Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Twin Pines Nursing And Rehabilitation during CMS and state inspections, most recent first.
Incomplete MAR/TAR Documentation for Medications and Wound Care: Staff failed to accurately document medication administration and wound care for several residents. A resident with cognitive impairment had missing MAR entries for an antispasmodic, another resident with a stage 3 heel wound had missing TAR documentation for daily wound care, a resident with allergic rhinitis had inconsistent MAR entries for nasal spray and a missing levothyroxine entry, and another resident with a stage 3 buttock pressure ulcer had missing wound care documentation. Staff interviews indicated doses and treatments were sometimes given but not entered, while other entries were marked in haste or left blank.
A CMA used the same BP cuff on three residents without sanitizing it between uses, stating she relied on her own practice and had not been taught to clean it between residents. In a separate event, an LVN provided wound care to a resident with a stage 3 pressure ulcer without a gown despite the resident being on EBP status; the room lacked an EBP sign and PPE cart, and the DON stated staff were supposed to wear a gown for wound care on EBP.
Failure to Maintain Resident Dignity During Feeding: Two residents with severe cognitive impairment and mechanically altered diets were observed being fed by staff who were standing over them rather than feeding at eye level. The ADON and an MA both acknowledged that standing while feeding was not respectful or dignified, and the DON stated that staff should be at eye level because standing can appear intimidating.
A resident's medical information was left visible on a medication cart computer screen while an RN was in another resident's room assessing a resident who had fallen. The RN stated the screen should not have been left open because it was a HIPPA violation, and the DON also confirmed exposed resident information on a computer screen was a HIPPA violation.
Failure to Refer Resident for PASARR Level II Review After New Mental Health Diagnosis: A resident admitted with dementia later had documented schizoaffective disorder and bipolar disorder, but the PASARR Level 1 screenings still showed no mental illness and no level II referral was made. The MDS Coordinator confirmed the resident’s mental health diagnoses after admission and stated the resident should have been referred to the local mental health authority when the new diagnosis was identified; the DON stated MDS staff should review PASARR accuracy and refer residents with newly diagnosed mental illness for proper services.
PASARR screenings were not accurately completed for two residents. One resident with dementia and Major Depressive Disorder and another resident with COPD, severe cognitive impairment, and bipolar disorder were both marked as having no mental illness on their PASARR Level 1 screenings. The MDS coordinators confirmed the errors, and the DON stated PASARR assessments should be reviewed for accuracy.
Care Plan Did Not Reflect EBP Status for Pressure Wound: A resident with a stage 3 pressure ulcer to the right buttock had wound treatment orders and was observed with an open wound and moderate serosanguineous drainage, but the comprehensive care plan only addressed pressure ulcer prevention and did not include EBP status. An LVN stated the resident was on EBP status, while RNs and the DON stated EBP status should have been care planned.
Two residents with severe cognitive impairment had scissors left in their rooms, including by the bedside, on a dresser, and on a chair. One resident had dementia and a care plan noting nail clippers were not safe to keep at bedside; the other had impaired cognition and a care plan focused on monitoring mental status changes. Both residents said they used the scissors to open items and had not been told they could not have them. CNA and LVN interviews confirmed sharps were not allowed in resident rooms and neither resident was care planned to have scissors.
A resident with asthma, anxiety, HF, kidney failure, and allergic rhinitis missed multiple doses of prescribed fluticasone nasal spray because the medication was not available in the cart and was not consistently tracked or located. Staff reported marking the MAR as "other" when the spray was missing, but the ADON was unaware it was out of stock, there was no designated medication-ordering process, and the DON later found the spray in a medication cart.
Unlocked Medication Cart Left Unattended: The 100-hall med cart was observed unlocked and unattended while the assigned RN was in a resident room assessing a resident who had fallen. RN stated the cart should not have been left unsecured because residents or visitors could access medications, and the DON stated a med cart should never be left unlocked and unattended. Facility policy stated meds and biologicals must be stored safely, securely, and properly, with access limited to authorized staff.
A resident with AFib and other cardiac conditions did not receive ordered digoxin level monitoring as scheduled. The chart showed the last digoxin level was drawn months earlier, and the missing labs were acknowledged by nursing staff during interview. Staff described a lab-order process involving computer entry and paper requisitions, but said the labs were missed after a switch to a new lab system and that staff were not fully trained on the process.
Two residents with significant cognitive and physical impairments had active diet orders and observed use of mechanical soft textures and divided plates that were not reflected in their comprehensive person-centered care plans. One resident with cerebral palsy, hemiplegia, and moderate intellectual disability had a long-standing order for an RCS/LCS/NSOT diet with a divided plate and only pink sugar, and staff, including an ST, confirmed the divided plate was needed and used, but it was omitted from the care plan. Another resident with Alzheimer’s disease, dementia, and anxiety had orders for a regular diet with mechanical soft texture, a divided plate, drinks in coffee cups, and double liquids, and was observed receiving mechanical soft food, yet the care plan only listed a regular diet and supervision for eating without noting the mechanical soft texture or divided plate. The MDS nurse, DON, and interim ADM acknowledged that the care plans should accurately reflect these required interventions.
A resident with severe cognitive impairment, multiple fractures, vascular dementia, Down syndrome, and bradycardia had a quarterly MDS showing a need for moderate assistance with eating and a mechanically altered diet, including mechanical soft texture, pureed meat with gravy, and a magic cup at lunch. Although active orders and meal observations confirmed these interventions and assistance were being provided, the comprehensive person-centered care plan continued to list only an ADL self-care deficit and a regular diet with an optional divided plate, omitting the required eating assistance and specific diet orders. The MDS RN, DON, and interim ADM acknowledged that the care plan had not been reviewed and revised by the interdisciplinary team after the MDS assessments as required by facility policy.
Staff entered a resident's room without knocking on multiple occasions, despite being trained on resident rights and facility policy requiring them to do so. The resident, who has multiple medical and mental health conditions, reported feeling upset and that her privacy was invaded. Leadership confirmed the expectation to knock and monitor compliance, but the deficiency occurred when staff failed to follow this protocol.
Two residents with significant medical and cognitive needs did not have their call lights within reach while in bed, despite care plans requiring this for safety and fall prevention. Observations confirmed the call lights were either on the floor or on a bedside table out of reach. Staff interviews revealed inconsistent practices and lack of a formal policy regarding call light placement.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation for the resident's care.
Two residents with severe cognitive impairment experienced preventable accidents due to the facility's failure to identify and address known hazards, such as unbuckling seatbelts during van transport and manipulating bed controls. Staff did not consistently report or document unsafe behaviors, and care plans were not updated to include necessary interventions after incidents, resulting in injuries including a laceration and a knee fracture.
A resident with hemiplegia and reduced mobility experienced an unwitnessed fall resulting in a leg fracture, but the subsequent MDS assessment failed to document the major injury due to reliance on EMR incident closure and lack of manual tracking. Staff interviews revealed gaps in oversight and assessment accuracy during a period without a DON, leading to the deficiency.
A resident with cancer diagnoses missed a scheduled oncology appointment due to the facility's failure to arrange transportation. The resident and his representative reported previous cancellations of appointments for similar reasons. Interviews with staff revealed confusion and lack of communication regarding appointment scheduling and transportation, contributing to the deficiency.
A facility failed to maintain privacy for two residents. One resident's medical information was potentially exposed when a medication aide left a computer screen unlocked. Another resident's privacy was compromised during wound care due to a jammed curtain that could not be fully closed, leaving the resident exposed. The first resident had intact cognition, while the second had severe cognitive impairment and required assistance with hygiene.
The facility's kitchen failed to meet food safety standards, with issues such as uncovered tea glasses, improper hairnet use by a dietary aide, and unsanitary conditions in the pantry, including spilled salt, sweetener, and flour on the floor, as well as an oily substance and dusty debris on surfaces.
