Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Villages On Macarthur during CMS and state inspections, most recent first.
Two residents were found without adequate access to the call light system—one had no call light cord in his room, and another could not reach her call light because it was tied to the bed while she was in her wheelchair. Staff were unaware of these issues, and both residents had to rely on alternative means to request assistance. Facility policy requires call lights to be within easy reach at all times.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A working call system was not available in each resident's bathroom and bathing area, as observed during the survey. This deficiency was cited due to the lack of a functional system for residents to request assistance in these areas.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, and the facility did not ensure the regimen was free from unnecessary drugs.
A Dietary Aide did not follow the prescribed recipe for preparing a pureed meal, using gravy instead of beef broth and failing to achieve the required smooth texture. The Dietary Manager confirmed the recipe was not followed, resulting in a pureed meal that lacked proper flavor and consistency for residents on pureed diets.
A resident with quadriplegia and contractures was unable to use the temporary call bell provided during a facility-wide call light system outage, leaving her without a reliable means to contact staff for assistance. Staff and nursing leadership were aware of the resident's inability to use the bell, and the care plan required accessible call devices, but no suitable alternative was initially provided.
A resident with multiple mental health diagnoses was discharged without a completed interdisciplinary discharge summary, missing essential sections such as recapitulation of stay, physician signature, and summaries from social services, activities, and therapy. Nursing notes documented the resident's departure against medical advice, and staff interviews confirmed that required documentation was not completed or verified by the responsible departments.
A resident with severe cognitive impairment and multiple mental health diagnoses, including a new diagnosis of schizophrenia, was not referred for a required PASRR assessment after the new diagnosis. The responsible MDS nurse did not complete the necessary screening or notify others, and the facility lacked a specific PASRR policy, relying instead on state guidelines.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs for support with basic daily functions.
A resident with COPD and other chronic conditions was observed receiving oxygen at 3 L/min instead of the ordered 2 L/min. The resident and staff were unaware of who authorized the increase, and there was no documentation or physician order for the change. Nursing staff and the DON confirmed that oxygen levels should be checked and maintained as ordered, but this was not done, resulting in a deficiency in respiratory care.
Two residents receiving pain management medications did not have accurate narcotic counts or proper documentation on the medication cart. A nurse administered morphine and oxycodone but failed to sign the narcotic log as required. Both the ADON and DON could not confirm recent audits of medication carts, and no training records on narcotic administration were available, despite facility policy requiring immediate documentation.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A deficiency was cited when a resident's care plan was found to be incomplete, lacking measurable timetables and specific actions to address all identified needs. Surveyors observed that the care plan did not fully document or plan for the resident's care requirements.
A resident with cognitive impairment and a history of wandering accessed a disinfectant cleaner, leading to chemical burns and acute respiratory failure. The resident was found with the cleaner after a housekeeper had cleaned the room, and staff were unaware of the chemical's presence until symptoms appeared. The facility's failure to secure hazardous materials resulted in the resident's hospitalization.
A facility failed to implement PASRR Level II recommendations for a resident with cerebral palsy, anxiety disorder, and depression, resulting in a delay in therapy services. The resident was not assessed for Occupational and Speech Therapy as agreed upon in a meeting, due to the facility's failure to submit the necessary NFSS form request by the deadline. The Director of Rehab was unaware of the required services until a later meeting, and the facility lacked a PASRR policy, relying on the manual instead.
A resident with a complex medical history, including dementia and an above-the-knee amputation, required extensive assistance for transfers. A CNA attempted to prepare the resident for a transfer using a mechanical lift without the required two-person assistance, leading to the resident nearly falling and sustaining a head injury. Interviews revealed a common practice of preparing residents for transfers alone, despite facility policy requiring two staff members for mechanical lift operations.
The facility failed to ensure sharps containers in six resident rooms and on three medication carts were monitored and changed before becoming overfilled, posing a risk of exposure to bloodborne pathogens. Observations showed containers filled past the Fill Line, and interviews revealed unclear responsibilities among staff. The facility's policy required containers to be discarded when three-quarters full, which was not followed.
