Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Town East Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Delayed Incontinent Care and ADL Assistance: Two residents with dementia and significant ADL dependence did not receive timely brief changes or personal care. One resident’s RP reported waiting over an hour for a brief change, and the resident cried out from burning during wiping with perineal redness noted in the chart. The other resident reported call lights going unanswered for 30 minutes to 3 hours, brief changes occurring less often than expected, and staff sometimes leaving her in bed after care instead of returning her to her chair.
A resident with dementia, multiple chronic conditions, severe cognitive impairment, incontinence, wheelchair use, and complete dependence for ADLs had a documented history of a recent fall and a comprehensive care plan that included a bedside floor mat as a fall-prevention intervention. During two observations, the resident was found in bed with the call light in reach but without the care-planned floor mat at the bedside. An LVN, the DON, and the Administrator each confirmed that a floor mat was an established intervention following the resident’s fall and that bedside nursing staff were responsible for ensuring its presence, while the facility’s policy required implementation of all comprehensive person-centered care plan interventions.
A CNA provided in-bed care alone to a dependent male resident with multiple neurological and physical impairments, despite the care plan and Kardex requiring two-person assistance. The resident fell from the bed and sustained a head laceration requiring sutures. The CNA admitted to not checking the Kardex, and facility leadership showed inconsistent understanding of the resident's assistance needs, leading to neglect and resident injury.
A resident with significant cognitive and physical impairments, requiring two-person assistance for bed mobility and care, was injured when a CNA provided care alone and the resident rolled off the bed, sustaining a head laceration. The CNA did not check the care plan or Kardex for required assistance level, and other staff confirmed the need for two-person assist was documented. The incident resulted in the resident being sent to the hospital for treatment.
Six medication carts were found unlocked and unattended at the nurses' station, with drawers facing outward toward the hallways. Multiple staff, including LVNs and a CMA, confirmed that medication carts should be locked when not in use, but could not explain why the carts were left unsecured. The facility's policy requires all drugs and biologicals to be stored in locked compartments, and staff interviews confirmed this expectation.
A resident with significant medical needs, including G-tube feeding, had their feeding pump paused by CNAs who were not licensed or formally trained to operate the equipment. Multiple staff interviews confirmed that only licensed nurses should handle G-tube pumps, but CNAs routinely paused them during care, and there was no clear facility policy specifying authorized personnel for this task.
A resident with dementia and moderate cognitive impairment eloped from the facility without staff realizing she was missing. A CNA saw her walking outside behind family members and returned her to the building, while the charge nurse later checked her vitals and gave a breathing tx after she appeared exhausted and short of breath. Staff reported they did not hear the door alarm, the incident was not reported immediately, and the resident’s care plan did not include elopement interventions despite prior elopement risk evaluations.
Failure to provide nail care for dependent residents: four residents with diagnoses including MS, dementia, diabetes, CVA, and Parkinson's disease were observed with long, jagged, and dirty fingernails, and two residents stated they wanted their nails trimmed and cleaned. Records showed each resident needed assistance with personal hygiene, while CNA and nursing interviews confirmed nail care was expected to be provided by staff and that long, unclean nails increased infection and skin tear risk.
Improperly Stored Frozen Food in Kitchen Freezer: Surveyors observed frozen beef patties and chicken steak fries left uncovered in opened boxes in the kitchen freezer. A Dietary Aide, the Dietary Manager, and another staff member stated that food in the freezer should be appropriately covered and sealed, and the facility policy required foods stored in the refrigerator or freezer to be covered, labeled, and dated.
A facility failed to keep resident call systems accessible in rooms and shared toilet areas. Multiple bathroom pull strings were missing, and one resident with dementia, weakness, and FTT had the call light button on the floor behind the bed and out of reach. The DON and Administrator stated residents should always have call lights within reach, and the facility policy required an operative audible and visual call light system accessible from rooms and bathing/toileting areas.
Failure to include elopement interventions in a resident’s care plan. A resident with dementia, CKD, AFib, and other diagnoses had a BIMS score of 7 and was assessed as low risk for elopement, yet she was found walking down the street near the facility after eloping. Staff notified the MD and RP, placed the resident on 15-minute checks, and later reviewed the care plan, which did not address elopement interventions. The DON, ADON, MDS Coordinator, and Administrator stated elopement interventions should have been in the care plan and that there was no process for reviewing elopement evaluations to determine interventions.
Unlabeled G-tube hydration bag. A resident with dementia, dysphagia, and a G-tube was observed with a feeding pump that had two bags hanging, including a hydration bag containing colorless liquid that was not labeled or dated. An agency LVN, the ADON, and the DON all stated that tube feeding supplies, including the hydration bag, should be labeled and dated, and the DON said the charge nurse should have dated the bag when the feeding was started.
Missing Oxygen Signage for Two Residents on O2 Therapy: Two residents receiving O2 at 3 L/min via NC had no No Smoking/Oxygen in Use sign posted outside their room doorway. Both residents had care plans and MD orders for ongoing oxygen therapy, and an RN confirmed the missing signage during observation. The DON stated the facility expected tubing changes on Sundays and daily checks, while the facility policy required No Smoking/Oxygen in Use signs.
