Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Treemont Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and significant physical limitations was assessed as high risk for elopement, but this risk was not incorporated into the care plan and staff did not notify the DON of the elevated score. During a night shift, a door alarm sounded and an RN checked the door but did not go outside around the building before returning to complete a head count, at which point the resident was found to be missing. Around the same time, a CNA from another floor encountered the resident outside but mistook him for a homeless person and did not intervene. The resident ultimately eloped off the premises and was located by police near a main road and transported to a hospital, where no injuries were found.
A resident with a history of stroke, hemiplegia, dementia, and psychiatric conditions was admitted, then sent to the hospital the next day for evaluation of possible aspiration related to a G-tube. Documentation showed an unplanned discharge to a short-term hospital, and the resident was not allowed to return. Interviews with the DON, ADON, BOM, and Marketer/Admissions revealed the resident had been clinically but not financially approved, was admitted by confusion while management was absent, and was not funded or fully identified. Staff acknowledged that transportation had been arranged for another individual and that, once the error was recognized, the resident was not readmitted after hospitalization, contrary to the facility’s written discharge planning policy regarding residents returning from the hospital.
A resident with moderate cognitive impairment and multiple medical conditions exited the facility unsupervised by observing and using a door code after a delivery person, without staff presence in the hallway or at the entrance. The resident was later found at a family member's residence in a stressed and medically compromised state, having walked a significant distance before being located and taken to the hospital.
Three CNAs provided resident care while their certifications were expired, as confirmed by registry and timecard reviews. Staff interviews indicated that both HR and the CNAs were responsible for monitoring certification status, but lapses occurred, and a policy for registry verification was not provided when requested.
A resident with multiple comorbidities, including end stage renal disease and chronic heart failure, experienced shortness of breath during transport to dialysis, resulting in a missed appointment. Facility staff did not immediately notify the physician or complete required documentation of the change in condition, despite facility policy and direct instructions from the ADON. Both the physician and NP confirmed they were not informed of the event at the time.
A facility's second-floor storage room was found unlocked and disorganized, containing broken and hazardous equipment. Staff interviews revealed confusion about key access and security protocols. The Administrator confirmed the expectation for storage rooms to remain locked to prevent unauthorized access and potential harm.
The facility failed to store and handle food according to professional standards, risking food-borne illness. Observations revealed expired and improperly stored food items, such as unrefrigerated Teriyaki Sauce and unsealed boiled eggs, contrary to facility policy and FDA guidelines.
The facility failed to maintain an effective Infection Prevention and Control Program, as CNAs did not change soiled gloves during incontinence care for two residents. One resident, dependent on assistance for toileting hygiene, had gloves not changed after cleaning, and the same gloves were used to place a clean brief. Another resident, requiring moderate assistance, had cream and a clean brief applied with contaminated gloves. Facility policies on perineal care and infection control were not followed.
The facility failed to secure medication carts, leaving them unlocked and unattended in hallways. RN, LVN, and MA acknowledged the carts should be locked to prevent unauthorized access. The carts contained various medications, and the facility's policy did not address medication security. The DON confirmed the expectation for carts to be locked at all times.
The facility failed to maintain safe operating conditions for kitchen equipment, with leaking pipes in the walk-in refrigerator and ice build-up in the freezer. Observations showed a bucket collecting water from a leaking fan-cooler unit and ice forming on food boxes. Interviews revealed that the issues were known but unresolved for an unspecified duration.
The facility failed to maintain an effective pest control program, leading to the presence of gnats, flies, and roaches in the kitchen, resident rooms, and dining areas. Residents reported frequent sightings of pests, and staff interviews revealed a lack of awareness about pest reporting procedures. The pest sighting log confirmed a roach sighting in the kitchen, with pest control visits occurring monthly.
A resident at risk for falls, with a history of malnutrition and urinary tract infection, fell and sustained skin tears when a PTA failed to use a gait belt during ambulation. The resident required partial to moderate assistance, and the facility's policy mandated the use of a gait belt, which was not followed.
A facility failed to respect a resident's privacy and dignity when a medical assistant entered the resident's room without knocking or requesting permission. The resident, who was cognitively intact and had a history of mental health disorders, expressed distress at the intrusion. Interviews confirmed the importance of knocking and obtaining permission, as outlined in the facility's policy on resident rights.
