Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Treasure Hills Healthcare And Rehabilitation Cente during CMS and state inspections, most recent first.
A resident with cognitive impairment, dysphagia, weakness, and limited mobility was observed in bed with 10-15 black ants on the blanket, food crumbs on the linens, and crumbs on the floor around and under the bed. The RN, Housekeeping Supervisor, DON, and Administrator confirmed the room cleanliness issue and the presence of pests, and the facility's housekeeping policy required routine cleaning of floors, fixtures, and furniture.
Oxygen Not Maintained as Ordered: A resident with acute respiratory failure with hypoxia, asthma, and COPD did not receive ordered continuous O2 via NC when surveyors observed the concentrator set at 2 LPM but the cannula not in place. The tubing was found under the resident’s head, and the RN later replaced the cannula after checking the resident’s O2 saturation. The resident had severe cognitive impairment and could not recall whether the cannula had been removed or fallen off.
A resident with impaired cognition and substantial/maximal assistance needs for personal hygiene had long facial hair despite a care plan preference for shaving. Staff gave inconsistent accounts about offering shaving, did not document refusals, and CNAs and the DON acknowledged the resident had not been consistently shaved or properly tracked.
MDS Did Not Include Active Fracture Diagnosis: A resident’s quarterly MDS failed to list an active diagnosis of a displaced fracture of the right great toe, even though the face sheet, physician orders, and care plan all reflected the fracture. The MDS Coordinator said the diagnosis should have been included but was missed as an oversight, and the DON acknowledged the MDS is a compilation of assessments from all departments and that the missing diagnosis could affect billing.
Care plans for two residents did not accurately reflect DNR status. One resident with pneumonia and acute respiratory failure had a DNR order and severely impaired cognition, but his care plan did not include code status. Another resident with COPD and vascular dementia also had a DNR order and severely impaired cognition, but her care plan still included an incorrect intervention for full code measures, including CPR and AED use. MDS staff, the SW, and the DON confirmed the discrepancies in the EMR and care plans.
A resident with SOB, COPD, and oxygen dependence had an O2 order for 3 LPM via NC, but observation found the concentrator set at 2.5 LPM instead. RN confirmed the setting was incorrect, and the DON stated nurses were responsible for checking O2 settings and following physician orders. The resident was observed in bed with no signs of respiratory distress.
Incomplete Documentation of Resident’s Change in Condition: An LVN failed to document a resident’s initial complaint of left knee pain and did not clearly communicate the change in condition to the incoming nurse. The resident, who had multiple chronic diagnoses and intact cognition, later had repeated knee pain documented by another LVN, was treated with Tylenol, and was ultimately found to have a subacute patellar fracture after the MD was notified.
Failure to Enforce Contact Isolation PPE Use: A resident on contact isolation for MRSA bacteremia and a MRSA UTI had a representative enter the room without PPE. PPE was available at the door, but the isolation sign was not visible, and the representative said he was not told to use protective equipment. RN A and the DON stated staff and visitors should wear PPE before entering rooms under contact isolation.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not coordinate assessments with the PASRR program and failed to refer a resident for necessary services, resulting in noncompliance with assessment and referral requirements.
A medication cart was found unlocked and unattended in a hallway, with an RN later acknowledging responsibility and stating she had left it unsecured while using another cart's computer. The DON confirmed that all staff are expected to lock medication carts when unattended, in accordance with facility policy requiring all drugs and biologicals to be stored in locked compartments.
Two separate resident-to-resident altercations occurred, resulting in one resident being struck and another sustaining a skin tear, with staff and administration demonstrating confusion about the classification of abuse and the required timeframe for reporting such incidents. Despite assessments and notifications being completed, the facility's policy lacked clarity on current regulatory reporting requirements, and staff relied on outdated guidance.
The facility did not report two separate resident-to-resident altercations involving physical contact and a minor injury to the state agency within the required two-hour timeframe. Although residents were assessed and found to have no or minor injuries, and notifications were made to medical and administrative staff, the incidents were not reported promptly due to confusion about regulatory requirements and lack of specific guidance in the facility's abuse policy.