An infection control deficiency occurred when an LVN used gloves kept in a uniform pocket while performing G-tube dressing care for one resident with dementia, CVA, aphagia, and a feeding tube, instead of using gloves from the box. A second resident with HTN, DM2, CVA, aphagia, and a feeding tube was on EBP, but an LVN administered meds via G-tube using gloves only and did not don a gown during high-contact care, despite the room signage and the DON’s confirmation that gown use was required.
A resident with hemiplegia and hemiparesis was found to have their call light out of reach, despite being bed-bound and dependent on assistance. Staff interviews revealed awareness of the importance of call light accessibility, but inconsistent adherence to the policy. The facility's policy requires call lights to be accessible, but this was not effectively implemented, leading to a deficiency in accommodating the resident's needs.
A resident with dementia and hemiplegia did not have a comprehensive care plan addressing her ADLs and left-hand contraction. Despite being dependent on staff for personal hygiene, her care plan lacked necessary interventions. Facility staff, including the DON and MDS Coordinators, acknowledged the oversight, which could impact resident care.
The facility failed to maintain proper hygiene and nail care for two residents, one with severe cognitive impairment and total dependence, and another with dementia requiring moderate assistance. Both residents were found with long, dirty, or chipped fingernails, posing risks of infection and self-injury. Staff acknowledged the need for regular nail care, especially for diabetic residents, as per facility policy.
A resident with a history of stroke and a contracted left hand was using a soft hand roll without a physician's order. Despite the resident's cognitive intactness and the use of the hand roll since admission, staff interviews revealed a lack of awareness about the need for an order. The absence of a documented order could lead to improper application and potential risk, although no immediate skin issues were noted.
The facility failed to deliver mail to residents on Saturdays, as reported by five residents during an interview. The Director confirmed mail distribution occurred only Monday through Friday, and the weekend receptionist lacked a key to access the mail lockbox. The Administrator was unaware of this issue, which contradicted the facility's policy requiring mail delivery within 24 hours, including Saturdays.
A facility failed to administer a COVID-19 test and nasal spray to a resident as ordered by a nurse practitioner. The test order was miscategorized, delaying its execution, and the nasal spray order was placed in the MAR instead of the TAR, leading to missed doses. Staff interviews revealed a lack of awareness and understanding of the orders, with the DON acknowledging errors in order categorization.
The facility's kitchen failed to meet food safety standards by not labeling potato rolls with expiration dates and not ensuring staff used proper hair restraints. Observations revealed that staff members had unsecured hair while preparing and serving food, risking contamination. Interviews confirmed awareness of these requirements, but lapses occurred, potentially endangering residents' health.
The facility failed to implement its Water Management Program to prevent Legionella bacteria growth, as no testing was conducted in June and July 2024. Additionally, a CNA did not follow proper PPE protocols when entering a resident's room on COVID-19 isolation precautions, wearing only a mask and gloves instead of full PPE. The CNA was unclear about PPE expectations for non-direct care tasks, despite signage and verbal reminders from the DON.
The facility failed to maintain proper hygiene for two residents, resulting in unclean and untrimmed fingernails. Both residents required assistance with personal hygiene due to cognitive and physical impairments. Despite care plans specifying regular nail maintenance, observations showed neglect in this area. Interviews with staff confirmed the responsibility for nail care was shared between CNAs and nurses, with specific protocols for diabetic residents. The facility's policy on nail care was not adhered to, leading to the deficiency.
The facility failed to ensure proper pharmaceutical services, as observed with a medication cart managed by an LVN. Blister packs for a resident's lorazepam and another's tramadol had broken seals with pills still inside, indicating a lapse in procedures for drug management. Interviews revealed that the LVN did not check blister packs during shift changes, contrary to facility protocol, which contributed to the deficiency.
A facility failed to secure medications as required, leaving a resident's nasal spray and inhaler on the bedside table instead of in a locked compartment. The resident, with moderate cognitive impairment and chronic respiratory issues, had not used the medications since they were left there by a nurse. Interviews with staff confirmed that medications should not be left unsecured.
Delayed Incontinent Care and ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance with ADLs for two residents who were dependent or substantially dependent for toileting and personal hygiene. Resident #1 had diagnoses including UTI, lack of coordination, muscle weakness, age-related physical debility, and dementia, with an annual MDS showing moderate cognitive impairment, dependence for oral hygiene, toileting, bathing, dressing, footwear, and personal hygiene, and always incontinent of bowel and bladder. Resident #1’s care plan identified total dependence for bathing, dressing, feeding, personal hygiene, oral care, and toileting, with interventions for cleaning the peri-area with each incontinence episode. Resident #1’s RP reported that during the week of 05/04/26, it took over an hour for staff to change Resident #1’s brief after he requested assistance around 12:30 PM. He stated he waited 45 minutes after the first request, then went to the nurse’s station and asked again, waited another 35 to 40 minutes, and still no one came. He reported that when staff finally changed Resident #1, she screamed because it burned when wiping, and he believed she may have had a rash. A progress note dated 05/05/26 documented redness to the perineal area, and the skin issue had not been evaluated. Resident #2 had diagnoses including vascular dementia, melena, UTI, and cognitive communication deficit, with a quarterly MDS showing moderate cognitive impairment, dependence for toileting, bathing, lower body dressing, and footwear, and always incontinent of bowel and bladder. Resident #2 stated staff took 30 minutes to 3 hours to answer her call light for brief changes, that she was changed about three times a day, and that on one day her brief was only changed twice, around lunchtime and before bed. She also stated aides sometimes changed her brief and did not return, and that when staff changed her in bed they sometimes left her there instead of transferring her back to her wheelchair. During observation of incontinent care, Resident #2’s skin was intact and there were no skin concerns. The DON and Administrator stated they were unaware of any issue with changing Resident #1 and Resident #2 and identified the risk of residents being soiled and developing UTIs.