The facility failed to maintain a safe and sanitary environment in Hallways A and E, with issues such as cracked doors, dislodged phone jacks, scrape marks, water-damaged ceiling tiles, and dislodged floor molding. These deficiencies were observed and confirmed by the Assistant Maintenance Director and the Administrator.
A resident with Alzheimer's and a fall risk had their call light placed out of reach, contrary to their care plan. The nursing assistant admitted to the oversight, and the facility lacked a formal policy on call light accessibility, though it was monitored by charge nurses.
A resident's right to a safe, clean, and comfortable environment was compromised due to a foul odor emanating from their restroom. Despite the restroom appearing clean, the odor persisted for several days, causing discomfort to the resident. Staff interviews indicated that the odor might have been caused by issues with the drains, which had been a problem in the past.
A facility failed to include a resident's medication allergies and physician-prescribed diet in the baseline care plan within 48 hours of admission, as required by policy. The resident, with conditions such as COPD and Chronic Kidney Disease, was admitted without this critical information documented, which was confirmed by RN/MDS B. The responsibility for baseline care plans was with the recently resigned DON, and the oversight was not caught by the admitting nurse or ADONs.
A resident with severe cognitive impairment and multiple health issues experienced several falls, including two with injuries, but the facility failed to update her care plan with new interventions. Despite discussions in management meetings, the care plan was not revised after significant falls, leaving staff without current information to prevent future incidents. The facility's policy required care plan updates after significant changes, but this was not followed, highlighting a process failure in maintaining current care plans.
The facility failed to ensure a hazard-free environment in the Hallway A shower room, where two unsecured bottles of K-Quat cleaning disinfectant were found. The AIT and LVN acknowledged the risk of residents accessing and potentially consuming the product. The Housekeeping Supervisor confirmed that the disinfectant should have been secured in a locked cabinet.
A resident with dementia and COPD had their oxygen tubing and mask improperly stored, with the tubing coiled on the concentrator and the mask on the floor. Staff interviews confirmed the equipment should be bagged to prevent contamination, but the facility's policy lacked guidance on proper storage.
A facility failed to store Latanoprost eye drops in a refrigerator as required, leaving it at room temperature in the Annex Medication Room. An LVN confirmed the medication was not stored correctly, which could affect its effectiveness. The DON, responsible for medication room maintenance, had recently resigned, creating uncertainty about oversight.
A resident with dementia and a moderate risk of wandering eloped from the facility unnoticed, despite having a care plan in place. The resident was found at a convenience store after crossing a street, and the incident was unwitnessed. Facility staff confirmed that door alarms were working, but the elopement still occurred, highlighting a failure in supervision and accident prevention.
A resident with a known egg allergy was served meatloaf containing egg, leading to an allergic reaction. The resident self-administered an epi-pen and was transferred to the hospital. The cook admitted to not following the recipe, resulting in the oversight. This incident highlights a failure in communication and adherence to dietary protocols.
The facility failed to maintain adequate staffing levels, particularly during night shifts, resulting in delayed responses to call lights, cold meals, and insufficient care for residents. Staff and residents reported significant delays in assistance and meal services, with some residents waiting over an hour for help. The facility's assessment did not adequately address staffing needs, contributing to these ongoing issues.
A LTC facility reported a 16% medication error rate involving two residents. An LVN administered medications late and failed to give one medication due to dosage form issues. The errors were attributed to a busy shift and the absence of a medication cart, violating the facility's policy of administering medications within one hour of the scheduled time.
The facility failed to ensure medication carts were locked and attended, as required by regulations. Observations revealed that medication carts were left unlocked and unattended, with medications accessible to unauthorized individuals. LVN F admitted to leaving a cart unlocked while attending to a resident, and similar issues were noted with other carts. The facility's policy mandates that carts be locked and medications not be pre-prepared, which was not adhered to.
Three residents in the facility did not receive their prescribed dietary support. A resident with dementia and weight loss did not receive a health shake or red glass as prescribed. Another resident with severe cognitive impairment and dysphagia was served an inadequate portion of pureed spaghetti and meatballs due to incorrect scoop usage. A third resident with severe cognitive impairment and a pressure ulcer did not receive a prescribed house shake with dinner. The facility's red glass program, intended to alert staff to residents needing additional monitoring, was not followed.
The facility failed to document wound care treatments for two residents with severe cognitive impairment and Stage 4 pressure ulcers. Interviews with the DON and an LVN revealed lapses in the auditing process, with both unaware of missed treatments. The facility's policies on infection control and hand hygiene were reviewed, but no corrective actions were mentioned.
A resident with severe cognitive impairment was left exposed during wound care when an LVN walked away to retrieve a trash can, violating the facility's policy on resident dignity and privacy. Interviews with staff confirmed that the resident should have been covered to maintain privacy.
Two residents in an LTC facility were unable to press the call light due to physical and cognitive limitations, despite care plans indicating the need for reachable call lights. Observations and staff interviews confirmed the residents' inability to use the call lights, and no alternative solutions were provided, violating their right to reasonable accommodation of needs.
A resident with severe cognitive impairment and multiple health issues did not have their care plan updated to reflect edema in the left hand and the need for elevation, despite these conditions being documented. Facility staff interviews revealed a lack of communication and clarity regarding the responsibility for updating care plans, leading to the oversight.
A resident with multiple diagnoses, including dementia and malnutrition, experienced significant weight loss, but the facility failed to update the care plan to reflect prescribed dietary interventions. Despite being on a mechanically altered diet and receiving nutritional supplements, the care plan was not revised to include these changes. Interviews with staff revealed inconsistencies in updating care plans, contrary to facility policy.
A resident with severe cognitive impairment and a Stage 4 pressure ulcer did not receive adequate pain management during wound care procedures. Despite verbal expressions of pain, nursing staff failed to assess or administer pain relief, contrary to the facility's policies. The resident's previous opioid medication was discontinued, and only a PRN order for Tylenol was in place, which was not consistently used before wound care.
A resident with dysphagia and no teeth was not provided with a mechanically ground meat diet as prescribed, leading to difficulty in eating. Despite a dietary order change, the resident was served whole meat, indicating a communication lapse within the facility's dietary department.
A resident with a documented onion allergy was served a meal containing onions, as the staff was not informed of the allergy. The resident could not eat the meal and was not provided an alternative, contrary to the facility's food preparation policy.
Two residents with severe cognitive impairments and Stage 4 pressure ulcers received wound care that did not adhere to infection control protocols. An LVN and an RN failed to perform proper hand hygiene before and during the procedures, increasing the risk of infection. The facility's policies on infection control were not followed, as observed during the survey.
The facility did not post the required nurse staffing information at designated entrances on two consecutive days. Observations confirmed the absence of postings, and interviews revealed that the ADON responsible for this task was off duty and unaware of who would cover her responsibilities. The DON admitted there was no staffing policy in place.
Incomplete MAR/TAR Documentation for Medications and Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for multiple residents by leaving medication administration and treatment records undocumented in the MAR/TAR. For Resident #8, nursing staff did not document administration of Dicyclomine HCl on 2/1/2026, 2/9/2026, 2/16/2026, and 2/17/2026. During interview, a CMA stated the medication had been administered but the administration box in the MAR was not clicked. For Resident #2, who had a BIMS score of 0 and a stage 3 pressure wound to the left heel, the order required daily wound care with cleansing, Santyl gel, calcium alginate, and a dry dressing. The MAR/TAR did not show documentation of the left heel wound care on 02/06/2026, 02/07/2026, 02/10/2026, and 02/11/2026. An LVN stated the missing documentation may have resulted from being pulled to work on the floor and falling behind on documentation in the electronic record, and that wound care had been done and documented on paper instead. For Resident #75, the MAR for February 2026 did not accurately reflect administration of Fluticasone Propionate nasal spray, with multiple entries showing doses not administered and other entries showing doses administered. Staff stated the medication had not been available at times, while other staff stated the medication had been in the building but could not be found, and that some documentation was marked in haste. The MAR also had no documentation for Levothyroxine Sodium on 2/17/2026, although a CMA stated it had been administered but the administration box was not clicked. For Resident #43, who had a stage 3 pressure ulcer to the right buttock and was cognitively intact, the TAR did not document ordered wound care on 2/5/26, 2/6/26, 2/7/26, and 2/10/26. The resident stated the bandage was not changed every day except when needed, and an LVN stated the missing documentation could have resulted from falling behind on documentation.
