Above 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 Ware Memorial Care Center during CMS and state inspections, most recent first.
A resident with multiple cardiac and psychiatric diagnoses, dependent in most ADLs but cognitively intact, was given several high-risk oral medications by an LVN, who then left the medications in a cup on the dining table while standing several yards away at the med cart. The resident reported that staff routinely leave medications for self-administration, despite no care plan for self-administration and facility education materials stating that medications must not be left unattended and that nurses should observe ingestion. Other nursing staff, including an RN, another LVN, the ADON, and the DON, stated it was never acceptable to leave residents alone with medications, highlighting that the LVN’s practice conflicted with facility expectations and documented best practices.
MDS assessments were inaccurate for several residents. Three residents were coded for bed rails as restraints even though their care plans and orders showed the rails were used for positioning or mobility, and one resident who used CPAP at bedtime was not coded for that therapy. Observation, interview, and record review confirmed the mismatch between the MDS coding and the residents’ actual care and orders.
Medication administration and storage deficiencies were identified when an LPN left morning meds with two residents to take on their own instead of staying with them until the meds were swallowed. One resident had multiple meds left at bedside despite not being able to identify them, and another resident had a cup of morning meds and water left on an over-bed table. Surveyors also found expired eyedrops on one med cart and expired insulin glargine on another, while staff acknowledged the products were past their allowed use periods.
Unsafe food handling and inadequate hair restraints in the kitchen. Staff and other individuals were observed in the kitchen without proper beard covers or hair restraints, including a staff member with a moustache uncovered and a maintenance worker and outside repairman without appropriate coverings. Multiple staff also handled food and serving items with gloved hands after touching other kitchen surfaces, and one staff member touched a roll to check doneness before returning it to the tray. Interviews showed staff knew the expected handwashing, glove change, and tongs practices but did not follow them during the observations.
Incomplete DNR Form Lacked Notary Date: A resident with atrial fibrillation, peripheral vascular disease, hypertension, and severe cognitive impairment was identified as DNR, but the DNR form in the record lacked a dated notarial acknowledgment. The DON, SW, and RN all reviewed the document and acknowledged it was not properly completed, with the RN stating it would be considered null and void without the notary date.
Loose Pills Found in Medication Cart: The facility failed to store medications in accordance with accepted professional principles when two loose pills, identified as Levothyroxine and Atorvastatin, were found in the 1-Northwest Hall medication cart. An LVN stated loose medication could lead to missed doses and early depletion of medication supply, while the ADON and DON described inconsistent cart checks by night staff and acknowledged that loose or expired medications should be reviewed.
Hand Hygiene Not Performed During Wound Care: An LVN did not perform hand hygiene when moving from the dirty to the clean portion of wound care for a resident with dementia, Parkinson's disease, and a coccyx pressure ulcer. The nurse removed gloves after cleansing the wound, did not clean hands, then donned new gloves and applied collagen and a dressing. The DON stated staff are expected to perform hand hygiene during care tasks such as wound care, and facility policies identified hand washing as a key infection prevention measure.
Failure to Timely Encode Discharge and Death MDS Assessments: The facility did not encode required MDS assessments within the required timeframe for three residents after transfer or death events. One resident with heart and kidney disease and hospice services died in the facility, one resident with Alzheimer’s disease and multiple cancers was discharged to an acute care hospital, and one resident with Alzheimer’s disease and hospice services died in the facility. The EHRs lacked the required death in facility or discharge MDS entries, despite progress notes and discharge summaries documenting the events.
A resident admitted without a pressure ulcer developed an unstageable ulcer on the coccyx within two weeks due to the facility's failure to notify the wound care nurse, perform weekly skin assessments, and document skin conditions accurately. The resident, with severely impaired cognition and dependent on staff for ADLs, was at risk for skin issues. The facility's lack of communication and documentation led to delayed care and worsening of the ulcer.
The facility failed to adhere to professional standards for food service safety, with deficiencies observed in 7 out of 8 resident snack refrigerators. Issues included improper storage, labeling, and dating of food items, as well as the presence of expired foods and staff items. Staff frequently used the refrigerators for personal food storage, and there was confusion about who was responsible for cleaning them. The lack of policies and cleaning schedules contributed to unsanitary conditions, posing a risk of foodborne illness.