Failure to Implement Care-Planned Bedside Fall Mat for High-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of a comprehensive, person-centered care plan for one resident with a history of falls. The resident was an elderly male with dementia, respiratory failure, spinal stenosis, heart disease, and diabetes, who was severely cognitively impaired with a BIMS score of 01, always incontinent of bowel and bladder, had a recent fall, used a wheelchair for mobility, and was completely dependent on staff for transfers, toileting, showers, and dressing. His comprehensive care plan, dated 12/26/2025, documented an actual fall with no injury and included specific fall-prevention interventions such as a floor mat, anticipating needs, and ensuring the call light was within reach. On two separate observations on the same day, the resident was seen resting comfortably in bed with his call light within reach, but no floor mat was present at the bedside despite it being a listed care plan intervention. An interview with the LVN assigned to the resident confirmed that he had fallen about a month prior and that his fall precautions included a fall mat, which she stated should have been at the bedside; she was unsure why it was not in place and acknowledged it was her responsibility to ensure its presence. The DON and the Administrator both stated that the resident had a fall and that a bedside floor mat while resting in bed was one of the interventions, and each affirmed that it was the bedside nurse’s responsibility to ensure the mat was present. The Administrator also stated there was no specific fall mat policy but that she expected all interventions listed on the comprehensive care plan to be implemented, consistent with the facility’s written policy requiring development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables.
Failure to Follow Care Plan Results in Resident Injury Due to Inadequate Assistance
Penalty
Summary
A certified nursing assistant (CNA) failed to follow the care plan for a male resident with multiple diagnoses, including cerebrovascular accident, non-Alzheimer's dementia, Parkinson's disease, dysphasia, and muscle weakness. The resident was assessed as having moderate cognitive impairment and was dependent on staff, requiring two-person assistance for bed mobility, transfers, and activities of daily living. Despite this, the CNA attempted to provide in-bed care alone, turned the resident onto his side, and the resident subsequently rolled off the bed, sustaining a laceration to the left forehead that required sutures and hospital evaluation. The CNA admitted to not checking the Kardex to confirm the required level of assistance and stated she had always provided care to this resident alone, unaware of the two-person assist requirement. The care plan and Kardex both indicated the need for two-person assistance, but this was overlooked. The incident was witnessed by another staff member, and the resident was found on the floor with active bleeding. The nurse on duty confirmed that the CNA did not request help and that the care plan clearly required two-person assistance for bed mobility and transfers. Interviews with facility leadership revealed inconsistent understanding of the resident's care requirements, with the DON initially believing the resident was a one-person assist and only learning of the two-person requirement after the incident. The administrator did not conduct an independent investigation and relied on the DON's report, attributing the incident to a possible typo in the care plan and oversight by the CNA. The failure to follow the care plan and ensure staff were aware of and adhered to residents' assistance needs resulted in the resident's injury and constituted neglect as defined by facility policy.
Removal Plan
- CNA A in-serviced one-on-one by DON on resident positioning, bed mobility, using draw sheet, and getting assistance when needed.
- CNA A terminated and has not worked since.
- All staff in-serviced on Abuse/Neglect/Exploitation, Incidents/Accidents, and how to safely care for dependent residents, completed by ADON with Compliance Nurse oversight.
- DON/Administrator in-serviced on Abuse, Neglect, Incidents, and Investigating, including immediate suspension of employee accused of abuse/neglect, completed by Compliance Nurse.
- 100% audit completed to review plan of care, Kardex, and care profile on residents who are dependent assistance, completed by DON/ADON or designee with Compliance Nurse oversight.
- Care guides reviewed for compliance and accuracy, completed by DON/ADON or designee with Compliance Nurse oversight.
- Nursing staff in-serviced on guidance for accessing Kardex, care plans, and how to safely care for residents with positioning and incontinent care, completed by DON/ADON/designee.
- Weekend supervisor trained to monitor incidents/accidents on weekends and immediately report any issues identified to Administrator/DON by DON.
- All incidents reviewed and no other instances of abuse or neglect noted from the audit, completed by DON/Admin.
- Incident with Resident #1 self-reported via email by DON.
- Investigation initiated; facility self-reported the incident.
- All Abuse/Neglect allegations will be reported and investigated per policy; DON and Administrator will ensure investigations are completed timely.
- Administrator oversight provided by Regional President of Operations.
- No employees will be allowed to return to work until they have been in-serviced on the Abuse/Neglect policy and how to safely care for residents.
- Nurses will be responsible for ensuring compliance; DON/ADON/Admin will monitor.
- Incidents/Accidents and Complaints will be reviewed daily by DON or designee, weekend supervisor, and reported to Administrator immediately for investigation.
- Clinical review team (Admin, DON, ADON, MDS, Director of Operation) will discuss all incidents and accidents.