The facility failed to provide adequate pharmaceutical services, with discrepancies in narcotic logs and improper documentation by staff. Two medication carts showed mismatches between narcotic administration records and actual pill counts for residents receiving Tramadol, Hydrocodone-Acetaminophen, and Lorazepam. LVNs failed to document administration correctly, leading to potential risks. The DON acknowledged the need for proper documentation and noted a lack of recent in-service training.
The facility failed to secure medications in resident rooms, with four residents having various medications unsecured on their bedside tables. Staff were unaware of these medications, and the facility lacked procedures for self-administration assessments. The oversight posed risks of adverse reactions if other residents accessed the medications.
The facility failed to maintain proper sanitation standards for the ice machine scoop in the kitchen, as observed by the presence of water and gray buildup in the scoop holder. The Dietary Manager, responsible for kitchen sanitization, acknowledged the issue, indicating a lapse in the cleaning routine, which could risk cross-contamination and air-borne illnesses.
A facility failed to maintain an effective infection prevention and control program, as observed during medication administration for two residents with feeding tubes. An LVN did not adhere to proper hand hygiene protocols, using the same gloves after touching various surfaces without changing them or performing hand hygiene before administering medications. Interviews confirmed that the facility's policy required hand hygiene before resident contact, but the LVN acknowledged the failure to follow these protocols.
The facility failed to maintain an effective pest control program, with flies and gnats observed in multiple areas, including the kitchen and hallways. Staff interviews confirmed awareness of the issue, and pest control services were engaged biweekly. Despite these efforts, pests remained present, indicating a deficiency in the program.
A resident with acute respiratory failure was not provided with continuous oxygen therapy as ordered by the physician. Observations showed the resident without the prescribed oxygen during the day, and staff interviews revealed a misunderstanding of the orders, with an LVN believing the oxygen was to be used as needed. The DON confirmed the expectation to follow physician orders but noted a lack of recent training on oxygen therapy.
A resident with multiple health conditions, including cerebral palsy and coronary artery disease, received enteral feeding at an incorrect rate due to a miscommunication during nurse handover. The feeding pump was set at 75 ml/hr instead of the prescribed 70 ml/hr, contrary to the facility's policy requiring verification of physician orders. Staff interviews revealed the error and the expectation for nurses to double-check orders before administration.
Failure to Ensure Resident Access to Call Light System
Penalty
Summary
The facility failed to ensure that two residents had adequate access to the call light system, which is necessary for them to request staff assistance. One resident, a male with end stage renal disease, hemiplegia, aphasia, and moderate cognitive impairment, did not have a call light cord in his room. He reported that he would yell out to staff if he needed something, as he did not have a way to alert them otherwise. Staff members, including a CNA and an LVN, were unaware that this resident lacked a call light cord and noted that he typically called out or went to the nurses' station when he needed assistance. Another resident, a female with encephalopathy, sepsis, urinary tract infection, and impaired functional abilities, was unable to reach her call light cord because it was tied to the bed repositioning bar on the opposite side from where she was seated in her wheelchair. She stated that she would wait for staff to check on her to communicate her needs, as she could not access the call light. A CNA acknowledged that call light cords tied to beds were often out of reach for residents in wheelchairs but had not reported the issue. The ADON and Administrator were not aware of these deficiencies prior to the survey. Facility policy requires that call lights be plugged in and within easy reach of residents at all times.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Nonfunctional Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance when needed, was not available or functional in these specific areas of the facility. The absence of a working call system in these locations was directly noted during the survey, leading to the citation.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents’ drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Follow Pureed Diet Recipe Results in Unpalatable and Improperly Textured Meal
Penalty
Summary
A deficiency occurred when a Dietary Aide failed to prepare a pureed lunch meal according to the facility's established recipe, which was designed to conserve nutritive value, flavor, and appearance. During observation, the aide blended breaded chicken fried steak patties with white gravy instead of following the recipe that required beef base and water to create beef broth. The aide acknowledged that she was instructed to use gravy but recognized that the recipe called for broth, and not following it could affect the meal's flavor and acceptability for residents on pureed diets. Further observation and interviews revealed that the pureed chicken fried steak was not smooth and contained grizzled parts, and the spinach lacked flavor. The Dietary Manager confirmed that the recipe was not followed and that the gravy was intended to be added only on top prior to serving. The facility's policy required staff to use and follow provided recipes, but this was not adhered to in the preparation of the pureed meal, resulting in a product that did not meet the required standards for texture and flavor.
