Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Villa At Mountain View during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment, dependent on staff for dressing, was observed asleep in bed wearing only underwear while the room door was open. The resident’s care plan did not address her behavior of undressing when hot, despite her roommate and multiple staff (including an LVN and CNAs) reporting that she frequently removed her pants or gown and remained in her underwear, with the roommate controlling the room temperature. Staff acknowledged it was not acceptable for the resident to lie in bed in underwear with the door open and recognized lack of privacy and exposure as concerns, while leadership confirmed that this behavior should have been care planned and that the situation represented a dignity and resident rights issue under the facility’s own dignity policy.
Surveyors found that the facility did not maintain a safe, clean, and comfortable environment, as evidenced by strong odors from large trash bins in multiple halls and the use of strong-scented sprays by staff to mask these odors, which could affect residents with respiratory issues. Additionally, mechanical lifts and a shower bed were left unlocked and stored in hallways, contrary to facility policy and life safety guidance, creating potential hazards for residents.
Staff failed to follow enhanced barrier precautions by not wearing required PPE such as gowns and gloves during high-contact care activities, including repositioning, perineal care, handling soiled linens, and G-tube care for a resident with severe cognitive impairment and a gastrostomy tube. Despite EBP signage and available PPE, staff did not consistently adhere to infection control protocols, and hand hygiene was not always performed after care.
Five residents with significant physical and/or cognitive impairments were found to have call lights out of reach, including on the floor or behind furniture, despite care plans and facility policy requiring accessibility. Staff interviews confirmed the expectation that call lights be within reach at all times, but this was not consistently followed.
A nurse left a computer tablet displaying a resident's EMAR and insulin administration details unattended on a medication cart for several minutes, with the screen visible to others nearby. The resident had complex medical needs and no cognitive impairment. Facility policy requires confidentiality of resident information and that computer screens be locked when unattended, but this was not followed in this instance.
A medication cart was left unattended and unlocked in a resident hallway, with two residents present in their room nearby. An LVN had just administered medication and left the cart accessible while attempting to speak with a doctor, contrary to facility policy requiring medication carts to be locked when not in use. The incident was observed by a surveyor and confirmed through staff interviews and policy review.
A resident with severe cognitive impairment and a history of mood disorders was able to leave the facility unsupervised through a back door, despite being care planned for wandering risk and requiring a wander guard bracelet. The resident was found on the street near a busy highway with a skin tear, and staff interviews revealed gaps in awareness and recall of the incident. The deficiency involved a failure to provide adequate supervision and ensure the effectiveness of assistance devices to prevent elopement.
A resident with severe cognitive impairment and a history of malnutrition was served a pureed meal instead of the prescribed regular ground diet, as indicated on the meal ticket. Staff interviews and observations confirmed the error occurred due to a lack of proper verification of the meal texture before service, despite established procedures and policies.
A resident with severe cognitive impairment and multiple pressure ulcers had weekly labs ordered to be sent to her infectious disease physician. Although the labs were drawn, the facility did not ensure the results were sent to the physician as ordered, and the physician's clinic reported not receiving the results despite repeated requests. Facility staff could not confirm or document that the labs were sent, which was not in accordance with facility policy.
A resident with a history of multiple mental health diagnoses and severe cognitive impairment received a new diagnosis of schizoaffective disorder, bipolar type, but was not referred for a new PASRR assessment as required. Staff interviews revealed confusion about the process, and documentation was incomplete, resulting in the resident not being evaluated for PASRR services.
A resident with multiple medical conditions and complex medication needs did not have a comprehensive care plan developed and implemented as required. The care plan lacked measurable objectives and timeframes for diabetes management, use of antidepressants, opioid use, insulin administration, and ADL care, despite these needs being identified in the assessment and physician orders. Facility staff confirmed the care plan was incomplete and not consistent with policy requirements.
A resident with a feeding tube did not receive enteral nutrition and water flushes according to physician orders, as nursing staff set the feeding pump to incorrect rates and failed to verify updated orders. Staff interviews revealed a lack of awareness of order changes and inconsistent adherence to facility policy requiring verification of feeding and flush rates.
A resident with end-stage renal disease and other comorbidities did not have dialysis communication forms fully completed on several occasions, with only pre-dialysis information documented and treatment details missing. Nursing staff reported challenges in obtaining completed forms from the dialysis center, and oversight failed to identify the incomplete documentation, despite facility policy requiring full completion of these records.
The facility did not ensure accurate narcotic logs and medication administration records for two residents, resulting in discrepancies between the recorded and actual counts of controlled medications. An LPN failed to log one administration and signed off for a dose that was not given, leading to mismatched records and delayed medication for a resident. The DON confirmed that staff are required to document and reconcile narcotic counts according to facility policy.
A nurse crushed and mixed all prescribed medications together in one cup of pudding and administered them to a resident with severe cognitive impairment, without a physician's order to do so. This resulted in a medication error rate of 10% after 30 opportunities, as confirmed by observation, interviews, and record review. Facility leadership and training materials indicated that a physician's order was required for crushing and mixing medications, but no such order was present for this resident.
A resident with severe cognitive impairment and a history of mental health conditions eloped from the facility and was found outside by staff with a skin tear. Although the incident was documented internally and the resident was treated, the facility did not report the elopement and injury to the state agency as required by regulation. Staff interviews and record reviews confirmed the lack of external reporting despite existing policies and staff training on timely reporting of such events.