The facility failed to serve meals according to the established menus, leading to discrepancies in the food provided to residents. Observations revealed that meals did not match the posted or cycle menus, and staff interviews highlighted a lack of communication and oversight in the meal service process. The RD and ADM acknowledged the issues, attributing them to inadequate supervision by the FPM.
The facility's kitchen was found to have multiple sanitation and maintenance deficiencies, including unclean equipment, dented pans, improperly sealed spices, expired canned goods, and personal items in the kitchen. Staff interviews revealed a lack of adherence to food safety protocols, with risks of cross-contamination and foodborne illness. Ongoing issues with water on the floor and a leaking freezer condenser were also noted.
A resident with sleep apnea and hypertension was receiving oxygen therapy at a higher rate than prescribed by the physician, with the concentrator set at 3 Lpm instead of the ordered 2 Lpm. This discrepancy was observed and confirmed by nursing staff, highlighting a failure to adhere to physician orders and facility policy, potentially risking the resident's health.
A resident with dementia and neurocognitive disorder with Lewy bodies was prescribed Zyprexa, an antipsychotic, without a proper diagnosis of psychosis. The medication was intended to manage aggression and anxiety, but the facility's policy requires a specific documented condition for such prescriptions. Interviews revealed that the DON and Administrator were unaware that antipsychotics should not be prescribed solely for dementia.
A facility failed to properly store and label insulin, resulting in an expired vial being found in a medication cart. Staff interviews confirmed that insulin should be discarded after 28 days, but the vial remained in use past this period, contrary to facility policy.
The facility failed to serve meals at an appetizing temperature, affecting two residents during lunch. Observations showed that food items were below the required temperature due to delays in meal service. Staff interviews revealed a lack of clarity and responsibility for ensuring timely meal distribution, leading to cold food being served. Residents expressed dissatisfaction, and staff acknowledged the potential negative impact on nutritional status.
A resident with severe cognitive impairment and multiple medical conditions had a non-functioning call light, which was not within reach. Facility staff, including the Maintenance Supervisor, Dietary Manager, and a CNA, failed to ensure the call light was operational, despite the facility's policy requiring such checks. This oversight could prevent the resident from obtaining necessary assistance.
A resident with severe cognitive impairment and multiple medical conditions was found to have a non-functional call light in their room, which could prevent them from obtaining assistance when needed. Despite staff being assigned to check on residents and their rooms daily, the issue was not identified or reported. Interviews revealed that the Maintenance Supervisor was unaware of the problem, and the Dietary Manager and CNA did not verify the call light's functionality, contrary to facility policy.
Unclean Resident Room With Food Crumbs and Ants
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to keep one resident room sanitary, orderly, and comfortable. Resident #2, a [AGE]-year-old female admitted on 10/13/25 with cognitive communication deficit, dysphagia, muscle weakness, need for assistance with personal care, and reduced mobility, had a BIMS score of 8 on the quarterly MDS, indicating moderate cognitive impairment. Her care plan stated she had ADL self-care performance deficits related to dementia, limited mobility, and intermittent confusion, and that she required tray set-up to eat independently. During an observation on 6/09/2026, the resident was lying in bed awake and 10-15 black ants were seen on top of her blanket. The blanket had food crumbs, and food crumbs were also seen on the floor around and under the bed. CNAs immediately removed the bed linens and placed them in a plastic bag. No ants were seen on the resident's body during toileting and dressing, and after transfer to the wheelchair no further ants were seen. Interviews with the RN, Housekeeping Supervisor, DON, and Administrator confirmed the room cleanliness issue, the presence of pests, and that the housekeeper had not cleaned under the bed earlier that morning. The facility's housekeeping policy required routine cleaning of floors, fixtures, and furniture.