Failure to Provide Accessible Call System During Call Light Outage
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with quadriplegia and contractures, who was dependent on staff for all activities of daily living. Following a thunderstorm that caused the facility's call light system to fail, the resident was provided with a temporary call bell that she was physically unable to use due to her contractures and limited arm mobility. The resident reported that her only option to call for help was to yell, which she stated was unreliable. Staff interviews confirmed awareness that the resident could not use the provided bell, and that she normally used a flat push pad call light when the system was operational. Despite staff increasing the frequency of checks on the resident to every 15 to 30 minutes, no alternative communication device that the resident could use was initially provided. The care plan for the resident specifically required that the call light and personal items be kept within reach, and that she be reminded to call for assistance. The facility did not have a policy addressing call lights, and staff acknowledged that the temporary solution did not meet the resident's needs until a modified device was later provided.
Incomplete Discharge Summary Documentation
Penalty
Summary
The facility failed to ensure the completion of a discharge summary for one resident who was reviewed for discharge. Specifically, the discharge summary for a female resident with diagnoses including bipolar disorder, schizophrenia, and depression was not completed following her discharge. The resident's electronic health record lacked a completed Minimum Data Set (MDS) assessment, and the interdisciplinary discharge summary form was missing key sections such as the recapitulation of the resident's stay, physician signature, social services summary, activity summary, and therapy services summary. Nursing notes indicated the resident left the facility against medical advice, with all medications and belongings provided to her at the time of departure. Interviews with facility staff revealed that the social worker had only recently started at the facility and completed only his portion of the discharge summaries for residents. Other departments were responsible for their respective sections, and the medical records staff was tasked with ensuring the entire discharge summary was completed. However, in this case, the medical records staff did not identify the incomplete discharge summary, and the director of nursing confirmed that all departments should have completed their sections. The facility was unable to provide a discharge summary policy prior to the survey exit.
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, an older female with severe cognitive impairment and a BIMS score of 03, was admitted with active diagnoses of depression disorder and anxiety disorder. On a later date, she received a new diagnosis of schizophrenia, but the facility did not refer her to the appropriate state-designated mental health authority for review, nor was a new PASRR evaluation completed as required. The initial PASRR Level 1 screening did not indicate a mental illness, and the new diagnosis was not followed up with the necessary assessment. Interviews revealed that the DON was aware a new PASRR evaluation should have been completed after the new diagnosis, but the responsible MDS nurse was transitioning to another facility and did not follow up or inform others. The Regional MDS nurse was not aware of the new diagnosis until notified by the DON and confirmed that no new PASRR screening had been done. The facility administrator stated there was no specific PASRR policy in place, and the facility relied on state guidelines.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. This failure to assist affected residents who were dependent on staff for basic daily functions.
Failure to Provide Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, heart failure, and a history of stroke, was not provided respiratory care in accordance with physician orders. The resident was ordered to receive continuous oxygen at 2 liters per minute via nasal cannula, with staff responsible for monitoring and maintaining this level each shift. However, observations on multiple occasions revealed the resident was receiving oxygen at 3 liters per minute. The resident confirmed she was supposed to be on 2 liters and was unaware of any change to 3 liters. Nursing staff, including an LVN, also confirmed the order was for 2 liters and could not identify who had increased the oxygen flow or when the change occurred. The LVN acknowledged that any change in oxygen delivery should be communicated to and ordered by a physician, and that staff were responsible for monitoring and documenting oxygen levels each shift. The DON stated that staff should check the resident's oxygen level, tubing, and water each shift, and that any changes to oxygen flow should be documented and ordered by a physician. The DON also noted that the resident or family members sometimes changed the oxygen level, necessitating staff education to prevent unauthorized adjustments. Review of facility policy confirmed that licensed nursing staff are required to provide treatments as ordered by the physician. The failure to ensure the resident received oxygen therapy as ordered, and to monitor and document changes, resulted in a deficiency related to the provision of safe and appropriate respiratory care.