A resident with multiple complex medical conditions experienced an unwitnessed fall resulting in back pain and abnormal x-ray findings. Nursing staff failed to immediately notify the responsible party, instead contacting a different family member not listed as the responsible party. The responsible party was not informed of the fall or hospital transfer in a timely manner, despite facility policy requiring such notification.
Nursing staff failed to notify the correct responsible party after a resident experienced an unwitnessed fall, abnormal x-ray findings, and a hospital transfer, instead communicating with a non-designated family member. This resulted in the actual responsible party not being promptly informed about significant changes in the resident's condition, in violation of privacy and confidentiality requirements.
A resident with moderate cognitive impairment and multiple complex medical conditions did not have a comprehensive ADL care plan developed or implemented, despite being dependent on staff for most daily activities and at risk for falls and pressure injuries. The omission was confirmed through record review and staff interviews, revealing gaps in care planning and communication among facility staff.
A resident with complex medical needs and high risk for pressure injuries developed a sacral wound and a new left heel wound after staff failed to provide timely incontinence care and did not consistently communicate or document care needs. Inadequate assessment, incomplete care planning, and reliance on incorrect information led to lapses in care, resulting in the development and progression of pressure ulcers.
A resident with multiple complex conditions and a newly diagnosed sacral pressure ulcer did not have this diagnosis added to their EMR profile by the responsible MDS staff, resulting in incomplete medical records. The absence of a designated backup for updating diagnoses and the lack of a written medical records policy contributed to the deficiency.
Two residents eloped from the facility without staff awareness, highlighting a failure in supervision and monitoring. One resident, with a history of cognitive impairment, removed her Wanderguard and left the facility. Both residents were not identified as elopement risks, and their absence was not discovered until the next shift. Staff familiarity with the residents' routines may have contributed to the oversight.
The facility's kitchen failed to meet professional food safety standards, with unlabeled, undated, and unsealed food items found in the refrigerator, freezer, and pantry. Additionally, a trash can without a lid was observed in the food prep area, and lighter fluid was improperly stored in the dry food storage area. Staff interviews revealed training on proper procedures, but compliance issues persisted, posing contamination risks.
A facility failed to update a resident's care plan to reflect their elopement risk and use of a wanderguard, despite the resident's history of elopement. Staff interviews revealed confusion over responsibility for care plan updates, and the Administrator downplayed the importance of the care plan. The facility's policy requires care plans to be updated for identified risks, which was not followed, potentially placing the resident at risk.
A resident with multiple health issues attempted to elope by removing her Wanderguard, but the LTC facility failed to document the incident as required by policy. The DON was unaware of the incident, and the Administrator believed a report was unnecessary since the resident did not leave the premises.
The facility failed to ensure that sharps disposal bins on nurse medication and treatment carts were kept below the full line, posing a risk of exposure to contaminated sharps. LVNs responsible for these carts acknowledged the hazard, and interviews confirmed that nursing staff were expected to change the bins when full. The facility's policy required replacement of containers when 75% to 80% full, but this was not adhered to.
Two residents missed their dialysis appointments due to transportation issues, and the facility failed to notify their physicians or document the missed appointments. This lack of communication and documentation could have led to serious health risks. The facility's policy requires notifying the physician of any changes in condition, but this was not followed.
Two residents missed their dialysis appointments due to a failure in arranging alternate transportation after the contracted service canceled. The facility's receptionist did not communicate the cancellation, and the facility van was unavailable. Despite the oversight, both residents remained stable, but the incident highlighted deficiencies in the facility's processes.
The facility failed to maintain a clean restroom for two residents and did not ensure functional door handles for two other residents. One resident's restroom had a dried black substance resembling fecal matter, and two residents had a missing door lever, making it difficult to open the door from the inside.
Two residents in a LTC facility did not receive timely incontinent care, leading to feelings of neglect and potential health issues. One resident, with moderate cognitive impairment, was left unchanged for several hours despite pressing the call light. Another resident, with no cognitive impairment but physical limitations, experienced similar delays and developed a rash. Staffing issues and inadequate response to call lights were identified as contributing factors.
