Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Weslaco Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to keep resident information private when an LPN left a medication cart computer screen unlocked and visible with a resident’s photo, DOB, and medication log. The facility also failed to maintain privacy during medication administration when an MA left the door, privacy curtain, and, in one case, the window open while giving meds and checking blood pressure for three residents, allowing others to see inside. The DON, ADON, and staff acknowledged that resident information should be protected and privacy maintained during care.
A resident with dementia, DM2, and chronic venous insufficiency had a PIV and IV medication orders, but the IV flush orders were discontinued while the catheter remained in place. The MAR and order summary showed no current flush orders, and an LPN stated he did not flush the IV because there were no physician orders. The DON verified the flush orders were discontinued and said the IV should have been discontinued at the same time.
Multiple infection control failures were observed in the LTC facility. A resident with a sacral pressure ulcer did not have an EBP sign posted outside the room, a medication aide did not perform adequate hand hygiene before and after med pass, a CNA did not sanitize hands between assisting two residents with meals, an IV dressing was not clearly labeled, and two CNAs reused wipes and missed hand hygiene during incontinent care for a resident with dementia and severe functional dependence.
A resident with dementia and severe cognitive impairment was receiving Zyprexa for anxiety/agitation and aggressive behavior related to restlessness and agitation while on hospice. The MAR and care plan documented the antipsychotic use, but the NP and DON acknowledged the resident did not have a diagnosis of psychosis, schizophrenia, or bipolar disorder, and the medication’s listed indication did not match the resident’s documented diagnosis.
Failure to Care Plan Enhanced Based Precautions: A resident with a Stage II pressure ulcer, DM2, and moderate cognitive impairment had a care plan for wound care and infection monitoring, but it did not include Enhanced Based Precautions. The physician order summary showed daily wound treatment orders, but no EBP order was present. An MDS nurse stated EBP should have been care planned, and the DON stated it was important to complete for a patient-centered care plan.
A CNA administered PRN liquid cough medication to a resident instead of the nurse, despite the resident’s care plan and physician order for the medication to be given by licensed staff. The resident said the CNA brought the cough medicine when the nurse was supposed to, and the CNA acknowledged she was not authorized to give meds and that it was her error; the RN said he poured the medication and handed it to the CNA while standing at the doorway.
A resident with CHF and acute/chronic respiratory failure was ordered oxygen at 2 LPM via NC every shift, but during observation the concentrator was set at 2.5 LPM. The resident said she needed oxygen all the time and could not reach the concentrator herself. An LVN said he checked the setting every 2 to 3 hours and last saw it at 2 LPM earlier in the day, while the DON said the charge nurse was responsible for checking oxygen settings.
Eye drops on a hall med cart were found without open dates, including Brimonidine and fluorometholone. CMA said medication aides were responsible for labeling eye drops when opened and that they expired 30 days after opening. The DON said charge nurses and med aides were responsible for checking eye drops, and the facility policy required nurses to monitor expiration dates and remove expired meds.
Kitchen Food Storage and Labeling Deficiency: Surveyors observed 3 juice pitchers in the refrigerator that were not labeled or dated, and 1 pitcher was left uncovered. A staff member said she did not know why the items were not labeled, while the DM stated labeling was needed for the 1st in 1st out process and that items should be covered to prevent contamination. The facility’s Food Storage Policy required refrigerated foods to be dated, labeled, and tightly sealed in approved covered containers.
A resident with a stage II pressure ulcer and Type 2 DM did not have a physician order for enhanced barrier precautions, even though the facility’s policy required an order for residents with wounds. The care plan addressed wound care and infection monitoring, but it did not include EBP. Staff interviews showed the nurse who found the wound was expected to enter the order, and the ADON and DON stated physician orders should be entered as soon as received.
A resident’s quarterly MDS assessments failed to code an active Anxiety diagnosis in Section I, even though the care plan identified Anxiety and the physician order summary included Buspirone for Anxiety Disorder. The MDS nurse confirmed the omission, and the DON confirmed the resident had Anxiety and that the MDS nurse was responsible for completing the assessments.
A resident with obstructive sleep apnea and hypertension required nightly BiPAP therapy, which was documented in the care plan, physician orders, and MAR, and the resident also had documented shortness of breath when lying flat. Despite this, the BiPAP treatment was not coded in Section O of the resident’s quarterly MDS. During interviews, the DON reported not knowing whether BiPAP should be captured on the MDS and deferred responsibility to MDS staff, while an LVN/MDS nurse acknowledged that BiPAP use met the 7-day lookback criteria and should have been coded according to CMS RAI Manual guidance.
A resident with vascular dementia, Parkinsonism, and hemiplegia who required extensive assistance with ADLs had an undated comprehensive care plan that did not include the use of grab bars, even though staff reported that grab bars were in place and used for holding and repositioning. The care plan addressed impaired skin integrity, dry skin, and pruritus, with interventions such as encouraging avoidance of scratching, routine skin inspections, and reporting scratches and changes in skin condition to nursing and the MD/NP. An LVN observed dry, scabbed scratches on the resident’s wrist but did not report them, believing only open or infection-risk wounds required notification, contrary to the documented care plan and facility policy requiring reporting of scratches and skin changes. The DON later confirmed that scratches should have been reported and that there was no specific policy for assessing grab bar use, despite their presence and use by the resident.
A resident with Alzheimer's Disease and severe cognitive impairment developed a new skin tear, but staff failed to perform a required head-to-toe skin assessment immediately after its discovery. Although the injury was reported among staff, no one completed the comprehensive assessment as outlined in facility policy, resulting in incomplete documentation and delayed evaluation of the resident's overall skin condition.
A resident with hypertension and moderate cognitive impairment was given nifedipine by an LVN even though her heart rate was below the ordered threshold, contrary to physician orders and facility policy. There was no documentation that the nurse or physician was consulted prior to administration.
A resident with multiple cardiac conditions had an Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form that was not fully completed, as it lacked the required physician's signature. Although the resident and responsible parties had signed the form and the DNR status was reflected in the care plan and electronic records, staff acknowledged the form was incomplete without the physician's signature. The process for obtaining the signature was delayed, and the incomplete form was still placed in the nurse's station binder.