- Admin/DON will monitor to ensure compliance.
Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during care for a resident with significant physical and cognitive impairments. The resident, who had a history of cerebrovascular accident, non-Alzheimer's dementia, Parkinson's disease, dysphasia, and muscle weakness, was assessed as requiring two-person assistance for bed mobility, transfers, and activities of daily living. Despite this documented need, the CNA provided care alone, turned the resident on his side, and the resident subsequently rolled off the bed, sustaining a laceration to the forehead that required hospital treatment. The incident was witnessed and documented by nursing staff, who responded to the scene and provided immediate care, including applying pressure to the wound and arranging for hospital transfer. Interviews with staff revealed that the CNA was unaware of the resident's two-person assist requirement and had not checked the Kardex or care plan prior to providing care. Other staff members, including nurses and administrative personnel, confirmed that the resident's care plan and Kardex indicated a two-person assist was necessary, and that the CNA did not request help as required by facility policy. Further investigation showed that the CNA had a history of working with the resident and had previously provided care alone, indicating a lack of adherence to established protocols. The Director of Nursing (DON) and Administrator acknowledged that the CNA did not follow the care plan and facility policy, and that there was a failure to ensure staff were consistently aware of and following residents' required levels of assistance. The incident resulted in the resident sustaining an injury due to inadequate supervision and assistance during care.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as required by policy and professional standards. During an observation, six medication carts located at the nurses' station were found unlocked with drawers facing outward toward the hallways, and no staff was present at the station. Multiple staff interviews confirmed that medication carts should be locked when not in use, regardless of their location, and staff were unable to explain why the carts were left unlocked. The facility's policy, revised in April 2019, specifies that all drugs and biologicals must be stored in locked compartments, and nursing staff are responsible for maintaining secure medication storage areas. The surveyor's findings were based on direct observation, staff interviews, and a review of facility policy. Staff members, including LVNs and a CMA, acknowledged the expectation that medication carts remain locked when not in use, but could not provide a reason for the lapse. The Regional Nurse also confirmed that leaving medication carts unlocked, even at the nurses' station, was not acceptable and posed a risk. The surveyor did not determine which staff members were responsible for leaving the carts unsecured.
Unlicensed Staff Adjusted G-Tube Pumps Without Proper Training or Authorization
Penalty
Summary
The facility failed to ensure that only licensed and trained nursing staff adjusted gastrostomy tube (G-tube) pumps for a resident who was dependent on enteral feeding due to multiple medical conditions, including hemiplegia, aphasia, bed confinement, moderate protein-calorie malnutrition, and a history of intracerebral hemorrhage. Record reviews and staff interviews revealed that unlicensed staff, specifically CNAs, were placing G-tube pumps on hold during routine care such as changing and repositioning the resident. These CNAs reported that they had learned how to pause the pumps by observing nurses, but did not have formal training or knowledge of the risks involved. Multiple licensed nurses confirmed that only licensed staff should handle G-tube pumps, but acknowledged that CNAs commonly paused the pumps and that there was no clear policy specifying who was responsible for this task. The deficiency was further evidenced by the lack of a specific facility policy outlining which staff members were authorized to operate G-tube pumps. The Regional Nurse confirmed that only licensed staff were expected to handle the pumps, but also acknowledged the absence of a written policy. Documentation showed that the issue came to light after a CNA reported a resident vomiting, and it was discovered that CNAs had been pausing the G-tube pump without proper authorization or training. The resident involved was unable to communicate due to cognitive and physical impairments.
Resident Eloped Without Staff Awareness
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents when a resident with dementia eloped from the building without staff awareness. The resident was an older female with diagnoses including dementia, atrial fibrillation, chronic kidney disease, obstructive and reflux uropathy, atherosclerotic heart disease, and asthma. Her quarterly assessment reflected a BIMS score of 7, indicating moderate cognitive impairment, and she used a wheelchair for mobility. Her elopement evaluations were scored as low risk, and her care plan did not document elopement interventions. On the evening of the incident, a CNA observed the resident walking outside the front entrance behind a group of family members and then near the edge of the parking lot by the street. The CNA escorted her back into the facility. The charge nurse checked the resident’s vital signs after her return and noted she appeared exhausted and short of breath, so a breathing treatment was given. The charge nurse stated she did not report the incident until the next morning because she was busy, and she could not remember hearing any door alarms. Another CNA stated he did not hear alarms that day and was unaware the resident was an elopement risk. The DON stated she learned of the incident the next morning and was unsure when the resident was last seen. The Administrator stated the facility was unsure how the resident left the building and that the emergency missing-resident process could not be implemented because staff did not realize she was missing. The facility’s policy stated that if a resident is missing, the elopement/missing resident emergency procedure is to be initiated, and if a resident is identified as at risk for wandering or elopement, the care plan is to include strategies and interventions to maintain safety. The report also noted that the resident’s care plan lacked elopement interventions despite the elopement evaluations indicating risk.