Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Stayton At Museum Way during CMS and state inspections, most recent first.
Expired medications were found in a nurse cart and a medication room, including multivitamins with zinc, multivitamins, niacin, and bisacodyl suppositories. An LVN, the ADON, and the DON each stated that nurses, med aides, and Central Supply were responsible for checking expiration dates, but the expired items had not been removed. Staff acknowledged that expired meds could be administered and may be ineffective.
A resident with dementia and an anxiety disorder had an active PRN lorazepam order while receiving hospice services. The pharmacist consultant repeatedly noted that the PRN psychotropic order required a 14-day stop date, but the DON did not act on the recommendations. The LVN and ADON stated PRN psychotropic orders usually require a stop date, and the facility policy said pharmacist recommendations are acted upon by staff and/or the prescriber.
A resident with dementia and anxiety had an active PRN Lorazepam order for anxiety that was entered without a stop date. Hospice consultation notes repeatedly stated that the PRN psychotropic order still required a 14-day stop date, while the MAR showed no doses were given. Staff interviews reflected confusion about the requirement, and the DON stated she misunderstood the regulation and believed an indefinite indication for use meant the stop date was not needed.
Two residents were subjected to neglect and potential abuse in a facility. One resident was startled by a skeleton placed by a CNA, causing her to fall and sustain injuries. Another resident ingested medications from a family member's purse, leading to hospitalization. The facility failed to monitor the resident post-incident and allowed the family member to continue visiting without restrictions, despite concerns about the resident's ability to access the medications independently.
A resident with cognitive and physical impairments was found unresponsive after taking barbiturates not prescribed to her, leading to hospitalization. The facility did not report the incident to the state agency, despite policy requirements, as they believed the hospital's report to Adult Protective Services was sufficient. Staff interviews indicated doubts about the resident's ability to access the medications independently.
A facility failed to provide appropriate incontinence care for a resident with severe cognitive impairment and multiple health issues, leading to fecal impaction and sepsis. Despite being prescribed stool softeners and laxatives, the facility did not consistently document bowel movements, resulting in the resident's decline and eventual death. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition, and there was no policy for monitoring bowel movements.
A facility failed to secure medications, as observed with an unattended and unlocked medication cart. RN A left the cart accessible while retrieving medications from another cart, admitting the lapse. The DON confirmed the risk of residents accessing medications and the potential for drug diversion, noting the absence of a specific medication storage policy.
A resident with a wound experienced improper care due to RN A's failure to follow protocols, including using non-sterile dressings, reusing disposable components, and not applying prescribed ointment. The facility also missed performing weekly skin assessments, increasing the risk of infection and complications.
A resident in an LTC facility did not receive medications as ordered, leading to a deficiency in pharmaceutical services. RN A administered Miralax without a physician's order, telling the resident it was given to relieve constipation. The resident was upset due to not receiving routine medications since admission. The DON emphasized the need for physician orders before medication administration and noted the absence of specific policies related to medication administration.
A facility failed to maintain an effective infection control program when an RN did not follow protocol during a wound vac dressing change for a resident. The RN reused disposable components and did not don a gown, increasing infection risk. The resident had a history of chronic infection and required wound vac treatment. The DON instructed the reuse of supplies due to a lack of new ones, and weekly skin assessments were not documented.
The facility's kitchen failed to meet food safety standards, with expired and improperly stored food, lack of labeling, and inadequate personal protective equipment use by staff. Observations included unlabeled and unsealed food items, and unsanitary conditions in the dry storage area, posing contamination risks.
The facility failed to ensure that call lights were accessible to three residents, leaving them unable to request assistance. A resident with muscle weakness and cognitive impairment could not reach his call light, which was on the floor. Another resident's call light was also on the floor, unnoticed by staff. A third resident was unable to find his call light under the bed, despite staff entering the room. Staff interviews confirmed the importance of accessible call lights.
The facility failed to ensure proper respiratory care for three residents, leading to deficiencies in the storage and management of respiratory equipment. A resident with chronic respiratory failure had a nasal cannula improperly stored on her wheelchair. Another resident with sleep apnea had a CPAP mask not bagged when not in use, and there was no physician order for the CPAP. A third resident's nasal cannula was improperly stored, touching the wheelchair's wheel. The facility lacked specific policies for respiratory care.