The facility failed to maintain a safe, clean, and homelike environment in two resident rooms. In one room, tiles in the bathroom were missing pieces, exposing bare concrete, while another room had tiles with gaps and a cracked tile. The Maintenance Supervisor was aware of the issue but stated that the repair crew had stopped operations months ago. The DON noted the potential trip hazard posed by the damaged tiles.
A resident with an indwelling urinary catheter was found with a leaking catheter bag that had not been changed for two months, despite facility policy and physician orders requiring regular monitoring and changes as needed. The urine was cloudy with sediment, and staff interviews confirmed awareness of the need to change dirty or leaking catheters to prevent infection, yet no action was taken.
A facility failed to implement policies and procedures to prevent neglect, resulting in a resident being missing for 15 hours after a hospital visit. The resident, who was cognitively intact and generally independent, checked himself into the ER and was later released to a homeless shelter without the facility's knowledge. The incident was not reported to the State Survey Agency.
The facility failed to report an incident involving a missing resident who was found at a homeless shelter after being released from the hospital. The resident, who was cognitively intact, was taken to the hospital for an appointment and later checked himself into the ER. The hospital released him with a bus pass, and the facility staff could not locate him until the next day. The incident was not reported to the State Survey Agency within the required timeframe.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistive devices to prevent accidents, resulting in a resident’s elopement from the building without staff knowledge. The resident was an elderly male with dementia, prior cerebral infarction, hemiplegia/hemiparesis, generalized muscle weakness, and atherosclerotic heart disease. His admission MDS showed a BIMS score of 1, indicating severe cognitive impairment. An Elopement Risk Assessment completed shortly after admission scored him at 16, identifying him as at high risk for elopement, but his care plan dated 03/02/26 did not include elopement risk as a focus with goals or interventions. Progress notes from admission through the date of the incident documented no prior elopement attempts or exit-seeking behaviors. On the night of the incident, the east exit door alarm sounded at approximately 01:00 a.m. The nurse on duty, RN A, reported that she immediately went to the door and looked but did not see any residents; she then conducted a head count and discovered that the resident was missing. The DON stated that RN A did not go outside the building to look for the resident when the door alarm sounded, and the administrator stated it was the nurse’s responsibility to go around the building at the time of the alarm. While the alarm had sounded and staff were searching, a CNA who worked on another floor encountered the resident outside around 12:30 a.m.; the CNA later stated in writing that he thought the man was homeless and did not recognize him as a resident because he worked on a different floor and had never seen him before. After the resident was identified as missing, staff initiated the facility’s elopement/missing resident protocol and searched the building and surrounding premises, and local law enforcement was notified. Within a short time, police contacted the facility to report that the resident had been found wandering off facility grounds and transported him to a hospital for evaluation. The administrator reported that the resident was found near a hospital or a crossing bridge near the hospital, at least as far as the main road and not near the facility, estimating the distance as a 5–10 minute walk or longer for this resident. Hospital evaluation and subsequent skin assessment on return documented no injuries or acute issues. The DON later acknowledged that the resident’s high elopement risk score had been known, that the care plan should have reflected monitoring for elopement/exit-seeking behaviors, and that staff had not notified her when the resident’s initial elopement assessment score exceeded the facility’s high-risk threshold.
Removal Plan
- All staff received training on abuse and neglect as well as training on elopement response with emphasis on the need to check outside the building in response to door alarms.
- All residents were reassessed for elopement risks.
- An AD Hoc QAPI meeting was conducted to review the elopement.
- Door locks and alarms were checked and are checked daily.
- Door alarm monitoring and missing resident/elopement monitoring are completed daily.
- Door alarm codes continue to be changed monthly.
- Elopement drills are conducted three times per week.
- The DON monitors all residents' elopement scores daily by generating and reviewing a daily report for changes and scores over 10.
