accurate during the period reviewed. The record also showed that the resident’s current care plan identified impaired cognitive function or impaired thought processes related to bipolar disorder, vascular dementia without behavioral disturbance, and schizophrenia. The record review further showed that Resident #4’s PASRR documentation was incomplete. The care plan did not include PASRR services, and the medical record contained prior PL1 screenings from 2019 and 2022, including one positive determination for mental illness and later negative determinations, but it did not contain a PL1 screening using the revised June 2023 pre-admission screening form or a PASRR level II evaluation prior to admission. During interview, the Regional MDS Nurse stated the facility had undergone a transition in January 2023 and that schizophrenia required a thorough assessment by the Local Authority before it could be a valid diagnosis, and the Administrator stated staff were being worked with to ensure accurate documentation in medical records.
Call Light System Not Working in Available Resident Room
Penalty
Summary
The facility failed to ensure that a working call system was available in room [ROOM NUMBER], which was marked as available for new residents. During an observation on 3/22/2026 at 10:23 am on the 200 hall, the call light for room [ROOM NUMBER] was activated, shown by the light flashing outside the room door in the hallway, but the surveyor did not hear the call light ringing at the nurses station. At the nurse call light panel behind the nurses station, there was no light and no ringing sound for room [ROOM NUMBER], although a light for another room on the 100 hall lit up and the panel began to ring. During an interview at 10:25 am, LVN C stated the nurse call light panel lit up and rang when a resident pushed the call light, but the panel was not activated for room [ROOM NUMBER] and she did not know why the light above the door was flashing. At 10:30 am, LVN B reported that the room was empty and housekeeping had been in the room and activated the light but could not turn it off. At 10:31 am, the surveyor observed the call light box in room [ROOM NUMBER] hanging from the wall and connected only by wires, with both call lights plugged into the box. Housekeeper K stated she had cleaned the 200 hall but had not yet entered room [ROOM NUMBER] and was unaware the light was going off because she had not heard the ringing. The Administrator stated that the beds listed on the Bed Classification report were available beds, and the 3740 Bed Classification form dated 3/22/2026 showed room [ROOM NUMBER], bed A and bed B, as ready for move-in.
Inaccurate MDS Coding of Resident Diet Status
Penalty
Summary
Surveyors identified that the facility failed to ensure an accurate MDS assessment for one resident when the resident’s diet was incorrectly coded. The resident was an older female with multiple diagnoses including acute and chronic respiratory failure with hypoxia, neuromuscular bladder dysfunction, insomnia, morbid obesity, type 2 diabetes mellitus, bipolar disorder, tracheostomy status, and polyphagia. Her significant change MDS assessment dated 02/17/2025 documented that she was on a mechanically altered diet, despite other records and observations indicating otherwise. The resident’s comprehensive care plan dated 03/03/2025 listed a focus of a regular diet with regular texture and consistency, and active orders as of 03/16/2026 showed a regular diet, regular texture, and regular consistency per hospice with a start date of 12/02/2025. On observation, the resident was seen being assisted with eating a lunch consisting of regular food with regular texture and consistency, and her meal ticket also reflected a regular diet. In interviews, the resident stated she had been on a regular diet since admission. MDS staff acknowledged errors in the MDS, including missing the resident’s CPAP under non-invasive mechanical ventilator and failing to reflect the regular diet on the significant change MDS, and stated they did not know how these items were missed. The ADON and the administrator both confirmed that the resident was on a regular diet and emphasized that MDS accuracy is important to show what care residents need, consistent with the facility’s MDS policy and the CMS RAI User’s Manual requirement that assessments accurately reflect the resident’s status.
Failure to Change Gloves and Perform Hand Hygiene During Incontinent Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices during incontinent care for one resident. The resident was an elderly female with multiple serious medical conditions, including pneumonia, MRSA infection, a stage 4 sacral pressure ulcer, type 2 diabetes mellitus, a tracheostomy, a gastrostomy, and neuromuscular bladder dysfunction. Her MDS assessment showed she was severely cognitively impaired, rarely understood and could rarely be understood, and was dependent on staff for ADLs. Her care plan identified bowel incontinence with an intervention to provide perineal care after each incontinent episode. During observation of incontinent care, an LVN wiped feces from the resident’s anal area, discarded the soiled wipe, and then continued handling the soiled brief and placing a clean brief under the resident without removing her soiled gloves, performing hand hygiene, and donning clean gloves. She completed the incontinent care while still wearing the same contaminated gloves. In a subsequent interview, the LVN acknowledged she should have removed the soiled gloves, sanitized her hands, and put on clean gloves before placing the clean brief. The ADON stated the nurse should have changed gloves after cleaning the anal area to prevent cross-contamination. Facility policies on perineal care and hand hygiene required doffing gloves and performing hand hygiene after contact with body fluids or excretions, which were not followed in this instance.