Failure to Accurately Document and Account for Narcotic Administration
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring accurate narcotic counts and documentation for two residents receiving pain management medications. Specifically, on one medication cart, the narcotic administration records for morphine sulfate and oxycodone did not match the actual pill counts in the blister packs for two residents. The nurse responsible for administering these medications admitted to giving the medications but failed to sign off on the Narcotic Administration Record log as required by facility policy. This lapse in documentation was confirmed during interviews, where the nurse acknowledged forgetting to sign and recognized the importance of this step. Further interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that both expected staff to document narcotic administration on both the Medication Administration Record (MAR) and the narcotic log, but neither could recall the last time they audited the medication carts. Additionally, when training records on narcotic administration were requested, none were provided. The facility's own policy required immediate documentation of controlled medication administration, including date, time, amount, and nurse's signature, which was not followed in these instances.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in noncompliance with regulations regarding the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Resident Ingests Disinfectant Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, resulting in a serious incident involving a resident with cognitive impairment. The resident, who had a history of wandering and cognitive deficits related to dementia, was found with a bottle of disinfectant cleaner containing ammonium chloride compounds. This occurred after a housekeeper had cleaned the resident's room earlier in the day. The resident was later observed with symptoms consistent with chemical ingestion, including swollen lips and vomiting, and was subsequently sent to the hospital. The resident's medical history included a progressive neurological condition, high blood pressure, diabetes, and Alzheimer's disease. The resident's care plan noted his tendency to wander and his cognitive deficits, which required specific interventions to address unmet needs. Despite these documented needs, the resident was able to access a hazardous chemical, leading to a diagnosis of acid burns to his oral mucosa and acute respiratory failure, necessitating intubation. Interviews with facility staff revealed that the disinfectant spray was found on the resident's bedside table, and there was uncertainty about how the resident obtained it. The staff, including CNAs and LVNs, were not aware of the presence of the chemical until after the incident occurred. The facility's policy required that cleaning supplies be locked away, but it was unclear how the disinfectant ended up in the resident's possession, highlighting a lapse in adherence to safety protocols.
Failure to Implement PASRR Recommendations for Resident
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II determination and evaluation report for a resident reviewed for PASRR assessments. The resident, a female with cerebral palsy, anxiety disorder, and depression, was admitted to the facility with severe cognitive impairment and speech deficits. Despite a meeting held on January 6th, where it was agreed that the resident would be assessed for Occupational and Speech Therapy, the facility did not submit the necessary NFSS form request by the specific deadline, resulting in a delay in therapy services. The Director of Rehab was not initially involved in the PASRR meeting and was unaware of the required therapy services until a subsequent meeting on February 14th. Following this meeting, the necessary paperwork was completed, and the resident was assessed for occupational therapy on February 16th. The Administrator revealed that the previous MDS Nurse was responsible for PASRR meetings and was unaware of the approval for new services through PASRR. The facility did not have a PASRR policy covering PASRR positive policy and procedures, relying instead on the manual.
Inadequate Supervision and Assistance in Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who required extensive assistance with transfers and mobility. A Certified Nursing Assistant (CNA) did not follow the resident's care plan and attempted to prepare the resident for a transfer using a mechanical lift without the required assistance. This action placed the resident at risk, resulting in an incident where the resident nearly fell from the bed and sustained a head injury. The resident involved was an elderly female with a complex medical history, including dementia, psychotic disturbance, Type II diabetes, unsteadiness of feet, lack of coordination, and an above-the-knee amputation of the right leg. Her care plan indicated she was a fall risk and required a two-person assist for bed mobility and transfers. Despite this, the CNA attempted to prepare the resident for a transfer alone, leading to the resident rolling off the bed and hitting her head on the bed rail. Interviews with staff revealed that it was common practice for aides to prepare residents for mechanical transfers alone before calling for help. However, the facility's policy required two staff members for mechanical lift operations. The Director of Nursing (DON) and MDS Coordinator acknowledged the discrepancy between the resident's MDS assessment, which indicated a need for extensive assistance, and the actual practice of allowing one-person assistance. This inconsistency contributed to the incident, as the resident's condition required more support than was provided.