Oxygen Not Maintained as Ordered
Penalty
Summary
The facility failed to ensure that Resident #1 received oxygen therapy as ordered on 6/09/2026. Resident #1 was an [AGE]-year-old female admitted on 6/06/2026 with diagnoses including acute respiratory failure with hypoxia, asthma, and chronic obstructive pulmonary disease. Her admission record also reflected severe cognitive impairment on the 6/10/2026 MDS assessment. Her care plan and MAR directed that oxygen be applied via nasal cannula at 2 LPM continuously to keep saturation at or above 90%. During observation on 6/09/2026 at 11:18 a.m., the oxygen concentrator was on and set at 2 liters per minute, but Resident #1 did not have the nasal cannula in place; the tubing was found at the head of the bed under her head. At 12:04 p.m., the RN checked the resident’s oxygen saturation, which was 93%, then positioned the nasal cannula in place. The resident stated she felt fine and could not remember whether she had removed the cannula or whether it had fallen off. The RN said she had last checked cannula placement at 10:24 a.m. The DON later stated the facility did not have an in-house respiratory therapist and that nurses provided respiratory care services.
Failure to Provide and Document Facial Shaving Care
Penalty
Summary
The facility failed to treat one resident with respect and dignity by not removing her facial hair and not consistently offering or documenting facial shaving care. The resident was a female admitted with diagnoses including need for assistance with personal care, muscle weakness, lack of coordination, and reduced mobility. Her quarterly MDS showed a BIMS score of 09 and substantial/maximal assistance needed for personal hygiene, and her care plan included that she preferred to have facial hair shaved. Progress notes from 09/09/2025 through 12/10/2025 did not include documentation that she refused facial hair shaving. During observation on 12/08/2025, she had long facial hair on her upper lip, chin, and both cheeks extending from the front of her ears down to her chin, and she stated it had been about a month since she had been offered shaving. Interviews showed inconsistent staff practice and lack of documentation. The resident stated CNAs offered to shave her about every 2 weeks, but this time it had been about a month, and she felt she did not want to bother the CNAs by asking to be shaved. A CNA stated shaving was part of personal hygiene, knew the resident had long facial hair, and had not asked her if she wanted to be shaved or reported a refusal because she had never asked. Another CNA stated the resident had a beard, had never asked to be shaved, and that one CNA usually shaved her. A third CNA stated she had last shaved the resident about two weeks earlier and hoped other CNAs would take the initiative. The DON stated the resident did not like to shave, that she had often asked and the resident refused every time, but she did not document the refusals; she also stated CNAs were supposed to offer shaving with showers and notify the nurse if care was refused.
MDS Did Not Include Active Fracture Diagnosis
Penalty
Summary
Resident #13’s quarterly MDS assessment did not accurately reflect the resident’s status because it failed to include the diagnosis of displaced unspecified fracture of the right great toe, initial encounter for closed fracture. The resident’s record showed a face sheet listing end stage renal disease, diabetes mellitus type II, the right great toe fracture, and age-related osteoporosis without current pathological fracture. The physician order summary dated 09/24/2025 also reflected the right great toe fracture diagnosis, and the care plan dated 9/24/25 identified a focus related to the resident’s right great toe proximal phalangeal fracture r/t osteoporosis and mild osteoarthritis. The quarterly MDS reflected Section I active diagnoses with Musculoskeletal I4000 marked as other fracture, but the facility did not check off the active diagnosis and did not add the displaced fracture of the right great toe in I8000 as an additional active diagnosis. During interview, the MDS Coordinator stated she was responsible for completing the MDS assessments and adding diagnoses, and said the fracture diagnosis should have been included but was missed as an oversight. The DON stated the MDS is a compilation of assessments from all departments and acknowledged that not adding a diagnosis could affect billing.
Care Plans Did Not Reflect DNR Code Status
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes for two residents whose code status was identified in their records. For one resident, the admission record showed diagnoses including pneumonia and acute respiratory failure with hypoxia, the admission MDS reflected a BIMS score of 5 indicating severely impaired cognition, and the order summary reflected a DNR order effective on the admission date. However, the resident's care plan assessment did not include his code status. For the second resident, the admission record showed diagnoses including COPD, cognitive communication deficit, and vascular dementia, and the quarterly MDS reflected a BIMS score of 3 indicating severely impaired cognition. Her order summary reflected a DNR order effective on the listed date. Her quarterly care plan included a focus that she had elected DNR status, but one intervention stated to initiate full code measures in case of cardiac arrest, including CPR and AED use, which was inconsistent with her DNR status. During interviews, MDS staff reviewed the electronic medical record and confirmed that both residents had DNR status documented in the dashboard, orders, and uploaded DNR forms, but the care plan for one resident did not include code status and the other resident had an incorrect intervention. The SW stated it was her responsibility to ensure code status was care planned and said she had skipped over one resident and had not removed the full code intervention for the other. The DON stated nursing staff would go directly to the order and DNR form if a resident coded and acknowledged being advised of the care plan issues.