Failure to Implement Abuse and Neglect Reporting Policy
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse and neglect for one resident whose records were reviewed. Specifically, a resident accused a respiratory therapist (RT) of yelling at her when she requested a larger cup of ice. The RT documented the resident's allegation in the progress notes but did not report the allegation to the Administrator, who is the designated abuse and neglect coordinator, as required by facility policy. The RT only informed her supervisor that the resident was unhappy, without mentioning the specific allegation of yelling. The facility's policy requires all employees to report any allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property to the Administrator immediately, and if the allegation involves abuse or results in serious bodily injury, the report must be made within two hours. In this case, the Administrator became aware of the allegation two days later during a review of the RT's progress notes and subsequently reported the incident to the State Agency. Interviews confirmed that the RT and her supervisor were trained on abuse and neglect reporting, but the RT did not recognize the need to escalate the resident's allegation as required. The resident involved had significant medical needs, including acute and chronic respiratory failure with hypoxia, depression, anxiety, myopathy, dysphagia, and was dependent for care. She was NPO and received enteral nutrition, had a tracheostomy with mechanical ventilation, and was permitted ice chips under specific conditions. The incident occurred during the provision of ice chips, and the resident expressed concern about the RT's behavior, which was not promptly reported according to policy.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin, were reported immediately, but no later than two hours after the allegation was made. Specifically, a resident who was dependent for care, had a tracheostomy with mechanical ventilation, and was on a restricted diet, accused a respiratory therapist (RT) of yelling at her when she requested a larger cup of ice. The RT documented the resident's allegation in the progress notes but did not report the incident to the Administrator, who serves as the abuse and neglect coordinator. The RT stated she informed her supervisor that the resident was not happy but did not mention the specific allegation of yelling. The supervisor confirmed that he was only told about the resident's dissatisfaction with the ice, not about any abuse allegation. The incident was not reported to the Administrator or the state agency until two days later, when the administrative team reviewed the progress notes and discovered the documentation of the resident's allegation. At the time of the incident, the resident was sometimes understood and sometimes understood others, with a BIMS score indicating the interview could not be completed. The resident later denied any abuse or issues with staff during an interview. The facility's policy required immediate reporting of all allegations of abuse, neglect, or mistreatment to the Administrator, but this protocol was not followed in this case, resulting in a delay in reporting the allegation to the appropriate authorities.
Neglect During Tracheostomy Capping Trial
Penalty
Summary
The facility failed to ensure that a resident was free from neglect during a tracheostomy capping trial. The resident, who had a history of stroke, cerebral aneurism, diabetes, deep vein thrombosis, hypertension, quadriplegia, and seizures, was admitted with a tracheostomy. During a capping trial, the resident was left unmonitored, and no staff were physically present in her room. The resident became unresponsive and was transported to the emergency room, where she later died. The facility did not have a policy or procedure in place for capping trials at the time of the incident. Interviews with staff revealed that there was no requirement for staff to be present during tracheostomy capping trials, and the facility relied on physician orders that did not specify the need for continuous monitoring. The Director of Nursing (DON) and Respiratory Therapy (RT) staff stated that the resident's co-morbidities contributed to the cardiac arrest during the third capping trial. The RT Director admitted that there was no system in place to monitor the heart rate during the trial, and the oximeter used did not have an audible alarm to alert staff in case of an emergency. Family members of the resident were assured by the RT Director that staff would be present during the initial capping trials, but this was not the case during the third trial. The resident's Responsible Party (RP) expressed concerns about the resident's inability to communicate during an emergency and was not informed or present during the third trial. The lack of continuous monitoring and the absence of a clear policy on capping trials contributed to the neglect of the resident, resulting in her unresponsiveness and subsequent death.