Failure to Allow Hospitalized Resident to Return Due to Financial Approval Issues
Penalty
Summary
The deficiency involves the facility’s failure to establish and follow a written policy permitting residents to return after hospitalization, resulting in a resident not being allowed to return and instead being effectively discharged while hospitalized. The resident was an older female admitted with a primary diagnosis of unspecified cerebral infarction (stroke) and secondary diagnoses including hemiplegia and hemiparesis affecting the right dominant side, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Admission records showed she was admitted on 02/23/2026, and the MDS entry tracking reflected that admission date. The following day, an MDS discharge record documented an unplanned discharge to a short-term general hospital, and the discharge summary stated she was sent to the hospital for evaluation due to G-tube issues and possible aspiration with slightly coarse sounds in the upper right lobe, though she denied cyanosis or respiratory distress. Interviews with facility staff revealed that the resident was clinically approved for admission but not financially approved. The DON stated the resident did not return from the hospital because she was not financially approved. The Marketer/Admissions staff reported that the resident was not funded and lacked an identification card, having only a green card, and therefore was not approved for admission based on funding. The ADON and BOM both confirmed that the resident was clinically but not financially approved, and that she was admitted by confusion while management was not in the building, as the facility had been expecting two other new admissions. The BOM indicated transportation had been set up for the wrong person, leading to this resident’s arrival, and that once the discrepancy was recognized, the plan was to transfer her back to the sending facility; however, she was instead sent to the hospital for treatment and not allowed to return. The facility’s discharge planning policy referenced completing discharge planning when anticipating discharge to another setting, but the report did not show that this policy was followed to permit the resident’s return after hospitalization.
Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, type 2 diabetes, anxiety disorder, and acute respiratory failure with hypoxia exited the facility without supervision and walked approximately two miles to a family member's residence. The resident, who had a BIMS score of 12 indicating moderately impaired cognition and was being treated for a urinary tract infection, was last seen in her room after requesting to eat breakfast there. Staff discovered the resident missing during a routine medication pass and initiated a search of the facility and surrounding area. Video surveillance revealed that the resident exited her room using a walker and approached the front door shortly after a delivery person had used the keypad to exit. The resident was observed attempting to use the keypad and successfully opened the door, leaving the facility unsupervised. No staff were present in the hallway or at the front entrance during this time. The resident was later found at a family member's apartment, appearing stressed, lethargic, hungry, dehydrated, with low blood sugar and elevated blood pressure, and was subsequently taken to the hospital. Interviews with facility staff and administration confirmed that the resident had not previously expressed a desire to leave the facility and had not attempted to elope before. Staff also reported that the resident had been seen lingering near the front lobby in the days prior to the incident. The facility's elopement prevention and response policies required staff to report any resident attempting to leave or suspected of being missing, but the resident was able to observe and use the door code without staff intervention, resulting in her unsupervised exit.
Expired CNA Certifications Result in Deficiency
Penalty
Summary
The facility failed to ensure that three certified nurse aides (CNAs) maintained current nurse aide certifications while employed and actively providing care to residents. Record reviews showed that CNA A, CNA B, and CNA C all had expired certifications according to the Nurse Aide Registry, yet each continued to work scheduled shifts during the period their certifications were not valid. Timecard reports confirmed that these CNAs worked multiple shifts while their certifications were expired. Interviews with staff revealed that CNAs were responsible for notifying Human Resources (HR) and administration when their certifications expired, but CNA A did not inform staff of her expired license. The Director of Nursing (DON) and the Administrator both stated that HR was expected to complete background and registry checks prior to hire and annually thereafter, and that staff were responsible for notifying HR of expiring certifications. The facility was unable to provide a policy for nurse aide registry verification when requested.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical status. The resident, an older female with acute respiratory failure, chronic diastolic heart failure, end stage renal disease, and dependence on renal dialysis, experienced an episode of shortness of breath while being transported to a scheduled dialysis appointment. As a result, she missed her dialysis session. Documentation showed that the resident was on continuous oxygen therapy and had orders to maintain oxygen saturation above 92%. Review of the resident's medical record revealed no evidence that a Change in Condition Assessment was completed following the episode of shortness of breath, nor was there documentation that the physician was notified at the time of the event. A late entry was made two days later, but both the physician and nurse practitioner confirmed during interviews that they were not made aware of the episode when it occurred. The nurse practitioner and physician both stated that shortness of breath in this resident, given her comorbidities, would be considered a change in condition that warranted notification. Interviews with facility staff indicated that the ADON instructed the LVN to notify the physician and complete a Change in Condition Assessment, but the LVN only left a voice message for the physician and did not document this action or complete the assessment. The LVN cited the timing of the shift change as a reason for not completing the documentation, assuming the oncoming nurse would do so. The facility's policy required immediate notification and documentation of significant changes in status, which was not followed in this instance.