The facility failed to inform residents about the removal of bedrails, affecting their mobility and comfort. Several residents, including those with conditions like epilepsy and Alzheimer's, reported their bedrails were removed without consent, despite requests for their return. The facility's plan to reassess bedrail needs was delayed, leading to resident complaints and a failure to uphold their rights to participate in care decisions.
The facility failed to provide necessary Medicare/Medicaid coverage notices to three residents, preventing them from being informed of their rights to appeal the termination of skilled services. The residents, with various medical conditions, were not given the required NOMNC and SNF ABN forms upon discharge from skilled services. Staff members were either unfamiliar with the process or deemed the notices unnecessary, leading to a deficiency in communication and documentation.
A resident with multiple health conditions was inaccurately assessed as having an indwelling catheter in her MDS assessment, despite no medical records or observations supporting this. The MDS Coordinator confirmed the error, highlighting potential financial and service impacts. The facility's policy mandates accurate assessments, and the error could affect reimbursement and billing.
The facility failed to change nebulizer tubing for two residents, one for four months and the other for six months, despite a policy requiring monthly changes. Observations showed cloudy tubing and particles in masks, indicating poor maintenance. Staff confirmed the oversight, acknowledging the risk of infection due to prolonged use of the same equipment.
A facility failed to provide adequate pharmaceutical services, leaving a resident unattended with medications and storing expired medications in two areas. The resident, with multiple medical conditions, was left with her morning pills by an LPN, contrary to the facility's expectations. Expired medications were found in the Rehabilitation and LTC medication room and the 1-North medication room, with staff acknowledging the potential negative impact on resident care. The facility lacked comprehensive policies for medication storage and self-administration.
A Schedule III narcotic was improperly stored in the Rehabilitation and LTC medication room, found on a refrigerator shelf instead of in a locked box. LVN C confirmed the issue, noting the lack of a log for tracking its use. The DON acknowledged the storage error, citing a missing key for the lock box. The facility also lacked a policy for medication storage, as confirmed by a review of the policy manual and unanswered requests for the policy.
The facility failed to maintain accurate fall risk evaluations for a resident with a history of falls, leading to discrepancies in medical records. The resident experienced multiple falls, including one resulting in a laceration and ER transfer, but the fall risk evaluations incorrectly stated no falls in the last three months. Interviews with the DON and LVNs confirmed the errors in documentation.
Medications Left Unattended and Unobserved Administration by LVN
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensure accurate dispensing and administration of medications by not remaining with a resident until medications were taken. An [AGE]-year-old male resident with persistent atrial fibrillation, depression, essential hypertension, heart failure, and edema was admitted with multiple high-risk medications ordered, including an antidepressant, anticoagulant, diuretics, an opioid, and an anticonvulsant. His MDS showed intact cognition (BIMS 15) and dependence in all ADLs except eating and oral hygiene, and his care plan did not identify him as self-administering medications. On the morning in question, record review of the MAR showed that an LVN administered several medications to this resident, including Lasix, a multivitamin, Senna-Plus, spironolactone, Zoloft, Eliquis, gabapentin, metoprolol tartrate, and hydrocodone-acetaminophen. During observation in the dining room, the resident was seen sitting at a table with another resident, with a small oval orange-pink pill on the table and a plastic medication cup containing approximately eight medications in front of him, along with a lidded cup of what appeared to be coffee. No staff were present at that time, and the resident stated that staff leave his medications with him for him to take on his own every day. A subsequent observation showed the resident still seated with the medications in front of him while the LVN stood 4–6 yards away at the medication cart looking at a computer screen. The LVN stated she leaves the medications with the resident because he takes one pill at a time and will not take them if she stands there, adding that she stays close where she can watch and acknowledging that not watching could result in him not taking the medicine or saving it. Other nursing staff, including an RN, another LVN, the ADON, and the DON, stated it was never acceptable to leave residents alone with medications, citing risks such as other residents taking the medications, hoarding, or missed treatment. Facility documents, including the admission packet and a POC Education-Medication Administration form signed by the LVN, specified that medications are not to be left unattended with residents and that best practice is to observe residents while they take medications, but the facility’s written drug administration and pharmacy services policies did not explicitly address remaining with residents until medications are taken.
