Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Veranda Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with severe dementia and high dependence for transfers reported rib pain after being assisted with a shower, later describing that staff lifted her by her arms while she was standing. Family reported the new right-sided pain to nursing, and an NP ordered rib x‑rays, which showed rib fracture deformities and possible pneumonia. An RN received the x‑ray report but focused on the pneumonia findings and missed the documented fractures, and did not report the injury of unknown origin to facility management as required. The DON and Administrator later acknowledged that the incident, which involved a possible neglect situation, was not reported to the state agency within the required timeframe, contrary to the facility’s abuse-prevention policy requiring immediate internal reporting and timely external reporting of all allegations and injuries of unknown source.
A resident with severe dementia, osteoporosis, and dependence on staff for transfers and bathing developed rib pain after a shower, later reporting that staff had lifted her under the arms while she was standing. CNAs reported using a two-person transfer to a shower chair and denied that the resident stood or complained of pain. Over the next days, the resident continued to report right-sided pain, leading an NP to order rib x‑rays, which showed rib fractures along with possible pneumonia; however, the initial nursing and NP review focused on the pneumonia and missed the fracture findings, delaying recognition of an injury of unknown origin. The DON later identified the fractures, sought multiple clarifications from the mobile x‑ray provider due to inconsistent rib descriptions, and then notified the NP, who arranged hospital evaluation, where CT imaging confirmed subacute and chronic bilateral rib fracture deformities. Despite facility policy requiring immediate reporting of all allegations and injuries of unknown origin to the Administrator and State agencies, the DON and Administrator acknowledged that the fracture findings and associated injury of unknown origin were not reported to the State within the required 2‑hour timeframe while the facility attempted to verify the x‑ray results.
A resident with dementia, severe cognitive impairment, and dependence for transfers and bathing was care planned for two-person assist with transfers and one-person assist for showers. After being showered, the resident later reported being stood up and lifted under the arms, experiencing rib pain that was subsequently reported by the family. An NP later ordered rib x‑rays for right-sided pain; the x‑ray showed acute mildly displaced right rib fractures and pneumonia, but an RN focused only on the pneumonia findings and missed the fractures. The DON later identified the fracture findings amid conflicting rib descriptions from multiple x‑ray readings, acknowledging that nurses were expected to read and act on x‑ray reports. This resulted in a delay in recognizing and addressing the rib fractures, contrary to professional standards, the care plan, and the resident’s expressed pain.
A resident with osteomyelitis, cellulitis, a stage 4 sacral pressure ulcer, paraplegia, and a PICC line was observed receiving IV vancomycin from a bag that lacked a proper label, showing only a date and RN initials. The bag did not include the resident’s name, medication dose, frequency, or route, despite an active order for vancomycin 1 g IV every 8 hours. The RN reported he had just hung the bag, discarded the original label, and knew the bag should have been labeled with full medication information. The DON confirmed the expectation that nurses ensure IV medication containers are correctly labeled and consistent with facility policy requiring verification of the container’s label against the prescriber’s order.
A resident with Alzheimer's disease, anxiety, and a mood disorder had a bedtime alprazolam order. On one evening, an LVN documented on the MAR that the alprazolam dose was administered, but the controlled drug record and narcotic count showed it was not given because the resident was asleep. The LVN reported she signed the MAR before checking the resident, did not remove the medication from packaging, and recorded on the controlled drug record that no dose was provided, but failed to correct the MAR entry. The DON confirmed the discrepancy and that facility policy requires documenting on the electronic MAR at the time medications are actually administered.
A medication cart was found unlocked and unattended in front of the nurse's station, with an RN responsible for the cart present nearby but not securing it. The RN stated he had unlocked the cart for an auditor and was unaware it remained unlocked. The DON confirmed that staff are expected to lock medication carts when unattended, in accordance with facility policy.
The facility did not maintain an effective pest control program, as roaches were observed coming out of a floor drain in the kitchen following nearby construction. Staff reported the issue to management, and records showed regular fumigation, but the pest problem persisted despite these efforts.