Unsecured and Disorganized Storage Room Poses Safety Risks
Penalty
Summary
The facility failed to ensure that equipment in the second-floor storage room was secure and inaccessible to unauthorized staff and residents. During an observation, the storage room was found unlocked, unorganized, and dirty, containing various broken and potentially hazardous equipment such as wheelchairs, a bed frame with sharp edges, and an overbed table with missing veneer. Additionally, the room contained poles for g-tube feeding, a broken bedside table, repair parts, stacked mattresses, and various liquids and items scattered on the floor. The equipment was piled haphazardly, indicating a lack of organization and safety measures. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN), and Certified Nursing Assistant (CNA), revealed inconsistencies in the understanding and enforcement of the storage room's security protocols. The ADON admitted to having been in the room earlier and believed it was locked afterward, but was unsure of how many keys existed or who had access. The LVN and CNA both acknowledged the room should be locked but were uncertain about key access and the room's security status. The facility's Administrator confirmed the expectation that storage rooms remain locked to prevent unauthorized access and potential harm, aligning with the facility's policy that mandates monthly sweeps and organized storage of equipment.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, the facility did not properly store, prepare, distribute, and serve food, which could potentially lead to food-borne illnesses among residents. During the inspection, it was noted that a 1-gallon container of Teriyaki Sauce, opened and dated 05/05/24, was not refrigerated as required by the manufacturer's instructions. Additionally, a container of apple sauce and a bag of boiled eggs were found in the walk-in refrigerator past their use-by dates, with the apple sauce dated 07/13/24 and a use-by date of 07/16/24, and the eggs dated 07/13/24 with a use-by date of 07/18/24. The eggs were also not sealed properly, leaving them exposed to air. Interviews with the Kitchen Manager and a cook revealed that the facility's policy required all food to be dated upon receipt and when opened, with perishable items to be discarded by their use-by dates. However, the observed practices did not align with these policies, as evidenced by the presence of expired and improperly stored food items. The facility's policy, as well as the U.S. FDA Food Code, mandates that food be stored in covered containers or sealed bags to prevent contamination, which was not followed in these instances.
Infection Control Deficiency Due to Improper Glove Use
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper glove use during incontinence care for two residents. For Resident #60, a CNA did not change soiled gloves after cleaning the resident's peri area and buttocks, and continued to use the same gloves to place a clean brief and adjust the resident's blankets. This resident, who was dependent on assistance for toileting hygiene, had a BIMS score of 15, indicating no cognitive impairment, and was being monitored for signs of infection due to incontinence. Similarly, for Resident #75, another CNA failed to change gloves after cleaning the resident's soiled peri and buttocks area, and applied cream and a clean brief with the same contaminated gloves. This resident, who required moderate assistance with toileting hygiene, had a BIMS score of 14, suggesting intact cognition, and was diagnosed with a urinary tract infection. The facility's policies on perineal care and infection control precautions were not adhered to, as CNAs did not change gloves or perform hand hygiene as required.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to ensure that medications were secure and inaccessible to unauthorized staff or residents, as observed in three out of four medication carts reviewed. Specifically, the medication carts for Unit 2, Unit 3, and Unit 23 were found unlocked and unattended in the hallways. RN H left the medication cart for Unit 2 unlocked while attending to a task in a resident's room, acknowledging that the cart should always be locked to prevent unauthorized access. Similarly, MA I left the medication cart for Unit 23 unlocked while administering medications in a resident's room, and LVN J left the medication cart for Unit 3 unlocked while washing hands in a bathroom, both acknowledging the importance of keeping the carts locked. The facility's policy on medication storage did not address the security of medications, and no additional policy was provided upon request. The Director of Nursing (DON) confirmed the expectation that medication carts should be locked at all times. The unsecured medication carts contained various medications, including Gabapentin, Midodrine, Lasix, Naproxen, Famotidine, Depakote, Zyprexa, Metoprolol, Cyproheptad, and Insulin Lispro, among others. This oversight could potentially lead to unauthorized access and ingestion of medications by residents or staff.