MDS assessments inaccurately coded bed rail use and CPAP therapy
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected resident status for four residents. Resident #1, Resident #2, and Resident #40 were each coded on their MDS assessments as using bed rails as restraints, while Resident #28 was not coded for CPAP therapy even though he used CPAP at night. The deficiency was identified through observation, interview, and record review of the residents’ assessments, care plans, and active orders. Resident #1’s quarterly MDS completed 01/10/26 listed bed rails under Section P0100 - Physical Restraints. Her care plan and active order stated that side rails were used for positioning. During observation on 02/10/26, she did not have bedrails up, and she stated staff put them down during the day and up at night so she could use them to get in and out of bed and move around in bed. Resident #2’s annual MDS completed 12/06/25 also listed bedrails under physical restraints. Her care plan and active order stated bilateral side rails were for self-positioning in bed and for transfers in and out of bed. During observation, she had quarter bed rails in use and stated she used them to assist with getting in and out of bed and moving around in bed. Resident #40’s quarterly MDS completed 11/01/25 listed bed rails under physical restraints, while his care plan and active order identified bed rails for mobility. During interview, he stated the bed rails helped him reposition and move from side to side, especially during brief changes. Resident #28’s annual MDS completed 12/24/25 indicated he did not have non-invasive mechanical ventilator use on admission or while a resident. However, his care plan identified that he used CPAP at night, and his active order stated CPAP at bedtime. During observation, a CPAP machine with tubing and mask was present in his room. During interview, he stated he had used CPAP for years and staff helped him with his CPAP care; a family member also stated he had used CPAP therapy for 15 years. The MDS Coordinator acknowledged the coding errors for the bed rail residents and the CPAP omission, stating the assessments were incorrect and would need to be corrected.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for two residents. Resident #46, an older female with diagnoses including rheumatoid arthritis, hypothyroidism, depression, hypertension, gout, pain, cognitive communication deficit, and hyperlipidemia, had a BIMS score of 15 and no swallowing issues documented on the MDS. Her MAR showed she received multiple morning medications from LVN A, but during observation she was seated with a plastic medication cup containing several pills on her tray table and stated the nurse left the medications with her to take. She also stated she did not know what the medications were, and later said it was normal for the nurse to leave her medications with her to take on her own. Resident #79, an older female with diagnoses including cognitive communication deficit, hypothyroidism, pain, atrial fibrillation, and hypertension, had a BIMS score of 14 and no swallowing issues documented on the MDS. Her MAR showed she received multiple morning medications from LVN B, including levothyroxine scheduled at 6:30 AM per resident request. During observation, she was lying in bed with a small medication cup containing more than six pills and a cup of water on her over-bed table. She stated the medications were her morning medications and that the nurse regularly left them with her to take on her own. The report also documented medication storage issues on two medication carts. On the Southeast Hall medication cart, Genteal eyedrops were observed opened and marked with an expiration date, and LVN A stated eye drops were to be disposed of every 90 days. On the Southwest Hall medication cart, insulin glargine was observed with an open date and an expiration date, and LVN G stated the insulin was expired and should have been pulled and replaced. The DON stated insulin should be marked with the date opened and the date it expires, and that expired insulin could have less efficacy. The DON also stated that if an eye drop medication was expired, there could be an issue with infection control.