A resident with multiple diagnoses, including dementia and gait abnormalities, experienced a witnessed fall that was documented in the care plan and progress notes. However, the fall was not coded in the discharge MDS assessment, as required, due to a breakdown in communication between nursing staff and the MDS department. This resulted in the resident's fall not being accurately reflected in the official assessment.
The facility did not update or implement comprehensive care plans for two residents, omitting a dementia diagnosis for one and failing to include antibiotic treatment for pneumonia for another. Staff interviews and record reviews confirmed that care plans were not promptly revised to reflect new diagnoses or treatments, contrary to facility policy and regulatory requirements.
A resident was administered Seroquel, an antipsychotic, without a proper supporting diagnosis, as the documented condition was dementia without behavioral or psychotic disturbances. Nursing staff and the ADON acknowledged that lewy body dementia alone is not an appropriate indication for antipsychotic use, and facility policy requires psychotropic medications to be used only when nonpharmacological interventions are contraindicated. Despite this, the medication was continued without clear clinical justification.
Surveyors found that a medication cart contained expired famotidine, and interviews with an LVN, ADON, and DON confirmed that nurses were responsible for checking and removing expired medications. The facility's policy required identification and removal of expired drugs, but this was not followed, resulting in noncompliance with professional standards.
A live roach was observed in a hallway, and staff interviews confirmed that while pest control services are provided monthly and sightings are logged, roaches have still been seen in the facility. The Administrator acknowledged there is no formal pest control policy, and records showed multiple recent roach sightings and treatments.
A resident with severe cognitive impairment experienced an alleged incident of physical abuse during a bed bath by two CNAs, which was reported by a hospice CNA. The facility failed to report the allegation to the State Survey Agency within the required timeframe, as their internal investigation found no substantiated evidence of abuse.
A facility failed to maintain an effective infection control program when a CNA entered a resident's room on contact precautions without donning the required PPE. The resident had an ESBL infection, and despite signage indicating the need for PPE, the CNA did not wear a gown or gloves. Interviews with staff revealed inconsistencies in understanding and following infection control policies.
The facility failed to ensure that physicians acted upon and documented their rationale in response to pharmacist recommendations for three residents, leading to delays in addressing medication evaluations and adjustments.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. During a kitchen observation, 27 gallons of expired water were found in the emergency water supply area. The Dietary Manager and Administrator acknowledged the issue, which violated the facility's Emergency and Disaster Planning policy requiring non-expired water supplies.
The facility failed to limit PRN orders for psychotropic drugs to 14 days without proper physician documentation for a resident with multiple diagnoses, including anxiety and major depressive disorder. The resident received Lorazepam PRN multiple times over two months without a stop date or physician evaluation, despite recommendations from the pharmacy consultant. Staff interviews revealed a lack of timely action on these recommendations, leading to non-compliance with the facility's policy and regulatory requirements.
The facility failed to ensure that two residents' Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) forms were fully and correctly completed, specifically lacking physician signatures. Staff interviews revealed inconsistencies in the process and understanding of obtaining the necessary signatures, and the facility did not have a specific policy concerning DNR forms.
The facility failed to report allegations of abuse involving a resident within the required 24-hour timeframe. An elderly female resident with Alzheimer's and dementia was observed being inappropriately touched by another resident. The incident was not reported immediately, and it was only after the resident's responsible party requested it that the local police and State Survey Agency were notified the following day. The delay in reporting violated the facility's policy and regulatory requirements.
The facility failed to implement a baseline care plan for a resident requiring maximum assistance for eating, leading to her being left hungry and thirsty. Despite hospital orders and an occupational therapy evaluation indicating total dependence, the resident was incorrectly assessed as needing only supervision, resulting in inadequate feeding assistance.
The facility failed to assist a resident with severe malnutrition and other health issues with eating, despite hospital orders indicating she required maximum assistance. Observations and interviews revealed that the resident was left without help during meals, leading to poor nutritional intake. Staff inconsistencies and communication failures contributed to the deficiency.
The facility failed to provide adequate respiratory care for two residents by not administering oxygen at the physician-ordered rate, not setting up suctioning equipment, and not properly documenting oxygen saturation levels. These failures placed the residents at risk of respiratory complications.
A resident was found with a tube of Gelmicin medication on his overbed table, which was brought in by a family member and not prescribed by the physician. Staff were aware but did not report or document the incident, and the resident's care plans did not reflect permission to self-medicate.
A resident with cognitive impairment and multiple medical conditions had family members bring in medication for personal use, which was not documented in the clinical records. Staff were aware but did not report or document the incident, violating the facility's documentation policy.
Failure to Protect Resident Privacy and Confidential Information
Penalty
Summary
The facility failed to keep resident personal and medical records private and confidential when a computer screen on a medication cart in the 400 hallway was left unlocked. During observation, the screen displayed an unknown resident’s photo, date of birth, and medication log. A surveyor asked nearby LVN A who the cart belonged to, and LVN A identified it as belonging to LVN C, who was in a room providing care to a resident. LVN A then locked the screen and went to locate LVN C. In an interview, LVN C stated she had been called to assist a resident while at her computer, pressed the lock button, and assumed the screen had locked. She stated she walked away without verifying that the screen was actually locked and acknowledged that the screen displayed resident personal and medical information. She stated that exposing that information was a HIPAA violation and that she had failed to lock it properly this time. The DON and Administrator stated staff had been in-serviced frequently on HIPAA and that resident information on computer screens should not be visible to unauthorized people. The facility also failed to maintain privacy during medication administration for three residents. MA J was observed administering medications, including eye drops, and checking blood pressure while leaving the door open, the privacy curtain open, and, for one resident, the window open. One resident’s roommate was seated between the two beds, and during another medication pass several people walked past the room and looked inside. MA J stated she was supposed to close the door, privacy curtain, and window before checking blood pressures and administering medications, but forgot to do so. The ADON and DON stated staff were expected to provide privacy during medication administration and other care, and the facility’s resident rights and medication administration policy stated that resident information must be kept confidential and privacy must be provided.