A facility failed to update a resident's care plan to include a dietary supplement, Ensure, as recommended by a dietitian's assessment. This oversight led to a significant weight loss of 5.15% in the resident, with no physician orders for the supplement in place. Interviews revealed that the dietitian had submitted orders that were rejected, and the DON was unaware of the resident's weight loss and lack of orders.
A resident with Alzheimer's and malnutrition did not receive prescribed Ensure shakes due to a lack of physician orders, resulting in a 5.15% weight loss. The dietitian documented the need for the shakes but failed to ensure orders were submitted and care plans updated. The DON was unaware of the weight loss and lack of orders, and the facility's policy on weight loss monitoring was not effectively executed.
Two residents with indwelling catheters were not provided privacy bags for their catheter bags, compromising their dignity. Observations showed the catheter bags were visible, and staff interviews revealed confusion about the facility's policy on using privacy bags. The facility's policy on resident rights emphasizes treating residents with respect and dignity, which was not upheld in these cases.
A resident with sleep apnea was not accurately assessed for CPAP use in her MDS Assessment, leading to a lack of documentation in her care plan and physician orders. Observations confirmed the presence of a CPAP machine in her room, and staff interviews highlighted the oversight in reflecting this in her medical records.
A facility failed to develop a comprehensive care plan for a resident with sleep apnea, despite the resident using a CPAP machine at night. The resident's MDS Assessment did not reflect CPAP use, and there was no physician order or care plan in place. Staff interviews revealed a lack of coordination in ensuring care plans were complete, with the MDS Nurse noting the CPAP was not triggered in the MDS, leading to the oversight.
Two CNAs failed to perform proper hand hygiene and glove changes during incontinent care for two residents, one with reduced mobility and the other with severe cognitive impairment. These lapses in infection control practices were acknowledged by the CNAs and confirmed by facility staff, highlighting the risk of cross-contamination and infection.
Expired Medications Left in Cart and Medication Room
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for 1 medication cart and 1 medication room reviewed. During observation, surveyors found an expired bottle of multivitamin with zinc in the Hall B nurse cart with an expiration date of 08/2025. LVN A stated it was his responsibility to check the cart daily for expired medications, but he had not checked that morning. He also stated that if the expired medication were not removed, it could be administered and the dose might not be therapeutic or could cause harm to residents. In the Hall A medication room, surveyors observed 2 bottles of multivitamins with expiration dates of 05/2025, 1 bottle of multivitamins with an expiration date of 08/2025, 3 bottles of niacin with an expiration date of 09/2025, and 1 box of bisacodyl suppositories with an expiration date of 06/2025. LVN A stated that nurses and Central Supply were responsible for checking and removing expired medications from the medication room, and that after Central Supply restocked the room, nurses were expected to verify expiration dates. The ADON stated medication aides and nurses should check carts daily, Central Supply stocked the medication room, and nurses should also check expiration dates when pulling medications. The DON stated nurses and medication aides should know what medications were on their cart and their expiration dates, and that expired medications were at risk of being administered and may have been ineffective.
Pharmacist Recommendations for PRN Lorazepam Were Not Acted Upon
Penalty
Summary
The facility failed to ensure that drug regimen irregularities identified by the pharmacist consultant were acted upon for one resident whose medications were reviewed. Resident #5 was admitted with diagnoses including non-Alzheimer's dementia and an anxiety disorder, had no BIMS score calculated, had short- and long-term memory problems, and had severely impaired cognitive skills for daily decision making. Her medication profile showed an active order for lorazepam 0.5 mg tablet, ordered as needed four times daily starting 07/19/25, and her care plan noted she required indefinite PRN anxiety medication for intermittent needs per hospice. Her September and October 2025 MARs showed she did not receive any doses of the PRN lorazepam. The pharmacist consultant issued recommendations on 07/21/25, 08/19/25, and 09/22/25 stating that, even with hospice status, the active PRN lorazepam order required a 14-day stop date. The facility's monthly medication regimen review policy stated that recommendations are acted upon by facility staff and/or the prescriber, but the DON stated she misunderstood the regulation and did not change the PRN lorazepam order. The LVN and ADON both stated that PRN psychotropic orders usually had a 14-day stop date, and the ADON said the stop date should have been requested when the order was entered.
