Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Janisch Health Care Center during CMS and state inspections, most recent first.
A fire occurred in one hall, resulting in the death of a resident who was dependent on staff for all care. Staff were unable to access the hall for several minutes due to locked doors triggered by the fire alarm, delaying emergency response. After the fire was extinguished, staff did not assess or render aid to the affected resident, and some residents were left unattended or not evaluated after evacuation. Staff had not been trained on emergency response for severe burns, and the facility had known about the door access issue for months without resolving it.
Staff failed to promptly extinguish a fire involving a resident, used a non-fire retardant blanket that worsened the flames, and did not assess or render aid after the fire was out, resulting in the resident's death. Multiple residents were left in their rooms during the fire, leading to prolonged smoke exposure, and the facility did not follow its fire safety plan. The affected resident had significant mobility limitations and was dependent on staff for care.
The facility did not follow its approved menus for resident meals, making undocumented substitutions without registered dietitian approval and failing to post menus as required. A resident received a meal missing a side, and desserts were changed due to budget constraints, with no evidence of proper oversight. Staff interviews confirmed that menu changes were made based on preferences and cost, but without the necessary documentation or approval, placing residents at risk of inadequate nutrition.
Failure to follow up on an implanted port removal order. A resident with severe cognitive impairment, cancer history, and an indwelling port to the R upper chest had a physician order for oncology evaluation for port removal, but the facility did not act on it for weeks and did not document communication with the RP or family about the port’s use, maintenance, or removal. The resident reported pain and discomfort from the port, while the DON and ADON stated staff were expected to monitor ports and follow up on the need for the device.
A fire in a resident room resulted in one fatality and smoke exposure to 22 residents. The administrator did not report the incident to the State Survey Agency within the required two-hour window. Staff extinguished the fire and evacuated residents, but the resident who died did not receive an immediate nursing assessment after the fire. The deceased had significant medical needs and was a compliant smoker. Other residents in the affected area had cognitive and physical impairments and were also exposed to smoke.
Two residents' MDS assessments were found to be inaccurate: one resident with left-sided paralysis and total dependence for ADLs was not documented as having functional limitations or paralysis, and another resident with severe cognitive impairment and a history of wandering was not initially documented as exhibiting wandering behavior, despite frequent observations and care planning for such. Staff interviews and record reviews confirmed these discrepancies, and responsible staff acknowledged the errors as oversights.
A resident's care plan was not updated by the interdisciplinary team to reflect the removal of a urinary catheter and the resolution of a pressure ulcer, despite medical records and staff confirming these changes. The care plan continued to list both issues as active until surveyor intervention, and staff interviews revealed confusion about who was responsible for updating care plans.
A facility failed to promptly notify the RP and follow up on physician-ordered changes for two residents. One resident developed a new cough with diminished lung sounds and had a CXR ordered to rule out pneumonia, but the order was not completed for several days and the RP was not notified until later. Another resident had an oncology order for evaluation of an implanted port causing discomfort, yet the chart showed no earlier family notification about the port or the need for removal; the resident later reported pain at the port site and the RP said the family had not been informed.
A facility failed to ensure an LPN was competent to administer meds via g-tube and understand EBP for a resident with a PEG tube, hemiplegia, and hemiparesis. During observation, the LPN gave meds through the g-tube with residue left in medication cups, did not know what EBP meant, and discarded a medication cup in the resident’s trash. The DON later said the facility could not find training records and had never assessed the LPN’s g-tube competency, despite policies requiring EBP training and separate administration of enteral tube meds.
A resident with hemiplegia, hemiparesis, and PEG tube status received G-tube meds with residue left in the cups after administration of a multivitamin, sennosides-docusate sodium, vitamin C, and thiamine. Surveyors observed an LPN administering the meds and identified a 9% med error rate, with the LPN stating she had no orientation training on G-tube administration and had shadowed another nurse who gave all G-tube meds together.