Failure to Maintain IV Flush Orders for a Resident with a Peripheral IV
Penalty
Summary
The facility failed to ensure parenteral fluids were administered in accordance with physician orders for one resident who had diagnoses including unspecified dementia, type 2 diabetes mellitus, and chronic peripheral venous insufficiency. Resident #7’s record showed IV medication use, and the care plan identified the resident as having Enhanced Barrier Precautions due to a PIV/surgical wound/pressure ulcer and being at risk for infection, depression, and decline in physical activity. The MAR reflected orders for ceftriaxone IV and for flushing the peripheral IV line with 10 mL of NS before and after each medication and every shift for patency, but those flush orders were discontinued on 7/16/26. On 7/27/26, the resident was observed sitting in a wheelchair with an IV catheter in the right hand; the site had no redness, swelling, pain, or discomfort. Record review showed there were no current orders to flush the IV catheter, and the order summary also reflected no orders to flush the IV catheter. During interview, the LVN stated he did not flush the IV because there were no physician orders and said the IV flush order had been discontinued on 7/16/26. The DON verified that the IV flush orders were discontinued on 7/16/26 and that the IV should have been discontinued at the same time, and stated the floor nurses were responsible for ensuring physician orders were received to maintain IV patency.
Infection Control Lapses During Wound Care, Hand Hygiene, IV Care, and Incontinent Care
Penalty
Summary
The facility failed to maintain infection prevention and control practices for multiple residents during observation, interview, and record review. Resident #39 had a stage II pressure ulcer to the left sacral area, diabetes mellitus, and moderate cognitive impairment. The record reflected wound care orders for cleansing and dressing the sacral wound, but there was no order for Enhanced Barrier Precautions and no care plan implemented to place the resident on enhanced barrier precautions. During observation, there was no EBP sign displayed outside the resident’s room. Staff interviews confirmed that the resident should have had a sign posted because of the wound, and that the sign was intended to alert staff to use appropriate PPE during care. Hand hygiene failures were observed during resident care and medication administration. During medication administration for Resident #84, a medication aide performed hand hygiene for 11 seconds before giving medications and 9 seconds afterward, despite stating that handwashing should be done for at least 20 seconds. Resident #84 had diabetes, chronic kidney disease, and CHF, and required partial to moderate assistance with personal hygiene and toileting hygiene. During meal assistance, CNA K assisted two residents with feeding and did not perform hand hygiene between assisting Resident #94 and Resident #45. Resident #94 had Parkinsonism, dementia, muscle wasting and atrophy, and required substantial to maximal assistance with eating; Resident #45 had cerebral palsy, dysphagia, muscle wasting and atrophy, and also required substantial to maximal assistance with eating. Resident #7 had IV therapy and a care plan identifying the need for Enhanced Barrier Precautions due to IV medication and wound-related risk. The resident’s IV dressing was observed without a clearly legible date label, and staff stated they could not determine when the dressing had last been changed. For Resident #61, who had Alzheimer’s disease, dementia, muscle wasting and atrophy, severe cognitive impairment, and dependence for toileting hygiene, CNA G and CNA H performed incontinent care with multiple infection control lapses. CNA G reused wipes on the urinary catheter tubing, vaginal area, and buttocks, and both CNAs failed to sanitize their hands between glove changes on multiple occasions. The facility policies reviewed addressed hand hygiene, perineal care, medication administration, and Enhanced Barrier Precautions, and staff interviews acknowledged the expected practices and the observed deviations.
Unnecessary Psychotropic Medication Use Without Appropriate Diagnosis
Penalty
Summary
The facility failed to ensure the right to be free from chemical restraint was provided for one resident reviewed for unnecessary medications. Resident #13, a female with diagnoses including dementia, depression, restlessness, and agitation, had a BIMS score of 03 indicating severe cognitive impairment and was receiving hospice services. During observation, she was in the dining area eating lunch, appeared groomed and dressed appropriately, and did not appear to be in distress. Record review showed Resident #13 was receiving Zyprexa (olanzapine) 2.5 mg by mouth daily for anxiety/agitation and aggressive behavior related to restlessness and agitation. Her care plan documented behaviors such as smearing feces, restlessness, and agitation, and also listed Zyprexa as part of her plan. The MAR showed the medication was given without missed doses, and behavior and side effect monitoring entries repeatedly noted no behaviors. The order summary reflected the resident was under hospice care, and the hospice nurse reordered Zyprexa. The manufacturer’s prescribing information reviewed by surveyors stated Zyprexa is indicated for schizophrenia, bipolar I disorder, and certain depressive episodes associated with bipolar disorder. In interview, the NP stated that anxiety/agitation and aggressive behavior related to restlessness and agitation were inappropriate diagnoses for Zyprexa and that the medication was more appropriate for psychosis, schizophrenia, or bipolar disorder. The DON stated the resident did not have a diagnosis of psychosis, schizophrenia, or bipolar, and acknowledged that agitation and restlessness were behaviors rather than diagnoses. The facility’s medication monitoring policy required a written diagnosis or indication to support medication use and documentation of clinical rationale when used outside state guidelines.
Failure to Care Plan Enhanced Based Precautions
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident that included measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs. Resident #39 was admitted with diagnoses including a Stage II pressure ulcer and Type 2 diabetes mellitus, and the MDS assessment showed a BIMS score of 09, indicating moderate impaired cognition. The resident’s care plan documented a Stage II pressure ulcer to the left sacral area with interventions to follow wound care orders and monitor for signs and symptoms of infection, but it did not include a care plan for Enhanced Based Precautions. The physician order summary reflected daily wound treatment for the left sacral Stage 2 pressure wound, including cleansing, Silvadene cream, adaptic gauze, dry dressing, and medfix retention tape, with a start date of 07/19/2026. There was no physician order for Enhanced Based Precautions. During interview, the MDS nurse stated she was responsible for developing the care plan and said Enhanced Based Precautions should have been care planned, but there was no order. The DON stated that Enhanced Based Precautions should have been care planned and that it was important to complete it to ensure the resident had a patient-centered care plan.
CNA Administered PRN Cough Medication
Penalty
Summary
The facility failed to provide care by qualified persons in accordance with the resident’s written plan of care when CNA D administered liquid cough medication to a resident with dysphagia, paraplegia, fibromyalgia, and intact cognition. The resident’s care plan noted that he had complaints of cough at times and had PRN medication in place to treat it, and the physician order was for guaifenesin oral liquid 200 mg/10 mL, 10 mL by mouth every 4 hours as needed for cough. During interview, the resident stated that CNA D gave him cough medicine and that the nurse was supposed to bring it to him. CNA D stated that the resident asked for cough medicine, that she told RN E, and that she gave the medication while RN E stood by the resident’s door. CNA D acknowledged that CNAs were not authorized to give medication and said it was her error to give it. RN E stated he poured the medication into a cup and handed it to CNA D while he stood at the doorway to ensure safety, and the DON later confirmed she was informed of the grievance regarding the CNA giving the medication.