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary ADL assistance to maintain good grooming and personal hygiene for four residents who were dependent on staff for nail care. During observation and interview, Resident #24 was found lying in bed with fingernails on both hands approximately 0.6 cm long, jagged, and discolored with black matter underneath. Resident #24 stated she wanted her fingernails trimmed and cleaned. Her record showed diagnoses including MS, quadriplegia, and heart failure, and her MDS indicated she was dependent on staff for personal hygiene. Resident #5 was observed lying in bed with left-hand fingernails approximately 0.7 cm long, jagged, and discolored with black matter underneath. Resident #5 stated she wanted her fingernails trimmed. Her record reflected diagnoses including diabetes mellitus, dementia, muscle weakness, CVA, Alzheimer's disease, and legal blindness, and her MDS showed she needed moderate assistance with personal hygiene. Resident #75 was observed lying in bed and nonverbal due to declining health, with long and dirty fingernails up to two inches long on both hands. Her record reflected diagnoses including hemiplegia and hemiparesis following cerebral infarction, vascular dementia, acute respiratory failure with hypoxia, and acquired absence of eye. Her MDS showed severe cognitive impairment and need for assistance with personal hygiene. Resident #88 was observed lying in bed with long and dirty fingernails up to two inches long on both hands. Resident #88 stated he wanted his fingernails cleaned and trimmed but staff had not offered to do it. His record reflected diagnoses including unspecified dementia and Parkinson's disease with dyskinesia, and his MDS showed moderate cognitive impairment and substantial/maximal assistance needed for personal hygiene. Interviews with CNA and nursing staff indicated nail care was expected to be provided by nursing staff and CNAs, with diabetic residents' nails trimmed by nurses. The DON and Administrator stated nail care should be completed as needed, nails should be observed daily, and nail care was the responsibility of clinical staff, CNAs, nurses, and activities staff. The facility policy stated the purpose of fingernail care was to clean the nail bed, keep nails trimmed, and prevent infections.
Improperly Stored Frozen Food in Kitchen Freezer
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen reviewed for food and nutrition services. On 08/12/25 at 9:45 AM, observation of the facility freezer showed 2 big plastic bags of frozen beef patties and 1 big plastic bag of chicken steak fries left uncovered in opened brown boxes, exposing them to frigid air. During interviews, a Dietary Aide stated that all food items in the kitchen should be covered appropriately and that it was usually the cooks’ responsibility to seal food in the freezer. The Dietary Manager stated that everyone in the kitchen was responsible for food storage, but cooks were ultimately responsible for covering food items in the freezer appropriately, and that all foods should be appropriately covered and sealed. A staff member identified as [NAME] A also stated that everyone in the kitchen was responsible for appropriate food storage and that foods in the freezer should be appropriately sealed and covered. Review of the facility policy titled Food Receiving and Storage stated that all foods stored in the refrigerator or freezer will be covered, labeled, and dated.
Missing and Inaccessible Resident Call Lights
Penalty
Summary
The facility failed to ensure that resident bedside, toilet, and bathing areas were adequately equipped with a working call system that would allow residents to call for staff assistance. During observation on 08/12/25, the call light pull strings were missing from shared toilet call light outlets in multiple resident rooms, including those used by Resident #50 and Resident #38, Resident #79 and Resident #36, Resident #65, Resident #6 and Resident #57, Resident #78, Resident #5 and Resident #8, and Resident #53 and Resident #27. The Maintenance Director observed the missing strings and stated they needed to be within reach of a resident who was on the floor. Resident #56’s record showed diagnoses of dementia, weakness, and adult failure to thrive. Her care plan identified her as at risk for falls related to dementia and confusion. On 08/12/25, she was observed lying in bed with the bed in the highest position, and the call light button was on the floor behind the bed on the left side. She was not able to answer interview questions. Later that day, a CNA found the call light cord and button on the floor in her room and placed it within her reach, stating she would not be able to call for help if she were incontinent or having an emergency. The DON stated the expectation was that residents should always have the call light within reach and that the call light should be placed on the resident’s dominant side. The Administrator stated the call light button should always be within residents’ reach, clipped to their clothes or linen, and that missing bathroom call light strings should be reported to Maintenance and replaced. The facility policy stated that an audible and visual call light system was to be operative and that residents should be able to access a system that notifies nursing from their room and/or bathing and toileting facilities.
Failure to Include Elopement Interventions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents reviewed for care plans, including a failure to develop an elopement care plan for one resident after an elopement event. Resident #97 was an [AGE]-year-old female admitted with diagnoses including dementia, atrial fibrillation, chronic kidney disease, obstructive and reflux uropathy, atherosclerotic heart disease, and asthma. Her quarterly MDS reflected a BIMS score of 7, indicating moderate cognitive impairment, use of a wheelchair for mobility, and no wandering behavior noted in Section E. Elopement evaluations completed on 2/11/25 and 5/13/25 scored her as low risk for elopement. The Provider Investigation Report stated that on 6/12/25, a CNA found the resident walking down the street near the facility and assisted her back inside after recognizing her as a resident. The physician and responsible party were notified, and the resident was placed on 15-minute checks beginning 6/13/25 until discharge on 6/30/25. Review of the resident’s care plan on 8/12/25 showed that elopement interventions were not addressed. During interviews, the MDS Coordinator, ADON, DON, and Administrator stated elopement interventions should have been included in the care plan, that the ADON and DON were responsible for entering them, and that there was no process in place for reviewing elopement evaluations to determine interventions. The facility policy on Wandering and Elopements stated that if a resident is identified as at risk for wandering, elopement, or other safety issues, the care plan will include strategies and interventions to maintain safety.