PRN Lorazepam Order Lacked Required 14-Day Stop Date
Penalty
Summary
The facility failed to ensure Resident #5 was not given a psychotropic drug without the required 14-day PRN limit. Resident #5 was admitted with diagnoses including non-Alzheimer’s dementia and anxiety disorder, and her admission MDS reflected short- and long-term memory problems and severely impaired cognitive skills for daily decision making. Her medication profile showed an active PRN order for Lorazepam 0.5 mg, started on 07/19/25, with no stop date listed. Her care plan noted anxiety manifested by verbal distress and stated that she required indefinite PRN anxiety medication for intermittent needs per hospice. Survey review also showed repeated hospice consultation reports stating that the active PRN Lorazepam order required a 14-day stop date even with hospice status. The September and October MARs reflected that she did not receive any tablets of the ordered PRN Lorazepam. During interviews, the LVN stated the order should have had a 14-day stop date, the ADON said the stop date was usually associated with PRN psychotropic orders and was not sure why it was missing, and the DON stated she misunderstood the regulation and believed an indefinite doctor’s indication for use meant the stop date was not required. The facility policy on psychotropic medications stated that PRN orders for psychotropic medications are limited to 14 days.
Facility Fails to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, resulting in injuries and hospitalization. In the first incident, a CNA placed a skeleton in the doorway of a resident's room, startling her and causing her to fall. The resident, who was cognitively intact and required supervision for mobility, sustained skin tears and bruising. Despite the resident's initial reluctance to report the incident, video footage confirmed the CNA's actions, leading to his termination. In the second incident, a resident with impaired cognition and physical limitations ingested medications belonging to a family member, resulting in hospitalization for an unresponsive state. The resident, who had a history of stroke and required assistance with all activities of daily living, was found to have barbiturates in her system. The facility failed to implement measures to monitor the resident after the incident, and the family member continued to visit without restrictions, despite concerns about the resident's ability to access the medications independently. The facility's policies on abuse prevention and resident rights were not effectively enforced, as evidenced by the lack of monitoring and failure to restrict the family member's visits. Interviews with staff and family members highlighted discrepancies in the facility's response to the incidents, and the facility's visitor log contradicted claims that the family member had not visited after the resident's return from the hospital.
Failure to Report Alleged Neglect Involving Resident's Medication Incident
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who was found unresponsive after taking barbiturates that were not prescribed to her. The resident, a female with a history of chemical imbalance, stroke, and impaired cognition, was admitted to the hospital where a urine drug screen revealed the presence of barbiturates. The resident's family member had left a purse containing medications, including Fioricet, in the resident's room, which was later found in the hospital. The family member suspected the resident might have taken the medications from the purse. Interviews with facility staff, including a nurse and an occupational therapist, indicated skepticism about the resident's ability to access and consume the medications due to her physical and cognitive limitations. The hospital staff also expressed concerns about the resident's ability to have taken the medications without assistance, leading to a diagnosis of intentional overdose. Despite these concerns, the facility did not report the incident to the state survey agency, believing that the hospital's report to Adult Protective Services sufficed. The facility's Director of Nursing and Administrator were aware of the situation but did not take further action to report the incident as required by their policy. The facility's policy mandates immediate reporting of all alleged violations involving mistreatment, neglect, or abuse to the appropriate authorities. However, the facility failed to adhere to this policy, as evidenced by the lack of notification to the state agency, despite the resident's family member visiting multiple times after the incident.
Failure in Incontinence Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident who was incontinent of bladder, leading to a deficiency in incontinence care. The resident, an elderly male with severe cognitive impairment and multiple health issues, including hypo-osmolarity, hyponatremia, and pressure ulcers, was admitted to the facility with a care plan that included the use of disposable briefs and regular cleaning of the peri-area. Despite this, the facility did not adequately monitor or document the resident's bowel movements, which is crucial for managing incontinence and preventing complications. The resident's medical records indicated that he was prescribed stool softeners and laxatives to manage constipation, yet there was a lack of consistent documentation of bowel movements across different shifts. This lack of documentation and monitoring led to a situation where the resident developed fecal impaction, which was only discovered upon hospital admission. The hospital records revealed a large amount of formed stool throughout the colon and rectum, and the resident was diagnosed with sepsis and septic shock, ultimately leading to his admission to hospice care and subsequent death. Interviews with facility staff, including CNAs, LVNs, and the ADON, revealed a lack of awareness and communication regarding the resident's constipation issues. Staff members did not recall any specific concerns about the resident's bowel movements, and there was no facility policy in place for monitoring bowel movements. The facility's failure to document and address the resident's bowel movements in a timely manner contributed to the resident's decline and eventual death, as reported by the resident's POA.