Unsafe Food Handling and Inadequate Hair Restraints in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 2 kitchens when kitchen staff and other individuals in the kitchen did not consistently use proper hair restraints, beard coverings, hand hygiene, and glove sanitation practices. During observation of kitchen food preparation activities, a staff member was seen with a beard cover under his chin and not covering his moustache, and later with his moustache uncovered. A maintenance manager was observed in the kitchen without a beard cover, and an outside repairman was in the kitchen floor area repairing equipment without a hairnet or beard cover. Additional observations showed multiple kitchen staff handling food and kitchen items with gloved hands after touching other surfaces. One staff member touched various kitchen surfaces and then handled rolls and a puree blender without changing gloves. Another staff member touched kitchen surfaces, handled rolls, and placed them into serving pans. A third staff member touched kitchen surfaces, removed rolls from the oven, checked a roll for doneness by touching it, returned it to the tray, and put the pan back in the oven. During lunch service, a staff member touched kitchen surfaces, plated food, and then picked up a roll with a gloved hand and placed it on a plate. Interviews confirmed that staff understood beard covers, hair restraints, handwashing, glove changes, and use of tongs were expected, but several stated they had forgotten or had not followed those practices at the time of the observations. The dietary manager stated beard covers and hair restraints should always be worn, moustaches should always be covered, tongs should always be used for bread, and food should not be touched with hands that had touched other surfaces. Record review showed facility policies requiring handwashing and appropriate hair restraint use, and the USDA Food Code cited requirements for effective hair restraints and handwashing during food preparation and when changing tasks.
Incomplete DNR Form Lacked Notary Date
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advance directive for 1 of 25 residents reviewed. Resident #55, a female admitted with diagnoses including unspecified atrial fibrillation, drug-induced subacute dyskinesia, peripheral vascular disease, and hypertension, was identified as DNR in the advance directive section of the record. Her quarterly MDS showed a blank BIMS summary score and indicated she was severely impaired in cognitive skills for daily decision making. Her care plan included an intervention for advanced directives stating not to administer CPR if heart stops and/or breathing stops, and her active physician orders included a DNR order. The clinical record contained a DNR signed by the resident's representative and physician, but the notary section lacked a date showing when the notary completed the form. The DON reviewed the document and stated it was not correct because of the missing notary date. The SW stated she was responsible for verifying DNRs and acknowledged she mistook the notary commission expiration date for the date signed. RN C reviewed the form and stated it would be considered null and void without the notary date and that CPR would have to be initiated if needed, which would be against the resident's or representative's wishes. The facility policy stated residents have the right to make choices regarding treatment, including withholding life-sustaining treatment.
Loose Pills Found in Medication Cart
Penalty
Summary
The facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 of 10 medication storage areas reviewed, the 1-Northwest Hall medication cart. During observation on 02/11/2026 at 08:44 AM with LVN E present, two loose pills were noted in the cart and identified by LVN E as Levothyroxine and Atorvastatin. The facility policy titled Drug Security Policy dated 01/30/2017 stated that medications must be properly labeled and stored in a locked medication room, cabinet, or cart. During interview on 02/11/2026 at 1:24 PM, LVN E stated loose medication in a medication cart can result in a resident missing a dose, the medication running out early, and insurance not refilling it. On 02/11/2026 at 2:17 PM, the ADON stated the night shift should check medication carts on Tuesdays and Thursdays for good condition, including no loose pills, and reported night staff would need retraining on inspecting carts. On 02/12/2026 at 9:01 AM, the DON stated the night shift should review all medication carts for loose or expired medications, but they often get busy and cannot complete that duty; the DON also stated loose pills in a cart should not be an issue if there are 1-2 loose pills.
Hand Hygiene Not Performed During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when LVN E did not perform hand hygiene properly during wound care for Resident #11. Resident #11 was admitted with diagnoses including Parkinson's disease, dementia, osteoarthritis, and repeated falls, and his clinical record showed he was moderately cognitively impaired, dependent on staff for most ADLs, and had one stage 2 pressure ulcer. His active order required wound care to the coccyx wound with cleansing, collagen application, and a dressing change every day shift for wound healing. During observation of wound care, LVN E cleaned the wound with wet 4x4s, dried it, removed gloves, did not perform hand hygiene, then put on new gloves and applied collagen before covering the wound with a dry dressing. LVN E later stated hand hygiene should have been performed when moving from the dirty to the clean portion of the wound care. LVN F stated hand hygiene should have been performed between the dirty and clean portions of care, and the DON stated staff are expected to perform hand hygiene by removing gloves, washing hands, and placing on new gloves during tasks such as wound care, catheter care, and incontinent care. The facility's infection control, handwashing, and perineal care policies all identified hand hygiene as a required part of infection prevention.