Oxygen Flow Setting Not Maintained as Ordered
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with combined CHF, acute and chronic respiratory failure, dyspnea, and hypertension. The resident’s care plan directed oxygen therapy via nasal cannula as ordered, and the physician’s order required oxygen at 2 LPM via NC every shift for hypoxia related to acute and chronic respiratory failure. During observation, the resident was in bed with the head of the bed elevated, had a nasal cannula in place, and was not in respiratory distress, but the oxygen concentrator was set at 2.5 LPM rather than the ordered 2 LPM. The resident stated she needed oxygen all the time and could not reach the concentrator herself. An LVN stated he checked the resident every 2 to 3 hours and had last checked around noon, when the setting was at 2 LPM, but did not know how it had been moved and suggested vibration from the concentrator could have caused it. The DON stated the charge nurse was responsible for checking oxygen settings, and the Administrator stated staff had been in-serviced on reading the oxygen flow meter and that concentrators had been serviced as a preventive measure.
Eye Drops Left Without Open Dates on Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and labeled in accordance with accepted professional principles for 1 hall 300 medication cart of 4 medication carts reviewed. During an observation on 7/26/26 at 2:10 p.m., two boxes of Brimonidine eye drops and one box of fluorometholone eye drops were found on the Hall 300 med aide medication cart without an open date written on them. The report states that eye drops were to be labeled with an open date when first opened, and that they expired 30 days after opening. During an interview on 7/26/26 at 2:20 p.m., CMA J said it was the medication aide's responsibility to check and ensure eye drops were labeled with an open date, and that she would not know when the medication expired without that date. She also said the ADON and pharmacy consultant checked eye drops to ensure they were labeled. During an interview on 7/28/2026 at 2:15 p.m., the DON said the facility labeled OTC medications, insulin, and eye drops with an open date, and that charge nurses and medication aides were responsible for checking eye drops. Record review of the facility policy titled, Expiration Dating and Expired Medication, dated 10/01/19, stated that all nurses who administer medications were responsible for monitoring expiration dates and that expired medications were not to be administered.
Kitchen Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. On 07/26/26 at 10:15 AM, observation of the refrigerator revealed 3 juice pitchers that were not labeled or dated when made, and 1 of the pitchers did not have a lid on it. During an interview at 10:17 AM, the staff member stated she did not know why the food items had not been labeled. The DM stated that labeling the juice pitchers was important because of the 1st in 1st out rule and that food not used could expire. The DM also stated that if expired food was served to residents, they could get sick or get food poisoning, and that items should be covered to prevent things from falling inside the container that could cause residents to get sick. The DM stated it was the responsibility of the person who made the food or drink to label it. Record review of the Food Storage Policy with a revised date of 06/01/19 stated that refrigerated foods must be dated, labeled, and tightly sealed in clean, nonabsorbent, covered containers approved for food storage.
Missing EBP Order for Resident With Pressure Ulcer
Penalty
Summary
The facility failed to ensure medical records were maintained in accordance with accepted professional standards for 1 of 16 residents reviewed, Resident #39. Resident #39 was a [AGE] year-old male admitted on [DATE] with diagnoses including Stage II pressure ulcer and Type 2 diabetes mellitus. His MDS assessment dated 05/26/2026 showed a BIMS score of 09, indicating moderate impaired cognition. His care plan reflected a stage II pressure ulcer to the left sacral area with interventions to follow wound care orders and monitor for signs and symptoms of infection, but it did not include enhanced barrier precautions. Record review showed a physician order summary dated 07/26/2026 with wound treatment orders starting 07/19/2026 for the left sacral pressure wound, but there was no physician order for enhanced barrier precautions. During interviews, the LVN stated the nurse who found the wound was responsible for entering the enhanced barrier precaution order and said she did not know the order was missing. The ADON and DON stated nurses were responsible for entering physician orders and that the order should be entered as soon as it was received. The DON also stated the order was needed so the intervention could be care planned, signage posted, and the resident protected from unnecessary bacteria transmitted from staff clothing during care. The facility's Enhanced Barrier Precautions policy stated an order would be obtained for residents with wounds.
MDS assessments omitted active anxiety diagnosis
Penalty
Summary
Resident #10’s Quarterly MDS assessments dated 03/12/2026 and 06/08/2026 were not coded to include the resident’s diagnosis of Anxiety in Section I, Active Diagnoses, Psychiatric/Mood Disorder. Record review showed the resident’s face sheet listed diagnoses including Depression, Anemia, Muscle Wasting and Atrophy, and Type 2 Diabetes Mellitus, and the 06/08/2026 MDS reflected a BIMS score of 07, indicating severe cognitive impairment; the earlier quarterly MDS reflected a BIMS score of 05, also indicating severe cognitive impairment. The resident’s care plan, though not dated, identified Anxiety and included interventions to administer medication as ordered, obtain behavioral health consults as needed, and notify the MD and RP if signs and symptoms of anxiety were not relieved or increased in frequency and intensity. The physician order summary reflected Buspirone 10 mg for Anxiety Disorder with a start date of 02/25/2026. During interview, the MDS nurse confirmed that Anxiety should have been coded on both quarterly MDS assessments but was omitted, and the DON confirmed the resident had a diagnosis of Anxiety and that the MDS nurse was responsible for completing the assessments.