An LVN crushed a resident's ordered Metoprolol for G-tube administration, then later discarded the cup with the medication in the resident's room trash after a BP check could not be completed because the cuff battery was low. The LVN said meds should go in the sharps container on the med cart, and the consultant pharmacist stated unopened or unused meds should be placed where no one could reach them.
Delayed Chest X-Ray Follow-Up: A resident with a G-tube, prior pneumonia, and severe cognitive impairment had a provider order for a CXR after cough, congestion, and diminished lung sounds were noted. The order was entered and confirmed, but nursing did not document or follow up on it, and the x-ray was not completed until several days later. The DON said the RN failed to document the order and follow up, and the MD said the delay was not acceptable.
Failure to Use Required Gown During Wound Care: An LVN provided wound care to a resident on Enhanced Barrier Precautions without wearing the required gown. The resident had DM2 with a foot ulcer and osteomyelitis, and the care plan called for gown and gloves during high-contact care, including wound care. The resident said staff usually wore a yellow gown, and the LVN said she forgot to wear it. The ADON, who was also the Infection Preventionist, confirmed gown and gloves were needed for hands-on care and wound care under the facility policy.
Failure to Update Daily Nurse Staffing Posting: The facility failed to keep the daily nurse staffing report current and readily available at the central nursing station. Surveyors observed the posting still dated an earlier day on multiple occasions, even though it was supposed to show the current date, census, staffing, and hours worked for RN, LPN/LVN, CNA, and other nursing staff. The DON stated she was responsible for the posting and that it was normally updated when she arrived in the morning.
Two residents at high risk for falls did not have fall mats included in their care plans, despite experiencing falls. Staff interviews highlighted the importance of listing such interventions for resident safety, and the DON acknowledged the oversight.
A facility failed to securely store medications, as 18 loose pills were found in a medication cart assigned to an LVN. The LVN was responsible for maintaining the cart's cleanliness and acknowledged the risks of loose pills, such as allergic reactions or residents consuming them. The DON confirmed the responsibility of checking carts and the potential harm from loose pills, while the Regional Nurse Consultant noted packaging issues.
Failure to Protect Residents During Fire and Inadequate Emergency Response
Penalty
Summary
The facility failed to protect residents from neglect and did not ensure their right to be free from abuse, neglect, and exploitation, as evidenced by a fire incident on the 400 Hall that resulted in the death of a resident. Staff were unable to timely extinguish the fire and did not assess or render aid to the affected resident after the fire was put out. The resident, who had a history of stroke with left-sided weakness, was dependent on staff for all activities of daily living and required a mechanical lift with two staff for transfers. She was found with severe burns and expired in the facility immediately after the fire. The medical examiner confirmed that the resident had significant burns and soot in her airway, indicating she was breathing during the fire. The facility was aware for over six months that, upon activation of the fire alarm system, control access doors would lock and prevent staff from entering the 400 Hall without a code. During the fire, staff were unable to access the hall for three minutes, leaving only one CNA on the hall with the residents. Security footage and interviews confirmed that staff struggled to open the doors, attempted to enter codes, and were delayed in providing assistance to residents, including the one who was on fire. Some residents were left unattended or not assessed after evacuation, and staff did not know the unlocking mechanisms for the controlled access doors during the emergency. Interviews with staff and the DON revealed that prior to the incident, staff had not been trained on how to respond to residents with severe burns, and no assessment or aid was rendered to the resident after the fire was extinguished. The DON acknowledged that staff should have assessed the resident but did not do so. The medical director stated that staff should have monitored vital signs and breathing and stayed with the resident until EMS arrived. The lack of timely intervention and assessment contributed to the severity of the incident, and the facility's failures affected all residents on the 400 Hall during the emergency.