Failure to Timely Encode Discharge and Death MDS Assessments
Penalty
Summary
The facility failed to encode required MDS assessments within 7 days after completion for three residents who had transfer, discharge, or death events. Resident #49, a male with heart disease, kidney disease, and hospice services, died in the facility, but the EHR under the MDS tab did not show a death in facility assessment. The last MDS listed was a significant change assessment, and the resident’s progress notes and discharge summary documented that he was pronounced dead by hospice and released to the funeral home. Resident #53, a male with diagnoses including Alzheimer’s disease, left clavicle fracture, prostate cancer, and bone cancer, was discharged to an acute care hospital, but the EHR did not contain a discharge MDS assessment. His admission MDS showed a BIMS score of 15, need for assistance with all ADLs, and opioid medication use. The record also showed no discharge summary in the miscellaneous tab, and the care plan did not mention discharge plans. Resident #60, a female with Alzheimer’s disease who was receiving hospice services, died in the facility, but the EHR did not show a death in facility MDS assessment. The last MDS listed was a significant change assessment. Progress notes documented that she died in the evening and her body was released to the mortuary shortly afterward, and the discharge summary identified her as deceased and discharged to the mortuary.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident who was admitted without a pressure ulcer. Within two weeks of admission, the resident developed an unstageable pressure ulcer with eschar on her coccyx. The facility did not notify the wound care nurse of the ulcer, nor did they accurately document the resident's skin conditions, which led to delayed care for the ulcer. The resident, who was admitted for rehabilitation services, had a severely impaired cognition and was dependent on staff for activities of daily living. Despite being at risk for skin issues, the facility did not perform weekly skin assessments or document any treatment for a coccyx pressure ulcer until after the resident was admitted to the hospital. The hospital records indicated that the pressure ulcer was present upon admission, and the resident's responsible party, who was a nurse, confirmed that the ulcer was unstageable with eschar and tunneling. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's pressure ulcer. The Director of Nursing and other staff members admitted that weekly skin assessments were not conducted, and the wound care nurse was not informed of the ulcer. The facility's failure to follow its own policies on skin care and prevention contributed to the development and worsening of the resident's pressure ulcer.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as observed in 7 out of 8 resident snack refrigerators located in the dining rooms. The deficiencies included improper storage, labeling, and dating of food items, as well as the presence of expired foods, non-food items, and staff items in the refrigerators. Additionally, the cleanliness of the refrigerators was not maintained, with food spills and crumbs observed in several units. During observations and interviews, it was noted that the refrigerators were intended for resident use, but staff frequently used them for personal food storage, contrary to facility policy. There was a lack of clarity among staff regarding who was responsible for maintaining and cleaning the refrigerators. Interviews with various staff members, including the Dietary Manager, Housekeeping Supervisor, and nursing staff, revealed confusion and a lack of policies or cleaning schedules for the resident refrigerators. The facility's policies on food storage and safety were not adequately implemented, as evidenced by the unlabeled, undated, and improperly stored food items. The absence of cleaning sheets and clear responsibility for refrigerator maintenance contributed to the unsanitary conditions. The report highlights the risk of foodborne illness due to these deficiencies, as acknowledged by several staff members during interviews.
Failure to Inform Residents and Return Bedrails
Penalty
Summary
The facility failed to ensure that residents were informed in advance about the risks and benefits of proposed care, treatment alternatives, and options, as well as their right to choose their preferred alternatives. This deficiency affected five specific residents and five additional residents interviewed anonymously. The issue primarily revolved around the removal of bedrails, which residents had requested to be returned for their mobility, positioning, and comfort. Despite these requests, the facility did not return the bedrails for ten days or more, leading to feelings of discomfort and disrespect among the residents. Resident #13, a cognitively intact male with multiple diagnoses including epilepsy and Alzheimer's, expressed his frustration over the removal of his bedrails, which he used for safety and mobility. Similarly, Resident #15, a cognitively intact female with conditions such as CHF and epilepsy, reported her bedrails were removed without her consent, despite having a physician's order for their use. Resident #47, who had been using bedrails for years, found them locked and inaccessible, and was told by staff that state regulations prohibited their use. Resident #70, who was severely cognitively impaired, also had his bedrails removed, affecting his ability to reposition himself. Resident #75, who used bedrails for stability during transfers, reported the removal of her bedrails and her desire to have them returned. The facility's Director of Nursing (DON) and Administrator acknowledged the removal of bedrails, citing a previous survey deficiency and a decision to reassess the need for bedrails facility-wide. They planned to replace bedrails with U-Bars unless ordered by physical therapy. However, the reassessment process was delayed, and the facility had not completed evaluations for all residents who requested the return of their bedrails. The facility's actions led to multiple resident complaints and a failure to uphold residents' rights to participate in their care and make decisions about their treatment.