Failure to Maintain Resident Dignity and Privacy When Undressed With Door Open
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to dignity and privacy by allowing her to lie in bed in only her underwear with the room door open. Surveyors observed the resident, an elderly female with dementia and severe cognitive impairment, asleep in Bed A wearing only underwear while the door to her room was open. Her medical record indicated she was dependent on staff for dressing and lower body dressing and had impairments in both lower extremities, but her comprehensive care plan did not reflect that she had a behavior of undressing or removing her clothing. During interviews, the resident stated she did not remember that she had been without pants earlier. Her roommate reported that the resident would get hot and take her pants off, and that this had occurred the previous night, with the resident not putting her pants back on until the next morning. The roommate also stated that staff typically closed the curtain or door when the resident was in her underwear and that she herself would tell the resident to take off some clothes when she was hot. Multiple staff members, including an LVN and CNAs, confirmed that the resident frequently became hot, took off her pants or gown, and would be left in her underwear, and that the roommate controlled the room temperature on her side of the room. Staff interviews further showed that they recognized it was not acceptable for the resident to lie in bed in her underwear with the door open and identified lack of privacy and potential exposure as concerns. The LVN stated the resident was confused, did not typically keep her pants on, and that staff had removed her pants for toileting and attempted to close the door, close the curtain, and put clothes on her, but the resident would get up and reopen the door. The ADON acknowledged that the resident’s behavior of undressing with the door open should have been included in the care plan if it was a regular behavior and recognized exposure as a risk. The Administrator stated staff were expected to protect residents and maintain their dignity and identified the situation as a dignity and resident rights concern, while the facility’s own policy required all staff to promote and maintain resident dignity and act upon information regarding resident preferences.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents across five of six halls. Surveyors observed multiple 32-gallon trash bins emitting strong odors of urine and feces in several hallways, which led to complaints from residents about the smell. In response to these odors, a CNA was seen spraying a strong-scented perfume down one hallway, and another staff member reported using Febreze. The use of perfume was acknowledged by the Treatment Nurse as potentially harmful to residents with respiratory issues. Staff interviews confirmed that the odors were a recurring issue and that scented sprays were used in an attempt to mask them. Additionally, mechanical lifts and a shower bed were observed unlocked and stored in hallways on multiple occasions. The administrator stated that the equipment could not be locked due to life safety requirements regarding egress pathways, but communication from the Life Safety Director clarified that the issue was not about locking the equipment, but rather that such equipment should not be stored in the egress pathways at all. Facility policy indicated that accessible hazards, such as unlocked equipment, should be secured to prevent injury, but this was not followed, resulting in unsafe conditions for residents.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff not following enhanced barrier precautions (EBP) for a resident requiring such measures. The resident in question was a male with severe cognitive impairment, total dependence for activities of daily living, and a gastrostomy tube, who was placed on EBP due to the presence of an indwelling medical device. Facility policy and CDC guidance required staff to wear gowns and gloves during high-contact care activities for residents on EBP. On several occasions, staff members, including an LVN and CNAs, provided high-contact care such as repositioning, perineal care, handling soiled linens, and G-tube care to the resident without donning the required personal protective equipment (PPE) such as gowns and gloves. Observations by the surveyor confirmed that staff failed to use appropriate PPE during these activities, despite EBP signage being posted above the resident's bed and PPE supplies being available in the room. Additionally, hand hygiene protocols were not consistently followed, as one CNA was observed not washing hands or using hand sanitizer after disposing of trash. Interviews with staff, including the wound care nurse, CNAs, LVN, ADON, DON, and the Medical Director, confirmed that they were aware of the EBP requirements and the need for PPE during high-contact care. However, despite this knowledge and the presence of visual cues, staff did not consistently adhere to infection control procedures. The facility had 23 residents on EBP at the time, and the failure to follow established protocols was directly observed and corroborated by staff interviews and record reviews.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to five residents who required varying levels of assistance and were at risk for falls. Observations on a specific date revealed that the call lights in the rooms of these residents were not within their reach. In several cases, the call lights were found on the floor, under beds, behind side tables, or otherwise out of reach, despite care plans specifying that call lights should be accessible to the residents at all times. The residents involved had significant medical conditions, including muscle weakness, hemiplegia, hemiparesis, and abnormalities of gait. Some residents had severe cognitive impairments, as indicated by low BIMS scores, and required maximal or moderate assistance with activities of daily living such as dressing, bed mobility, and transfers. During interviews and observations, some residents were unable to locate their call lights or did not respond when asked about them, while others confirmed that their call lights had been out of reach for some time. Staff interviews confirmed that it was the responsibility of all staff members, including CNAs, LVNs, the ADON, and the DON, to ensure that call lights were within reach of residents at all times. Staff acknowledged that call lights are essential for residents to request assistance or alert staff in case of need. Facility policy and in-service training materials also specified that call lights should always be within residents' reach, but this expectation was not met during the observations documented in the report.
Unattended Computer Screen Exposes Resident Medical Information
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) left a computer tablet displaying a resident's electronic medication administration record (EMAR) unattended on top of a medication cart. The screen was visible for approximately three minutes without any staff present, during which time it displayed the resident's picture and details of a recent insulin administration. The medication cart was positioned in the doorway of a resident's room, with other residents nearby and staff observed at a distance. The resident whose information was exposed had multiple complex medical conditions, including cirrhosis, renal insufficiency, viral hepatitis, diabetes mellitus, asthma, and respiratory failure. The resident required assistance with activities of daily living and had no cognitive impairment, as indicated by a BIMS score of 15. The EMAR on the unattended computer showed specific details about the resident's insulin administration, including the dosage and timing, which could have been viewed by other residents or visitors. Interviews and observations confirmed that the LVN left the computer unlocked while attempting to locate a physician, and the facility's policies require that resident information be kept confidential and computer screens locked when unattended. The incident was identified during a surveyor's observation, and the LVN acknowledged that leaving the screen unlocked was a violation of HIPAA and facility policy.