Failure to Accurately Code BiPAP Use on MDS Assessment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an accurate MDS assessment for one resident who used a BiPAP device. The resident was admitted with diagnoses including obstructive sleep apnea and hypertension. The resident’s quarterly MDS showed a BIMS score of 14, indicating cognitively intact status, and documented shortness of breath when lying flat. However, in Section O (Special Treatments, Procedures, and Programs), the item for non-invasive mechanical ventilator/BiPAP (O0110G1/G2) was not checked, despite the resident’s ongoing BiPAP use. Record review showed the resident’s comprehensive care plan, initiated on 02/19/2026, documented the need for BiPAP to treat sleep apnea and included multiple respiratory-related interventions. Physician orders reflected active BiPAP settings of 14/9 to be used nightly, and the MAR showed BiPAP use on each day reviewed in April. During interviews, the DON stated she did not know whether BiPAP should be captured on the MDS and indicated MDS staff were responsible for completion. The LVN/MDS nurse confirmed that BiPAP use should be coded on the MDS if used within the 7-day lookback period, acknowledged that the MAR showed daily BiPAP use, and stated that the device should have been reflected on the most recent quarterly MDS. CMS RAI Manual guidance cited in the report specifies that CPAP/BiPAP devices must be coded in Section O when used, confirming that the resident’s BiPAP treatment met criteria for inclusion but was omitted from the assessment.
Failure to Care Plan Grab Bar Use and to Follow Skin Integrity Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident, and failure to follow the existing care plan related to skin integrity. The resident had vascular dementia, Parkinsonism, and left-sided hemiplegia/hemiparesis following a cerebral infarction, and was cognitively intact with a BIMS score of 14. The resident required substantial/maximal assistance for personal hygiene, dressing, bathing, toileting hygiene, and was dependent for lower body dressing and footwear. The most recent comprehensive care plan, which was undated, did not include the resident’s use of grab bars, despite multiple staff acknowledging that grab bars were in place and used by the resident to hold on and assist with repositioning. The care plan did address the resident’s risk for impaired skin integrity related to decreased mobility, friction/shear, incontinence, dry skin, and itching/pruritus. Interventions included encouraging the resident to avoid scratching, keeping fingernails short, performing skin inspections with care and as needed, observing for redness, open areas, scratches, cuts, bruises, and reporting changes to the nurse, and notifying the MD/NP of changes in skin condition. These interventions were initiated and revised on multiple dates, and the facility’s Comprehensive Care Plans policy required that care plans include measurable objectives and timeframes to meet identified needs, and that qualified staff be notified of their responsibilities for carrying out interventions. Despite these care plan directives, a nurse (LVN B) observed dry, scabbed, healed scratches on the resident’s left wrist during a shift and did not report them to the MD/NP or document them as a change in skin condition. LVN B stated that the scratches were already scabbed over, with no redness or swelling, and believed that only open wounds or scratches at risk for infection needed to be reported, even though the care plan specified reporting scratches and changes in skin condition. The treatment nurse later confirmed she had not previously noticed the scratches and only became aware of them after they were brought to her attention, and the DON stated that if staff noted scratches, they were expected to call the MD or NP and enter a progress note, even if the scratches were dried and scabbed over. Additionally, the DON acknowledged that grab bars were used by the resident and that the facility typically care planned such items, but there was no policy addressing assessment of grab bars, and the resident’s care plan and orders did not reflect their use.
Failure to Perform Timely Head-to-Toe Skin Assessment After New Skin Tear
Penalty
Summary
A deficiency occurred when staff failed to perform a head-to-toe skin assessment immediately after discovering a new skin tear on a female resident with Alzheimer's Disease and severe cognitive impairment. The resident was identified as being at risk for impaired skin integrity due to incontinence, friction/shear, and decreased mobility, with care plan interventions requiring weekly and as-needed skin inspections. On the day the skin tear was found, the MDS nurse noted the injury and informed the charge nurse, but neither conducted a full head-to-toe assessment as required by facility policy and professional standards. Documentation shows that a skin assessment was not performed on the day the wound was discovered. Interviews with the wound care nurse, MDS nurse, and charge nurse confirmed that all were aware of the need for a comprehensive skin assessment after a new wound is found, but each believed the responsibility lay with another staff member. The facility's policy required detailed documentation of skin assessments, including wound description and other relevant observations, which was not completed at the time of the incident. The deficiency was identified through observation, record review, and staff interviews, with the resident's skin tear later observed to be nearly healed.
Failure to Hold Antihypertensive Medication for Low Heart Rate
Penalty
Summary
A significant medication error occurred when a resident with a history of essential hypertension and a moderate cognitive impairment was administered nifedipine extended release 90 mg, a blood pressure medication, despite her heart rate being below the physician-ordered parameter. The resident's medication order specified that nifedipine should be held if systolic blood pressure was less than 100 or heart rate was less than 60, and the nurse should be notified. On the date in question, the resident's heart rate was recorded at 56, but the medication was still administered by an LVN. Interviews with the LVN and the Director of Nursing (DON) confirmed that the facility's policy and the physician's order required the medication to be held and the nurse or physician to be notified if vital signs were outside the specified parameters. There was no documentation that the LVN consulted with a nurse or physician before administering the medication. The facility's policy on medication administration also required holding medications for vital signs outside prescribed parameters, which was not followed in this instance.
Failure to Obtain Physician Signature on OOH-DNR Form
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form was properly completed, specifically lacking the required physician's signature. The resident in question was a cognitively intact female with multiple cardiac-related diagnoses, including syncope, hypertensive urgency, mitral valve disorder, atrioventricular block, paroxysmal atrial fibrillation, and somnolence. Her care plan and physician orders indicated a DNR status, and the resident had signed the OOH-DNR form, but the attending physician had not signed the document as required. Interviews with facility staff revealed that the process for completing DNR forms involved the social worker providing the form to the resident or family, obtaining necessary signatures, and then forwarding the form to medical records for the physician's signature. Staff acknowledged that the DNR form was not considered complete without the physician's signature, but the form was still placed in the binder at the nurse's station even if incomplete. The medical records staff stated that they attempted to obtain the physician's signature within 24 hours, but in this case, the form remained unsigned by the physician until the surveyor's inquiry. Further interviews with nursing and administrative staff confirmed that the code status was updated in the electronic record system and DNR binder based on the resident or responsible party's signature, even if the physician had not yet signed the form. Staff also indicated that there was no set timeframe for obtaining the physician's signature, and the process could be delayed if the physician was not present in the facility. The facility's policy required that advance directives be supported and facilitated, but the lack of a physician's signature on the OOH-DNR form meant the directive was incomplete at the time of review.