Failure to Monitor Resident During Capping Trial Leads to Fatality
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required tracheostomy care and tracheal suctioning, consistent with professional standards of practice and the resident's care plan. During a capping trial, the resident was left unmonitored, and no staff were physically present in the room. As a result, the resident became unresponsive and was transported to the emergency room, where they later died. The facility did not have a policy or procedure in place for capping trials at the time of the incident. The resident, who had a history of stroke, cerebral aneurysm, diabetes, deep vein thrombosis, hypertension, quadriplegia, and seizures, was admitted to the facility with a tracheostomy. The care plan included tracheostomy care and capping trials, with specific instructions to monitor respiratory rate, depth, and quality. However, during the third capping trial, the resident was found unresponsive with no pulse, and CPR was initiated. The facility's lack of a monitoring system and the absence of staff during the trial contributed to the resident's condition worsening. Interviews with staff revealed that there was no requirement for staff to be present during capping trials, and the facility lacked a policy on capping trials. The resident's family had been assured that staff would be present during the trials, but this was not the case. The pulmonologist and respiratory therapy director acknowledged that the facility did not have adequate monitoring equipment or a policy in place, which could have alerted staff to the resident's condition during the trial.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights for three residents were within reach, which is a necessary accommodation for their needs and preferences. Resident #2, an 89-year-old female with osteoporosis, type 2 diabetes, and high blood pressure, was found with her call light on the floor, out of reach. Her care plan indicated she was at risk for falls and required the call light to be within reach. During an interview, the assigned nurse confirmed the call light was on the floor and acknowledged the risk of falls if the call light was not accessible. Similarly, Resident #28, a female with schizophrenia, encephalopathy, and tachycardia, and Resident #80, a female with end-stage renal disease, anxiety disorder, and high blood pressure, were also found with their call lights on the floor. Both residents had intact cognition and expressed concerns about their inability to call for help. The Director of Nursing (DON) acknowledged the lack of a policy regarding call lights and emphasized the importance of ensuring accessibility to prevent potential negative outcomes.
Failure to Accurately Reflect Resident's Diagnosis in MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for one resident whose assessments were reviewed. Specifically, the resident's diagnosis of anxiety was not identified as an active diagnosis on the resident's quarterly MDS assessment. This oversight was discovered during a review of the resident's records, which included a face sheet, physician orders, and medication administration records. These documents indicated that the resident had been prescribed Ativan for anxiety, and progress notes listed anxiety disorder as one of the resident's diagnoses. However, the MDS assessment did not reflect this diagnosis, indicating a discrepancy in the resident's documented health status. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, revealed that the resident's anxiety disorder was diagnosed by both the primary care physician and the hospice physician. The DON acknowledged that the diagnosis was listed in the progress notes but was not transcribed into the resident's list of diagnoses on the MDS assessment. The Administrator suggested that there might have been a system breakdown in the medical records process, which led to the MDS nurse not being informed of the diagnosis. The facility used the RAI manual as their policy for resident assessments, which emphasizes the importance of coding diseases that directly relate to the resident's current health status.
Failure to Include Anxiety Disorder in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is a deficiency in meeting the resident's mental, nursing, and psychosocial needs. Specifically, the care plan did not address the resident's diagnosis of anxiety disorder or the active orders for anti-anxiety medication, Ativan. This oversight was identified during a review of the resident's records, which showed a diagnosis of depression and anxiety disorder, as well as a prescription for Ativan to be administered as needed for anxiety. The deficiency was further highlighted during an interview with the Director of Nursing (DON), who acknowledged that the resident's anxiety disorder diagnosis was documented in progress notes but was not included in the comprehensive care plan. This omission occurred because the diagnosis was not transcribed into the resident's list of diagnoses and care plan by the MDS LVN. The facility's policy requires that comprehensive care plans include measurable objectives and timeframes to address all identified needs, but this was not adhered to in this case.
Improper Storage of Medications in Nurse Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles. During an observation of the 200 Hall Nurse Medication Cart, it was found that there were seven loose medication pills inside one of the drawers. This was confirmed by CMA D, who stated that the pills must have dropped during her medication pass that morning. The Director of Nursing (DON) acknowledged that medication carts should not have loose medications and that it was the responsibility of the medication aide who accepted responsibility for the cart. Additionally, the facility policy from 2003 indicated that medication carts must be clean.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by improperly storing a 6.5 lb. container of thawed frozen strawberries in the walk-in cooler. During an observation, it was noted that the container was opened with approximately 1/4 of the strawberries remaining, but it lacked a label indicating the date it was opened or a use-by date. This oversight was confirmed during an interview with a dietary aide, who acknowledged the absence of proper labeling and the potential risk of foodborne illness due to this failure. The facility's policy on food storage requires that open packages of food be stored in closed containers with covers or sealed bags and dated as to when they were opened. Additionally, the U.S. FDA Food Code mandates that ready-to-eat, time/temperature control for safety food must be clearly marked with the date it was opened if held for more than 24 hours. Despite these guidelines, the facility did not comply, as evidenced by the lack of date marking on the strawberries, which could place residents at risk for foodborne illness.