Two residents did not have comprehensive, person-centered care plans that addressed their identified needs. One resident with severe cognitive impairment and physical limitations was not care planned for required feeding assistance, and the care plan incorrectly listed a feeding tube. Another resident with nicotine dependence and COPD was not care planned for smoking, despite being on the facility's smoking list and self-reporting as a smoker. Staff interviews revealed confusion and lack of communication regarding both residents' care needs.
A resident receiving IV therapy for cellulitis was found to have a peripheral IV dressing on her right hand that was not labeled with the date and initials, as required by facility policy and professional standards. While the left wrist IV dressing was properly labeled, the right hand dressing was not, and staff interviews confirmed the omission. Facility policies and competency checklists require all IV dressings to be labeled to ensure proper monitoring and timely changes.
A resident with multiple chronic conditions and intact cognition experienced misappropriation of funds when a former ABOM accessed the resident's bank account and withdrew money without consent on multiple occasions. The unauthorized transactions went undetected by the facility until the resident noticed missing funds and reported the issue, leading to a police investigation and the staff member's admission of theft.
Two residents with behavioral health needs did not receive ordered psychiatric evaluations and treatment after incidents involving aggression and psychosocial concerns. Despite physician orders and care plan interventions, there was no documentation of psychiatric consultations or follow-up, as the responsible social worker failed to carry out the referrals.
A resident with dementia and recent cataract surgery did not receive prescribed prednisolone eye drops to the left eye at the ordered frequency, due to discrepancies between the physician's prescription and the facility's medication orders. Nursing staff and the DON reported confusion over the correct dosage and frequency, and the resident was described as resistant to providing post-visit orders, leading to the medication being administered incorrectly.
A facility failed to maintain accurate and complete medical records for a resident's DNR status. Despite the resident's clear communication and documentation of her DNR wishes, the required OOH-DNR form was missing from her medical record. Staff interviews revealed confusion and lack of responsibility in handling DNR forms, leading to the oversight.
The facility failed to maintain an infection prevention and control program, leading to deficiencies such as improper disinfection of equipment, failure to wear appropriate PPE, and incorrect PICC line dressing changes. These actions could lead to cross-contamination and infections.
A female resident with dementia and mobility issues, identified as high risk for elopement, exited the facility unnoticed and was found near a highway. The investigation revealed that she exited through a door in hall 300, despite staff attempts to redirect her. The Environmental Manager noted that the door alarm was not very loud, and landscapers working nearby might have inadvertently allowed her to leave.
The facility failed to ensure a resident had access to a call light within reach, despite the resident's need for assistance due to hemiplegia and hemiparesis. Staff interviews confirmed the importance of accessible call lights, and the facility's policy was not followed, leading to the deficiency.
Failure to Implement Abuse and Neglect Reporting Policies for Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to implement its written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for one resident with severe cognitive impairment and significant physical dependence. The resident, an elderly female with unspecified dementia and muscle weakness, was dependent on two staff for bed-to-chair and chair-to-bed transfers and required staff assistance for bathing. She had a history of pain at a surgical amputation site and was receiving PRN Tramadol for moderate to severe pain. A quarterly MDS showed a BIMS score of 3, indicating severely impaired cognition, and care plan documentation confirmed her dependence on staff for transfers and bathing. On a shower day, two CNAs reported that they provided a two-person assist transfer from bed to shower chair and back, with one CNA remaining in the room to fix the bed while the other showered the resident. Both CNAs stated the resident did not complain of pain during the transfers and that she was showered on a shower chair, not standing. In contrast, the resident later reported that “the ladies picked her up from the bottom of her arm,” that she was standing in the shower, and that she felt rib pain at that time but did not tell anyone. The resident’s responsible party stated that the resident began complaining of right-sided pain that afternoon after the shower and that she notified nurses, though she could not recall which nurse. The responsible party further reported that the resident later told her that the CNAs had “pulled her” after the shower. Subsequently, the NP was informed by the family that the resident was complaining of right-sided pain and ordered bilateral rib x‑rays and laboratory tests. Nursing documentation showed that the NP assessed the resident and did not observe bruising or deformity, and that the resident at times denied pain and refused scheduled analgesics. X‑ray results later revealed rib fracture deformities and possible pneumonia. RN D acknowledged receiving the x‑ray report, forwarding it to the NP, and missing the notation of rib fractures, focusing instead on the pneumonia findings. The DON stated that this incident should have been reported to facility administration as soon as RN D received the x‑ray report and that the incident was not reported to the state agency within the required timeframe because the facility was seeking clarification of the x‑ray findings. The Administrator confirmed he was notified after the x‑ray clarification and acknowledged that injuries of unknown origin should be reported within two hours, consistent with the facility’s abuse-prevention policy requiring immediate reporting of all allegations of abuse or neglect to the Administrator and timely reporting to state and federal agencies. The combination of the resident’s report of being pulled and experiencing pain during showering, the subsequent identification of rib fractures, the failure of RN D to report the injury of unknown source to facility management upon receipt of the x‑ray report, and the delay in reporting the possible neglect incident to the state agency demonstrate that the facility did not follow its own written policies and procedures for preventing and responding to potential abuse and neglect. These failures occurred despite the resident’s high level of dependence for transfers and her severe cognitive impairment, and despite the facility’s policy specifying immediate internal reporting and timely external reporting of all allegations of abuse, neglect, and injuries of unknown origin.