Failure to Provide Medicare/Medicaid Coverage Notices
Penalty
Summary
The facility failed to inform residents of their rights regarding Medicare/Medicaid coverage and potential liabilities for services not covered. Specifically, the facility did not provide the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to three residents when their skilled services were terminated before the exhaustion of covered days. This oversight could prevent residents from being aware of their right to appeal the decision to end Medicare coverage for skilled services. Resident #31, a female with a history of cerebrovascular disease, COPD, heart failure, and dysphagia, was admitted to the facility from an acute care hospital. Her Medicare Part A coverage began on 10/15/24, and she was discharged to an assisted living facility on 11/20/24. Despite her transition, there was no documentation indicating that she received the necessary NOMNC or SNF ABN forms, which would have informed her of her rights to appeal the termination of skilled services. Similarly, Resident #82, a male with musculoskeletal issues, atrial fibrillation, and muscle weakness, and Resident #240, a female with a fracture, osteoarthritis, and heart failure, were also not provided with the required notices. Both residents were admitted from acute care hospitals and had Medicare Part A coverage. The facility's staff, including the IP and DON, were either unfamiliar with the process or believed the notices were unnecessary due to the residents' transitions to lower levels of care. This lack of communication and documentation highlights a significant deficiency in the facility's handling of Medicare/Medicaid coverage notifications.
Inaccurate MDS Assessment for Urinary Catheter
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically regarding the presence of a urinary catheter. The resident, a female with multiple diagnoses including cerebrovascular disease, epilepsy, lupus, diabetes, and dementia, was marked as having an indwelling catheter in her quarterly MDS assessment. However, a review of her medical records, including her order summary report and care plan, revealed no orders or care plans for an indwelling catheter. An observation confirmed that the resident did not have an indwelling catheter, and interviews with the MDS Coordinator and the Director of Nursing (DON) verified that the MDS was marked incorrectly. The MDS Coordinator acknowledged the error, stating it might have been marked by accident, and emphasized the potential financial and service-related impacts of such inaccuracies. The facility's policy requires that assessments accurately reflect the resident's current status, and the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual provides specific steps for assessing the presence of urinary or bowel appliances. The incorrect marking of the MDS could affect reimbursement and billing, and if done intentionally, could be considered fraud.
Failure to Change Nebulizer Tubing in a Timely Manner
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as evidenced by the lack of timely changes to nebulizer tubing. Resident #6, a cognitively intact female with chronic obstructive pulmonary disease (COPD) and other health issues, had her nebulizer tubing unchanged for four months. Observations revealed that the tubing appeared cloudy, and the mask had small particles inside, indicating a lack of maintenance. Despite the resident's report that staff provided all necessary respiratory care, the facility did not have specific orders or procedures for changing respiratory equipment. Similarly, Resident #79, a moderately cognitively impaired male with obstructive sleep apnea and other conditions, had his nebulizer tubing unchanged for six months. Observations showed the tubing was cloudy and discolored, with particles on the mask's inner surface. The facility's policy required monthly changes and nightly assessments of respiratory equipment, but this was not adhered to, as confirmed by staff interviews. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledged the oversight and the potential risk of infection due to the prolonged use of the same equipment. The facility's administrator admitted that there was no specific policy detailing the frequency of respiratory equipment care, only that it should be provided. The facility's existing policy on respiratory equipment maintenance, dated 2016, emphasized standardized and consistent equipment changes to ensure cleanliness and proper maintenance. However, the lack of adherence to this policy resulted in the deficiency, placing residents at risk for respiratory infections and other complications.
