Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Side Campus Of Care during CMS and state inspections, most recent first.
Unlabeled tea pitchers and dented cans were found in the kitchen. Staff stated the tea should have been labeled with the drink name and use-by date when filled, and that dented cans were supposed to be separated from regular stock for discard or return for credit. The Dietary Manager and other kitchen staff acknowledged the items were not stored as required, and the facility policy required products to be labeled and dated and dented cans to be kept separate.
Improper Medical Waste Disposal and Uncovered Waste Container: The facility failed to ensure proper disposal of medical waste and failed to keep a medical waste container covered on a secure unit medication cart. An alcohol wipe with blood was observed on the floor in a hallway, and the lid on the cart's medical waste container was observed open and unsecured. An LVN stated blood glucose testing wipes should be discarded in the medical waste bin, while the MA and DON stated the container should be kept closed after use; the facility policy required blood-soiled disposable items to be placed in designated medical waste containers that are kept covered at all times.
Baseline Care Plan Not Entered for Newly Admitted Resident: A resident with multiple serious diagnoses, including bladder cancer, heart disease, diabetes, and failure to thrive, did not have a baseline care plan entered into PCC within the required timeframe after admission. Staff gave inconsistent accounts of who was responsible and when the plan should be completed, and the record showed the care plan was overdue and not documented in the EHR assessments tab.
A resident with documented allergies to tomato, red food color, and red dye received a lunch tray with ketchup packets on it even though the tray ticket listed tomato-related allergies. The resident said he had told nursing staff about the allergy multiple times and described prior itching and throat-tightening symptoms if he ate ketchup. The LVN did not check the tray before serving it, and the Dietary Manager, RD, and DON stated staff were expected to verify trays against allergy information before meals were served.
A CNA was observed standing over a resident with severe physical and cognitive impairments while assisting with eating, rather than sitting at eye level as expected by facility policy. The CNA stated she could not find a clean chair and did not want to delay feeding, but this action did not align with the facility's standards for promoting dignity and a homelike environment during meal times.
A resident with a history of drug abuse and multiple medical conditions was found unresponsive and tested positive for methadone, which was not prescribed. The resident alleged receiving methadone from a staff member, but later denied this to staff and authorities. Facility records confirmed no order for methadone, and staff interviews indicated no prior evidence of nonprescription drug use. The facility did not promptly initiate a thorough investigation or report the incident as required by policy.
A resident with a history of substance abuse and multiple medical conditions was found unresponsive and later tested positive for Methadone, which was not prescribed. The resident alleged that a staff member provided the drug, but later denied this in follow-up interviews. Facility staff and leadership did not promptly investigate or report the incident as required by policy, and there was a delay in initiating a provider investigation and notifying the state agency. This failure to follow established abuse prevention and drug policies resulted in a deficiency.
A resident with chronic respiratory conditions who required continuous oxygen therapy ran out of oxygen during a community appointment after being sent with only one portable tank. The appointment lasted longer than anticipated, and staff did not provide an extra tank as required by the care plan. The resident experienced shortness of breath and chest pain, leading to emergency transport to the hospital.
A resident with a history of substance abuse was found unresponsive and later tested positive for Methadone, a drug not prescribed to him. The resident alleged he received the drug from a staff member but refused to identify who. Despite this, facility leadership did not immediately report the incident to law enforcement or the State Agency as required, delaying notification while gathering more information.
A resident with a history of substance abuse was found unresponsive and tested positive for methadone, which was not prescribed. The resident alleged receiving methadone from a staff member but later denied the incident. The facility did not promptly investigate or report the allegation as required, and initial actions were limited to staff in-services and care plan updates, with no evidence of a thorough investigation until prompted by external parties.
The facility failed to document the use of bed rails, grab bars, or mobility bars in the care plans of four residents, despite their use for repositioning and personal care. This oversight was identified through observations and interviews, highlighting a risk of unmet needs and lack of continuity in care.
A facility failed to ensure a resident's self-administration of G-tube medications was clinically appropriate. The resident, with moderate cognitive impairment and a history of cancer, was allowed by an LVN to self-administer medications without verifying G-tube placement. The DON confirmed that staff should check G-tube placement before administration, and facility policy requires prescriber orders and interdisciplinary team assessment for self-administration.
A resident was unable to participate in activities over the weekend due to not receiving personal clothing, as the facility's laundry process did not distribute clothes on weekends. The resident, dependent on staff for dressing, remained in bed and wore clothes from the lost and found. The laundry aide confirmed that clothing was not distributed on weekends, leading to a backlog on Mondays.
Two residents in a facility did not have their G-tube placements verified by LVNs before administering medications and feeds, contrary to physician orders and facility policy. One LVN forgot to check due to nervousness, while another was caught off guard by a surveyor. The DON confirmed the expectation for staff to verify G-tube placement, as per facility policy.
A resident in an LTC facility had unsecured medications on her bedside table, contrary to State and Federal laws requiring locked storage. The resident, who had multiple injuries and impaired vision, was not permitted to self-administer medications, and there was no order or care plan for self-administration. Facility staff, including an LVN, MA, ADON, and DON, were unaware of the unsecured medications until notified by a surveyor, indicating a lack of communication and adherence to facility policy.