Failure to Timely Report Injury of Unknown Origin and Possible Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an injury of unknown origin, as a potential allegation of abuse, neglect, exploitation, or mistreatment, to the State Survey Agency within the required 2-hour timeframe. The resident involved was an elderly female with unspecified dementia of severe degree, as evidenced by a BIMS score of 3, and muscle weakness. Her care plan and MDS documented that she required two-person assistance for bed-to-chair transfers and one-person assistance for bathing/showering. She had a history of pain at a surgical amputation site and was receiving PRN Tramadol for moderate to severe pain. On a Saturday in March, the resident was showered by a CNA who reported that she and another CNA provided a two-person transfer from bed to shower chair and back, and that the resident did not complain of pain during these transfers. Both CNAs stated the resident did not stand in the shower and remained on the shower chair. In contrast, the resident later stated that “the ladies picked her up from the bottom of her arm,” that she was standing in the shower, and that she felt rib pain at that time but did not tell anyone. The resident’s responsible party reported that the resident began complaining of right-sided pain that afternoon, that she notified nursing staff (though she could not recall which nurse), and that the resident received pain medication. The responsible party further stated that the next day the resident was able to say that the CNAs had pulled her after the shower. On a later date in March, the NP rounded and, after being informed by the family that the resident was complaining of right-sided pain, assessed the resident and ordered bilateral rib x‑rays and labs. Nursing documentation that afternoon noted the resident’s complaint of bilateral rib pain and the x‑ray order, and an evening note by the DON documented that the resident denied pain, had full range of motion, and no discoloration. X‑ray results were obtained and sent to the NP, who focused on possible pneumonia and ordered antibiotics and additional treatments. The DON and NP later acknowledged that the rib fracture findings on the x‑ray were initially missed, resulting in delayed recognition of rib fractures. The DON stated that she was notified of the fracture findings the following day, sought clarification from the mobile x‑ray provider due to inconsistent rib descriptions across multiple readings, and then contacted the NP, who arranged for hospital evaluation. The hospital CT scan documented subacute and chronic bilateral rib fracture deformities and bilateral pleural effusions with adjacent airspace disease and atelectasis. Despite the presence of rib fractures of unknown origin in a resident with severe cognitive impairment and dependency for transfers, the DON stated that the incident was not reported to the State agency when the fracture was first identified because the facility was “verifying” the x‑ray results, and that the incident should have been reported to the Administrator and to her as soon as the RN received the x‑ray report. The Administrator stated he was notified by the DON the next day and that injuries of unknown origin should be reported within 2 hours. The facility’s own abuse policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate State or Federal agencies within applicable timeframes. The surveyors concluded that the facility failed to ensure that this injury of unknown origin, discovered on the date of the x‑ray, was reported immediately, but no later than 2 hours, to the State Survey Agency.