Failure to Monitor and Change Overfilled Sharps Containers
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that sharps containers in six resident rooms and on three medication carts were monitored and changed before becoming overfilled. Observations revealed that sharps containers in Rooms 330, 340, 602, 704, 707, and 710, as well as on medication carts for the 300, 500, and 700 Halls, were filled past the designated Fill Line, preventing the disposal flaps from closing properly. This oversight could potentially expose residents to bloodborne pathogens due to improper disposal of used sharps. Interviews with staff, including LVNs and the ADON, indicated a lack of clarity and responsibility regarding the monitoring and changing of sharps containers. LVN A and LVN B acknowledged the risk of exposure to used sharps due to overfilled containers, while the ADON and DON stated that all nursing staff were responsible for changing the containers. The DON admitted to being unaware of the fill line on the sharps containers and expressed the need for immediate staff education. The facility's Infection Control policy, dated January 2022, specified that sharps containers should be discarded when three-quarters full, a guideline that was not adhered to in this instance.
Inadequate Pharmaceutical Services and Documentation Errors
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by discrepancies in narcotic logs and improper documentation by staff. On two medication carts, the narcotic administration records did not match the actual pill counts for residents receiving Tramadol and Hydrocodone-Acetaminophen. Specifically, the narcotic administration record for one resident showed 17 pills remaining, while the blister pack contained 16 pills. Similarly, another resident's record indicated 50 pills remaining, but the blister pack had 49 pills. These discrepancies were due to the failure of LVN E to document the administration of narcotic medications correctly and in a timely manner. Additionally, LVN G also failed to document the administration of Lorazepam accurately, resulting in a mismatch between the narcotic administration record and the blister pack count. Interviews with the LVNs revealed that they were aware of the requirement to sign off on the narcotic count sheet immediately after administration but failed to do so due to being busy or forgetting. The Director of Nursing (DON) acknowledged the expectation for staff to document narcotic medications when administered and noted that recent in-service training on medication administration had not been conducted.
Failure to Secure Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and labeled according to professional principles, as required by State and Federal laws. This deficiency was observed in four residents who had medications unsecured in their rooms. Resident #102 had a bottle of nystatin powder on her bedside table, which she brought from the hospital without the facility's knowledge. Resident #167 had multiple inhalers and nebulization solutions on his bedside table, which he used daily without proper storage. Resident #170 had a bottle of ibuprofen tablets on her bedside table, which she used as needed for pain. Resident #175 had a bottle of Vitamin C tablets on his bedside table, which was brought by a family member and taken daily. The facility's staff, including LVN D, were unaware of the presence of these medications in the residents' rooms until the survey. LVN D acknowledged that residents should not have medications in their rooms and that it was the nurse's responsibility to check and secure medications. The facility did not have any residents assessed for self-administration of medications, and the staff had been trained on medication storage. However, the training did not prevent the oversight of unsecured medications in residents' rooms. Interviews with the ADON and DON revealed that their expectations were for staff to check residents' rooms for medications and notify doctors and families if found. They emphasized the risk of other residents taking unsecured medications, which could lead to adverse reactions. The facility's Medication Storage policy did not address medications stored at bedside for self-administration, indicating a gap in their procedures.