Failure to Accurately Code Resident Fall in MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status, specifically by not coding a witnessed fall that occurred on 3/30/25. Record reviews showed that the resident, who had diagnoses including muscle wasting, lack of coordination, gait abnormalities, dementia, and Alzheimer's disease, experienced a fall that was documented in the incident log, care plan, and progress notes. The care plan and progress notes indicated that the fall was witnessed, and appropriate notifications and monitoring were documented at the time of the incident. Despite this documentation, the discharge MDS assessment did not indicate that the resident had experienced a fall since admission or prior assessment, as required by CMS's RAI Version 3.0 Manual. Interviews with facility staff confirmed that the fall should have been captured in the MDS, and its omission was attributed to a lack of communication between nursing staff and the MDS department. The MDS coordinator acknowledged that the fall was not coded and explained that this could result in incomplete information being communicated to subsequent care providers.
Failure to Update and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulatory standards. For one resident with a diagnosis of dementia and Alzheimer's disease, the most recent care plan did not include dementia as an active diagnosis, despite the resident's medical record and MDS assessment indicating its presence. Interviews with facility staff revealed that the care plan was not updated to reflect this diagnosis, with staff citing a lack of recent physician documentation and a high BIMS score as reasons for omission. The MDS nurse acknowledged that dementia was included on the MDS due to hospital discharge information but was not care planned because it was not considered an active diagnosis by the physician at the time. Another resident, who was being treated for pneumonia with antibiotics, did not have this treatment reflected in their care plan. The care plan, dated prior to the pneumonia diagnosis and antibiotic order, was not updated to include the new medical intervention. Staff interviews confirmed that the care plan should have been updated immediately upon receipt of the antibiotic order, and failure to do so could impact the delivery of necessary care. The facility's policy requires that care plans be updated promptly to reflect new diagnoses and treatments, but this was not followed in this instance. Record reviews and staff interviews consistently indicated that the lack of timely updates to care plans could result in gaps in communication and care delivery. The facility's own policy mandates the inclusion of measurable objectives and timeframes in care plans to address all identified needs, but these requirements were not met for the two residents in question. The findings demonstrate that the facility did not ensure care plans were current and comprehensive, as required by both internal policy and federal regulations.
Antipsychotic Medication Administered Without Proper Diagnosis
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by administering Seroquel (quetiapine), an antipsychotic medication, without a proper diagnosis supporting its use. The resident in question had a diagnosis of unspecified dementia without behavioral or psychotic disturbances, as well as hallucinations, but the documentation did not indicate behavioral symptoms that would warrant antipsychotic therapy. The care plan and medical records showed the medication was ordered for 'lewy body dementia with behavioral disturbance,' but interviews with nursing staff and the ADON revealed that lewy body dementia alone is not an appropriate diagnosis for antipsychotic use, and staff were aware of the associated risks and black box warning for elderly patients with dementia-related psychosis. Despite the presence of a facility policy stating that psychotropic medications should only be used when nonpharmacological interventions are contraindicated and not for discipline or staff convenience, the medication was continued without clear justification. Staff interviews indicated confusion regarding the appropriateness of the diagnosis for Seroquel, and the DON confirmed that the physician provided the diagnosis but did not clarify the clinical rationale. The resident did not exhibit side effects at the time of review, but the facility did not address the lack of a proper diagnosis for the ongoing use of the antipsychotic medication.
Expired Medication Found on Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were stored and labeled according to professional standards on one of four medication carts. Specifically, a box of famotidine 10mg with an expiration date of 4/2025 was found on the 200 hall nurse's medication cart after its expiration date. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that nurses were responsible for checking expiration dates and removing expired medications from the carts. The staff acknowledged that expired medications could be less effective or potentially cause adverse effects. A review of the facility's Medication Administration policy indicated that medications are to be administered by licensed nurses in accordance with professional standards, including identifying and notifying the nurse manager of expired medications. Despite this policy, expired medications were not removed from the medication cart as required, resulting in noncompliance with storage and labeling standards for drugs and biologicals.
Deficient Pest Control Measures Result in Roach Sightings
Penalty
Summary
The facility failed to maintain effective pest control, as evidenced by the presence of a live roach observed in the hallway of the 400 hall. Staff responses included an LVN stepping on the roach and housekeeping staff cleaning it up. Interviews with staff members, including a CNA, LVN, Maintenance Director, Environmental Supervisor, and Administrator, revealed that while pest control services are provided monthly and a pest control sighting logbook is maintained at the nurse's station, sightings of roaches have occurred and are documented. The logbook showed entries for roach sightings in April and May, and pest control invoices confirmed that treatments were performed in response to these reports. Despite these measures, the facility did not have a formal pest control policy in place, as stated by the Administrator. Staff described a process for reporting and addressing pest sightings, including deep cleaning and communication with pest control vendors, but the continued presence of roaches indicated that these actions were not fully effective in preventing pest activity within the facility. The deficiency was identified through direct observation, staff interviews, and review of pest control documentation.
Failure to Report Alleged Abuse During Bed Bath
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident during a bed bath, which was conducted by two CNAs. The incident was initially reported by a hospice CNA who observed the facility CNAs taking over the bed bath in a harsh manner, with one CNA holding the resident's hands while the other poured water over her head. The resident was reportedly upset by this treatment, and the hospice CNA intervened to complete the bath herself. The incident occurred on March 10, but was not reported to the facility's administration until March 12. The resident involved in the incident is an elderly female with severe cognitive impairment, as indicated by a BIMS score of 07. Her medical history includes dementia, chronic kidney disease, atherosclerotic heart disease, hypertension, and she is receiving palliative care. The resident has a care plan addressing episodes of smearing feces, which includes interventions such as behavioral health consults and routine incontinent care. Despite the hospice CNA's report, the facility's administrator did not report the allegation to the State Survey Agency, as they conducted an internal investigation and found no substantiated evidence of abuse. The facility's policy requires reporting of all alleged violations within specified timeframes, but this was not adhered to in this case. Interviews with the involved CNAs and the resident did not yield any direct allegations of abuse, and the facility's administrator believed the investigation was sufficient to dismiss the need for external reporting.