Failure to Recognize Rib Fractures and Follow Care-Plan Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure 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 expressed choices. The resident was an elderly female with unspecified dementia with severe cognitive impairment, muscle weakness, and dependence on staff for transfers and bathing. Her care plan and MDS documented that she required two-person assistance for chair/bed-to-chair and toilet transfers and one-person assistance for showers. Despite this, the resident later reported that during a shower she was standing and that the CNAs picked her up from under her arms, at which time she felt pain in her ribs but did not immediately report it. The resident’s representative stated that the resident began complaining of right-sided pain after the shower and that she notified nursing staff, though she could not recall which nurse. In the days following the shower, the resident received PRN Tramadol for pain to a surgical site, and on a later date the NP was informed by the family that the resident was complaining of pain to the right side of her body. The NP assessed the resident, did not observe bruising or deformity, and ordered bilateral rib x‑rays along with laboratory tests. Nursing documentation on the same day reflected that the resident denied pain, had full range of motion, and no discoloration was noted. Mobile x‑rays were obtained, and the x‑ray report dated that day showed acute appearing mildly displaced fractures of the right 4th and 5th ribs anterolaterally, with a recommendation to correlate with timing of trauma and pain for age of fractures. However, the nurse who received the x‑ray report acknowledged that she missed the fracture findings and only focused on the pneumonia findings, forwarding the results to the NP without recognizing or acting on the rib fractures. The facility’s DON later reviewed the x‑ray report and noted the fracture findings, but there was confusion regarding which ribs were involved due to differing readings from the mobile x‑ray service. The DON stated that nurses were capable of reading x‑ray reports and were expected to identify and interpret them, yet the fracture results were not recognized or addressed until the following day. During this period, the facility’s policy on Diagnostic Test Results Notification required prompt notification of ordering providers of test results, but the initial fracture findings were not promptly identified or communicated as such. This sequence of events—failure to consistently follow the resident’s transfer and shower assistance requirements as care planned, failure to recognize and act on x‑ray findings of rib fractures, and delay in addressing those findings—constituted the failure to provide treatment and care according to orders, professional standards, the care plan, and the resident’s reported pain and preferences.
Unlabeled IV Vancomycin Bag Hung for a Resident Receiving PICC Infusion
Penalty
Summary
Surveyors identified a deficiency in the administration of IV medications when a resident receiving IV vancomycin via a PICC line had an unlabeled IV medication bag in use. The resident was an adult with osteomyelitis of the vertebra, sacral and sacrococcygeal regions, cellulitis of the lower limb, a stage 4 sacral pressure ulcer, muscle weakness, paraplegia, and a need for assistance with personal care. The care plan included administration of antibiotics per physician orders, and the physician had ordered vancomycin 1 gram IV every 8 hours for sacral wound infection, sacrococcygeal osteomyelitis, and cellulitis. During observation, the IV bag actively infusing into the resident’s PICC line was found to have only a date and nurse’s initials written in black marker, with no resident name, medication dose, frequency, or route indicated. In an interview, the RN who hung the IV bag acknowledged that he had just hung the bag, had thrown away the original label, and was aware that the bag was missing the required medication label information. He stated he knew the bag was supposed to include the resident’s name, dosage, frequency, and route, and acknowledged that failure to label the medication properly could lead to administering the wrong medication to the wrong resident or cause an infection. The DON confirmed that the RN knew he was required to label the IV medication bag and stated that she expected all nurses to label medications appropriately prior to administration, and that it was the administering nurse’s responsibility to verify that everything was labeled correctly. The facility’s policy on administration of IV medications and fluids required verification that the container’s label coincides with the prescriber’s order, including content, dose, prescribed rate, and expiration date of the solution.