Infection Control Failures During Blood Pressure Checks and Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when a CMA used the same blood pressure cuff on Resident #48, Resident #98, and Resident #83 without sanitizing the cuff between residents. During observation during the medication pass, the CMA obtained Resident #48’s blood pressure, then used the same cuff for Resident #98 and Resident #83 without cleaning it between uses. In interview, the CMA stated the cuff was her personal cuff, said she did not believe it was contaminated because it was placed over the residents’ clothes, and stated she usually sprayed it with bleach sanitizer after medication pass was completed. She also stated she had not been taught about sanitizing a blood pressure cuff while working for the facility and used her medication aide knowledge. The facility also failed to ensure proper PPE was used during wound care for Resident #43, who had a stage 3 pressure ulcer to the right buttock and was cognitively intact. The resident’s wound progress note described an improving stage 3 pressure wound with orders to clean the wound, apply Iodoform packing strip, calcium alginate, and dry dressing changes daily and as needed if the dressing was dislodged, saturated, or soiled. The care plan reflected the pressure ulcer and interventions to follow facility policies and protocols for prevention of skin breakdown, but it did not reflect that the resident was on EBP status related to the wound. During wound care observation, the LVN wore gloves but did not wear a gown, removed the dressing from the right buttock wound, and was observed squatting over the bed with her forearms resting on the resident’s bed while providing care. The wound had moderate serosanguineous drainage on the bandage. After the observation, the LVN stated the resident was on EBP status related to the open wound, but there was no EBP sign or PPE cart with proper equipment and supplies. The LVN stated she usually wore a gown for wound care and that not wearing proper PPE could result in spreading an infection to somebody else. The DON stated nursing staff were supposed to wear a gown when providing wound care for residents on EBP and that there should have been a sign posted outside the room to alert staff to use proper PPE.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to treat each resident with respect and dignity for 2 of 18 residents reviewed for dignity. Resident #50 was a [AGE]-year-old male with diagnoses including Alzheimer's disease, dementia, and Trisomy 21. His most recent quarterly MDS reflected severe cognitive impairment for daily decision-making, setup or clean-up assistance with eating, a swallowing disorder that caused coughing or choking during meals, and a mechanically altered diet. His care plan included supervision with eating as needed. During an observation and interview, the ADON was standing over the resident's left side while feeding him, and the ADON stated she was not supposed to be standing while feeding the resident because it was not respectful or dignified. Resident #90 was a [AGE]-year-old female with diagnoses including dementia with behavioral disturbance, diabetes, and muscle weakness. Her most recent quarterly MDS reflected severe cognitive impairment for daily decision-making, setup or clean-up assistance with eating, and a mechanically altered diet. Her care plan included one-person staff assistance with eating. During an observation and interview, MA H was standing over the resident's right side while feeding her. MA H stated she should feed the resident at eye level and that she was trying to get her to eat. The DON stated that standing while feeding a resident was a dignity issue and that staff should be at eye level while feeding a resident because otherwise it looks intimidating.
Resident Information Left Visible on Medication Cart Computer
Penalty
Summary
The facility failed to ensure the resident's right to personal privacy and confidentiality of personal medical records for 1 of 18 residents reviewed, Resident #84. Resident #84's face sheet showed he was a [AGE]-year-old male admitted with diagnoses including cellulitis, diabetes, asthma, and shortness of breath. During an observation on 2/19/26 at 7:23 a.m., the computer screen mounted on the medication cart in the 100 unit displayed Resident #84's medical information while RN C was using the cart computer and assessing another resident in a room. During interview, CMA I stated the computer was being used by RN C, and RN C stated she should not have left the screen open exposing Resident #84's medical information because it was considered a HIPPA violation. The DON also stated that exposed resident information on a computer screen was considered a HIPPA violation. The facility's Resident Rights document stated the facility must protect and promote resident rights, including privacy and confidentiality of personal and medical records.
Failure to Refer Resident for PASARR Level II Review After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for level II PASARR review after the resident developed newly diagnosed mental health conditions. Resident #3 was admitted with a primary diagnosis of unspecified dementia and had an MDS BIMS score of 10 out of 15, indicating moderate cognitive impairment. The resident’s face sheet listed diagnoses of schizoaffective disorder, bipolar type, with an onset date of 03/09/2023, and bipolar disorder, current episode depressed, moderate, with an onset date of 02/29/2024. The resident’s PASARR Level 1 screenings, completed at the hospital and at the nursing facility, both documented no evidence or indicator of mental illness, and the record showed no referral for level II review. During interview, the MDS Coordinator stated they were responsible for reviewing PASARR documents on admission and checking the clinical record for accuracy, and confirmed the resident had mental health diagnoses after admission. The MDS Coordinator stated the resident had not been referred for a level II review but should have been referred to the local mental health authority upon a new mental health diagnosis. The DON stated MDS coordinators should review PASARR assessments for accuracy and that a resident with a newly diagnosed mental illness should be referred so they can receive proper services. The facility policy on Form 1012 stated the NF completes Form 1012 when an individual's diagnosis is changed.
PASARR screenings were not accurately completed for two residents with mental illness
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for 2 of 7 residents reviewed for PASARR accuracy. Resident #3 was admitted with a primary diagnosis of unspecified dementia and had an MDS BIMS score of 10 out of 15, indicating moderate cognitive impairment. The resident’s face sheet also listed Major Depressive Disorder, recurrent, moderate with an onset date of 02/27/2023, but the PASARR Level 1 screening completed at the hospital and again at the nursing facility both marked mental illness as “no.” Resident #36 was admitted with a primary diagnosis of chronic obstructive pulmonary disease and had an MDS BIMS score of 6 out of 15, indicating severe cognitive impairment. The resident’s face sheet listed bipolar disorder, unspecified, with an onset date of 10/14/2024, but the PASARR Level 1 screening completed at the hospital and again at the nursing facility both marked mental illness as “no.” During interviews, the MDS Coordinators confirmed both residents were marked as not having mental illness on their PASARR screenings and confirmed both residents had mental illness. The DON stated the MDS coordinators should be reviewing PASARR assessments for accuracy, and the facility policy stated the PL1 screening form would be reviewed for completion and correctness prior to admission.
Care Plan Did Not Reflect EBP Status for Pressure Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #43 that included measurable objectives and timeframes to meet her medical, nursing, mental, and psychosocial needs. Resident #43 was a cognitively intact female admitted with diagnoses including disorders of bone density and structure, and her most recent MDS reflected a stage 3 pressure ulcer. A wound progress note authored by the NP documented an improving stage 3 pressure wound to the right buttock with treatment orders to clean the wound with wound cleanser, apply Iodoform packing strip, Calcium alginate, and dry dressing changes daily and as needed if the dressing was dislodged, saturated, or soiled. The comprehensive care plan revised on 2/18/26 identified a pressure ulcer to the right buttock and included interventions to follow facility policies and protocols for prevention of skin breakdown, but it did not reflect that the resident was on EBP status related to the wound. During wound care observation, the resident had an open wound with moderate serosanguineous drainage on the dressing. During interview, the LVN stated the resident was on EBP status related to the open wound, but there was no evidence of a PPE cart with proper equipment and supplies or an EBP sign, and the LVN stated the sign was gone and the cart was moved. RNs who developed MDS assessments stated EBP status was not care planned and should have been, and the DON stated EBP status was supposed to be care planned because it provided a picture of the resident and how to take care of them.