Oxygen Setting Not Maintained as Ordered
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who required oxygen therapy. Resident #47 was admitted with diagnoses including shortness of breath, COPD, and dependence on supplemental oxygen. The resident’s care plan called for oxygen via nasal cannula at 3 liters per minute continuously and humidified, and a physician order dated 12/8/2025 directed oxygen at 3 LPM via nasal cannula every shift. During observation on 12/8/2025 at 8:59 a.m., the oxygen concentrator was set at 2.5 liters per minute instead of the ordered 3 liters per minute. The resident was in bed with the head of the bed slightly elevated and no signs of respiratory distress were noted. RN A stated she was the nurse for the resident, confirmed the oxygen was set at 2.5 liters per minute, and said it should have been at 3 liters per minute per the physician order. The DON stated nurses assigned to that hall were responsible for checking oxygen settings twice per shift and as needed, and that they were to follow physician orders. The facility policy stated oxygen therapy is to be administered as ordered by the physician.
Incomplete Documentation of Resident’s Change in Condition
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident, specifically failing to document a change in condition related to left knee pain. The resident had diagnoses including congestive heart failure, legal blindness, end stage renal disease, chronic obstructive pulmonary disease, and lack of coordination. Her quarterly MDS reflected a BIMS score of 14, indicating intact cognition. Her care plan included pain medication therapy related to a left knee subacute patellar fracture, with interventions to administer medication as ordered. Record review showed that an LVN documented Tylenol administration for left knee pain on 12/06/25 at 3:56 am and again at 4:56 am, with the follow-up pain scale documented as 0. On 12/07/25, another LVN documented left knee pain, administered Tylenol, and recorded the pain as effective with a follow-up pain scale of 0. On 12/08/25, the resident again complained of left knee pain, and the LVN documented that the physician was called, the resident reported pain when bending the knee, no discoloration was noted, Tylenol was administered, and the resident’s responsible party was notified. During interview, the first LVN stated the resident had complained of left knee pain on 12/06/25, that she assessed the knee, found no swelling or discoloration, administered pain medication, and that the pain improved from 4/10 to 0; however, she did not create a progress note and did not remember whether she informed the incoming nurse. The second LVN stated she first received the resident’s complaint of left knee pain on 12/07/25 and did not receive report of any changes from the outgoing nurse on 12/06/25, 12/07/25, or 12/08/25. The DON stated there was a lack of communication between the nurses, that outgoing nurses must give report of changes and special instructions, and that the resident’s left knee pain had been alleviated by pain medication on the dates in question.
Failure to Enforce Contact Isolation PPE Use
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when Resident #100 was under contact isolation for MRSA bacteremia and MRSA infection of the urinary tract, but the resident’s representative entered the room without donning PPE. Record review showed the resident was admitted with UTI/MRSA, and physician orders dated 12/9/2025 specified contact isolation for MRSA bacteremia. The care plan dated 12/4/2025 also identified infection of the urinary tract related to MRSA and included contact isolation precautions for MRSA bacteremia. On 12/8/2025, observation showed an isolation sign outside the room that was not visible, while PPE including masks, gloves, and gowns was available on the door. The resident’s representative was observed inside the room up to the foot of the bed without PPE. In interview, the representative stated he was not notified that he needed to use protective equipment and said he knew the resident was on antibiotics. RN A stated that gown, gloves, and mask should be available outside the room for staff and family entering rooms under contact isolation, and that all staff and visitors should have worn PPE before entering. The DON stated contact isolation precautions should be followed by all staff because of the potential for spreading infections to other residents.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medication cart on the A Wing Hall was observed to be left unlocked and unattended against the nurse's station. During the observation, RN A approached the cart and noticed it was unlocked, subsequently securing it. In an interview, RN A acknowledged responsibility for the cart and stated that it was her expectation to lock the cart whenever she walked away. She admitted to leaving the cart unlocked because she went to another cart to use the computer. Further interviews with the DON confirmed that multiple staff, including herself and the ADON, were responsible for ensuring medication carts were locked. The DON reiterated that staff are expected to lock the medication cart when leaving it unattended. Facility policy review indicated that all drugs and biologicals are to be stored in locked compartments accessible only to authorized personnel. The failure to secure the medication cart was directly observed and acknowledged by staff, in contradiction to facility policy and professional standards.