Medication Security Lapse in Facility
Penalty
Summary
The facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents, as observed with medication cart #1. On the specified date, RN A did not lock the medication cart, leaving it unattended and accessible. This included a medication cup with two pills and a resident's medication blister pack left on top of the cart. The cart was located in Tower A and was not under the direct observation of authorized staff, allowing the drawers to be opened and medications to be accessed. During an interview, RN A admitted to leaving the cart unlocked while retrieving medications from another cart. The Director of Nursing (DON) confirmed that it was unacceptable to leave medication carts unlocked and unattended, emphasizing the risk of residents accessing medications they might be allergic to or the potential for drug diversion. The facility did not have a specific policy related to the storage of medications, which contributed to the oversight.
Improper Wound Care and Protocol Violations
Penalty
Summary
The facility failed to provide resident-centered care and services according to professional standards of practice for a resident with a wound. RN A did not remove the semi-occlusive dressing properly, causing the resident pain and discomfort. Additionally, RN A used non-sterile foam dressings and did not trim them to fit the wound bed, leading to improper application over intact skin. RN A did not follow the facility's protocol for wound vac dressing changes, including failing to don a gown and gloves for enhanced barrier precautions. The nurse reused disposable wound vac components, increasing the risk of infection. Furthermore, RN A did not apply the prescribed ointment to the surrounding skin as ordered by the physician. The facility also failed to perform weekly skin assessments for the resident, missing an opportunity to monitor the wound's progress. The DON acknowledged the lack of adherence to protocols and the reuse of supplies, which was not common practice. The facility did not have specific policies related to the frequency of skin assessments, contributing to the oversight.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for a resident reviewed for medication administration. RN A did not administer medications as ordered and informed the resident that Miralax was mixed with cranberry juice to relieve constipation, despite the resident not having an order for Miralax. This action was taken without contacting the physician to obtain the necessary order, placing the resident at risk of adverse drug reactions or not receiving the intended therapeutic benefit. The resident, a female admitted from an acute care facility with a left fibula fracture, expressed constipation and requested Miralax. RN A admitted to telling the resident that Miralax was administered to calm her down, as she was upset about not receiving any medications since admission. The Director of Nursing (DON) confirmed that orders must be received from the doctor before any medication is administered and highlighted the importance of checking medication availability or contacting the doctor for alternatives. The facility lacked specific policies related to medication administration, contributing to the deficiency.
Infection Control Deficiency in Wound Care Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN A during a wound vac dressing change for a resident. RN A did not adhere to the facility's protocol by failing to don a gown in addition to gloves, which is necessary to reduce the risk of transmission of bloodborne pathogens and apply enhanced barrier precautions. This oversight occurred during the wound vac dressing change on the resident's right knee, which was not performed according to the prescribed schedule. Additionally, RN A reused disposable components of the wound vac, including the suction device and tubing, which are intended for single use. This decision was made after being instructed by the DON to reuse these components due to a lack of new supplies. The reuse of these items increased the risk of infection for the resident, who had a history of a chronic infection and was undergoing treatment for a right knee wound with a wound vac. The resident involved was a female with a history of a fracture and infection related to a hip prosthesis. She required partial assistance with activities of daily living and had a surgical wound present on admission. The facility's failure to conduct weekly skin assessments further compounded the issue, as there was no documentation of a skin assessment being performed seven days after admission. The DON acknowledged the deficiencies observed and admitted to instructing RN A to reuse the disposable supplies, despite the increased risk of infection this posed.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its main kitchen, as observed during a survey. Expired foods were not discarded according to guidelines, and many food items in the refrigerator and freezer were not properly labeled or dated. Additionally, several food items were improperly sealed, leaving them exposed to air-borne contaminants. These lapses in food storage and labeling could potentially lead to cross-contamination and air-borne illnesses among residents. During breakfast service, the Executive Chef, a cook, and a culinary aide were observed not wearing appropriate hair and beard coverings, which is a violation of sanitary practices. The Executive Chef had a beard approximately one inch in length without a covering, while the cook and culinary aide had hair protruding from their caps without proper hairnets. This lack of proper personal protective equipment could contribute to contamination risks in food preparation areas. The dry food storage area was also found to be unsanitary, with storage bins for sugar and flour showing brownish and blackish dirt stains. Additionally, some food items, such as beans and sliced almonds, were left uncovered and open to air contaminants. These findings indicate a failure to maintain a clean and contaminant-free environment for food storage, which is essential for ensuring the safety and quality of food served to residents.