Failure to Provide Timely Fire Response and Resident Assessment During Fire Incident
Penalty
Summary
Facility staff failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals, as evidenced by a fire incident involving a resident who was engulfed in flames. Staff did not immediately extinguish the fire using a fire extinguisher and instead used a non-fire retardant blanket, which worsened the fire. After the fire was extinguished, staff did not assess or render aid to the resident, who subsequently expired in the facility. The resident had a history of stroke with left-sided weakness, was dependent on staff for mobility and transfers, and was a known smoker with a care plan addressing smoking-related risks. The last clinical assessment for this resident was completed prior to the incident, and no assessment was documented after the fire. During the fire, staff failed to follow the facility's fire safety plan for evacuating residents from the affected hall. Multiple residents were left in their rooms during the fire, resulting in prolonged exposure to smoke. Security footage and fire department reports confirmed that staff response was delayed and uncoordinated, with some residents being evacuated only after several minutes had passed. The fire department found that some residents were sheltered in place due to smoke conditions, and the fire was confined to the bed of the resident who expired. The fire alarm system operated as intended, alerting staff and prompting a response, but the evacuation process was not executed according to established protocols. Interviews with the facility's Medical Director and DON revealed that staff were not trained on how to respond to residents with severe burns prior to the incident. The DON acknowledged that no assessment was performed on the resident after the fire, which was a deviation from professional standards of practice. The Medical Examiner reported that the deceased resident suffered from second and third-degree burns, with significant charring and soot deposition in the airway, indicating the resident was breathing during the fire. The report also documented deficiencies in care and services for multiple other residents on the affected hall, including failures to provide assistance with mobility and ADLs as outlined in their care plans.
Failure to Follow and Document Approved Menus for Resident Meals
Penalty
Summary
The facility failed to ensure that planned menus were followed and prepared according to the weekly menu for six out of six meals reviewed. Observations, interviews, and record reviews revealed that the posted and served meals did not match the facility's approved weekly menu on multiple occasions. For example, the posted menu and the meals served for lunch and dinner on several days differed from the planned menu, with substitutions made without proper documentation or approval from the registered dietitian. Residents were served alternate items, such as a hamburger without a side, and desserts were substituted due to cost constraints, with no evidence of dietitian approval for these changes. Interviews with staff indicated that the Dietary Director made menu substitutions based on resident preferences and budget limitations, but was unable to provide documentation of dietitian approval for these changes. The Registered Dietitian confirmed that she had not approved the menu changes and that the process required a substitution log to be completed and signed off by the dietitian, which was not done. The Regional Registered Dietitian also stated that while resident feedback is considered, substitutions must maintain nutritional equivalence and be properly documented and approved. The facility's policy requires menus to be prepared in advance, posted in accessible areas, followed as posted, and any deviations to be approved by the dietitian. However, the investigation found that menus were not consistently posted, substitutions were made without proper approval, and documentation of these changes was lacking. This failure placed residents at risk of not receiving meals adequate to meet their nutritional needs.
Failure to Follow Up on Implanted Port Removal Order
Penalty
Summary
The facility failed to follow a physician order for a resident with an implanted port to obtain an oncology evaluation for port removal. The resident was a female admitted with diagnoses including left-sided paralysis after a stroke, depression, anxiety, repeated falls, and lung cancer. Her quarterly MDS showed severely impaired cognition, functional limitations in range of motion, and dependence for most ADLs. Her record also showed an indwelling medical device to the right upper chest and orders for central line dressing changes and enhanced barrier precautions related to the device. The physician order for oncology follow-up related to port removal was dated 07/23/25, but the record showed no documentation of communication to the resident’s representative about the implanted port, its use, maintenance, adverse reactions, or removal from admission through 09/17/25. On 09/19/25, the DON documented that while auditing the chart she noticed the July order and learned the family did not want the port removed. She spoke with the NP, who said the resident complained of pain at the port site, and then contacted the resident’s representative and caregiver to discuss the port and obtain the oncologist information. An appointment with oncology was then scheduled for 10/07/25. During observations and interviews, the resident stated the port bothered her and caused pain when she moved her arm or used her wheelchair, and she wanted it removed. The resident’s representative and family member stated they had not been notified earlier about the physician’s recommendation or the resident’s discomfort. The DON stated she did not know what happened between the July order and September, and the ADON stated nursing staff are expected to follow up on the need for any kind of port and that a resident admitted with an implanted port should have orders in place. The facility policy titled Infection Preventionist did not include information addressing implantable device monitoring.