Scissors Left in Rooms of Two Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards for two residents who had scissors in their rooms. Resident #58 had a diagnosis of unspecified dementia with severe cognitive impairment, a BIMS score of 6 out of 15, and required supervision or touching assistance with hygiene and dressing. Her care plan noted that she preferred to manicure her own nails with nail clippers but was not safe to keep them at bedside, with interventions to remind her to use the call bell and to check on her at routine intervals. Resident #71 had a diagnosis of unspecified protein-calorie malnutrition and severe cognitive impairment, with a BIMS score of 4 out of 15 and a need for supervision or touching assistance with hygiene and dressing. Her care plan addressed impaired cognitive function and included monitoring and documenting changes in cognition, decision making, memory, recall, awareness, expression, understanding, level of consciousness, and mental status. Despite these conditions and care plan concerns, scissors were observed in Resident #71's room on the bed and later on a chair next to the bedside. Scissors were also observed in Resident #58's room by the bedside and later on the dresser. During interviews, both residents stated they used the scissors to open items and had not been told by staff that they could not have them. CNA and LVN interviews confirmed that residents were not allowed to have scissors or other sharps in their rooms, that both residents were not care planned to have scissors, and that the DON stated sharps were not allowed in resident rooms unless care planned with a risk assessment. The facility policy reviewed addressed event reporting for variances but did not address hazards or residents having scissors.
Missed Fluticasone Doses Due to Medication Availability Issues
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met for one resident. Resident #75, a female with diagnoses including moderate persistent asthma, anxiety disorder, heart failure, kidney failure, and allergic rhinitis, had a physician order for Fluticasone Propionate Nasal Suspension 50 mcg/act, 1 spray in both nostrils two times a day, with no end date. Her MDS reflected moderate cognitive impairment for daily decision-making skills. Review of the February 2026 MAR showed multiple missed doses of the nasal spray, including several AM and PM administrations that were not given. During interviews, MA K stated the medication was not available and that she had marked "other" on the MAR because it was not in the medication cart. She reported notifying the ADON and the night shift LVN. The ADON stated she had not been aware the medication was not in stock, there were no designated staff assigned to order medications, and she was not aware of a process for auditing MAR discrepancies. MA I stated she had ordered the spray and believed it had been in the building but could not be found. The DON later stated the medication was found in a medication cart after the ADON was instructed to check all carts, and there was no procedure for checking regular medication deliveries and distribution except for controlled medications.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 6 medication carts reviewed. During an observation and interview on 2/19/26 at 7:23 a.m., the 100-hall medication cart was found left unlocked and unattended. MA I identified the cart as being assigned to RN C, who was not present at the cart at the time it was observed unsecured. During interview, RN C stated she was in a resident room assessing a resident who had fallen when the cart was left unlocked. RN C stated she should not have left the cart unlocked and unattended because other residents or visitors could gain access to medications that did not belong to them. The DON later stated that a medication cart should never be left unlocked and unattended because it created the potential for medication discrepancies and could allow access by someone who should not have access to the cart. Record review showed the facility’s Medication Storage in the Facility document stated that medications and biologicals are to be stored safely, securely, and properly, and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications.
Missed Ordered Digoxin Monitoring
Penalty
Summary
The facility failed to obtain ordered digoxin level laboratory tests for one resident with hypertensive heart disease, hypertension, hyperlipidemia, and atrial fibrillation. The resident’s orders included digoxin 125 mcg daily with digoxin levels every 3 months with routine labs, but the medical record did not contain digoxin level results after July 2025. The record was missing physician-ordered digoxin level results for October 2025 and January 2025, despite the standing order for routine monitoring. During interview, an LVN stated the last digoxin level drawn for the resident was in July 2025 and acknowledged that the October 2025 and January 2025 levels were not drawn per the physician’s orders. She stated that, when she had been the ADON, she was responsible for ensuring routine labs were carried out by obtaining the physician order and entering the lab order into the computer system so it would be sent electronically to the lab, but said the labs got missed and she was not sure what the current system was. The DON stated staff were instructed to obtain physician lab orders, complete a lab requisition form, and place it in a monthly lab binder, and the NP stated the facility had recently switched to a new lab and nobody knew how to use it, with staff not fully trained on the process for carrying out scheduled labs.
Failure to Include Ordered Diet Textures and Divided Plates in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans that included all ordered dietary interventions and adaptive equipment for two residents. For one resident with type II diabetes mellitus, major depressive disorder, hemiplegia and hemiparesis, moderate intellectual disability, and cerebral palsy, the comprehensive care plan dated 07/16/2025 identified a focus on potential risk for malnutrition with an RCS/LCS/NSOT diet, but did not include the ordered use of a divided plate. The resident’s active diet order, in place since 10/04/2024, specified an RCS/LCS/NSOT diet with regular texture and consistency, a divided plate, and only pink sugar, yet the divided plate was omitted from the care plan despite being part of his ongoing care. Surveyor observations on 02/06/2026 showed this resident consistently received meals on a plastic divided plate in both the assisted feeding dining room and his room. The resident exhibited involuntary muscle contractions and hand deformities related to cerebral palsy, and the speech therapist reported having evaluated him months earlier and recommending a divided plate due to his hand deformities and need for assistance. During an interview, the resident stated it was easier to eat with a divided plate. Despite these clinical needs and the standing physician order, the divided plate intervention was not reflected in the resident’s comprehensive care plan. For a second resident with Alzheimer’s disease, major depressive disorder, dementia, and anxiety, the quarterly MDS indicated he could usually understand and be understood, required setup and supervision for eating, and was on a therapeutic diet. His comprehensive care plan dated 07/11/2025 included a focus on ADL self-care performance deficit with supervision for eating as needed and noted that he was on a regular diet, but did not document his ordered mechanical soft texture diet or the need for a divided plate. Active orders dated 10/15/2025 specified a regular diet with mechanical soft texture, regular consistency, a divided plate, drinks in coffee cups, and double liquids. Observations confirmed he was receiving mechanical soft texture food, and his meal ticket reflected mechanical soft texture, yet these requirements were not incorporated into the care plan. The MDS nurse, DON, and interim administrator each acknowledged in interviews that the comprehensive person-centered care plan should accurately reflect the care and services the residents require.
Failure to Update Comprehensive Care Plan After MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to develop, review, and revise a comprehensive, person-centered care plan within seven days of the comprehensive assessment and after subsequent MDS assessments, as required. For one resident, the comprehensive care plan dated 03/20/25 listed an ADL self-care performance deficit and a regular diet with the option of a divided plate, but did not include that the resident required moderate assistance with eating or that she was on a mechanically altered diet with specific nutritional interventions. The facility’s own policy stated that the resident’s care plan would be reviewed after each admission, quarterly, annual, and/or significant change MDS assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. The resident involved was an older female with multiple diagnoses, including fractures of the left femur and right radius, vascular dementia, Down syndrome, and bradycardia. Her quarterly MDS assessment showed she was sometimes understood, usually understood others, had a BIMS score of 0/15 indicating severely impaired cognition, required moderate assistance with eating, and was on a mechanically altered diet. Active orders reflected a regular diet with mechanical soft texture, magic cup with lunch, pureed meat with gravy, and the option for a divided plate. Observations confirmed she was receiving a mechanical soft diet and assistance with eating at meals, and had a magic cup at lunch, but these needs and interventions were not reflected in the comprehensive care plan. During interviews, the MDS RN acknowledged not knowing why these needs and orders were missing from the care plan and stated it should have been reviewed and revised after the last comprehensive assessment, while the DON and interim administrator affirmed that the care plan needed to accurately reflect the care required and be reviewed and revised by the team after MDS assessments.