Unlabeled G-tube hydration bag
Penalty
Summary
The facility failed to ensure that Resident #44, a severely cognitively impaired male with diagnoses including unspecified dementia, dysphagia, gastrostomy status, diabetes mellitus, and hypernatremia, received appropriate treatment and services related to enteral feeding. Resident #44 had a G-tube and was ordered to receive Glucerna 1.5 at 70 mL per hour with 45 mL per hour water flushes for 22 hours, and he was also ordered NPO for everything. His care plan identified that he required tube feeding and was at risk for aspiration, with interventions to provide local care to the G-tube site and monitor for infection. During observation, the resident was in bed with a feeding pump at the bedside that was switched off and had two bags hanging. One bag was labeled and dated as tube feeding formula with the time hung, but the second bag contained colorless liquid and had no label, no date it was hung, and no resident name. An agency LVN identified the unlabeled bag as the hydration bag and stated it should have been dated and labeled each time before administration. The ADON and DON both stated that nurses were expected to date and label all G-tube feeding supplies, including the hydration bag, and the DON stated the charge nurse who initiated the feeding for the day should have dated the hydration bag. The DON also stated there was no specific policy for dating the hydration bag, but that it was a clinical expectation and standard nursing protocol.
Missing Oxygen Signage for Two Residents on O2 Therapy
Penalty
Summary
The facility failed to ensure oxygen in use signage was posted on the doorways of two residents who were receiving oxygen therapy. Resident #56 was a female with diagnoses including dementia, weakness, coronary artery disease, and adult failure to thrive, and her care plan and physician orders reflected oxygen at 3 liters per minute via nasal cannula every shift and as needed to maintain oxygen saturation above 98%. Resident #61 was a female with diagnoses including acute and chronic respiratory failure, asthma, and coronary artery disease, had a BIMS score of 13, and her care plan and physician orders also reflected oxygen at 3 liters per minute via nasal cannula every shift and as needed to maintain oxygen saturation above 98%. Observations showed both residents in bed with oxygen concentrators running at 3 L/min. During observation, the doorway to the residents’ room did not have No Smoking/Oxygen in Use signage posted outside the door. In interview, RN AK stated both residents were on oxygen therapy and that she did not see the oxygen in use sign on either room door. She stated every resident on oxygen therapy should have the sign to ensure safety if flammable objects were brought to the room. The DON stated the expectation was for tubing to be changed on Sundays and checked daily, and she stated she did not see any risk from the missing oxygen signage because the facility was a nonsmoking place. The facility policy titled Oxygen Administration stated that No Smoking/Oxygen in Use signs were required.
Infection Control Failures During G-Tube Care and EBP Use
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program for two residents who had feeding tubes. For one resident, the quarterly MDS dated 08/03/25 showed a female resident with dementia, cerebrovascular accident, urinary tract infection, aphagia, a BIMS score of 10/15, and a feeding tube. Her care plan directed staff to provide local care to the G-tube site as ordered and monitor for signs and symptoms of infection. During an observation on 08/14/25 at 10:11 AM, an LVN entered the resident’s room to change the feeding tube dressing, performed hand hygiene, donned clean gloves, sanitized the bedside table, removed the gloves, washed hands, and then put on clean gloves taken from his uniform pocket before continuing the dressing change. He removed the old dressing, cleaned the exit site with saline, again removed gloves, washed hands, and put on another pair of clean gloves from his pocket before applying a new split 4x4 gauze and paper tape to the feeding tube site. In interview, the LVN stated he kept a handful of gloves in his pocket for emergency use and said there was no difference between gloves in his pocket and an open box of gloves. For the second resident, the quarterly MDS dated 07/07/25 showed a male resident with hypertension, type 2 diabetes, cerebrovascular accident, aphagia, a BIMS score of 14/15, and a feeding tube. His care plan identified tube feeding related to dysphagia and directed staff to monitor and document signs and symptoms of aspiration fever and infection at the tube site. During an observation on 08/15/25 at 08:02 AM, the resident’s room had Enhanced Barrier Precautions signage indicating gown and gloves for high-contact care. An LVN prepared the resident’s morning medications, donned clean gloves, and administered the medications through the feeding tube without putting on a gown. In interview, the LVN stated residents with feeding tubes were under EBP and that gown use was required for high-contact care, and the DON stated medication administration per G-tube feeding was considered high-contact care under the facility’s EBP policy.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was consistently within reach, which is a deficiency in accommodating the needs and preferences of the resident. The resident in question, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was observed to be bed-bound and dependent on assistance for personal care. During an observation, the resident's call light was found hanging towards the floor and not within reach, which the resident confirmed was a recurring issue. Interviews with facility staff, including CNAs and an LVN, revealed that while they were aware of the importance of keeping the call light within reach, there was a lapse in ensuring this was consistently done. Staff members acknowledged the potential risks associated with not having the call light accessible, such as falls, injuries, and delays in care. Despite receiving in-service training on the importance of call lights, the staff did not consistently adhere to the policy of ensuring the call light was accessible to the resident. The facility's Director of Nursing and Administrator both emphasized the responsibility of all staff to ensure call lights are within reach to prevent risks such as falls, injuries, and other adverse outcomes. The facility's policy on answering call lights, revised in September 2022, clearly states the need for call lights to be accessible from various locations, including the bed. However, the deficiency indicates a failure in implementing this policy effectively, leading to the resident's inability to call for assistance when needed.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for a resident, specifically addressing her Activities of Daily Living (ADLs) needs. The resident, a cognitively intact female with a history of dementia and cerebrovascular accident resulting in hemiplegia, was dependent on staff for personal hygiene and showering. Despite these needs, her care plan did not include interventions for her ADLs or her left-hand contraction, which was managed with a soft hand roll to prevent discomfort. Interviews with facility staff, including the Director of Nursing (DON) and MDS Coordinators, revealed that the care plans were not updated to reflect the resident's current needs. The MDS Coordinator responsible for the care plans acknowledged the oversight and the potential impact on resident care, as staff would be unaware of necessary interventions. The facility's policy requires comprehensive, person-centered care plans to meet residents' needs, but this was not adhered to in this case.