Failure to Timely Report Fire Incident and Resident Death to Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the administrator and appropriate authorities as required. Specifically, the administrator did not report a fire incident in the 400 Hall, which resulted in the exposure of 22 residents to smoke and the death of one resident, to the State Survey Agency within the mandated two-hour timeframe. The incident was instead reported several hours later via email, despite the administrator being informed of the fire and fatality shortly after the event occurred. This delay in reporting was confirmed through record review of the facility's reporting system and interviews with staff. The fire occurred in a resident room and was discovered by a CNA, who observed a resident on fire. Staff responded by extinguishing the fire, contacting 911, and relocating residents from the affected area. Security footage showed staff attempting to evacuate residents, with some delays caused by locked doors and confusion during the evacuation process. The fire department and EMTs arrived on the scene, and one resident was pronounced deceased. The deceased resident had significant medical needs, including total dependence for mobility and ADLs, a history of stroke with left-sided weakness, and was a known smoker who was compliant with the facility's smoking policy. The cause of the fire remained undetermined at the time of the report. Interviews and documentation revealed that after the fire, the resident who suffered fatal burns did not receive an immediate assessment or medical intervention from nursing staff prior to the arrival of EMS. The DON acknowledged that staff were not trained on how to respond to severe burns prior to the incident and confirmed that no assessment was performed on the resident after the fire was extinguished. The medical examiner later confirmed that the resident had been breathing while on fire, with 26% of her body surface burned. Other residents in the affected hall had significant cognitive and physical impairments, requiring various levels of assistance for mobility and ADLs, and were also exposed to smoke during the incident.
Failure to Accurately Document Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of two residents. For one resident with a history of stroke, diabetes, depression, and mild cognitive impairment, the quarterly Minimum Data Set (MDS) assessment did not document left-sided hemiplegia and hemiparesis as a functional limitation in range of motion or as a diagnosis, despite multiple records and staff interviews confirming total dependence for activities of daily living (ADLs), use of a mechanical lift, and paralysis on the left side. The care plan, transfer records, and staff interviews consistently described the resident as bed- or wheelchair-bound, requiring maximal assistance, yet the MDS failed to capture these significant limitations. For another resident with severe cognitive impairment and a diagnosis of unspecified dementia, the quarterly MDS assessment did not initially document wandering behavior in Section E, even though the resident was observed walking throughout multiple hallways and had a documented history of wandering. The resident was care planned for use of a wander guard bracelet, had a daily order for a wander device alarm, and was visually checked for the device every shift. Staff interviews and observations confirmed frequent wandering behavior, but the MDS did not reflect this until it was later modified. The deficiencies were identified through interviews, observations, and record reviews, which revealed inconsistencies between the residents' actual conditions and the information documented in their MDS assessments. Staff responsible for completing the MDS acknowledged the errors and attributed them to oversight, resulting in assessments that did not accurately represent the residents' functional limitations or behaviors as required by federal regulations.