Failure to Protect Residents from Abuse and Timely Reporting of Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure residents' right to be free from abuse, neglect, and misappropriation of property, as evidenced by two separate resident-to-resident altercations involving four residents. In the first incident, a resident with severe cognitive impairment and a history of schizophrenia and dementia struck another resident, who had intact cognition, on the upper shoulder and neck. The event was witnessed via video surveillance, and both residents were assessed with no injuries found. The incident was reported to the appropriate parties, but there was confusion among staff and administration regarding the required timeframe for reporting such events, with the administrator and staff referencing outdated guidance and facility policy that did not specify the current regulatory requirement for reporting within two hours. In the second incident, two residents, both with cognitive impairments and histories of dementia and psychiatric disorders, engaged in a physical altercation over a towel in the dining room. One resident sustained a skin tear with scant bleeding to her hand, which was treated by nursing staff. Both residents were separated, assessed, and notifications were made to the physician, DON, and administrator. Video surveillance and staff interviews confirmed the altercation, but there was again a lack of clarity among staff and administration regarding the classification of the event as abuse and the appropriate reporting timeframe. The facility's policy did not provide a specific timeframe for reporting, and staff relied on their understanding of previous guidance, which was not aligned with current regulations. Throughout both incidents, staff and administration demonstrated inconsistent understanding of abuse reporting requirements, particularly regarding the two-hour reporting window for allegations of abuse. Training records indicated that staff had received education on abuse, neglect, and exploitation, but interviews revealed gaps in knowledge about current regulatory expectations. The facility's policy referenced following applicable regulations but did not specify the required reporting timeframe, contributing to the deficiency.
Failure to Timely Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including resident-to-resident altercations—were reported to the administrator and State Survey Agency within the required timeframes. Specifically, the facility did not report two separate resident-to-resident altercations within two hours as required by regulation. In the first incident, two female residents were involved in an altercation in the hallway, with one resident alleging she was hit by the other. Both residents were assessed and found to have no injuries, and notifications were made to the medical doctor, responsible parties, DON, and administrator. However, the self-report to the state was not submitted until more than two hours after the incident occurred. In the second incident, two other female residents were involved in a physical altercation in the dining room over a towel, resulting in a skin tear to one resident's hand. Both residents were separated, assessed, and notifications were made to the appropriate parties. The incident was not reported to the state within the required two-hour timeframe, as the self-report was submitted more than two hours after the event. Interviews with staff and the administrator revealed a lack of clarity and training regarding the specific two-hour reporting requirement for abuse allegations, with some staff and the administrator believing that a 24-hour timeframe was sufficient if there was no major physical injury. The residents involved in these incidents had varying degrees of cognitive impairment, as indicated by their BIMS scores and diagnoses such as dementia, schizophrenia, and bipolar disorder. Despite the absence of significant injuries and the residents' own reports of feeling safe, the facility's failure to report these altercations within the mandated timeframe constituted a deficiency. The facility's abuse policy did not specify the required reporting timeframe, and staff training records indicated that while abuse and neglect training had been provided, there was confusion about the regulatory requirements for timely reporting.