Inaccurate MAR Documentation for Controlled Psychotropic Medication
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving psychotropic medication. The resident, an elderly female with late-onset Alzheimer's disease, anxiety disorder, and a mood disorder with manic features, had a care plan addressing psychotropic medication use and an order for alprazolam 1 mg at bedtime. On a January date, the controlled drug record showed that the alprazolam dose was not provided, while the January 2026 MAR documented that the same dose was administered at 8:00 PM by an LVN. The resident’s significant change MDS showed a BIMS score of 01, indicating severe cognitive impairment. During interview, the LVN stated she signed the MAR first for the alprazolam dose, then went to check on the resident and did not administer the medication because the resident was already asleep. She reported that she did not remove the alprazolam from its packaging and documented on the controlled drug record that none was given. The LVN acknowledged that the correct process was to check the resident, retrieve the medication, sign the controlled drug record, administer the medication, and then sign the MAR as administered, and that she should have corrected the MAR entry but did not. The DON confirmed that the LVN was responsible for the medication administration and documentation on that date, that the MAR showed the medication as given while the controlled drug record and narcotic count showed it was not, and that facility policy required documenting on the electronic MAR as medications are administered, not before or after.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart assigned to the 1 and 2 hallways was observed left unlocked and unattended in front of the nurse's station. The cart was under the responsibility of an RN, who was present at the nurse's station but not attending to the cart. Upon being informed by the surveyor, the RN immediately locked the cart. The RN acknowledged responsibility for securing the cart and stated that he was expected to lock it whenever he walked away. He explained that he had unlocked the cart for an auditor, who left it unlocked, and he was unaware that it had not been secured. The Director of Nursing (DON) confirmed that multiple staff, including herself and the Assistant Director of Nursing (ADON), were responsible for ensuring medication carts were locked. The DON stated that staff were expected to lock the cart when leaving it unattended. Facility policy reviewed indicated that all medications must be stored securely, with access limited to authorized personnel, and that medication carts must be locked or attended at all times.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the kitchen. Observations during a tour of the kitchen revealed roaches coming out of the floor drain under the 2-compartment sink. Multiple staff interviews confirmed that the roach problem began when construction of a new parking lot started, and that roaches had been seen in the kitchen since then. Staff reported the issue to the Dietary Manager (DM), who in turn notified the Maintenance Director and the Administrator. The facility had been fumigated the previous week, but roaches continued to be observed in the kitchen. A review of the facility's pest control log showed that the facility had been fumigated monthly from January to May and twice in June for various pests, including roaches. The facility's Infection Control Policy/Procedures required an environment free of pests, with additional pest control visits when problems are detected and prompt reporting to the administrator. Despite these policies, the presence of roaches in the kitchen persisted, indicating that the pest control measures in place were not effective in keeping the kitchen free of pests.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable objectives and timeframes for two residents, as identified through observation, interview, and record review. For one resident with dementia, muscle weakness, dysphagia, anxiety disorder, and bipolar disorder, the care plan inaccurately documented the presence of a feeding tube and did not address the resident's need for substantial or maximal assistance with eating. Observations showed the resident was unable to feed himself, with his spoon out of reach and food spilled, requiring a CNA to feed him. Staff interviews revealed confusion about the resident's actual needs and the care plan's accuracy, with some staff believing he only needed set-up assistance and others acknowledging he required direct feeding assistance at times. The care plan for this resident was not updated to reflect his fluctuating ability to eat independently and his behavioral issues, such as spitting and refusing assistance. Staff interviews indicated that although CNAs often provided feeding assistance, the care plan did not specify this need, and there was a lack of clarity and communication among staff regarding the resident's actual requirements. The documentation error regarding a feeding tube further contributed to the lack of appropriate interventions in the care plan. For another resident with nicotine dependence and COPD, the care plan did not include any interventions related to smoking, despite the resident being on the facility's smoking list and self-reporting as a smoker. Staff interviews confirmed that the omission was due to a lack of communication and oversight, and the care plan was not updated to address the resident's smoking needs. Facility policy required that such needs be care planned, but this was not done, resulting in the resident's smoking status and related care needs not being addressed in the care plan.
Failure to Label IV Dressing According to Infection Control Standards
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including cellulitis, Alzheimer's disease, type 2 diabetes, dementia, muscle weakness, and osteoporosis, was observed to have a peripheral intravenous (IV) line dressing on her right hand that was not labeled with the date and initials as required by facility policy and professional standards. The resident was receiving IV medications and hydration for cellulitis and had orders for both IV fluids and antibiotics. The care plan and physician orders specified monitoring and care of the IV site, including daily checks and dressing changes as needed. During observation, it was noted that while the resident's left wrist IV dressing was properly labeled, the right hand IV dressing lacked both the date and initials. Interviews with the charge nurse, ADON, and DON confirmed that the dressing should have been labeled to track when it was inserted and to ensure timely dressing changes. The charge nurse acknowledged missing the labeling and stated she would remove the unlabeled IV because the duration it had been in place was unknown. Both the ADON and DON reiterated the importance of labeling to prevent infection and ensure compliance with the facility's protocols. Review of facility policies and competency checklists confirmed that labeling IV dressings with the date and initials is a standard requirement, and that IV sites are to be rotated every 72 hours. The failure to label the IV dressing was contrary to both facility policy and professional standards, as documented in the facility's infection prevention and control program and IV administration policies.