Failure to Knock Before Entering Resident Room Violates Dignity and Privacy
Penalty
Summary
Staff failed to treat a resident with respect and dignity by not knocking before entering her room on multiple occasions. Observations showed that both the MDS nurse and a speech therapist entered the resident's room without knocking, despite the resident being present and her call light being on. Interviews with the staff involved confirmed that they were trained on resident rights and facility policy, which requires staff to knock and announce themselves before entering any resident's room. Both staff members acknowledged that not knocking was disrespectful and intrusive, and that all residents should receive the same respect. The resident, who has a history of muscle weakness, difficulty walking, cognitive communication deficit, insomnia, major depressive disorder, and hypertensive emergency, reported that staff frequently entered her room without knocking, which upset her and made her feel her privacy was invaded. Facility leadership, including the DON and administrator, confirmed that the policy requires staff to knock and that monitoring is done through observations and rounds. The facility's resident rights policy emphasizes respect for personal privacy and dignity, but the failure of staff to follow this policy led to the deficiency.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for residents in their rooms, specifically for two residents with significant medical and cognitive needs. Observations revealed that one resident's call light was found on the floor under the bed while the resident was lying in bed, and another resident's call light was on a bedside table, out of reach, while the resident was also in bed. Both residents had care plans that required the call light to be within easy reach and for staff to remind or encourage them to use it for assistance as needed. Record reviews indicated that both residents had multiple diagnoses, including dementia, heart failure, and a history of falls, and required partial to moderate assistance with transfers and daily activities. Their care plans specifically included interventions for fall prevention and safety, such as ensuring the call light was within reach and checking on the residents at routine intervals. Despite these documented needs and interventions, staff failed to maintain the call lights within reach, as observed during the survey. Interviews with staff, including CNAs, LVNs, the DON, and the ADM, revealed inconsistent understanding and implementation of call light placement policies. While staff stated that the expectation was for call lights to always be within reach and that all staff were responsible for ensuring this, there was no formal written policy in place. Staff also acknowledged that failure to keep call lights within reach could result in residents being unable to call for help, but could not explain why the deficiency occurred for the two residents in question.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Prevent Accidents and Update Care Plans Following Resident Incidents
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with severe cognitive impairment. In the first case, a resident with end-stage renal disease, syncope, vascular dementia, and bradycardia, who was dependent for transfers and had a history of falls, was transported to dialysis in the facility van. Despite prior incidents where the resident had unbuckled her seatbelt or attempted to stand during transport, these behaviors were not documented in her care plan, and no interventions were implemented to address them. Staff, including the van driver and activity director, were aware of these behaviors but did not consistently report them to nursing or administration, and no team meeting was held to discuss or address the risk. As a result, the resident unbuckled her seatbelt during transport, fell from her wheelchair, and sustained a laceration to her forehead, requiring emergency medical attention. In the second case, another resident with severe vascular dementia and schizoaffective disorder, who required substantial assistance for transfers, experienced an unwitnessed fall from her low bed, resulting in a right knee patella fracture and a skin tear. Although interventions such as a floor mat and low bed were in place, the resident was able to manipulate the bed controller, raising the bed and increasing her risk of falling. Staff interviews revealed that the resident had a history of moving the bed out of the lowest position by pressing buttons on the controller, but this risk was not addressed in her care plan. After the fall, the care plan was not updated to include new interventions or to reflect the changes in the resident's condition, despite facility policy requiring immediate care plan revision after such incidents. In both cases, the facility did not identify or address known hazards and risks in the residents' environments, failed to update care plans with necessary interventions, and did not ensure that staff communicated and documented unsafe behaviors or incidents. These failures resulted in preventable accidents and injuries, and the lack of care plan updates meant that staff may not have been aware of the residents' specific risks or the interventions needed to prevent further incidents.
Failure to Accurately Code Major Injury on Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their clinical status, specifically regarding a fall with major injury. A male resident with a history of hemiplegia, hemiparesis, epilepsy, and reduced mobility experienced an unwitnessed fall in his room, resulting in a left leg fracture. Nursing notes documented the fall and subsequent injury, including swelling and the application of a brace. However, the resident's subsequent Quarterly MDS assessment did not indicate that a major injury had occurred, instead documenting that there had been no major injury since admission or the prior assessment, despite the definition of major injury including bone fractures. Interviews with facility staff revealed that the process for tracking and documenting falls relied heavily on the electronic medical record (EMR) system, which only flagged incidents that were marked as closed. The MDS Coordinator stated that if a fall incident was not closed in the EMR, it would not be included in the information used to complete the MDS assessment. In this case, the fall incident remained open for nearly two months, and as a result, the MDS assessment did not reflect the major injury. The absence of a Director of Nursing (DON) during this period contributed to lapses in oversight, as responsibilities were distributed among Assistant DONs and other staff. Further, the facility's administrative and clinical leadership described a process in which daily meetings were held to discuss incidents and update care plans, but there was no manual tracking system for falls, and the MDS Coordinators depended on the EMR's automated prompts. The compliance nurse and MDS Consultant were involved in reviewing documentation, but it was unclear if every assessment was checked for accuracy. Facility policy required that each assessment be conducted with appropriate participation from health professionals and that each individual certify the accuracy of their portion, but this process was not followed in this instance, resulting in an inaccurate assessment.
Failure to Transport Resident to Oncology Appointment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not transport a resident to a scheduled appointment with an oncologist. This failure was identified for a resident who had a diagnosis of secondary malignant neoplasm, squamous cell carcinoma, unilateral paralysis of vocal cords, and localized enlarged lymph nodes. The resident was cognitively intact and required substantial assistance with mobility. The deficiency occurred when the resident missed an oncology appointment due to the facility not scheduling transportation. The resident's care plan included the need to anticipate and meet his needs, which was not adhered to in this instance. The resident's representative and the resident himself reported that the facility had previously canceled appointments due to transportation issues, indicating a pattern of neglect in ensuring the resident attended necessary medical appointments. Interviews with facility staff revealed a lack of clarity and communication regarding the scheduling of appointments and transportation. The transportation nurse and LPN involved were unaware of the missed appointment, and there was confusion about the appointment's presence on the transportation calendar. The facility's administration acknowledged the absence of a formal procedure to ensure appointments were correctly documented and communicated, leading to the resident missing a critical oncology appointment.
Privacy Breach Due to Unlocked Computer Screen and Incomplete Curtain Closure
Penalty
Summary
The facility failed to ensure personal privacy for two residents, leading to a deficiency in maintaining confidentiality and dignity. For the first resident, a medication aide did not lock the computer screen after stepping away, potentially exposing the resident's personal medical information. This incident occurred in the dining room, where the aide admitted to not locking the screen, acknowledging that the resident's information might have been exposed. The resident had an intact cognition with a BIMS score of 15, indicating awareness of their surroundings. For the second resident, two LVNs were unable to fully close the privacy curtains while providing wound care, leaving a two-foot gap that exposed the resident's buttocks. The resident had severe cognitive impairment with a BIMS score of 3 and required assistance with toileting hygiene. The LVNs confirmed the curtain could not be closed due to a jam, and the housekeeping supervisor acknowledged issues with curtain maintenance, such as missing hooks and worn-out wheel bearings, which had not been addressed due to a lack of communication with the maintenance department.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Key deficiencies included the absence of foot-operated waste baskets near the hand-washing station, which is essential for maintaining hygiene standards. Additionally, a tray of glasses filled with tea was left uncovered, exposing the beverages to potential contamination. Dietary Aide H was observed wearing a hairnet that did not fully cover her hair, which could lead to hair contaminating food or food preparation areas. Further observations revealed unsanitary conditions in the pantry, including individual packets of salt and artificial sweetener scattered on the floor, an oily liquid substance under a container of fry oil, and spilled flour under a container of flour. Dusty debris was also noted on the lower shelf of the food preparation counter. These conditions violate the Food Code standards, which require food to be stored in a clean, dry location and protected from contamination, and nonfood-contact surfaces to be cleaned regularly to prevent soil residue accumulation.