Ice Machine Scoop Sanitation Deficiency
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety, specifically in relation to the cleanliness of the ice machine scoop in the facility's only kitchen. During an observation, it was noted that the ice machine scoop holder contained about a half inch of water with gray color buildup floating in it. The Dietary Manager, responsible for kitchen sanitization, acknowledged the issue upon discovery and mentioned that staff had been trained to clean the ice machine and scoop holder every two or three days. However, the presence of water and buildup indicated a lapse in maintaining the cleanliness standards, which could potentially lead to cross-contamination and air-borne illnesses among residents.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during medication administration for two residents with feeding tubes. Both residents, who were severely cognitively impaired and required feeding tubes due to dysphagia, were observed during medication passes. LVN A did not adhere to proper hand hygiene protocols, which included washing hands and changing gloves before and after resident contact. Specifically, LVN A was observed using the same gloves after touching various surfaces, such as the medication cart and bed controls, without changing gloves or performing hand hygiene before administering medications through the residents' feeding tubes. Interviews with LVN A and the Director of Nursing (DON) confirmed that the facility's policy required hand hygiene before resident contact and after contact with environmental surfaces. Despite having received in-service training on infection control, LVN A acknowledged the failure to follow these protocols. The DON reiterated the expectation for staff to practice appropriate hand hygiene and confirmed that the facility had conducted in-service training on handwashing and equipment cleaning. However, the observations indicated a lapse in adherence to these infection control practices, potentially placing residents at risk for infection.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies and gnats in various areas, including the kitchen, dining room, and hallways. Observations on consecutive days revealed multiple instances of flies and gnats in the kitchen, around the breakfast cart, and near the nurse's station. Interviews with staff, including the Dietary Manager and Maintenance Director, confirmed awareness of the pest issue. The Dietary Manager reported the problem to the Maintenance Director, who stated that pest control services were engaged biweekly and could respond on the same day if needed. Despite these measures, pests were still present, indicating a deficiency in the pest control program. A resident reported having roaches in her shower, which were addressed by the Maintenance Director and subsequently treated by the pest control company. The housekeeper also noted an increase in gnats and would report sightings to the Maintenance Director. The pest control log showed regular treatments targeting various pests, including flies and gnats, but the continued presence of these pests suggests that the program was not fully effective. The Maintenance Director mentioned using commercial-grade products and blue light sticky strips to manage the issue, but no structural damage was identified as a cause for pest entry.
Failure to Administer Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident who required continuous oxygen therapy as per physician orders. The resident, who had been diagnosed with acute respiratory failure, was observed multiple times without the prescribed 2 liters per minute of oxygen via nasal cannula. Despite the physician's order for continuous oxygen every shift, the resident was only using oxygen at night, and the oxygen tubing was found on the top of her bed during the day. The resident was unsure if the oxygen was supposed to be continuous, indicating a lack of communication and understanding of her care plan. Interviews with the facility staff revealed a misunderstanding of the physician's orders. An LVN assigned to the resident believed the oxygen was to be administered as needed, rather than continuously, and acknowledged that failure to follow the orders could lead to adverse health effects such as shortness of breath and hypoxia. The Director of Nursing confirmed that all nurses were expected to adhere to physician orders for oxygen therapy, but noted that no recent in-service training had been conducted on this issue, as it had not been previously identified as a problem.
Incorrect Enteral Feeding Rate Administration
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding. Specifically, the facility did not administer the enteral feed at the correct rate of infusion for a resident. The resident, a male with cerebral palsy, lung disease, anemia, aphasia, coronary artery disease, and gastroesophageal reflux disease, was dependent on staff for all activities of daily living. A physician's order had changed the tube feeding rate from 75 ml/hr to 70 ml/hr, but the feeding pump was observed to be infusing at the incorrect rate of 75 ml/hr. Interviews with staff revealed that the error occurred due to a miscommunication during the nurse handover, where the off-going nurse reported no changes in orders. The Licensed Vocational Nurse (LVN) acknowledged the mistake upon reviewing the order and corrected the feeding rate. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the expectation was for nurses to check and double-check orders before administering tube feedings. The facility's policy required checking the physician's order for formula, route, rate, and frequency, which was not adhered to in this instance.
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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 Irving
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northgate Plaza | 0.9 mi | ★★★★★ | 16 | 0 |
| Ashford Hall | 1.4 mi | ★★★★★ | 14 | 0 |
| Las Brisas Rehabilitation And Wellness Center | 2.3 mi | ★★★★★ | 4 | 0 |
| Avir At Irving | 2.5 mi | ★★★★★ | 10 | 0 |
| Avante Rehabilitation Center | 2.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.