Unattended and Unlocked Medication Cart Left Accessible in Resident Hall
Penalty
Summary
A deficiency occurred when a medication cart was left unattended and unlocked in the doorway of a resident room on Hall 500. The cart's lock was visibly disengaged, and no staff were present in the immediate area, while two residents were in their room watching TV. The incident was observed by a surveyor, who noted that the cart was accessible to anyone passing by. The nurse responsible for the cart, an LVN, returned to the cart a few minutes later and acknowledged that she had left it unlocked while attempting to speak with a doctor. She confirmed that the cart could have been accessed by unauthorized individuals during her absence and admitted that it should have been locked. The facility's policy requires all drugs and biologicals to be stored in locked compartments when not in use, and medication carts are not to be left unattended if open or accessible. The LVN stated she had just administered diabetic medication to a resident prior to leaving the cart. The incident was confirmed through observation, staff interviews, and review of facility policy and employee records. The administrator and DON were made aware of the incident and confirmed that leaving medication carts unlocked is against facility policy.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of depression and bipolar disorder was able to elope from the facility through the back door. The resident, who utilized a wheelchair and had a BIMS score indicating severe cognitive impairment, was found on the street attempting to go to a gas station across from the facility, which is located near a busy highway. The resident sustained a skin tear to his arm during the incident. Documentation shows that the resident's care plan identified him as being at risk for wandering and required the use of a wander guard bracelet, with interventions including monitoring the bracelet's placement and function, and observing the resident's location each shift. Despite these interventions being documented, the resident was able to leave the facility unsupervised. The elopement risk assessments completed prior to the incident did not indicate imminent risk, and there were no additional elopement risk assessments found in the resident's health chart. Staff interviews revealed that while staff were generally aware of elopement protocols and the use of wander guard systems, several staff members were unaware of the specific incident or did not recall details about the resident's elopement. The door through which the resident exited was equipped with a wander guard alarm system, which was observed to be functional at the time of the survey, but it is unclear from the report how the resident was able to exit undetected. The incident was documented in clinical notes and an accident/incident report, which described the resident's elopement and subsequent return to the facility. The resident's family was notified, and the event was reported by staff. The deficiency centers on the facility's failure to provide adequate supervision and ensure the effectiveness of assistance devices to prevent the resident's elopement, as required by the resident's care plan and facility policy.
Failure to Provide Prescribed Diet Texture to Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of protein-calorie malnutrition, hypertension, depression, and bipolar disorder was not provided with the prescribed regular ground diet. Instead, the resident was served a pureed meal, despite the meal ticket indicating the need for a regular ground texture. The resident expressed dissatisfaction with receiving pureed foods, stating that he did not want to eat when served the incorrect texture. Observations confirmed that the resident was given a pureed meal, and staff interviews revealed that the error was due to a failure to verify the correct food texture as indicated on the meal ticket. Multiple staff members, including Central Supply, the RD, the Dietary Manager, and the DON, acknowledged that the resident should have received the regular ground diet as prescribed. The process for meal verification involved several staff, but the error was not caught before the meal was served. The facility's policy required diets to be determined according to residents' needs and preferences, but this was not followed in this instance, resulting in the resident receiving the wrong food consistency.
Failure to Promptly Notify Physician of Lab Results
Penalty
Summary
The facility failed to promptly notify the infectious disease physician of laboratory results for one resident who required weekly lab monitoring as ordered by the physician. The resident, a female with severe cognitive impairment, diabetes, anxiety disorder, and multiple pressure ulcers including a stage 4 ulcer, was admitted with orders for weekly CRP, BMP, and CBC labs to be faxed to her infectious disease doctor. Although the facility obtained the required labs on three separate occasions, there was no documentation or confirmation that these results were sent to the physician as ordered. Interviews with the resident's family and the infectious disease doctor's clinic revealed that the clinic did not receive the lab results despite multiple requests and follow-up calls to the facility. The clinic only received one set of labs after the resident was discharged. Facility staff, including the ADON and DON, could not confirm or provide documentation that the labs were sent as required. This failure was not in accordance with the facility's own policy, which requires staff to document when, how, and to whom lab results are provided.
Failure to Coordinate PASRR Assessment After New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for one resident who was reviewed for PASRR assessments. The resident, a male with a history of depression disorder, anxiety disorder, psychotic disorder, and non-Alzheimer's dementia, was admitted with severe cognitive impairment. He received a new diagnosis of schizoaffective disorder, bipolar type, but the facility did not refer him to the appropriate state-designated mental health authority for review as required. The resident's PASRR Level 1 screening, completed previously, did not indicate a mental illness, and a subsequent 1012 Form listed a primary diagnosis of dementia, but sections of the form were incomplete. Interviews with facility staff revealed confusion regarding the need for a new PASRR evaluation following the new diagnosis. The Resident Care Coordinator (RCC) initially believed the dementia diagnosis on the 1012 Form overrode the new mental health diagnosis, but later acknowledged the form was not completed correctly and that a new PASRR Level 1 or 1012 Form should have been completed. The Director of Nursing (DON) confirmed that a new PASRR evaluation should be done when a new diagnosis is given. The facility's admission policy requires all new admissions and readmissions to be screened for mental disorders per the PASRR process.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions. The resident, a cognitively intact female, was admitted with diagnoses including chronic obstructive pulmonary disease, heart failure, hypertension, diabetes mellitus, muscle weakness, and septicemia. Her assessment indicated she required substantial to maximal assistance with activities of daily living (ADLs) and was receiving several medications, including antidepressants, antibiotics, diuretics, hypoglycemics, and opioids. Upon review, the resident's care plan lacked measurable objectives and timeframes for several critical areas. While the care plan addressed code status and fall risk with some goals and interventions, it did not include any goals or interventions for diabetes management, use of antidepressant medication, opioid use, insulin administration, or ADL care. Physician orders documented the administration of multiple medications, including insulin and antidepressants, but these were not reflected in the care plan as required. Interviews with facility staff, including the ADON and DON, confirmed that the care plan was incomplete and did not address all areas triggered by the resident's assessment. The ADON acknowledged responsibility for ensuring the care plan was accurate and complete, and both the ADON and DON recognized that incomplete care plans could result in staff not providing the necessary care. Facility policy required comprehensive care plans with measurable objectives and timetables to be developed within seven days of the assessment, but this was not followed in this case.