Environmental Deficiencies in Hallways A and E
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in two of the seven hallways reviewed. On Hallway A, several issues were observed, including wood cracks on the interior bathroom door in one room, a dislodged phone jack and a black scrape mark on the wall in another room, and wall penetrations in a third room. Additionally, water marks were found on ceiling tiles, and some tiles were missing at the end of Hallway A. On Hallway E, similar deficiencies were noted, such as paint scraped off the bathroom door in one room, a dislodged ceiling tile, and a continuously running toilet in another room. Furthermore, a section of floor molding was dislodged from the wall across from the TV viewing area. These observations were confirmed during an interview with the Assistant Maintenance Director and the Administrator, who acknowledged awareness of some of the needed repairs.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents to maintain their independence and safety. The deficiency was identified during an observation in the resident's room, where the call light was found on the nightstand, out of the resident's reach. This oversight was confirmed by the nursing assistant assigned to the resident, who admitted to placing the call light on the nightstand earlier in the morning and forgetting to return it to an accessible position. The resident involved in this deficiency is an elderly female with Alzheimer's disease, insomnia, and a history of seizures, conditions that increase her risk of falls and necessitate the availability of a call light for assistance. The resident's care plan specifically included an intervention to ensure the call light was within reach due to her fall risk. Despite this, the facility did not have a formal policy addressing call light accessibility, although the RCN acknowledged its importance and stated that charge nurses monitor this task during their rounds.
Foul Odor in Resident's Room Due to Drain Issues
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, as evidenced by a foul odor emanating from the restroom of the resident's room. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, Hyperlipidemia, and Anemia, had a BIMS score indicating moderate cognitive impairment. The resident reported that the odor had been present for a few days and was bothersome. Observations confirmed the presence of the odor, although the restroom appeared clean with no apparent source of the odor. Interviews with facility staff, including a nursing assistant and the administrator, confirmed the presence of the odor and suggested that issues with the drains might be the cause. The Housekeeping Supervisor acknowledged that similar issues had occurred in the past and were resolved by treating the drains. The facility's policy on resident rights emphasizes the provision of housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment, which was not upheld in this instance.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The baseline care plan for the resident did not include critical information such as allergies to specific medications (Atorvastatin, Flomax, and Tramadol) and the physician-prescribed diet. This omission was confirmed during an interview with RN/MDS B, who acknowledged that the baseline care plan should have included these details. The responsibility for developing baseline care plans was attributed to the Director of Nursing (DON), who had recently resigned, and the oversight was not caught by the admitting nurse or the Assistant Directors of Nursing (ADONs). The resident in question was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Hyperlipidemia, and Chronic Kidney Disease. The resident's clinical record indicated a regular diet with regular texture and consistency was ordered by the physician. The facility's policy on baseline care plans emphasizes the importance of completing and implementing these plans within 48 hours to ensure continuity of care, communication among staff, and resident safety. However, the failure to include essential healthcare information in the baseline care plan could result in improper care for the resident.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to review and revise the care plan for a resident after each assessment, specifically following falls that resulted in injuries. The resident, an elderly woman with severe cognitive impairment and multiple health issues including encephalopathy and orthostatic hypotension, experienced several falls since her admission. Despite these incidents, the care plan was not updated to reflect new interventions after falls on specific dates, including one that resulted in a head injury requiring medical attention. The resident's care plan, last reviewed in late November, did not include any updates or new interventions following her falls in September and December. The care plan had a focus area for fall risk, but the interventions listed were not revised after the resident's significant falls. Interviews with facility staff revealed that while falls were discussed in management meetings, the responsibility for updating the care plan was not clearly executed, particularly after the resignation of the Director of Nursing. The facility's policy required care plans to be reviewed and revised after significant changes, but this was not adhered to in the case of the resident. The lack of updates to the care plan meant that staff did not have access to the most current information needed to prevent future falls, as confirmed by interviews with the facility's nursing staff. The deficiency highlights a failure in the facility's process for ensuring care plans are kept current and reflective of residents' needs following significant events like falls.
Unsecured Cleaning Disinfectant in Shower Room
Penalty
Summary
The facility failed to maintain a hazard-free environment in the Hallway A shower room, as observed during a survey. On December 3rd, two unsecured 32-ounce bottles of K-Quat cleaning disinfectant were found in the unlocked shower room, one placed on a standing tile ledge and another inside an unlocked standing shower cabinet. During interviews, both the AIT and LVN acknowledged that the unsecured disinfectant bottles posed a risk hazard to residents who might enter the shower room and potentially consume the cleaning product. The Housekeeping Supervisor confirmed that the disinfectant should have been secured in a locked cabinet after use and acknowledged the risk of resident access to the product. The facility's admission packet, revised in April 2022, states that residents have the right to live in a safe, decent, and clean environment.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for a resident who required oxygen therapy, as observed during a survey. The resident, a male with dementia and chronic obstructive pulmonary disease, had an order for oxygen at 2-3 liters via nasal cannula at night and as needed for shortness of breath. Observations revealed that the resident's oxygen tubing and nasal cannula were not stored properly; they were coiled loosely on top of the oxygen concentrator, and the oxygen/nebulizer mask was found lying on the floor behind the concentrator. Interviews with the resident and staff confirmed the improper storage of the oxygen equipment. The resident mentioned that he used oxygen at night and sometimes received nebulizer treatments, with tubing changes occurring weekly. A Licensed Vocational Nurse (LVN) and the Resident Care Nurse (RCN) both acknowledged that the oxygen tubing and mask should be stored in a plastic bag to prevent contamination and damage. However, the facility's policy on oxygen administration did not address the proper storage of oxygen equipment, contributing to the deficiency.
Improper Storage of Latanoprost in Medication Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls in the Annex Medication Room. During an observation, a bottle of Latanoprost 0.0005% solution for a resident was found stored at room temperature on the medication room counter, despite the label indicating it should be refrigerated until opened. The Licensed Vocational Nurse (LVN) present confirmed that the medication was not stored in the refrigerator as required, which could affect its therapeutic effectiveness. Interviews with the LVN and the Registered Charge Nurse (RCN) confirmed that the Latanoprost should have been refrigerated until opened and that maintaining recommended storage temperatures is crucial to ensure medication effectiveness. The facility's policy on medication storage, revised in 2012, also specifies that Latanoprost should be refrigerated until initial use. The Director of Nursing (DON), who was responsible for the maintenance of the medication room, had recently resigned, leaving uncertainty about who would now oversee medication storage.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in an elopement incident involving a resident. The resident, a male with unspecified dementia, peripheral vascular disease, and bipolar disorder, was cognitively impaired with a BIMS score of 8 and had a moderate risk of wandering behavior. Despite these known risks, the resident managed to leave the facility unnoticed on the morning of June 21, 2024. The resident's care plan, which had been initiated in August 2022, identified a risk of wandering behavior, but the interventions in place were insufficient to prevent the elopement. On the day of the incident, the facility's van driver began searching for the resident at 8:15 a.m., and a Code Orange for elopement was called at 8:30 a.m. The resident was found at a convenience store several blocks away at 8:50 a.m. by facility staff and local law enforcement. The elopement was unwitnessed, and the resident had crossed a street to reach the location. The facility's incident report noted that the resident exited through one of the facility's entrance doors, but the door alarms were found to be in working order during subsequent observations. Interviews with the facility's staff, including the Administrator and Assistant Maintenance Director, confirmed that regular inspections of exit doors were conducted, but the elopement still occurred. The facility's policy on elopement prevention and response was in place, but it failed to prevent this incident, placing the resident in immediate jeopardy.