Equipment Maintenance Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, specifically in the kitchen area. During an observation, a five-gallon bucket was found half full of a water-like substance, with liquid dripping from a pipe connected to the fan-cooler unit in the walk-in refrigerator. The fan-cooler unit was also making a clanking noise. In the walk-in freezer, both fan-cooler units had ice build-up, forming icicles that dripped onto food boxes below, accumulating 2-3 inches of ice on top of the food boxes. Interviews revealed that the facility's administration and maintenance staff were aware of the issues. The Administrator mentioned that the fan-cooler units had been fixed but could not specify how long the pipes had been leaking. The Maintenance Supervisor stated that he had addressed the leaking pipes by blowing them out but was unsure of the duration of the leak, estimating he had been in the area the previous week. The facility's policy on Preventive Maintenance/Work-Order Request, dated 2003, indicates that the facility should repair or replace damaged or broken equipment as needed.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in various areas, including the kitchen, resident rooms, and dining areas. Observations revealed live gnats and small flies in a resident room and dining areas, with residents reporting frequent sightings of these pests. One resident mentioned seeing a roach in her room, while another resident reported seeing gnats in her room and the dining area. The presence of these pests during meal services and in resident living spaces indicates a lapse in maintaining a pest-free environment. Interviews with staff and residents highlighted a lack of awareness and communication regarding pest sightings. Several CNAs were unaware of the pest sighting log's location and procedures, although they acknowledged seeing gnats and occasionally roaches. The Maintenance Supervisor confirmed that staff should report pest sightings in the log, which is used to inform pest control treatments. The Director of Nursing expressed concerns about the potential cross-contamination risks posed by roaches in the kitchen. The pest sighting log confirmed a roach sighting in the kitchen, and the pest control company visits the facility monthly or more frequently if needed.
Failure to Use Gait Belt Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received the necessary assistance devices to prevent accidents, specifically for one resident reviewed for accidents. The incident involved a physical therapy assistant (PTA) who did not apply a gait belt to the resident before ambulating in the hallway. As a result, the resident fell and sustained a skin tear to the left elbow and right forearm. The PTA acknowledged the importance of using a gait belt to secure the resident and admitted to not using it because they were only planning to take a few more steps. The resident involved was of advanced age and had diagnoses of moderate protein-calorie malnutrition and a urinary tract infection. The resident's care plan indicated a risk for falls, and the Minimum Data Set (MDS) showed that the resident had a fall within the last month and required partial to moderate assistance with ambulating. Observations confirmed the absence of a gait belt at the time of the fall, and interviews with the Director of Physical Therapy reinforced the expectation that all PT staff should use a gait belt when working with residents. The facility's policy on moving a resident also required the use of a gait belt.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, specifically in the case of one resident. During an observation, a medical assistant (MA K) entered the room of a resident without knocking or requesting permission. This action was contrary to the facility's policy, which emphasizes the importance of knocking and obtaining permission to respect the resident's privacy and dignity. The resident, who was cognitively intact and had a history of bipolar disorder, major depressive disorder, anxiety, and post-traumatic stress disorder, expressed distress by yelling at MA K to leave the room. Interviews conducted with both the resident and MA K revealed that the resident did not want MA K in her room, and MA K acknowledged the importance of knocking before entering a resident's room. The facility's administrator also confirmed that staff should knock for privacy reasons and need permission to enter a resident's room. The facility's policy on resident rights, revised in 2016, supports the resident's right to personal privacy and a homelike environment, which was not upheld in this instance.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in two of the five rooms observed. In room #1125, the bathroom floor had two pieces of tile directly in front of the toilet with approximately 2-inch by 2-inch pieces missing, exposing the bare concrete below. In room #1207, the bathroom floor had five pieces of tile bordering the toilet with 1/4 inch gaps between them, exposing the concrete below, and one tile had a large 1/2 inch crack down the middle. The Maintenance Supervisor acknowledged awareness of the tile issues and mentioned that the crew responsible for repairs had ceased operations months ago. The Director of Nursing (DON) noted that cracked or loose tiles could pose a trip hazard if the tiles slipped or if the edges were raised. The facility's policy on Preventive Maintenance/Work-Order Request, dated 2003, indicated that the facility would repair or replace damaged or broken equipment or building amenities as needed. However, the failure to address the tile issues in the bathrooms of the observed rooms could lead to an unsanitary and uncomfortable environment for the residents.