Deficiencies in Medical Record Accuracy and Order Clarification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to potential risks of improper care. For one resident, the advance directive was not listed on the face sheet, consolidated physician's orders, or visible in the electronic health record (EHR). Although the resident's care plan indicated a Do Not Resuscitate order, the information was not readily accessible, which could lead to confusion in a code situation. The Director of Nursing (DON) acknowledged that the code status was not visible in the usual sections of the EHR but stated that licensed vocational nurses (LVNs) knew how to access the information. The Regional Resource RN later updated the resident's orders to make the advance directive more accessible. For another resident, there were conflicting diet orders, with one order for an NPO diet and another for a puree diet. This discrepancy was observed when a puree food tray was found on the resident's bedside table. An LVN confirmed the presence of conflicting diet orders and expressed concern about the potential negative impact on the resident's care. The DON admitted that the conflicting orders should have been clarified and attributed the oversight to a failure in verifying and addressing conflicting orders promptly. The facility's policy on physician's orders requires licensed nurses to review and ensure the accuracy of all orders, but this was not adhered to in this case.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident in a timely manner, as required by regulations. A family member of the resident reported to LVN A that LVN B was verbally and physically abusive towards the resident, including an incident where LVN B allegedly tugged the resident out of the restroom and made inappropriate comments. Despite being informed of this grievance, LVN A did not immediately report the incident to the Administrator or the Director of Nursing (DON) as required. Instead, LVN A placed the grievance form under the DON's door and did not recognize the behavior as abuse, believing it was acceptable for LVN B to express frustration. The resident involved had a history of cerebral palsy, depression, and anxiety disorder, with a moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. The facility's policy mandates that any allegations of abuse, neglect, or exploitation must be reported to the DON, administrator, and relevant authorities. However, the DON and Assistant Directors of Nursing (ADONs) were not informed of the incident by LVN A, and the grievance was not reported to the Health and Human Services Commission as required. This failure to report could potentially contribute to further abuse and neglect of residents.
Resident's Right to Retain Personal Possessions Violated
Penalty
Summary
The facility failed to honor a resident's right to retain and use personal possessions, specifically off-loading boots, which were taken away by staff. The resident, who was fully intact for daily decision-making skills, had been using the boots to prevent foot drop, a condition he was experiencing due to paraplegia. Despite the resident's request to keep the boots, they were removed by a male staff member, and the resident was left without any assistive devices, resulting in his feet being in a dropped position. The facility's administration justified the removal by stating there was no medical order for the boots and expressed concerns about potential pressure wounds. The Director of Rehabilitation (DOR) advised against the use of the boots, citing risks of infection and amputation, although he acknowledged that he was not an expert in physical therapy. The resident was provided with a wedge as an alternative, which he found uncomfortable and ineffective. The facility's policy on resident rights, which allows residents to retain personal possessions unless they infringe on others' rights or safety, was not adhered to in this case. The boots were discarded, and the resident's right to retain personal possessions was not respected.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for a resident who was unable to carry out activities of daily living independently. The resident, a male with multiple diagnoses including acute and chronic respiratory failure, neuropathy, and paraplegia, required substantial assistance for bathing and was dependent on a helper for transfers. The resident's care plan indicated a need for assistance with activities of daily living, including scheduled showers. However, the facility did not ensure the resident received scheduled showers on two occasions, leading to observations of poor hygiene and body odor. Interviews and record reviews revealed discrepancies in the documentation and execution of the resident's shower schedule. A hospitality aide, who was not certified to perform patient care tasks, was initially documented as having provided showers, but later stated she only assisted with transfers and documented on behalf of the shower aide. The Assistant Director of Nursing (ADON) and the Administrator claimed the resident had refused showers, but this was not documented. The facility's policy emphasized the importance of regular bathing for comfort and skin integrity, yet the resident's needs were not met according to the established schedule.