Failure to Accommodate Resident's Food Allergies
Penalty
Summary
The facility failed to ensure that food provided to a resident accommodated their known allergies, leading to a serious allergic reaction. On September 4, 2024, a resident with a documented allergy to eggs was served meatloaf containing egg, which resulted in the resident experiencing an allergic reaction. The resident, who had a history of anaphylaxis, self-administered an epi-pen and was subsequently transferred to the hospital for further evaluation. The resident's medical records clearly indicated an allergy to eggs, and the care plan had documented this allergy. Despite this, the dietary staff did not adhere to the resident's dietary restrictions. The cook admitted to not following the recipe and using egg in the meatloaf, which was confirmed during interviews with staff. This oversight placed the resident in immediate jeopardy, as they had to use emergency medication and seek hospital care. The incident highlights a breakdown in communication and adherence to dietary protocols within the facility. The dietary staff failed to verify the ingredients used in the meal, despite being questioned about the presence of egg. This lapse in procedure and communication led to the resident consuming a meal that triggered a severe allergic reaction, necessitating emergency intervention and hospitalization.
Inadequate Staffing Leads to Delayed Care and Resident Complaints
Penalty
Summary
The facility failed to maintain sufficient nursing staff with the appropriate competencies and skills to ensure resident safety and well-being. This deficiency was observed on multiple occasions, specifically during the night shifts from 6:00 PM to 6:00 AM on several dates. The number of Certified Nursing Assistants (CNAs) scheduled was inadequate compared to the resident census, leading to insufficient care for the residents. For instance, on certain nights, there were only one or two CNAs available for over 100 residents, which is far below the required staffing levels to meet the needs of the residents. The lack of adequate staffing resulted in numerous grievances from residents and their families. Complaints included delayed response times to call lights, with some residents waiting up to an hour or more for assistance. Additionally, meal services were delayed, with food often being served cold due to the lack of staff to deliver trays promptly. These issues were consistently reported in resident grievances, resident council meetings, and direct observations by surveyors. Interviews with staff and residents further highlighted the impact of staffing shortages. Staff members reported being overworked, with some working extended hours to cover shifts. This led to delays in medication administration and incomplete documentation. Residents expressed concerns about the safety and quality of care, noting that the limited number of staff made it difficult to receive timely assistance, particularly during emergencies. The facility's assessment did not adequately address staffing needs, contributing to the ongoing issues with insufficient care.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 16% due to 5 errors out of 30 opportunities. This involved two residents, Resident #17 and Resident #18, who did not receive their medications as scheduled. LVN F administered Trazadone and Nortriptyline to Resident #17 nearly two hours late and failed to administer Melatonin entirely. For Resident #18, Donepezil and Trazadone were administered three and two hours late, respectively. Resident #17, diagnosed with Dementia, Schizoaffective Disorder, Major Depressive Disorder, and Insomnia, was supposed to receive Melatonin, Nortriptyline, and Trazadone at specific times. However, the medications were administered late, and Melatonin was not given at all due to the unavailability of the correct dosage form. LVN F acknowledged the lateness and the omission, citing a busy shift and the absence of the medication cart as reasons for the delay. Resident #18, with diagnoses including Dementia, Schizoaffective Disorder, Major Depressive Disorder, and Bipolar Disorder, experienced similar issues with medication timing. The medications Donepezil and Trazadone were administered late, and LVN F attributed the delay to a busy shift and the need to prioritize other resident care tasks. The facility's policy requires medications to be administered within one hour of the scheduled time, which was not adhered to in these instances.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. This deficiency was observed in three medication carts, where medications were left unattended and accessible to unauthorized individuals. Specifically, a medication cart by the nurses' station was found unlocked with a medication cup containing pills on top of it, and no staff or residents were present in the area. LVN F admitted to preparing medications in advance and acknowledged that the cart should not have been left unlocked and unattended. Additionally, LVN F left another medication cart unlocked while attending to a resident in a room, with another resident standing next to the cart, potentially allowing access to the medications. Similar observations were made with medication carts on the 300 hall, where they were found unlocked and unattended, with residents nearby. The facility's policy clearly states that medication carts must be locked when not in use, and medications should not be removed from their packaging until administration. The DON confirmed that these expectations had been communicated to the nursing staff multiple times.
Failure to Provide Prescribed Nutritional Support to Residents
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of three residents. Resident #7, who had diagnoses including dementia, iron deficiency anemia, and weight loss, did not receive a prescribed health shake or a red glass during a meal observation. The resident's dietary plan included a mechanical soft diet and a health shake with meals due to weight loss, but these were not provided during the observed meal. Resident #11, with severe cognitive impairment and dysphagia, was on a pureed diet. During an observation, the resident was served a portion of pureed spaghetti and meatballs that was not in accordance with the facility's recipe, which specified a #6 scoop. Instead, a smaller #16 scoop was used, resulting in an inadequate portion size. The staff member responsible for serving the meal was unable to confirm the correct scoop size and admitted to using a smaller scoop for purees. Resident #15, who had severe cognitive impairment and a stage 4 pressure ulcer, was on a mechanical soft diet with a house shake prescribed for supper. During an observation, the resident did not receive the house shake with their dinner. The facility's policy on the red glass and fortified food program, which aims to alert staff to residents needing additional monitoring, was not followed, as evidenced by the absence of the red glass on the meal trays of the affected residents.
Deficient Documentation of Wound Care for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, specifically regarding the documentation of wound care treatments as ordered by physicians. Resident #5, who was admitted with severe cognitive impairment and a Stage 4 pressure ulcer, did not have documented wound care on several specified dates in April. Similarly, Resident #15, also with severe cognitive impairment and a Stage 4 pressure ulcer, had missing documentation for wound care on specified dates in March and April. Interviews with facility staff, including the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN), revealed lapses in the auditing process for wound care records. The DON and LVN were responsible for ensuring wound care was completed, but both were unaware of the missed treatments. The LVN admitted to not consistently auditing the Wound Care Administration Records when working on the floor and was unsure if she worked on the days when treatments were missed. The DON stated that the LVN reported no missed treatments during morning meetings, despite the blanks in the records indicating otherwise. The facility's policies on infection control and hand hygiene were reviewed, emphasizing the importance of proper hygienic practices in preventing infection spread. However, the report does not indicate any corrective actions or follow-up measures taken by the facility to address the deficiencies in record-keeping and wound care documentation.
Resident Dignity Compromised During Wound Care
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during wound care. Specifically, during an observation of wound care for a resident with severe cognitive impairment and multiple diagnoses, including dementia and hemiplegia, a Licensed Vocational Nurse (LVN) left the resident exposed while retrieving a trash can. This action occurred after the LVN had removed the resident's dressing, leaving the resident's buttocks and sacral wound exposed. Interviews conducted with facility staff, including another LVN and the Director of Nursing (DON), confirmed that the resident should not have been left exposed during wound care. The facility's policy on resident rights, which emphasizes the importance of treating residents with respect and dignity and ensuring personal privacy during medical treatment, was not adhered to in this instance.
Failure to Provide Accessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident #5 and Resident #15, were able to press the call light when assistance was needed, which is a violation of their right to reasonable accommodation of needs. Resident #5 was admitted with multiple diagnoses, including dementia, hemiplegia, and severe cognitive impairment, and was dependent on others for all self-care and mobility. Despite the care plan indicating the need for a reachable call light, observations and interviews revealed that Resident #5 was unable to press the call light due to physical limitations, and staff were aware of this issue but did not provide an alternative solution. Similarly, Resident #15, who was readmitted with conditions such as Alzheimer's disease, dementia, and functional quadriplegia, also faced challenges in using the call light due to severe cognitive impairment and physical limitations. The care plan for Resident #15 also emphasized the importance of having a reachable call light, yet observations showed that the resident was unable to use it. Interviews with staff confirmed that Resident #15 was unable to press the call light, and there was no evidence of alternative accommodations being provided. The facility's policy on resident rights emphasizes the need for reasonable accommodation of resident needs, yet the failure to provide accessible call lights for these residents indicates a deficiency in adhering to this policy. Interviews with staff, including the Director of Nursing, revealed a lack of evaluation and provision of suitable call light alternatives for these residents, despite their known limitations. This oversight could potentially place residents at risk of not receiving timely care or attention when needed.