Failure to Change Leaking Catheter Bag
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a deficiency in preventing urinary tract infections. The resident, a male with a diagnosis of Obstructive and Reflux Uropathy, was observed with a leaking catheter bag that had not been changed for two months. The urine in the tubing was cloudy with white sediment, and the catheter bag was stained and leaking despite the clamp being closed. The resident's care plan and physician orders required monitoring of the catheter for leakage, blockage, sediment buildup, or low output every shift, but there were no progress notes regarding the catheter from 07/08/24 to 07/22/24. Interviews with facility staff, including CNAs and LVNs, revealed that they were aware of the need to change dirty or leaking catheters to prevent infection. However, the catheter was not changed despite its condition, and the facility's policy required that catheters and drainage systems be changed as needed unless ordered otherwise by the physician. The failure to change the leaking catheter bag placed the resident at risk of infection, as confirmed by staff interviews.
Failure to Implement Policies and Procedures to Prevent Neglect
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent neglect, as evidenced by an incident where a resident was missing for approximately 15 hours after leaving the hospital for a doctor's appointment. The facility did not follow its policy to report the incident to the State Survey Agency. This failure could place residents at risk of lacking timely reporting of incidents. The resident involved was a cognitively intact male with a BIMS score of 15, who used a wheelchair for mobility. He was taken to the hospital for an appointment and subsequently checked himself into the ER, reporting suicidal thoughts. The hospital staff released him with a bus pass to a homeless shelter, and the facility was not informed. The resident spent the night under an overpass before being found at the homeless shelter the next day. Interviews with facility staff revealed that the resident was generally independent, alert, and oriented, and did not require a staff member to accompany him to appointments. The facility staff and police searched for the resident when he was not found at the hospital. The facility did not report the incident to the State Survey Agency, believing the resident was never truly missing and was not in danger.
Failure to Report Missing Resident Incident
Penalty
Summary
The facility failed to report an incident involving a resident who went missing for about 15 hours after leaving the hospital for a doctor's appointment. The resident, who was cognitively intact and able to make his own decisions, was taken to the hospital by a van driver. After the appointment, the resident checked himself into the ER, claiming to have suicidal thoughts. The hospital staff released the resident with a bus pass to a homeless shelter without informing the facility. The facility staff, including the DON and the van driver, attempted to locate the resident and eventually contacted the police when they could not find him. The resident was found the next day at a homeless shelter and expressed that he did not want to return to the facility. He signed an AMA discharge form and was assessed to have no visible concerns or injuries. The facility's failure to report the incident to the State Survey Agency within the required timeframe was a significant deficiency. The DON and the Administrator believed that the resident was not in danger and that they had 24 hours to report the incident. However, the facility's policy required immediate reporting of such incidents. The facility staff, including the DON, ADON, and Administrator, all acknowledged that the resident was alert, oriented, and able to make his own decisions. Despite this, the incident should have been reported promptly to ensure proper follow-up and intervention. Interviews with the resident, his family, and various facility staff revealed that the resident was generally quiet, compliant with care, and had never expressed a desire to leave the facility. The resident's family expressed concerns about the resident's mental state and the facility's decision to send him to the appointment unattended. The facility's policy on abuse and neglect required prompt reporting of such incidents, but this was not adhered to in this case, leading to a delay in addressing the resident's situation and ensuring his safety.
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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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Signature Pointe | 1.9 mi | ★★★★★ | 13 | 0 |
| The Legacy Midtown Park | 3.4 mi | ★★★★★ | 3 | 0 |
| Brentwood Place Three | 3.6 mi | ★★★★★ | 14 | 1 |
| South Dallas Nursing & Rehabilitation | 3.6 mi | ★★★★★ | 38 | 0 |
| Brentwood Place One | 3.6 mi | ★★★★★ | 3 | 0 |
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