Misappropriation of Resident Funds by Former Staff Member
Penalty
Summary
A deficiency occurred when a former Assistant Business Office Manager (ABOM) accessed a resident's bank account information and withdrew funds without the resident's knowledge or consent on 18 separate occasions, resulting in a total loss of $4,671.22. The resident, a male with diagnoses including COPD, muscle weakness, hypertension, and atrial fibrillation, had intact cognitive function as indicated by a BIMS score of 14. The unauthorized transactions took place over several months, and the resident only became aware of the missing funds after noticing discrepancies in his account and seeking assistance from the Business Office Manager (BOM). The facility did not detect the misappropriation until the resident reported the issue, at which point it was discovered that the former ABOM had linked the resident's bank account to her personal Cash App and transferred funds without permission. The ABOM had access to residents' financial information as part of her duties, including assisting with Medicaid applications. The police were involved, and the former ABOM admitted to the theft and was subsequently arrested. The facility's policy states that residents have the right to be free from misappropriation and exploitation, but this was not upheld in this instance.
Failure to Provide Ordered Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to two residents who were identified as needing psychiatric evaluation and treatment. Both residents had physician orders for psychiatric consultation following incidents involving behavioral or psychosocial concerns. Despite these orders, there was no evidence in the residents' records of any psychiatric consultation being scheduled, completed, or followed up on. One resident, a male with diagnoses including dementia, cognitive communication deficit, and metabolic encephalopathy, exhibited combative and aggressive behaviors, including an incident where he was physically aggressive toward another resident and a nurse. His care plan included an intervention for psychiatric evaluation and treatment as ordered by the physician. However, the order for psychiatric services was not acted upon, and no documentation of a psychiatric evaluation was found in his record. The second resident, also a male with Alzheimer's disease and cognitive communication deficit, was involved in an altercation where he was kicked by another resident. His care plan addressed potential psychosocial well-being problems and included an order for psychiatric evaluation and treatment. Similar to the first case, there was no documentation of a psychiatric consultation or follow-up. Interviews with facility staff, including the DON and Administrator, confirmed that the social worker responsible for making the referrals did not follow through with the orders, and no psychiatric services were provided as required.
Failure to Administer Eye Drops as Prescribed Following Cataract Surgery
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications as prescribed for a resident following cataract surgery. Specifically, a male resident with a history of dementia, cystoid macular degeneration, and recent cataract surgeries was prescribed prednisolone eye drops for both eyes. The physician's prescription ordered one drop in the right eye twice daily and one drop in the left eye three times daily. However, the facility's physician order and subsequent medication administration records reflected that the resident received the drops in both eyes only twice daily, not adhering to the prescribed frequency for the left eye. Interviews with nursing staff and the Director of Nursing (DON) revealed confusion regarding the correct dosage and frequency of the eye drops. Staff indicated that they could not administer medications without a clear and complete physician's order and would seek clarification if orders were unclear. The DON acknowledged discrepancies between the written prescription and the order entered into the facility's system, noting uncertainty about whether multiple or conflicting orders had been received from different clinics. The resident was also described as resistant to providing post-visit orders, which contributed to the confusion. A review of the facility's medication administration policy confirmed that orders must be accurately implemented as written. Despite the error, the ophthalmic assistant from the prescribing clinic stated that the deviation in administration likely had minimal to no effect on the resident, as there was no evidence of inflammation or negative outcome documented. The deficiency was identified through record review and staff interviews, which confirmed that the resident did not receive the medication as prescribed during the specified period.