Failure to Maintain Resident Hygiene and Nail Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #1, a male with severe cognitive impairment and total dependence for all ADLs, was observed with long and dirty fingernails. Despite his inability to communicate verbally due to aphasia, he indicated through nodding that he wanted his fingernails trimmed and cleaned. A CNA confirmed the condition of his nails and acknowledged the potential health risks, including infection and self-injury. Resident #2, a female with dementia and moderate assistance needs for personal hygiene, was also found with long and chipped fingernails. She expressed a desire to have her nails trimmed. A CNA and an LVN both recognized the need for nail care and the associated risks of infection and skin breakdown. The facility's policy required nail care to be performed regularly, especially for residents with diabetes, where only nurses were permitted to trim nails. The DON stated that nail care should be provided every shower day and as needed, and acknowledged that dirty fingernails could pose an infection control issue.
Lack of Physician's Order for Soft Hand Roll
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for the use of a soft hand roll for her contracted left hand. This deficiency was identified during an observation, interview, and record review process. The resident, who is cognitively intact with a BIMS score of 15/15, has a history of stroke resulting in hemiplegia and a contracted left hand. Despite the resident's use of a soft hand roll since her admission, there was no documented physician's order for this device in her care plan or physician's orders. Interviews with staff, including a CNA, RN, DON, PT Director, and the Administrator, revealed a lack of awareness regarding the necessity of a physician's order for the soft hand roll. The CNA and RN were unaware of the requirement, and the DON and PT Director admitted to not knowing that an order was needed. The Administrator acknowledged that it was the nurse's responsibility to ensure an order was in place. The absence of a physician's order for the soft hand roll could lead to improper application and potential risk to the resident, although no immediate skin issues were observed.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents' right to receive mail on Saturdays, which is a deficiency in promoting residents' access to communication methods. During a confidential group interview, five residents reported that mail was only delivered from Monday to Friday, coinciding with the business office's operational days, and not on weekends. The Director confirmed that mail was distributed Monday through Friday and mentioned that the weekend receptionist was supposed to distribute mail on weekends. However, the Director was unsure if the receptionist had a key to the lockbox where mail was left by the carrier. The Administrator was unaware of the issue and confirmed that the weekend receptionist did not have a key to access the mail on Saturdays. The facility's policy stated that mail should be delivered to residents within 24 hours of delivery, including Saturdays, which was not being adhered to.
Failure to Administer COVID-19 Test and Nasal Spray
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care according to professional standards of practice. Specifically, the facility did not promptly administer a COVID-19 test for a resident when it was ordered by a nurse practitioner. The order for the test was placed under the wrong category, which resulted in it not being added to the Treatment Administration Record (TAR) and subsequently not being carried out in a timely manner. The resident, who was cognitively intact and had a history of cerebrovascular disease, hypertension, and hyperlipidemia, was experiencing nasal congestion and a slight cough at the time. Additionally, the facility did not follow the nurse practitioner's order for a nasal spray for the same resident. The order for the nasal spray was incorrectly categorized, leading to it being recorded in the Medication Administration Record (MAR) instead of the TAR. As a result, the nasal spray was not administered on the specified dates. A Certified Medication Aide (CMA) noted the order but did not administer the nasal spray, as it was outside their scope of practice, and informed a nurse, though the specific nurse was not recalled. Interviews with staff revealed a lack of awareness and understanding of the orders, with the Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledging the categorization errors. The nurse practitioner expected the orders to be executed promptly to prevent the spread of illness and ensure timely treatment. The DON admitted to a lapse in educating the new nurse practitioner on the facility's order entry process, which contributed to the errors in order categorization.
Food Safety and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, the facility did not ensure that potato rolls stored in the walk-in refrigerator were labeled with an expiration date. This oversight was noted during an observation on July 9, 2024, at 9:41 AM. The absence of an expiration date on the potato rolls could potentially lead to the use of expired food items, posing a risk of food-borne illness to residents. Additionally, the facility did not ensure that kitchen staff used appropriate hair restraints while preparing and serving food. On July 10, 2024, during the lunch meal service, it was observed that Dietary Aide F and the Assistant Dietary Manager were not wearing hair restraints that fully covered their hair. Dietary Aide F had long braids that were not completely secured under the hair restraint, and the Assistant Dietary Manager had loose strands of hair not properly covered. Both staff members were involved in food preparation and serving tasks, which could lead to hair contamination in the food served to residents. Interviews with the involved staff members revealed an awareness of the requirement for proper hair restraints and food dating, but lapses in adherence to these standards were acknowledged. The Dietary Aide and Assistant Dietary Manager admitted to not fully securing their hair, and the Dietary Manager confirmed the expectation for all kitchen staff to wear hair restraints and date food items appropriately. The facility's policies, as well as the FDA Food Code, emphasize the importance of these practices to prevent cross-contamination and ensure food safety.