Inadequate Use of PPE in Contact Precaution Room
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA E, who did not don the appropriate personal protective equipment (PPE) before entering the room of a resident on contact precautions. The resident, a cognitively intact male with a history of heart failure, type 2 diabetes mellitus, and an ESBL infection in the urine, was on contact isolation due to the ESBL infection. Despite the signage indicating contact precautions, CNA E entered the resident's room without wearing a gown or gloves, moved the resident in his wheelchair, and adjusted the bedside table without using the required PPE. Interviews with various staff members, including CNA E, LVN F, CNA G, LVN ADON H, and the DON, revealed a lack of consistent understanding and adherence to the facility's infection control policies. CNA E incorrectly believed that PPE was not necessary without direct contact with the resident, while other staff members confirmed that PPE should be worn every time when entering a room with contact precautions. The facility's policy, aligned with CDC guidelines, mandates the use of PPE to prevent the transmission of infections, but the failure to adhere to these protocols was evident in this incident.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that physicians acted upon and documented their rationale in response to pharmacist recommendations for three residents. For Resident #35, the physician did not provide a rationale for the continued use of Lorazepam, Hydroxyzine, and Clonazepam until after surveyor intervention. The pharmacist had recommended a gradual dose reduction for these medications, but the physician's response was delayed and only provided after the surveyor's involvement. Additionally, the physician's rationale for extending the PRN order for Lorazepam was not documented in a timely manner. For Resident #58, the physician did not respond promptly to the pharmacist's recommendation to evaluate the continued use of Omeprazole. The pharmacist had noted that long-term use of Omeprazole could lead to increased risks of C. Diff Colitis, CAP, and B12 deficiency. The physician eventually responded by discontinuing Omeprazole and prescribing Famotidine, but this response was delayed and only occurred after the surveyor's intervention. For Resident #87, the physician did not address the pharmacist's recommendation to review the continued use of Lithium and Zyprexa. The pharmacist had recommended evaluating these medications due to their potential side effects and the need for gradual dose reduction. The facility staff failed to obtain a timely response from the physician, and the pharmacist's recommendations remained unaddressed until after the surveyor's involvement. Interviews with facility staff revealed that the responsibility for obtaining physician responses was not clearly managed, leading to delays in addressing the pharmacist's recommendations.
Expired Emergency Water Supply
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety. During an observation of the kitchen, 27 gallons of water with a use-by date that had already passed were found stored in the emergency water supply area. The Dietary Manager, who was newly hired, acknowledged the presence of the expired water and stated that it had been there before her tenure. The Administrator also confirmed the issue and indicated that the expired water would be replaced. The facility's Emergency and Disaster Planning policy mandates that emergency water supplies must be stored under sanitary conditions and not be expired, which was not adhered to in this instance.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner documented that it was appropriate for the PRN order to be extended beyond 14 days. This deficiency was identified for one resident, a female with multiple diagnoses including convulsions, functional quadriplegia, delusion disorders, tremors, anxiety, diabetes, and major depressive disorder, who was under hospice care. The resident had an order for Lorazepam 0.5mg PRN for anxiety, which was administered multiple times over January and February without a stop date or physician evaluation for continued treatment beyond 14 days. The pharmacist consultant recommended compliance with the CMS Mega Rule Phase II, but the facility did not act on this recommendation in a timely manner, leading to the continued administration of the medication without proper documentation or evaluation by the physician. Interviews with facility staff revealed a lack of clarity and follow-through on the pharmacy consultant's recommendations, resulting in the failure to obtain a timely response from the prescribing physician. The facility's policy on psychotropic medication requires that such drugs are only given when necessary to treat a specific condition, with PRN orders limited to 14 days unless extended by a documented physician's rationale. Despite this policy, the facility did not adhere to these guidelines for the resident in question. The ADON and other staff members acknowledged the oversight and the potential adverse effects of not addressing the pharmacy consultant's recommendations promptly. The deficiency highlights a gap in the facility's process for managing PRN psychotropic medications and ensuring compliance with regulatory requirements.
Failure to Ensure Complete DNR Forms
Penalty
Summary
The facility failed to ensure that residents' Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) forms were fully and correctly completed, specifically lacking physician signatures. This deficiency was identified for two residents, one with chronic obstructive pulmonary disease, diabetes, and hypertension, and another with cerebral infarction, quadriplegia, atrial fibrillation, hypertension, and gastrostomy status. Both residents had documented DNR statuses in their care plans and medical records, but their OOH-DNR forms were missing the required physician signatures. Interviews with facility staff revealed that the social worker was responsible for obtaining the DNR forms and ensuring they were signed by the resident or their representative and witnesses. However, there was a lack of clarity and consistency in the process for obtaining the physician's signature. Staff members indicated that they considered the DNR forms valid as long as they were signed by the resident or their representative and witnesses, even if the physician's signature was missing. This practice was contrary to the requirement that a physician's signature is necessary for the DNR form to be valid. Further interviews highlighted that the facility did not have a specific policy concerning DNR forms, and there was confusion among staff about the correct procedure to follow when a resident coded. Some staff members believed that the DNR status should be honored based on the signatures of the resident or their representative and witnesses alone, while others understood that the physician's signature was also required. This inconsistency in understanding and practice could lead to residents' code status wishes not being honored in critical situations.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving Resident #49 within the required 24-hour timeframe to the State Survey Agency. Resident #49, an elderly female with Alzheimer's disease, dementia, and other mental health conditions, was observed by staff to have her breast area touched by Resident #1 while they were both in their wheelchairs. Despite the incident being observed and Resident #1 being moved to another hall, the facility did not report the incident immediately as no allegations were made at the time. It was only after Resident #49's responsible party (RP) requested the incident be reported to authorities the following day that the local police department was notified, and the incident was reported to the State Survey Agency later that evening. The investigation findings were unconfirmed for abuse, but the delay in reporting was a clear violation of the facility's policy and regulatory requirements. The Administrator acknowledged familiarity with the reporting timeline but could not explain the delay in reporting the incident. The facility's policy mandates immediate reporting of abuse allegations within two hours if serious injury is involved, or within 24 hours if not. The failure to adhere to this policy could place residents at increased risk for potential abuse and neglect due to unreported allegations.