Failure to Follow Physician Orders for Enteral Feeding Administration
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a feeding tube was provided with the appropriate treatment and services as ordered by the physician. Specifically, the resident, who had a history of dysphagia and moderate cognitive impairment, had physician orders for her feeding tube to be flushed with 50 mL of water every hour and to receive Jevity 1.2 at a rate of 55 mL/hr. However, observations and interviews revealed that the feeding pump was set to deliver Jevity 1.2 at 65 mL/hr and water flushes at 35 mL/hr, which did not match the physician's orders. Nursing staff admitted to not checking the current orders before administering the feedings and water flushes, and were unaware that the orders had been changed. Further interviews with facility staff, including the ADON and DON, confirmed that there was an expectation for nurses to verify and follow physician and dietitian orders, but this was not consistently done. The ADON acknowledged responsibility for updating orders in the electronic record and monitoring compliance, but had not checked the resident's pump settings since the orders were changed. Training records indicated that not all staff responsible for the resident's care had attended recent in-service training on enteral feeding administration. The facility's policy required staff to check enteral nutrition labels and administration rates against orders, but this was not followed in practice.
Incomplete Dialysis Communication Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards, the care plan, and the resident's preferences. Specifically, the dialysis communication forms for the resident were not completed with the necessary treatment information on multiple occasions. On the dates reviewed, only the pre-dialysis information was filled out, while the sections for dialysis treatment information were either left blank or marked as not applicable. The resident in question was an older female with moderate cognitive impairment and multiple active diagnoses, including renal insufficiency, renal failure or end-stage renal disease, heart failure, and respiratory failure. She was admitted to the facility and had physician's orders and a care plan indicating the need for regular dialysis. The process required the completion of pre- and post-dialysis sections on a communication form, with the expectation that the dialysis center would fill out the treatment information and return the form with the resident. Interviews with nursing staff revealed that the pre-dialysis section was completed by the morning nurse, and the afternoon nurse was responsible for ensuring the post-dialysis information was recorded. However, the dialysis center often did not return the completed forms, and the afternoon nurse sometimes had difficulty obtaining the necessary information. The ADON, responsible for oversight, was unaware that the forms were incomplete, and the facility's policy required all sections of the communication record to be completed and filed.
Failure to Maintain Accurate Narcotic Logs and Medication Administration Records
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring accurate narcotic logs and medication administration records for two residents on the 500 Hall medication cart. For one resident with a history of hip and knee replacement and moderately impaired cognition, the narcotic administration record for Acetaminophen-Codeine showed a discrepancy of one pill between the log and the blister pack. The medication was last administered in the morning, but the count did not match the record. For another resident with pain and intact cognition, the narcotic administration record for hydrocodone-acetaminophen also showed a one-pill discrepancy, with the log indicating one less pill than the blister pack. The medication was signed off as given, but the resident reported not receiving it until later when the nurse realized the omission. Interviews with the nurse responsible revealed she was unaware of the discrepancies and admitted to forgetting to log one administration and to signing off for a medication that was not actually given. The nurse acknowledged the importance of reconciling counts and logging medications immediately after administration, as per facility policy and training. The DON confirmed that staff are expected to document administration on both the medication administration record and the narcotic log, and that counts should be reconciled at each shift change. Review of facility policy and training materials supported these expectations.
Medication Error Rate Exceeds 5% Due to Improper Crushing and Mixing of Medications
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) crushed and mixed all of a resident's prescribed medications together in one cup of pudding and administered them without a physician's order to do so. The medications included bismuth/metronidazole/tetracycline capsules, Renal-Vite, and vitamin C. The LVN was observed preparing and administering the medications in this manner, and during an interview, admitted to not being aware that a physician's order was required to crush and mix the medications. The LVN also stated that she had been crushing and mixing the medications for the resident since admission without verifying the need for an order. The resident involved was a male with severe cognitive impairment, as indicated by a BIMS score of 5, and had diagnoses including pneumonia and chronic kidney disease. Review of the resident's records confirmed there was no physician order to crush and mix the medications. Facility leadership, including the ADON and DON, confirmed that staff are expected to have physician orders for crushing and mixing medications, and that the standing order for crushing was not present on the resident's medication administration record. The facility's training materials also specified that medications should not be crushed without an appropriate order.
Failure to Timely Report Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to the appropriate authorities as required by regulation. Specifically, the facility did not report an incident in which a resident with severe cognitive impairment and multiple mental health diagnoses eloped from the facility. The resident, who was assessed as being at risk for wandering and required a wander guard bracelet, was found outside the facility on the street by a staff member. Upon return, the resident was noted to have a skin tear on his left arm, which was treated by nursing staff. Documentation in the resident's clinical notes and an accident/incident report confirmed the elopement and injury. However, a review of the Texas Unified Licensure Information Portal showed that no incident report regarding the elopement was submitted to the state agency. Interviews with current and former staff, including the DON and Administrator, revealed that the incident was not reported to the state, and there was uncertainty among staff about whether the event was reportable. The facility's own policies required immediate reporting of such incidents to regulatory authorities, but this protocol was not followed in this case. The failure to report the elopement and associated injury was identified through observation, interview, and record review. The deficiency was further substantiated by the lack of documentation in state reporting systems and by staff interviews indicating a lack of awareness or recall of the incident. The facility's in-service training records showed that staff had been trained on abuse prevention and timely reporting, yet the required reporting procedures were not implemented for this event.