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents, which could prevent them from obtaining assistance when needed. Resident #8, a male with generalized muscle weakness and moderate cognitive impairment, was unable to reach his call light, which was found on the floor behind his wheelchair. Despite being assisted by a CNA, the call light was not placed within his reach, leaving him unable to call for help. Resident #21, a female with similar diagnoses, also had her call light on the floor beside her bed. She was aware of its location but could not reach it, and staff did not notice or rectify the situation until prompted. This oversight left her without a means to communicate her needs to the staff. Resident #143, a male with reduced mobility and impaired balance, was found searching for his call light, which was under his bed. Multiple staff members entered his room without noticing the misplaced call light, leaving him unable to request assistance. Interviews with staff, including the DON and ADON, confirmed the importance of accessible call lights, yet the deficiency persisted across multiple residents.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in the storage and management of respiratory equipment. Resident #29, diagnosed with chronic respiratory failure, emphysema, and COPD, was observed with a nasal cannula improperly stored on her wheelchair without a protective bag. This lack of proper storage was confirmed during an interview with the resident, who stated she had never seen a plastic bag for her nasal cannula. Resident #142, who has sleep apnea, was found to have a CPAP machine with a nasal pillow mask that was not bagged when not in use. The resident confirmed that she used the CPAP machine before admission and was unaware of the need to store the mask properly. Additionally, there was no physician order or care plan for the CPAP, which was acknowledged by the LVN and DON during their interviews. Resident #144, also diagnosed with chronic respiratory failure and COPD, had a nasal cannula connected to a portable oxygen tank that was improperly stored, with the prongs touching the wheelchair's wheel. This was confirmed by LVN A, who acknowledged the risk of cross-contamination and infection due to improper storage. The facility lacked specific policies for respiratory care and oxygen administration, as confirmed by the Administrator.
Failure to Revise Care Plan for Nutritional Needs
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan for a resident, which is a requirement to meet the resident's medical, nursing, and psychosocial needs. Specifically, the care plan did not include the provision of a dietary supplement, Ensure, twice daily, as recommended by a comprehensive nutritional assessment conducted by the dietitian. This oversight was identified during a review of the resident's records, which showed a significant weight loss of 5.15% within a short period, indicating a potential risk for further weight loss. Interviews revealed that the dietitian had documented the need for Ensure in the resident's nutritional assessment and had submitted physician orders for the supplement, which were somehow rejected. The dietitian acknowledged the omission of the supplement in the care plan and stated that she was responsible for ensuring the resident received the necessary dietary aid. The Director of Nursing (DON) was unaware of the resident's weight loss and the lack of orders for Ensure, despite claiming the resident had refused the supplement. However, there were no progress notes to support this claim, and no alternative nutritional assistance was documented.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to ensure that a resident received additional nutritional resources as recommended by a comprehensive dietary assessment. The resident, who was diagnosed with Alzheimer's Disease and malnutrition, was supposed to receive Ensure shakes twice daily to meet her nutritional needs. However, there were no physician orders for the Ensure shakes, and the resident experienced a 5.15% weight loss within a short period. The dietitian had documented the need for the Ensure shakes in the resident's nutritional assessment but did not follow through to ensure the orders were submitted and approved. Additionally, the dietitian did not update the resident's care plan to include the Ensure shakes. The Director of Nursing (DON) was unaware of the resident's weight loss and the lack of orders for the Ensure shakes. The DON stated that the resident had refused the shakes, but there were no progress notes to support this claim. The facility's policy on monitoring weight loss requires collaboration between the dietitian, nursing staff, and the interdisciplinary team to develop an appropriate plan of action, which was not effectively executed in this case. The failure to provide the Ensure shakes placed the resident at risk of unnecessary weight loss.