Failure to Implement Baseline Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to implement a baseline care plan for Resident #268 that included necessary instructions for feeding assistance upon her admission. Resident #268, a [AGE] year-old female with severe protein-calorie malnutrition, kyphosis, and adult failure to thrive, was admitted with hospital orders indicating she required maximum assistance for eating. However, the baseline care plan only noted that she needed setup or clean-up assistance for eating, which was insufficient given her condition. Observations revealed that Resident #268 was unable to feed herself and was not provided with the necessary assistance, leading to her being left hungry and thirsty on multiple occasions. Upon admission, the charge nurse assessed Resident #268 and observed her attempting to eat on her own, leading to the incorrect assumption that she only required supervision. This information was verbally communicated to the CNAs, who then failed to provide the necessary feeding assistance. Subsequent observations and interviews with staff indicated that Resident #268 was left without adequate support for eating, despite her evident inability to feed herself due to her physical and cognitive limitations. The occupational therapy evaluation conducted later confirmed that Resident #268 was totally dependent on assistance for all activities of daily living, including eating. Interviews with various staff members, including the Rehab Director and occupational therapist, highlighted a lack of communication and proper documentation regarding Resident #268's needs. The facility's policy required the development of a baseline care plan that included dietary orders and necessary assistance with activities of daily living, but this was not effectively implemented. The failure to address Resident #268's feeding assistance needs in her baseline care plan resulted in her not receiving the care and services required for her health and well-being.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. Resident #268, a [AGE] year-old female with severe protein-calorie malnutrition, kyphosis, and adult failure to thrive, was admitted with hospital orders indicating she required maximum assistance for eating. Despite these orders, the facility's baseline care plan only noted set-up or clean-up assistance for eating. Observations and interviews revealed that Resident #268 was not provided with the required assistance during meals, leading to poor nutritional intake and potential weight loss. On multiple occasions, Resident #268 was observed without assistance during meal times. On 03/12/24, she was seen sitting with her food plate in front of her but not eating, and no CNA was assisting her. Later, a CNA was observed removing her meal tray, which was untouched, and incorrectly stated that the resident only required supervision. The resident herself reported being hungry and thirsty and stated that no one had assisted her with eating. Further observations showed that staff did not respond to her requests for water, indicating a lack of proper care and attention to her needs. Interviews with facility staff revealed inconsistencies in the understanding and communication of Resident #268's care needs. The charge nurse and CNA's failed to follow hospital recommendations and did not report the resident's poor meal intake to the appropriate personnel. The dietary manager's records showed fluctuating meal intake percentages, with significant instances of low intake. The Assistant Director of Nursing acknowledged that the CNA should have assisted the resident with her meals, highlighting a failure in staff training and communication regarding the resident's care requirements.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice. For Resident #36, the facility did not administer oxygen at the physician-ordered rate of 5.0 Lpm via trach mask. Observations revealed that the oxygen was set at 4.5 Lpm on multiple occasions. Additionally, the suctioning equipment for Resident #36 was not set up or connected at the bedside, which is necessary for emergency use. Interviews with staff confirmed these discrepancies and highlighted a lack of adherence to the physician's orders and facility protocols for respiratory care. For Resident #57, the facility failed to monitor and document oxygen saturation levels in percentage as ordered by the physician. The resident's records showed that oxygen saturation levels were not consistently documented in percentage form, and instead, check marks were used. This lack of proper documentation could lead to unrecognized drops in oxygen saturation levels. Interviews with staff confirmed that oxygen saturation should be documented in percentage to ensure accurate monitoring. Both residents had significant medical histories that required diligent respiratory care. Resident #36 had multiple severe conditions, including respiratory failure with hypoxia and a tracheostomy, while Resident #57 had chronic obstructive pulmonary disease and other serious health issues. The facility's failure to follow physician orders and properly document care placed these residents at risk of respiratory complications and decreased quality of care.
Failure to Store Medications in Locked Compartments
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in locked compartments for one of eight residents reviewed for medication storage. Resident #50 was observed with a tube of Gelmicin medication on his overbed table, which he used for itching on his arms and legs. The medication was brought in by a family member from Mexico and was not prescribed by the resident's physician. The resident's care plans did not reflect any evidence that he was allowed to self-medicate, and there were no physician orders permitting self-administration of medications. Interviews with staff revealed that they were aware of the resident's use of the Gelmicin medication but had not reported it to the charge nurse or documented it in the resident's clinical chart. The Licensed Vocational Nurse (LVN) had spoken to the family member multiple times about the issue and had attempted to remove the medication from the resident's possession, but the family member continued to bring it back. The LVN had also contacted the resident's physician to prescribe an alternative medication for the itching but had not received a response until later. Further interviews with the Assistant Director of Nursing (ADON) and other staff members confirmed that residents were not allowed to keep their own medications unless permitted by a doctor's order. The staff had not documented the incident or informed the Director of Nursing (DON). The facility's policy on medication administration stated that residents are allowed to self-administer medications only when specifically authorized by the attending physician, which was not the case for Resident #50.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident who had family members bring in medications for personal use. The resident, who had moderately cognitive impairment and various medical conditions including cirrhosis of the liver and diabetes, was observed with a tube of Gelmicin medication on his overbed table. This medication was not documented in the resident's clinical chart, and there was no physician's order allowing the resident to self-administer it. Interviews with the resident and staff revealed that the family had been bringing in the medication from Mexico, and the staff were aware but had not documented this information or taken appropriate action to address it. The resident's care plans did not indicate that he would self-medicate, and there were no physician orders for self-administration of medications. Despite being aware of the situation, the staff, including a CNA and an LVN, did not report the incident to the charge nurse or document it in the resident's clinical records. The LVN had spoken to the family and the resident's physician about obtaining a similar medication but had not documented these communications. The facility's policy required accurate and timely documentation of all assessments, observations, and services provided, which was not followed in this case. Interviews with additional staff, including the ADON and RN, confirmed that residents were not allowed to keep personal medications without a doctor's order and that the staff should have documented the incident and informed the DON. The failure to document and address the resident's use of personal medication placed the resident at risk and was not in compliance with the facility's documentation policy.
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 264 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
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 Weslaco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Grande Manor | 0.6 mi | ★★★★★ | 20 | 0 |
| Windsor Nursing And Rehabilitation Center Of Wesla | 1.1 mi | ★★★★★ | 10 | 1 |
| Mid Valley Nursing & Rehabilitation | 7 mi | ★★★★★ | 20 | 0 |
| Veranda Rehabilitation And Healthcare | 8.2 mi | ★★★★★ | 7 | 0 |
| The Heights Of Alamo | 8.9 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.