Failure to Notify Responsible Party of Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the resident's responsible party following an unwitnessed fall that resulted in injury and required physician intervention, as well as during the subsequent transfer of the resident to the hospital. Specifically, after the resident was found on the floor with complaints of back pain, the nurse on duty attempted to call the responsible party but only left a voicemail and did not make further attempts to reach them or ensure the message was received. Documentation indicated that the responsible party was notified, but interviews revealed that the responsible party did not receive timely information about the fall or the hospital transfer. Further review showed that another nurse failed to notify the responsible party about the resident's transfer to the hospital after abnormal x-ray findings. Instead, communication was made with a family member who was not listed as the responsible party on the resident's face sheet. This led to confusion and a delay in the responsible party being informed about the resident's condition and hospital transfer. The responsible party only learned of the events after being contacted by the other family member and upon visiting the facility in person. The resident involved had multiple complex medical conditions, including atrial fibrillation, diabetes, and a history of falls, and was dependent on staff for most activities of daily living. The facility's own policy required immediate notification of the responsible party in the event of a significant change in condition, such as a fall or hospital transfer. However, staff failed to follow this policy, resulting in a lack of timely communication with the appropriate family member regarding the resident's fall, abnormal x-ray results, and transfer to the hospital.
Failure to Notify Responsible Party and Maintain Confidentiality of Medical Records
Penalty
Summary
The facility failed to ensure the right to personal privacy and confidentiality of personal and medical records for one resident, as required. Specifically, nursing staff did not notify the correct responsible party (RP) listed on the resident's face sheet following an unwitnessed fall and subsequent transfer to the hospital. Instead, staff communicated with a family member who was not designated as the RP, resulting in the actual RP not being informed in a timely manner about the resident's fall, abnormal x-ray findings, and hospital transfer. The resident involved was an elderly male with multiple complex medical conditions, including atrial fibrillation, hypertension, diabetes, metabolic encephalopathy, and a history of falls. He was cognitively impaired, dependent on staff for most activities of daily living, and at risk for pressure injuries. After an unwitnessed fall, the resident complained of back pain, and x-rays revealed abnormal findings. Orders were obtained for further evaluation, and the resident was sent to the hospital. Documentation and interviews confirmed that the RP listed on the face sheet was not notified promptly; instead, another family member was contacted and provided with information about the resident's condition and care. Interviews with staff and the RP confirmed that the RP did not receive notification about the fall or hospital transfer until much later, and only after he sought information himself. Nursing staff acknowledged confusion regarding which family member to contact and admitted to not verifying the correct RP before disclosing information. The documentation also showed inconsistencies in notification records, and the responsible staff did not follow established protocols for ensuring the correct party was informed of significant changes in the resident's condition.
Failure to Develop and Implement Comprehensive ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by regulatory standards. Specifically, the care plan did not include measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The care plan was missing critical information regarding the level of assistance needed for activities of daily living (ADLs) such as dressing, toileting, bed mobility, and transfers. The resident in question was an older male with moderate cognitive impairment, multiple complex medical diagnoses, and a history of falls. He was dependent on staff for most ADLs, including toileting, showering, and dressing, and was at risk for pressure injuries. Despite these needs being identified in his admission MDS assessment, the corresponding ADL care plan was not completed or available in the electronic medical record at the time of review. This omission was confirmed during interviews with the MDS Coordinator, who acknowledged the absence of the care plan and the potential for safety issues as a result. Further interviews with facility staff, including the Administrator and Director of Rehabilitation, revealed a lack of awareness regarding the missing care plan and inconsistencies in communication and responsibility for care plan development. The facility's own policy requires that care plans be individualized, comprehensive, and updated as resident conditions change, but this process was not followed for the resident, resulting in incomplete guidance for staff on how to meet the resident's needs.
Failure to Prevent and Manage Pressure Ulcers Due to Inadequate Incontinence Care and Communication
Penalty
Summary
A resident with multiple complex medical conditions, including atrial fibrillation, diabetes, and cognitive impairment, was admitted to the facility and assessed as being at risk for pressure injuries. Upon admission, initial nursing assessments documented intact skin with no wounds or discoloration. However, within days, a treatment nurse identified purplish discoloration on the resident's sacrum, and wound care was initiated. Documentation and interviews revealed inconsistencies regarding whether the sacral wound was present on admission or developed shortly after, with some staff stating the wound was not present at admission and others indicating it was. The resident was dependent on staff for activities of daily living, including toileting and incontinence care, and was always incontinent of bowel and occasionally of bladder. On one occasion, a CNA failed to provide timely incontinent care, leaving the resident soiled for an extended period. This lapse was observed by the resident's family member, who reported the resident's bed and clothing were saturated with feces and urine. The CNA later admitted to not checking the resident's care plan and relying on incorrect information from another CNA regarding the resident's continence status. The nurse on duty was made aware of the situation and ensured the resident was changed, but the incident was not promptly escalated to facility leadership. Subsequently, the resident developed an open sacral wound and later a new left heel wound, both of which were documented as acquired in-house. The care plan did not initially address all aspects of the resident's ADL care, and there were gaps in communication and documentation regarding wound care and skin assessments. The failure to provide consistent and timely incontinence care, along with inadequate communication among staff regarding the resident's needs and care assignments, contributed to the development and progression of pressure injuries.