Failure to Timely Update Care Plan After Catheter Removal and Wound Resolution
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by an interdisciplinary team for one resident. Specifically, the care plan was not updated to reflect the removal of a urinary catheter, which had an order for removal, nor was it revised when a pressure ulcer wound resolved and the related order was discontinued. Documentation showed that the resident's care plan continued to list an indwelling catheter and an active pressure ulcer after both had been resolved or removed, as confirmed by medical records, medication administration records, and staff interviews. Multiple staff members, including nurses and certified nursing assistants, confirmed that the resident no longer had a catheter or an active pressure ulcer, but the care plan was not updated until after surveyor intervention. The resident involved was an older male with a history of schizophrenia and moderate cognitive impairment. Medical records indicated that the Foley catheter was removed and the pressure ulcer had healed, yet the care plan still reflected these resolved issues. Staff interviews revealed confusion and lack of clarity regarding responsibility for updating care plans, with various staff members indicating that the DON, ADON, or wound care nurse might be responsible. The facility's policy required the interdisciplinary team to review and revise care plans after each assessment, but this was not followed in this case.
Failure to Notify Resident Representatives of Change in Condition and Treatment Orders
Penalty
Summary
The facility failed to immediately inform the resident, consult the resident’s physician, and notify the resident representative when there was a significant change in condition and a need to alter treatment for 2 residents. For one resident, the physician assessed a new cough with congestion and diminished breath sounds and ordered a chest x-ray on 10/01/25 to evaluate for pneumonia. The order was confirmed by nursing, but there was no evidence of follow-up or x-ray completion for several days, and the resident representative was not notified until 10/06/25. The resident had a history of stroke, aphasia, dysphagia, paralysis, anxiety, a feeding tube, and prior pneumonia, and was severely cognitively impaired and dependent for most ADLs. For the second resident, the record showed a physician order from 07/23/25 for oncology follow-up related to removal of an implanted port on the right chest that was causing discomfort. The resident had diagnoses including lung cancer, stroke with left-sided paralysis, depression, anxiety, repeated falls, and severe cognitive impairment. The chart reflected no documentation of communication to the resident representative from admission through mid-September regarding the port, its use, maintenance, adverse reactions, or removal. The DON later found the missed order while auditing the chart and documented that the family had not wanted the port removed, while the NP stated the resident complained of pain at the port site. The resident was observed and interviewed on multiple occasions and stated that the port hurt, especially when using a wheelchair, and that she wanted it removed. The resident representative and family member stated they had not been notified earlier about the discomfort or the physician’s recommendation for port removal. The DON stated that failure to follow physician orders and assess a port with no care could place residents at risk of infection, and that the resident’s cough and chest x-ray order represented a change in condition requiring notification of the doctor, family, and nursing follow-up.
Nurse Competency Gaps in G-Tube Medication Administration and EBP
Penalty
Summary
The facility failed to ensure nurses were competent to provide care for a resident with a PEG tube and Enhanced Barrier Precautions. Resident #1 was a male with diagnoses including hemiplegia and hemiparesis following cerebral infarction and gastrostomy status. His record showed he had a feeding tube, was on Enhanced Barrier Precautions related to the PEG tube, and had a care plan directing that all nutrition and hydration be given via feeding tube with medications administered as ordered. During observation, LVN G administered medications through the resident’s g-tube one at a time, but water was poured into the medication cups just before administration and the cups were only slightly agitated. Significant residue remained in the cups after Sennoside, Vitamin C, Thiamine, and a multivitamin were given. Metoprolol was crushed and left at bedside, but it was not administered because LVN G could not check the resident’s blood pressure due to a low battery in the cuff. LVN G then threw the medication cup with the crushed Metoprolol into the trash in the resident’s room. When interviewed, LVN G said she was unsure whether she could take the medication out of the room because the resident was on precautions, said she did not know what Enhanced Barrier Precautions were, and stated she had no training on g-tube administration during orientation. Interviews with facility leadership and staff showed inconsistent and incomplete competency oversight. LVN G said she shadowed another nurse and then was shadowed herself, but she did not know the last name of the nurse who trained her. The DON said nurses receive competency check-offs for g-tube administration and that the consultant pharmacist and regional nurse consultant observe nurses until proficient, but later said the facility was unable to find training records for LVN G and that the facility never assessed her competency for medication administration via g-tube. The Corporate Director of Compliance stated there was no policy regarding nurse competency when requested, while the facility’s policies stated staff receive Enhanced Barrier Precautions training upon hire and annually and that enteral tube medications are to be administered separately, not combined.