Failure to Update Resident Care Plan for Edema
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident within seven days of the comprehensive assessment and did not revise the care plan after each assessment. Specifically, the care plan for a resident was not updated to reflect the presence of edema in the left hand and the need for elevation, despite these conditions being documented in the resident's progress notes and order summary report. This oversight could potentially place residents at risk of having their current needs unmet. The resident in question had a complex medical history, including Alzheimer's Disease, Dementia, Type 2 diabetes, COPD, Cognitive Communication Deficit, Dysphagia, Functional Quadriplegia, a Stage 4 pressure ulcer, Depression, and Anxiety. The resident was severely cognitively impaired, with a BIMS score of 5, and was dependent on others for all self-care and mobility. Despite these significant health challenges, the care plan was not updated to address the edema and the prescribed intervention of elevating the left arm. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for updating care plans. The LVN and RN responsible for care plans stated that updates should occur during morning meetings when changes in resident conditions are discussed. However, the edema and elevation requirement for the resident's left arm were not communicated effectively, leading to the care plan not being updated. The Director of Nursing expected care plans to be updated on the day changes occurred, but this expectation was not met in this instance.
Failure to Update Resident Care Plan for Weight Loss and Diet
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by an interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. This deficiency was identified for a resident who had multiple diagnoses, including dementia, malnutrition, dysphagia, cognitive communication deficit, depression, and GERD. The resident experienced significant weight loss over several months, which was not adequately addressed in the care plan. The resident's care plan, last revised several months prior, did not reflect the prescribed diet and interventions for weight loss, despite the resident being on a mechanically altered and therapeutic diet. The care plan aimed for the resident to maintain stable weight and adequate nutrition, but it did not include the specific dietary orders and supplements that were being provided, such as a mechanically soft diet, nectar thick liquids, pureed meats, and nutritional supplements like ReadyCare 2.0 and Magic Cup. The facility's records showed a consistent trend of weight loss, yet the care plan was not updated to reflect these changes. Interviews with facility staff, including LVN A, RN A, and the DON, revealed that care plans were supposed to be updated with any changes in the resident's condition or orders. However, there was a lack of clarity and consistency in the process, as the care plan for the resident in question was not updated to include the current diet and weight loss interventions. The facility's policy required that care plans be revised based on changing needs, but this was not adhered to in this case.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for Resident #15, who was readmitted with multiple diagnoses including Alzheimer's Disease, Dementia, Type 2 diabetes, and a Stage 4 pressure ulcer. The resident's care plan indicated the need for pain management, especially during wound care procedures. However, observations revealed that the nursing staff did not assess or manage the resident's pain effectively during wound care sessions. Despite the resident's verbal expressions of pain, the staff continued the procedures without conducting pain assessments or administering pain relief. The resident's medical records showed a history of opioid use for pain management, but the medication was discontinued due to non-use. At the time of the observations, the resident did not have an active order for pain medication, except for a PRN order for Tylenol, which was not consistently administered prior to wound care. Interviews with the nursing staff, including LVN C and RN B, confirmed the lack of pain assessment and management during wound care, and the Director of Nursing was unsure if pain management assessments were conducted for the resident. The facility's policies on dressing changes and pain management emphasized the need for pre-medication and pain assessment, but these were not followed. The failure to adhere to these policies resulted in the resident experiencing unnecessary pain during wound care procedures, highlighting a deficiency in the facility's pain management practices for residents with severe cognitive impairments and significant medical needs.
Failure to Provide Mechanically Altered Diet
Penalty
Summary
The facility failed to provide meals prepared in a form designed to meet the individual needs of a resident, specifically Resident #6, who was prescribed a mechanical ground meat diet. Despite the dietary order change being communicated to the dietary department, Resident #6 was served a whole piece of chicken fried steak that was not cut up or ground, contrary to the prescribed diet. This oversight was observed during a meal service, where the resident expressed difficulty in eating the meat due to having no teeth. Resident #6 had a complex medical history, including diagnoses of hypokalemia, malnutrition, muscle wasting, dysphagia, and cognitive communication deficit, which necessitated a mechanically altered diet. The facility's policy required food to be prepared to meet individual needs, yet the dietary staff were unaware of the resident's specific dietary requirements. Interviews with staff revealed a lack of awareness and communication regarding the resident's dietary order, leading to the deficiency in meal preparation.
Failure to Accommodate Resident's Food Allergy
Penalty
Summary
The facility failed to provide food that accommodated the allergies of a resident, specifically Resident #16, who was allergic to onions. Despite the resident's care plan and order summary clearly indicating an allergy to onions, the resident was served a meal containing chicken salad with onions. This oversight occurred during a dinner service, where the resident was unable to consume the meal due to the presence of onions, which she identified as an allergen that causes her to break out in hives. The deficiency was further highlighted by the fact that the staff member responsible for preparing the meal was not informed of the resident's allergy. During an interview, the staff member admitted to using onions in the chicken salad and was unaware of any resident having an onion allergy. The facility's policy on food preparation, which emphasizes serving food in a form that meets individual resident needs, was not adhered to in this instance, leading to the resident not receiving an appropriate alternative meal.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN C and RN B during wound care procedures for two residents. For Resident #5, LVN C did not adhere to proper hand hygiene protocols. After gathering treatment supplies, LVN C left the treatment cart to retrieve a laptop and upon returning, did not wash or sanitize hands before preparing the tray and supplies. LVN C then donned gloves without washing or sanitizing hands, which is a breach of infection control practices. Similarly, for Resident #15, RN B did not follow proper hand hygiene protocols during wound care. RN B washed her hands for only 5 seconds before donning gloves, despite knowing the recommended duration is 20-30 seconds. After applying a silicone dressing, RN B changed gloves without washing or sanitizing her hands. This failure to maintain hand hygiene could contribute to the risk of infection and delayed wound healing for the residents. Both residents had severe cognitive impairments and were admitted with unhealed Stage 4 pressure ulcers. The facility's policies on infection control and hand hygiene were not followed, as evidenced by the observations and interviews conducted. The Director of Nursing expected nurses to provide wound care according to physician orders and maintain infection control, but the practices observed did not align with these expectations.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post the current nurse staffing information at the designated entrances on two consecutive days, 4/19/24 and 4/20/24. Observations revealed that the required staffing information was not available at entrance #1 and entrance #2 on both days. During an interview, the Director of Nursing (DON) acknowledged that the staffing pattern was not posted and stated that it was supposed to be displayed on the entrance #1 bulletin board. The Assistant Director of Nursing (ADON B), who was responsible for posting the staffing patterns, admitted that she was off duty and did not know who was responsible for the postings in her absence. Additionally, the DON mentioned that the facility did not have a staffing policy in place.
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 44 citations issued within 25 miles in the last 12 months — including the 2 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 Victoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Courtyard Rehabilitation And Healthcare Center | 1.6 mi | ★★★★★ | 14 | 2 |
| Riverside Oaks | 1.7 mi | ★★★★★ | 19 | 0 |
| Twin Pines North Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 4 | 0 |
| Southbrooke Manor Nursing And Rehabilitation Cente | 20.1 mi | ★★★★★ | 2 | 0 |
| Cuero Nursing And Rehabilitation Center | 24.2 mi | ★★★★★ | 5 | 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.