Incomplete Medical Record Documentation for Pressure Ulcer Diagnosis
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically by not adding a new diagnosis of a sacral pressure ulcer to the resident's electronic medical record (EMR) profile. The resident, an older male with multiple complex medical conditions including atrial fibrillation, hypertension, diabetes, and a history of falls, was assessed as being at risk for pressure injuries and had at least one pressure injury documented. Despite this, the new diagnosis of a sacral wound, identified on 03/31/25, was not entered into the EMR by the MDS Coordinator or other responsible staff. Interviews revealed that the MDS Coordinator was aware of the sacral wound but had not updated the EMR profile to reflect this diagnosis. The Administrator confirmed that there was no designated backup for adding diagnoses when the MDS Coordinator was absent, and acknowledged the importance of having accurate diagnoses in the EMR to reflect the resident's condition. Additionally, the facility did not have a written medical records policy available for review.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent elopement incidents involving two residents. Both residents left the facility without staff awareness, with the elopement occurring around 12:55 AM and not being discovered until after 6:00 AM during the next shift change. The staff were unaware of the residents' absence for several hours, indicating a lack of adequate supervision and monitoring. One of the residents, a female with a history of alcohol dependence, cognitive communication deficit, and other health issues, was able to remove her Wanderguard and leave the facility. Her care plan did not address elopement risks or the use of a Wanderguard, and her elopement risk assessment did not identify her as at risk. The other resident, a male with intact cognition, also left the facility without being noticed. Both residents were known to be in a relationship and were often seen together, which may have contributed to their ability to leave unnoticed. Interviews with facility staff, including the Administrator and DON, revealed that the residents were considered independent and not at risk for elopement prior to the incident. The staff's familiarity with the residents' routines and preferences may have led to a lack of vigilance in monitoring their whereabouts. The facility's failure to promptly identify and respond to the residents' absence placed them at risk for harm and serious injury.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Specifically, food items in the refrigerator, freezer, and pantry were not labeled, dated, or sealed, which is a violation of the facility's food storage policy. For instance, 16 cups of various juices and a bowl of barbeque shredded chicken in the refrigerator were not labeled or dated. In the dry storage room, a bag of dry cereal was found in a plastic storage bag that was not sealed. In the freezer, a 10-pound box of breaded chicken breast and a box of breaded yellow squash were not sealed, and a freezer-burned slab of pork ribs was found in a plastic bag that was neither sealed, labeled, nor dated. Additionally, the facility did not maintain cleanliness in the food preparation area, as evidenced by a trash can full of trash without a lid, which contradicts the facility's sanitization policy. Lighter fluid was also improperly stored in the dry food storage area, posing a risk of contamination. Interviews with the Nutrition Aide and Dietary Manager revealed that staff were trained on proper labeling, dating, and sealing of food items, but there were issues with compliance. The Dietary Manager acknowledged the risk of cross-contamination due to these oversights, and the Administrator recognized the potential for contamination due to improper food storage and trash management.
Failure to Update Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not address the resident's elopement risk or the use of a wanderguard, despite the resident having a history of elopement and wearing a wanderguard. This oversight was identified during a review of the resident's care plan and elopement risk assessment, which did not reflect the resident's current needs and risks. Interviews with facility staff revealed a lack of clarity and responsibility regarding the updating of care plans. The RN and DON both acknowledged that the care plan should have been updated to reflect the resident's elopement risk and wanderguard usage. The Administrator expressed that the care plan was not a major concern, focusing instead on the resident's placement. The facility's policy requires that care plans be updated to incorporate identified problem areas and risk factors, but this was not adhered to in this case, potentially placing the resident at risk of elopement and inadequate care.
Failure to Document Elopement Attempt
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who attempted to elope. The incident involved a resident with multiple diagnoses, including alcohol dependence, psychoactive substance abuse, cognitive communication deficit, generalized anxiety disorder, diabetes, depression, and essential hypertension. On the date of the incident, the resident removed her Wanderguard and attempted to leave the facility, expressing a desire to go home. Despite the resident's actions and the initiation of 1:1 monitoring due to the elopement risk, the facility did not complete an incident report as required by their policy. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of clarity and responsibility regarding the completion of the incident report. The DON, who was new to the position at the time, was unaware of the incident and could not locate a report. The Administrator believed that an incident report was unnecessary since the resident did not actually leave the premises. However, the facility's policy clearly states that an incident report should be completed immediately upon awareness of any accident or incident, which was not adhered to in this case.
Failure to Maintain Safe Sharps Disposal Practices
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that contaminated sharps disposal bins attached to nurse medication carts and a treatment cart were kept below the full line. Observations revealed that the sharps bins on the 100 and 400 Hall Nurse Medication Carts, as well as the facility's only treatment cart, were filled past the full line, posing a risk of exposure to contaminated sharps and potential bloodborne pathogens. LVN F, responsible for the treatment cart, acknowledged the hazard posed by overfilled sharps bins, as did LVN G and LVN H, who were responsible for the 400 and 100 Hall Nurse Medication Carts, respectively. Interviews with the ADON and the Executive Director confirmed that nursing staff were expected to change the sharps bins when they became full, as overfilled bins could not close properly and posed a risk of harm to residents and staff. The facility's policy on sharps disposal, revised in January 2012, required designated individuals to replace containers when they were 75% to 80% full. However, the facility's policy on accidents and hazards did not reflect the facility's role in preventing such hazards, indicating a gap in policy implementation and oversight.