Medication Error Rate Exceeded During G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors observed LVN G administering medications to a resident with a PEG tube and found residue left in the medication cups after administration of Multivitamin, Sennosides-Docusate Sodium, Vitamin C, and Thiamine HCL. The medication pass review identified 4 errors out of 43 opportunities, resulting in a 9% medication error rate, and the resident involved had diagnoses including hemiplegia and hemiparesis following cerebral infarction and gastrostomy status. Record review showed the resident had active orders for the four medications given via G-tube, and the care plan directed that all nutrition and hydration be provided via feeding tube with medications administered as ordered. During interview, LVN G stated she had worked at the facility for about a month, had no training on G-tube administration during orientation, and had shadowed another nurse who administered all G-tube medications together. The DON, regional nurse consultant, and consultant pharmacist all discussed the administration process, and the consultant pharmacist stated medications should be given individually through a G-tube and the cup should be rinsed to avoid residual medication remaining in the cup.
Crushed Metoprolol Discarded in Resident Room Trash
Penalty
Summary
The facility failed to ensure drugs and biologicals were secured and locked in accordance with currently accepted professional principles during medication administration by 1 of 2 staff observed. Resident #1 was a [AGE]-year-old male admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction and gastrostomy status, and his quarterly MDS indicated BIMS could not be conducted. His order summary showed Metoprolol Tartrate 25 mg to be given via G-tube once daily. During observation, LVN G crushed Resident #1's Metoprolol and placed it in an individual cup. When the LVN was unable to obtain a blood pressure reading because the cuff battery was low, she said she would give the medication later after administering the rest of the resident's medications. Later, LVN G threw the cup containing the crushed Metoprolol into the trashcan in the resident's room. During interview, LVN G said medications were supposed to be disposed of in the sharps container on the medication cart and stated she was unsure if she could take the medication out of the room because the resident was on precautions. The consultant pharmacist stated that if a medication was opened but not given, it should be placed in the sharps container so no one could reach in and take it out.
Delayed Chest X-Ray Order Follow-Up
Penalty
Summary
The facility failed to provide timely diagnostic radiology services for a resident who had a physician order for a chest x-ray to evaluate cough and congestion and rule out pneumonia. The resident had a history of left-sided paralysis after a stroke, aphasia, dysphagia, anxiety disorder, a gastrostomy tube, and pneumonia, and was severely cognitively impaired and dependent for most ADLs. On 10/01/25, the physician documented an audible cough with congestion and diminished breath sounds and ordered a chest x-ray. The order was entered and confirmed on 10/01/25, but the record showed no evidence of follow-up or x-ray completion from 10/01/25 through 10/05/25. On 10/06/25, the order was re-entered and radiology was notified, and the chest x-ray was completed that day. The radiology report showed no evidence of acute cardiopulmonary disease. Observations on 09/29/25 and 10/06/25 showed the resident lying in bed receiving tube feeding, nonresponsive, with unlabored breathing and no immediate distress. During interview, the RN said she did not know there was a pending x-ray and had not observed a cough, and she stated there had been no communication to nursing or the responsible party about the pending chest x-ray. The DON stated nursing staff were required to confirm radiology orders, enter them into the EMR, and document them in the progress note and 24-hour report log, and said the RN failed to document the order and follow up with the x-ray. The physician stated the resident’s cough and diminished lung sounds prompted the x-ray order because of concern for pneumonia, and said the 5-day delay was not acceptable.