Failure to Adhere to Nutritional Menus
Penalty
Summary
The facility failed to ensure that the meals served to residents met their nutritional needs and adhered to the established menus. During observations on two consecutive days, it was noted that the meals served did not match the posted or cycle menus. On the first day, the menu called for beef enchiladas with Spanish rice and peach cobbler, but residents received dry beef enchiladas with pinto beans or green beans with carrots, apple pie, and cornbread. On the second day, the menu called for Mexican meatloaf with buttered corn and banana, but residents were served meatloaf with corn, carrots, and a banana. These discrepancies were not communicated to the residents or staff, and there was no indication that substitutions were noted or justified. Interviews with staff revealed a lack of communication and oversight in the meal service process. RN A, responsible for checking trays, did not verify the menu items against the trays and was unaware of any substitutions. The Registered Dietitian (RD) acknowledged that substitutions might occur but did not ensure that these were communicated or documented. The Administrator (ADM) indicated that the Food Production Manager (FPM) was responsible for overseeing menu adherence but failed to do so. The facility's Quality Assurance and Performance Improvement (QAPI) records identified issues with meal service, including cold food, late trays, and non-compliance with menus, attributing these problems to inadequate supervision by the dietary manager.
Kitchen Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility was found to have multiple deficiencies in its kitchen operations, which were observed during a survey. The kitchen had issues with cleanliness and maintenance, including steam wells with a flaking whitish substance, and a shelf above the steam table with dark brown and reddish substances. Additionally, there were dented food holding pans, one of which had a sticky yellowish stain. Spices were not properly sealed, and expired canned goods were found in the dry storage area. Plastic dishes on the clean rack were found with debris, and personal items such as a paper plate with pizza and a soda can were improperly stored in the kitchen. Interviews with staff revealed a lack of adherence to food safety protocols. The dietary worker admitted to not having time to remove personal food items from the kitchen, acknowledging the risk of cross-contamination. The dietary aide was aware of the improper placement of her personal cup in the kitchen and admitted to not following handwashing protocols. The food production manager was unaware of the proper disposal of dented pans and the potential contamination risks of open spices. He also failed to check the use-by dates on canned goods upon delivery. Further investigation showed ongoing issues with water on the floor in the dry storage area and around the ice machine, which required continuous mopping. The walk-in freezer had significant icicles due to a leak in the condenser. The facility's administration was aware of these issues, and the food production manager was responsible for ensuring food safety and equipment maintenance. However, the deficiencies in kitchen operations and staff practices posed a risk of food contamination and illness among residents.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #293, who required oxygen therapy. The resident's physician had ordered oxygen to be administered at 2 liters per minute (Lpm) via nasal cannula to alleviate symptoms of hypoxia related to shortness of breath. However, during an observation, it was noted that the oxygen concentrator was set at 3 Lpm, which did not align with the physician's orders. This discrepancy was confirmed through interviews with the Licensed Vocational Nurse (LVN), Assistant Director of Nursing (ADON), and Director of Nursing (DON), who acknowledged the importance of adhering to physician orders to prevent potential harm to the resident. Resident #293, a female with a history of sleep apnea and hypertension, was receiving continuous oxygen therapy as part of her care plan. The facility's oxygen administration policy mandates that oxygen therapy be administered as per the physician's orders. The failure to comply with these orders could lead to adverse effects, such as hyperoxygenation or increased carbon dioxide levels in the blood, as noted by the nursing staff. The facility's oversight in ensuring the correct oxygen flow rate was a significant lapse in maintaining the standard of care for the resident.
Inappropriate Prescription of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #68, was not prescribed the antipsychotic medication Zyprexa without an appropriate diagnosis for its use. Resident #68, a male with diagnoses including dementia with behavioral disturbance and neurocognitive disorder with Lewy bodies, was administered Zyprexa despite not having a diagnosis of psychosis. The medication was prescribed to manage aggression and anxiety, as noted in the consent for antipsychotic treatment signed by the Director of Nursing (DON) and a Nurse Practitioner (NP). However, the facility's policy requires that psychotropic drugs are only given when necessary to treat a specific condition documented in the clinical record. Interviews with the DON and the Administrator revealed a lack of awareness that antipsychotic medications should not be given solely based on a dementia diagnosis. The DON acknowledged that Resident #68 had been receiving Zyprexa for a long time for aggression, and the Administrator admitted to confusion about the appropriateness of prescribing antipsychotics for dementia. The facility's psychotropic medication policy emphasizes the necessity of a specific diagnosis for administering such medications, which was not adhered to in this case.