Failure to Maintain Resident Dignity by Not Using Privacy Bags for Catheter Bags
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #19 and Resident #24, were treated with respect and dignity by not providing privacy bags for their catheter bags. Resident #19, a male with a flaccid neurogenic bladder, was observed on two occasions with his catheter bag visible from the doorway of his room, without a privacy bag. Similarly, Resident #24, a male with obstructive uropathy, was observed with his catheter bag visible when standing in front of him, also without a privacy bag. Both residents' care plans included interventions for catheter care, but these were not followed, compromising their dignity. Interviews with facility staff, including a CNA, Nurse Manager, ADON, LVN, and RN, revealed a lack of awareness and adherence to the facility's policy on maintaining resident dignity by covering catheter bags. The staff acknowledged that catheter bags should be covered with privacy bags to protect residents' dignity, but there was confusion about the facility's policy regarding this practice. The facility's policy on resident rights, revised in April 2024, stated that residents have the right to be treated with respect and dignity, which was not upheld in these instances.
Inaccurate Assessment of CPAP Use for a Resident
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the status of a resident, specifically regarding the use of a CPAP machine. Resident #142, a female with a diagnosis of sleep apnea, was not accurately assessed in her Comprehensive MDS Assessment, which did not indicate her use of a CPAP machine. Observations revealed that the CPAP machine and nasal pillow mask were present in the resident's room, and the resident confirmed she had been using the CPAP even before her admission to the facility. However, there was no care plan or physician order for the CPAP documented in her records. Interviews with facility staff, including the LVN, DON, ADON, and MDS Nurse, highlighted the importance of accurate assessments to ensure proper care. The DON and ADON acknowledged that the resident's use of a CPAP should have been reflected in the medical diagnosis, physician orders, MDS, and care plan. The MDS Nurse confirmed that the CPAP was not triggered in the MDS assessment due to the absence of a physician order, which was only transcribed after the deficiency was identified. The facility's policy requires timely assessments for new residents, which was not adhered to in this case.
Failure to Implement Comprehensive Care Plan for Resident with Sleep Apnea
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with sleep apnea. Despite the resident using a CPAP machine at night, there was no care plan in place to address this need. The resident's Quarterly MDS Assessment did not indicate the use of a CPAP, and there was no physician order for it. Observations confirmed the presence of a CPAP machine and nasal pillow mask in the resident's room, which the resident confirmed she used at night to help her sleep better. Interviews with facility staff, including the DON, ADON, Administrator, and MDS Nurse, revealed a lack of coordination and oversight in ensuring that all residents have appropriate care plans. The MDS Nurse acknowledged that the CPAP was not triggered in the MDS, resulting in the absence of a care plan for the resident. The facility's policy requires a plan of care for each resident, identifying problem areas and necessary interventions, which was not adhered to in this case.
Infection Control Lapses During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of two CNAs during the provision of incontinent care to two residents. The first incident involved a CNA who did not perform hand hygiene before putting on gloves and failed to change gloves or sanitize hands after handling soiled items and before touching clean items while assisting a resident with reduced mobility. This resident was cognitively intact and required assistance with personal care due to incontinence. The CNA admitted to neglecting hand hygiene and glove changes due to being in a hurry. In the second incident, another CNA also neglected to perform hand hygiene before donning gloves and failed to change gloves or sanitize hands after handling soiled items and before touching clean items while assisting a resident with severe cognitive impairment and incontinence. The CNA acknowledged the oversight and recognized the importance of hand hygiene in preventing cross-contamination and infection. Interviews with facility staff, including the LVN, DON, ADON, and Administrator, confirmed the importance of hand hygiene and glove changes in preventing infections. The facility's policy on hand hygiene emphasized its role in infection prevention, but the policy for incontinent care was not provided during the survey. The staff acknowledged the deficiencies and the potential risk of cross-contamination and infection due to the lapses in infection control practices.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Terrace | 0.6 mi | ★★★★★ | 0 | 0 |
| James L West Center For Dementia Care | 0.6 mi | ★★★★★ | 0 | 0 |
| Fort Worth Transitional Care Center | 0.9 mi | ★★★★★ | 18 | 1 |
| Downtown Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 10 | 0 |
| Arbor Lake Nursing & Rehabilitation, Llc | 1.2 mi | ★★★★★ | 2 | 0 |
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