Failure to Use Required Gown During Wound Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 resident reviewed for infection control. Resident #41 was a male admitted with diagnoses including Type 2 diabetes mellitus with foot ulcer and acute osteomyelitis of the right tibia and fibula. His quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment. His order summary showed Enhanced Barrier Precautions due to a wound, and his care plan stated that gown and gloves were required during high-contact care, including wound care. During observation on 10/1/25 at 10:15 a.m., LVN C provided wound care to Resident #41 without wearing a gown, even though an Enhanced Barrier Precautions sign was posted at the room door. During interview, Resident #41 stated staff usually wore a yellow gown when performing wound care. LVN C stated she forgot to wear the yellow gown and said she normally wore a gown when providing wound care. The ADON, who was also the Infection Preventionist, stated that staff needed to wear a gown and gloves when providing hands-on care for a resident on Enhanced Barrier Precautions and that wound care without a gown could possibly open a portal to infection. The facility policy stated that PPE for Enhanced Barrier Precautions is necessary during high-contact care activities, including wound care.
Failure to Update Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure that the daily nurse staffing posting was updated and readily accessible for review on 09/29/25, 10/03/25, and 10/04/25. An observation on 09/29/25 at 10:16 AM found the Daily Staffing Report at the central nursing station still dated 09/24/25. The posting listed the facility census, staff types, and hours worked for the day and night shifts. An observation on 10/03/25 at 02:54 PM found the Daily Staffing Report posted at the central nursing station dated 10/03/25 with the census, staff types, and hours worked for both shifts. An observation on 10/04/25 at 08:22 AM found the Daily Staffing Report at the central nursing station still dated 10/03/25. In an interview on 10/06/25 at 02:47 PM, the DON said she was responsible for the nurse staffing posting and that it had to include the date, census, staffing, and quantity of each staff type. She said she updated the posting Monday through Friday and prepared Saturday and Sunday postings for the weekend supervisor to uncover each day, and that the posting was normally updated when she came in at 9 AM. Record review of the facility policy titled Nurse Staffing Posting Information, revised 03/2025, stated that nurse staffing information must be posted daily and at the beginning of each shift.
Failure to Include Fall Mats in Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for two residents identified as high risk for falls. Resident #34, a female with hemiplegia and hemiparesis following a cerebral infarction, experienced three falls over six months. Despite being care planned for falls, her care plan did not include the intervention of a fall mat, which was observed next to her bed. Similarly, Resident #28, diagnosed with dementia and metabolic encephalopathy, had a fall recorded but her care plan also lacked the intervention of a fall mat, even though she had previously fallen onto one. Interviews with staff revealed that the absence of fall mats in the care plans could lead to increased risk of injury for these residents. A CNA and an LVN both noted the necessity of fall mats for these residents, with the LVN highlighting the importance of listing such interventions in care plans for new staff awareness. The DON acknowledged the responsibility of updating care plans with new interventions and confirmed that fall mats should have been included to prevent potential injuries.
Medication Storage Deficiency Due to Loose Pills in Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by the presence of 18 loose pills in a medication cart assigned to an LVN. These pills were found at the bottom of a drawer beneath tightly packed medication blister cards. The LVN, who was responsible for administering medications and maintaining the cleanliness of the cart, acknowledged the presence of the loose pills and the potential risks associated with them, such as allergic reactions or residents inadvertently consuming them. The Director of Nursing (DON) confirmed that the charge nurses, DON, and ADON were responsible for checking medication carts. The DON acknowledged the risks posed by loose pills, including the possibility of residents experiencing side effects or harm if they accessed the pills. The Regional Nurse Consultant noted that pills might fall out of blister cards due to pharmacy packaging. The facility's policy mandates that all medications be stored securely in locked compartments, but this was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caraday Of Houston | 1.6 mi | ★★★★★ | 1 | 0 |
| Highland Park Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Ashford Gardens | 2.1 mi | ★★★★★ | 24 | 0 |
| Houston Heights Nursing And Rehabilitation Center | 3.5 mi | ★★★★★ | 2 | 0 |
| Spring Branch Transitional Care Center | 5.7 mi | — | 0 | 0 |
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