Infection Control Deficiencies in Water Management and PPE Protocols
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two significant deficiencies. Firstly, the facility did not implement the measures outlined in their Water Management Program policy to prevent the growth of Legionella bacteria in their water system. A review of the facility's monthly water maintenance records for June and July 2024 showed no testing for Legionella bacteria growth. Interviews with the Administrator and the Operational Director confirmed that no water testing had been conducted, despite the risk of Legionella growth in the water system. The facility's Water Management Program, based on CDC and ASHRAE recommendations, was not fully executed, as it lacked testing to ensure the absence of Legionella growth. Secondly, the facility failed to ensure that a Certified Nursing Assistant (CNA) adhered to proper Personal Protective Equipment (PPE) protocols when entering and exiting the room of a resident on isolation precautions for COVID-19. The resident, who was cognitively intact and had multiple health conditions, was on airborne precautions. Despite signage indicating the need for full PPE, the CNA entered the resident's room wearing only a mask and gloves, believing that full PPE was unnecessary for tasks not involving direct care. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that staff were expected to wear full PPE as indicated on the signage, but the CNA was unclear about the expectations for non-direct care tasks. The CNA's employee file showed a competency evaluation for isolation care, but the CNA did not recall recent in-services on infection control or isolation precautions. The DON, who also served as the infection preventionist, acknowledged the lapse in PPE protocol and stated that a verbal reminder had been given to staff, although it was not documented. The facility's infection control guidelines required transmission-based precautions whenever more stringent measures than standard precautions were necessary, but these were not followed in this instance.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in two residents, both of whom had unclean and untrimmed fingernails. Resident #66, a male with severe cognitive impairment due to cerebral infarction, required assistance with personal hygiene. His care plan included regular nail care, but observations revealed his nails were long and dirty. Similarly, Resident #80, a male with moderate cognitive impairment and physical limitations, also had long and dirty fingernails despite his care plan specifying regular nail maintenance. Interviews with facility staff, including an LVN and the DON, confirmed that both CNAs and nurses were responsible for nail care, with nurses specifically handling residents with diabetes. The staff acknowledged the risk of infection and skin breakdown due to inadequate nail care. The facility's policy on nail care emphasized daily cleaning and regular trimming to prevent infections, yet these procedures were not followed for the two residents, leading to the identified deficiency.
Failure in Medication Management on Nurses Cart Hall 400
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, specifically in the management of medication carts. During an observation and record review, it was found that the medication cart in Hall 400, managed by LVN B, contained medications in unsecure containers. Specifically, the blister packs for a resident's lorazepam and another resident's tramadol had broken seals with the pills still inside, taped over. This indicates a failure in the procedures for acquiring, receiving, dispensing, and administering drugs, which could lead to drug diversion and residents not receiving the intended therapeutic benefits. Interviews with LVN B and the DON revealed that the facility's protocol required nurses and medication aides to check medication blister packs for broken seals during shift changes. However, LVN B admitted to not checking the blister packs during the count, and the DON confirmed that any broken seal should result in the pill being discarded. The facility's policy on medication labeling and storage also mandates contacting the dispensing pharmacy for instructions on returning or destroying discontinued, outdated, or deteriorated medications. The lack of adherence to these protocols contributed to the deficiency observed.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by State and Federal laws. Specifically, Resident #1's Fluticasone Propionate nasal spray and Trelegy Ellipta inhaler were found on the resident's bedside table instead of being secured in the medication cart or medication room. Resident #1, an elderly female with moderate cognitive impairment, Type 2 diabetes mellitus, and chronic respiratory failure, stated that a nurse had left the medications on her table the previous morning. The resident had not used the medications since they were left there. Interviews with the assigned LVN and the DON confirmed that medications should not be left unsecured in resident rooms. The LVN admitted to not noticing the medications during an earlier visit to the resident's room. The DON stated that no residents in the facility were authorized to self-administer medications and acknowledged the risk of leaving medications in rooms. The facility had previously conducted in-service training on medication administration, emphasizing that medications should not be left in resident rooms. The facility's policy on self-administration of medications also indicated that unauthorized medications found at the bedside should be turned over to the nurse in charge.
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 1,061 citations issued within 25 miles in the last 12 months — including the 38 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 Mesquite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Care Communities And Services Mesquite | 1.6 mi | ★★★★★ | 4 | 1 |
| Willowbend Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 19 | 0 |
| Palomino Place | 1.9 mi | ★★★★★ | 13 | 1 |
| Edgewood Rehabilitation And Care Center | 2.7 mi | ★★★★★ | 2 | 0 |
| Mesquite Village Wellness & Rehabilitation | 3 mi | ★★★★★ | 6 | 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.