Failure to Maintain Accurate DNR Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for a resident regarding their Advance Directives. Specifically, the medical record indicated that the resident had a Do Not Resuscitate (DNR) status, but the Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was missing from the resident's medical record. This discrepancy was discovered during a review of the resident's records and interviews with various staff members, including the Assistant Director of Nursing (ADON), Social Worker (SW), and Medical Records Clerk, who all confirmed the absence of the necessary documentation. The resident in question was a 90-year-old female with multiple diagnoses, including essential hypertension, myocardial infarction, dementia, and chronic kidney disease. Despite the resident's clear communication and understanding of her DNR status, as confirmed by her family member and documented in her care plan and physician's orders, the facility failed to have the required OOH-DNR form in the resident's electronic medical record. This oversight was identified when the family member was asked to sign a new DNR form, revealing that the original form from the hospital was not valid for the facility. Interviews with staff members highlighted a lack of clarity and responsibility regarding the completion and verification of DNR forms. The SW, BOM Assistant, and Medical Records Clerk each had different understandings of their roles in the process, leading to the failure to ensure the DNR form was properly completed and filed. The Director of Nursing (DON) acknowledged the error and mentioned that the form might have been deleted from the system by mistake. Eventually, the missing DNR form was found in old medical records, but the initial failure to maintain accurate and complete records posed a significant risk to the resident's expressed wishes regarding resuscitation.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to several deficiencies. One incident involved a Licensed Vocational Nurse (LVN) who did not properly disinfect equipment after providing wound care for a resident. The LVN used alcohol preps instead of disinfectant wipes to clean the bandage scissors, which could lead to cross-contamination and infection. Interviews with the LVN, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed that the correct procedure was not followed, and the facility's infection control policy was not adhered to. Another incident involved the same LVN failing to wear appropriate personal protective equipment (PPE) while providing care for a resident with a peripherally inserted central catheter (PICC) line. The LVN did not wear a gown as required by the Enhanced Barrier Precautions (EBP) and did not follow the proper procedure for changing the PICC line dressing. The LVN also failed to use a bio patch, clean the skin around the insertion site, or change the stat lock and saline/heparin locks as required. Interviews with the DON, Clinical Resource Nurse (CRN), and ADON revealed inconsistencies in the understanding and implementation of the facility's policies regarding PICC line care and EBP. The facility's policies and procedures for infection control, including the use of disinfectant wipes, proper PPE, and specific steps for PICC line dressing changes, were not followed. This lack of adherence to established protocols could lead to cross-contamination, infections, and other health complications for the residents. The facility's infection prevention and control program, as outlined in their documentation, was not effectively implemented, resulting in these deficiencies.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for Resident #1, a [AGE] year-old female with diagnoses including unspecified Dementia, Muscle weakness, Abnormalities of gait and mobility, and Cognitive communication deficit. Despite being identified as high risk for elopement, Resident #1 managed to leave the facility unnoticed on 12/06/23 and was found approximately 0.2 miles away near a highway by a driver. The facility's investigation revealed that Resident #1 exited through a door in hall 300, despite attempts to redirect her by staff members. The Environmental Manager mentioned that the door alarm was not very loud, and there was a possibility that the landscapers working in the fenced area might have inadvertently allowed Resident #1 to leave.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that residents had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the facility staff did not provide Resident #2 with a call light that was within reach. Resident #2, a [AGE] year-old female with hemiplegia and hemiparesis following a cerebral infarction, was observed in bed with her call light placed under her pillow and out of reach. Despite her attempts to reach the call light with her left hand, she was unable to do so. This failure could place residents who utilize call lights at risk for not having their needs met. Interviews with facility staff, including a CNA, an LVN, and the DON, confirmed that call lights should be accessible to all residents who can use them. The staff acknowledged that if the call light was not accessible, the resident could not receive the necessary assistance, potentially causing stress and anxiety. The facility's policy on call lights also emphasized the importance of placing the call device within the resident's reach before leaving the room. However, this policy was not followed in the case of Resident #2, leading to the identified deficiency.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Harlingen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mid Valley Nursing & Rehabilitation | 2 mi | ★★★★★ | 15 | 0 |
| Windsor Nursing And Rehabilitation Center Of Wesla | 7.6 mi | ★★★★★ | 5 | 1 |
| Valley Grande Manor | 7.9 mi | ★★★★★ | 12 | 0 |
| Weslaco Nursing And Rehabilitation Center | 8.2 mi | ★★★★★ | 4 | 0 |
| Harlingen Nursing And Rehabilitation Center | 10.6 mi | ★★★★★ | 11 | 1 |
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