Expired Insulin Found in Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to accepted professional principles, specifically concerning the expiration of insulin in one of the medication carts located in the A wing hallway. During an observation, it was found that an insulin vial had been opened on 8/12/2024 and was still in use past the 28-day expiration period. This oversight was confirmed through interviews with the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN) A, and Registered Nurse (RN) A, who all acknowledged that insulin vials should be discarded after 28 days from the opening date. The ADON and nursing staff expressed concerns that administering expired insulin could lead to adverse reactions or reduced potency, potentially affecting the therapeutic levels for residents. The facility's policy, revised in May 2023, mandates that medications be stored safely and securely, with expired or deteriorated medications removed immediately from storage. Despite this policy, the expired insulin was not discarded, indicating a lapse in adherence to the facility's medication storage and labeling procedures.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to provide residents with food at an appetizing temperature, specifically affecting two residents during a lunch meal. Observations revealed that meal trays were not served at the preferred temperature, with food items such as enchiladas and vegetables being significantly below the required temperature. The issue was compounded by delays in meal service, as trays were left on meal carts for extended periods, leading to cold food being served to residents. Interviews with staff indicated a lack of clarity and responsibility regarding the process for ensuring food was served warm, with no specific individual assigned to oversee the timely distribution of meal trays. Residents expressed dissatisfaction with the temperature of their meals, and staff acknowledged that the cold food could lead to decreased food intake, potentially affecting residents' nutritional status. The Registered Nurse (RN) and Registered Dietitian (RD) both recognized the potential negative impact of cold food on residents' health, including weight loss and dehydration. However, there was no immediate action taken to reheat the food or address the issue promptly, highlighting a gap in the facility's meal service process.
Failure to Ensure Resident's Call Light Functionality
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach and functioning properly, which could place residents at risk of being unable to obtain assistance when needed. The resident in question, a male with severe cognitive impairment and various medical conditions including dysphagia, unspecified convulsions, and muscle weakness, was observed to have his call light on the floor and not working. Despite being non-verbal, the resident was able to press the call light when handed to him, indicating his reliance on it for communication and assistance. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's call light functionality. The Maintenance Supervisor was unaware of the issue, and the Dietary Manager, responsible for checking the resident's room, admitted to not verifying the call light's functionality. Additionally, a CNA acknowledged the importance of checking call lights but did not confirm if it was working. The facility's policy requires staff to ensure call lights are within reach and functioning, yet this was not adhered to, leading to the deficiency.
Non-Functional Call Light Puts Resident at Risk
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident, identified as Resident #10, which could potentially place residents at risk of being unable to obtain assistance or help when needed. Resident #10, a male with severe cognitive impairment and various medical conditions including dysphagia, unspecified convulsions, and muscle weakness, was observed to have a non-functional call light in his room. The call light was found on the floor and did not activate the light outside the room when pressed. Despite being non-verbal, Resident #10 was able to press the call light when handed to him, indicating his ability to use it for communication. Interviews with facility staff revealed a lack of awareness and oversight regarding the non-functional call light. The Maintenance Supervisor was unaware of the issue, and the Dietary Manager, responsible for checking Resident #10's room, admitted to not verifying the call light's functionality that morning. The CNA also confirmed that she did not check if the call light was working, despite being trained to do so. The Administrator stated that department heads were assigned to check on residents and their rooms daily, including ensuring call lights were within reach and operational. The facility's policy requires immediate reporting of defective call lights, but this procedure was not followed in Resident #10's case.
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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 Harlingen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Palms Rehabilitation And Retirement | 0.3 mi | ★★★★★ | 7 | 0 |
| Sun Valley Rehabilitation And Healthcare Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Harlingen Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 11 | 1 |
| Windsor Nursing And Rehabilitation Center Of Harli | 0.8 mi | ★★★★★ | 5 | 0 |
| Windsor Atrium | 1.7 mi | ★★★★★ | 5 | 0 |
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