Deficiencies in Medication Management and Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by the improper handling and administration of medications for Resident #75 and the presence of expired medications in two medication storage areas. Resident #75, a cognitively intact female with multiple medical conditions including rheumatoid arthritis and osteoporosis, was left unattended with her morning medications by LVN B. The resident reported difficulty swallowing pills and often took them slowly, yet LVN B felt comfortable leaving the medications with her, assuming she could take them independently. This practice was contrary to the facility's expectations, as stated by the DON, who emphasized that nurses should ensure residents take their medications and document the administration. Additionally, the facility's medication storage practices were found to be deficient. During observations, expired over-the-counter medications were discovered in both the Rehabilitation and Long-Term Care medication room and the 1-North medication room. LVN C and LVN D acknowledged the issue, noting that expired medications could be ineffective and negatively impact resident care. The DON confirmed that it was the responsibility of floor nurses to check for expired medications and dispose of them properly, highlighting a lapse in adherence to this protocol. The facility's policies were also found lacking, as there was no policy available for medication storage despite multiple requests. The Drug Administration Policy did not cover self-administration, and there was no documentation of a care plan for Resident #75's self-administration of medications. This lack of comprehensive policies and oversight contributed to the deficiencies observed in medication management and storage within the facility.
Improper Storage of Controlled Drug in Medication Room
Penalty
Summary
The facility failed to properly store a controlled drug, specifically a Schedule III narcotic, in the Rehabilitation and Long-Term Care medication room. During an observation, it was found that Buprenorphine tablets were placed on a refrigerator shelf instead of being secured in the locked box provided on the refrigerator door. This improper storage was confirmed by LVN C, who acknowledged that the narcotic was accessible to any nurse without a log to track its use, potentially affecting resident care by making the medication unavailable for treatment. The Director of Nursing (DON) confirmed that the narcotic should have been stored in a locked box to comply with the double lock system. The DON mentioned an issue with not having a key to the lock box, which led to the narcotic being improperly stored. Despite attempts to address the issue with maintenance, the problem persisted. Additionally, the facility lacked a policy for medication storage, as confirmed by a review of the facility's policy manual and multiple requests for the policy from the Administrator and DON, which went unanswered.
Inaccurate Fall Risk Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systemically organized medical records for a resident, leading to inadequate documentation of fall risk evaluations. Specifically, the medical records for a resident with a history of falls did not accurately reflect the resident's fall incidents within the last 90 days. The resident, who had multiple falls resulting in injuries, had fall risk evaluations that incorrectly stated no history of falls in the last three months. This discrepancy was noted in the nurse's notes and fall risk evaluations dated January, February, and March, despite the resident experiencing falls during this period, including one that resulted in a laceration and transfer to the ER. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) revealed that the assessments were made in error, and the incorrect documentation could lead to inadequate care planning and risk management for the resident. The resident involved was an elderly female with diagnoses including muscle weakness, history of falling, insomnia, unspecified dementia with behavioral disturbances, hallucinations, and long-term use of anticoagulants. The resident was cognitively intact with a BIMS score of 13 and required total dependency for mobility tasks. Observations revealed the resident had bruising and a healing laceration on her forehead from a recent fall. The facility's policy on Electronic Health Records emphasized the importance of accurate and complete documentation, which was not adhered to in this case, leading to potential risks for the resident's safety and care quality.
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 79 citations issued within 25 miles in the last 12 months — including the 6 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Georgia Manor Nursing Home | 2.8 mi | ★★★★★ | 11 | 0 |
| Heritage Convalescent Center | 3.4 mi | ★★★★★ | 9 | 0 |
| Windflower Health Center | 3.4 mi | ★★★★★ | 1 | 0 |
| Amarillo Medical Lodge | 3.4 mi | ★★★★★ | 4 | 0 |
| Landmark Of Amarillo Rehabilitation And Nursing | 3.6 mi | ★★★★★ | 16 | 1 |
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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.