Failure to Notify Physician of Missed Dialysis Appointments
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there was a change in the resident's status. This deficiency was observed in two residents who missed their scheduled dialysis appointments due to transportation issues. The facility did not notify the attending physician or document the missed appointments, which is a requirement when there is a change in a resident's condition. Resident #1, a female with end-stage renal disease and other medical conditions, missed her dialysis appointment because the contracted transport service was unavailable. Despite attempts to reschedule, no alternative appointments were available. The facility's RN D did not notify the resident's physician or document the missed appointment, which could have led to serious health risks such as fluid overload. Interviews revealed that the facility's receptionist failed to communicate the transport cancellation, and the facility van was not available in time to transport the resident. Similarly, Resident #2, who also has end-stage renal disease, missed her dialysis appointment due to the same transportation issue. The facility did not notify her physician or document the missed appointment. Interviews with staff indicated a breakdown in communication and failure to arrange alternative transportation. The facility's policy requires notifying the physician of any changes in condition, but this was not followed, potentially putting residents at risk.
Failure to Provide Dialysis Transportation
Penalty
Summary
The facility failed to ensure that two residents who required dialysis received the necessary transportation to their appointments. On a specific date, the contracted transport service canceled the scheduled transportation for these residents, and the facility did not make alternate arrangements. This oversight resulted in both residents missing their dialysis appointments, which could potentially lead to health complications such as fluid overload. The report details that the facility's receptionist was informed of the cancellation by the transport company but did not communicate this to other staff or arrange for alternative transportation. The facility's van was unavailable because the driver had taken the keys home, and by the time the keys were retrieved, the dialysis appointments had already passed. The facility's staff, including the BOM and RN, were aware of the missed appointments but did not notify the residents' physician or family members as required by the facility's policy. The residents involved had significant medical histories, including end-stage renal disease requiring regular dialysis. Despite the missed appointments, both residents were reported to be stable, and no immediate adverse effects were noted. However, the failure to provide transportation and the lack of communication among staff highlighted deficiencies in the facility's processes for ensuring continuity of care for residents requiring dialysis.
Failure to Maintain Cleanliness and Functional Door Handles
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents. Specifically, the restroom in the room shared by two residents was found to be unclean, with a dried black substance resembling fecal matter on the floor and toilet seat. One of the residents in this room was severely cognitively impaired and always incontinent of bowel and bladder, making the cleanliness of the restroom particularly critical. The other resident was not present during the observation. The Director of Nursing (DON) acknowledged that the presence of feces on the ground posed a risk of contact or stepping on it, and the Administrator confirmed that housekeeping was responsible for daily cleaning, with CNAs also expected to disinfect as needed. However, the issue was not addressed in a timely manner, leading to an unsanitary environment for the residents involved. Additionally, the facility failed to ensure that two other residents had a functional door handle in their room. The lever on the inside of their room door was missing, making it difficult to open the door from the inside. One of the residents, who had intact cognition, reported that the lever had been missing for a while but did not express concern as they kept the door open and used a privacy curtain. The other resident had moderate cognitive impairment and was not interviewable. The Administrator acknowledged the risk of not being able to open the door in an emergency and stated that the door handle was fixed immediately upon notification, but could not confirm how long it had been missing.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADL) care, specifically timely incontinent care, for two residents. Resident #1, a female with moderate cognitive impairment and multiple health conditions, was observed in a room with a strong smell of urine. She reported not having been changed since 4 AM, despite pressing the call light at 9:40 AM. A CNA turned off the call light without providing care, and Resident #1 did not receive incontinent care until 11:45 AM. Her care plan required incontinent care every 2 hours, highlighting a failure to meet her needs. Resident #2, who has no cognitive impairment but suffers from various health issues including muscle weakness and paralysis of the right hand, also experienced delays in receiving incontinent care. She reported not having her brief changed since 6:00 AM and described a pattern of aides turning off her call light without providing care. She expressed feelings of neglect and reported developing a rash due to the lack of timely care. Her care plan also required assistance with ADL care, including incontinent care every 2 hours, which was not adhered to. Interviews with staff revealed issues with staffing, particularly in the 200-hall, where both residents reside. CNA-B confirmed the hall was understaffed and admitted to turning off Resident #1's call light without providing care due to being pulled to assist in another hall. CNA-C stated she would not provide care to residents who were rude or abusive, opting to switch assignments with other CNAs. The Administrator acknowledged the expectation for call light responses within 10 minutes and emphasized the responsibility of all staff to respond to call lights, but admitted to staffing challenges and the need for communication with residents when care could not be immediately provided.
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 1,319 citations issued within 25 miles in the last 12 months — including the 66 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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Skyline Nursing Center | 2 mi | ★★★★★ | 14 | 0 |
| The Laurenwood Nursing And Rehabilitation | 3.6 mi | ★★★★★ | 8 | 0 |
| The Renaissance At Kessler Park | 4.1 mi | ★★★★★ | 5 | 0 |
| Duncanville Healthcare And Rehabilitation Center | 4.6 mi | ★★★★★ | 18 | 0 |
| The Lennwood Nursing And Rehabilitation | 4.8 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.