Failure to Provide Specialized Rehabilitative Services for Foot Drop
Penalty
Summary
The facility failed to provide specialized rehabilitative services for a resident who required evaluation for foot drop and a possible brace. The resident, a male with a history of acute and chronic respiratory failure, neuropathy, and paraplegia, was admitted with a care plan that included interventions for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) as needed. Despite a physician's order dated 7/8/24 for therapy to evaluate the resident's foot drop, the evaluation had not been conducted by 7/13/24. During an observation and interview on that date, the resident was found without any assistive devices, and both feet were in a dropped position, indicating a lack of PT services to address the condition. Interviews with the Director of Rehabilitation (DOR) and the Administrator revealed that the facility had staffing challenges, with only one PT available on a limited basis. The DOR confirmed that PT services were needed for the resident's foot drop, which was outside the scope of OT services that had been provided. The facility's policy required rehabilitation screening for residents with changes in condition, but the resident had not been evaluated by PT as ordered. The Administrator was under the impression that the evaluation had already been completed, highlighting a communication gap within the facility's management.
Pest Control Deficiency Leads to Resident Wound Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an infestation of maggots in a resident's left heel wound. The resident, a male with anoxic brain damage and type 2 diabetes mellitus, was admitted to the facility with multiple pressure injuries, including a deep tissue injury on the left heel. Despite daily wound care orders, the resident was found to have maggots in the heel wound upon hospital admission, indicating a severe lapse in pest control and wound management. Observations and interviews revealed that flies were present throughout the facility, including in resident rooms and common areas. The pest control service had been addressing fly issues, but the measures were insufficient to prevent the infestation. The facility's pest control contract and service statements indicated ongoing fly problems, with recommendations for additional fly lights and treatments. However, the facility's actions, such as replacing glue boards and applying fly bait, were inadequate to control the fly population effectively. Interviews with facility staff and hospital personnel highlighted a lack of awareness and response to the pest issue. The facility's Director of Nursing and Administrator acknowledged the presence of flies but did not fully understand the potential harm to residents. The Maintenance Director was not adequately informed or trained on pest control measures, relying solely on the pest control company's guidance. This lack of effective pest control and staff awareness contributed to the resident's wound infestation, demonstrating a significant deficiency in maintaining a safe and sanitary environment.
Removal Plan
- Facility was inspected for flies to include all resident rooms by maintenance director and Administrator.
- All windows in facility were checked to ensure they are closed properly.
- All window screens in facility were inspected by maintenance director and administrator to ensure they are installed properly.
- Administrator and Maintenance director have placed standing fans at the front door and 100 hall door to help prevent flies from coming into facility.
- Fly bags were placed externally around the facility to help prevent flies from entering facility.
- 100% skin sweep was completed and all wounds assessed by DON and ADON, no issues related to flies noted.
- Pest control treated for flies.
- Medical Director was notified of the immediate Jeopardy situation.
- Admin and DON identified residents who choose or prefer to have their windows open and will complete a weekly inspection of their windows screens to ensure they are in good condition and installed correctly.
- In-services were initiated by the RCN for all staff regarding removing flies, identifying open windows and torn window screens, and notifying the Administrator and Maintenance Director immediately.
- In-service was initiated for all staff regarding pest control, window screens, windows and entry points and reporting these items to the Administrator and DON.
- In-services were initiated by the RCN for the Administrator and Facility Maintenance director regarding inspecting facility windows and window screens.
- In-service was initiated with Admin and Maintenance Director by RCN regarding their responsibility for reviewing maintenance care logs 5 times a week to ensure issues with pest control, screens, windows or points of entry are addressed appropriately.
- In-service was completed by RCN with HR coordinator regarding providing education on pest control to all new hires.
- Admin/Designee will conduct rounds in facility 5 times a week to ensure that all windows are closed, and window screens are installed properly.
- Admin/Designee will complete interviews with 5 staff members weekly x 6 weeks and periodically thereafter to ensure that staff are reporting the presence of flies appropriately.
- DON and Tx nurse will conduct weekly skin checks and wound rounds x 6 weeks and periodically thereafter to ensure no issues with flies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 929 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Nursing Center | 1.4 mi | ★★★★★ | 20 | 0 |
| Windsor Mission Oaks | 1.4 mi | ★★★★★ | 0 | 0 |
| Pecan Valley Rehabilitation And Healthcare | 2.3 mi | ★★★★★ | 9 | 0 |
| Buena Vida Nursing And Rehab-san Antonio | 2.4 mi | ★★★★★ | 26 | 5 |
| Southeast Nursing & Rehabilitation Center | 2.9 mi | ★★★★★ | 16 | 1 |
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.