A resident's bathroom call light was found non-functional, failing to alert staff when activated. The resident, requiring extensive assistance, confirmed the issue, which was unknown to staff until surveyors intervened. Facility policy mandates reporting and alternative measures for inoperable systems, which were not followed.
The facility failed to maintain a sanitary and comfortable environment in a shower room, where a musty odor and black substance were observed on the ceiling and tiles. The Housekeeping Supervisor noted improper priming before painting, and the CNA responsible for cleaning did not notice the issue. The DON and Interim Administrator acknowledged the unsanitary conditions, which could risk residents' respiratory health.
A resident with major depressive disorder and dementia attempted to leave the facility, but the necessary significant change of condition assessment was not completed within 14 days. The resident was moved to a secure unit, but the facility failed to update the elopement risk assessment and complete a new MDS assessment, leading to a deficiency in regulatory compliance.
Unlabeled tea pitchers and dented cans stored with regular stock
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in its only kitchen. During observation on 03/24/26 at 7:31 AM, eight 64-ounce pitchers of dark brown liquid were seen on the beverage station counter without labels or use-by dates. During a later observation on 03/24/26 at 7:46 AM, the dry food storage area contained four 4-ounce canned food items with dents: one can of apple slices, one can of mandarins, and two cans of grape jelly, all stored with the regular stock of canned goods. During interviews, kitchen staff and the Dietary Manager stated that beverages were supposed to be labeled with the name of the drink and dated with a use-by date when filled, and that the person who filled the pitchers was responsible for labeling and dating them. Staff identified the liquid in the pitchers as tea and stated that [NAME] D had filled the pitchers, but the pitchers were not labeled or dated at the time of observation. Staff also stated that all dietary staff were responsible for checking beverage labels and dates, and that the facility had recently held an in-service covering labeling and dating. Staff also stated that dented canned goods were not supposed to be stored with regular stock and should have been separated for discard or return for credit. The Dietary Manager and other staff stated that the dented cans had been mixed in with regular canned goods because they had not been thoroughly checked when stocked, and that all kitchen staff were responsible for removing dented cans when found. The facility policy titled Food Storage, dated 12/2020, stated that dented or bulging cans should be placed in a separate storage area and returned for credit, and that products should be labeled and dated.
Improper Medical Waste Disposal and Uncovered Waste Container
Penalty
Summary
The facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 medication carts reviewed for medical waste and for 2 of 3 halls reviewed. During observation on 03/26/2026 at 9:38 AM, an alcohol wipe with a blood stain was seen on the floor in the hallway of the secure unit. During observation on 03/26/2026 at 09:52 AM, the lid on the medical waste container on the secure unit medication cart was open and unsecured. During interview, LVN B stated she was responsible for conducting capillary blood glucose tests for residents on the secure unit and that when the test was completed, the alcohol wipe should be disposed of in the medical waste bin on the side of the medication cart. MA C stated the risk of having the side trash open was that a resident could get into the trash and be at risk for cross-contamination or infection if they met medical waste, and that the lid should be closed after use. The DON stated the expectation was for medical waste to be discarded appropriately in the trash and that after placing medical waste in the trash, the lid should be closed to ensure residents were not getting into it. Record review of the facility's Medical Waste Management Program stated that disposable items soiled with visible blood are placed in designated medical waste containers and that medical waste containers are kept covered at all times.
Baseline Care Plan Not Entered for Newly Admitted Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #179 within 48 hours of admission. Resident #179 was a newly admitted male with diagnoses including bladder cancer, acute ischemic heart disease, orthostatic hypotension, hypercalcemia, anemia, Type 2 diabetes, insomnia, hypertension, extrarenal uremia, adult failure to thrive, cachexia, and systemic inflammatory response syndrome. His MDS assessment reflected a BIMS score of 10. Record review showed no baseline care plan in the EHR assessments tab, and the baseline care plan was displayed in red with the date 03/14/26. During observation on 03/24/26, the resident was lying in bed asleep and was not alert for interview. In interviews, staff gave differing statements about who was responsible for completing and entering the baseline care plan and the expected timeframe, with responses ranging from 24 hours to 72 hours and from the admitting nurse to the DON, IDT, or social services. The Social Worker stated the IDT had completed the baseline care plan on 03/13/26 but it was not entered into the system, and that an in-service was held on 03/26/26 because the plan had not been entered for Resident #179. The DON stated the baseline care plan should have been completed within 48 hours of admission and entered into PCC on the same day the meeting was held. The facility policy stated that a person-centered baseline care plan was to be developed for each resident within 48 hours of admission.
Food Allergy Not Followed on Meal Tray
Penalty
Summary
The facility failed to accommodate a resident’s documented food allergies when Resident #180 received two ketchup packets on his lunch tray even though tomato, neutral red, and red dye were listed in his medical record, Food and Nutrition Profile, care plan, and tray ticket. Resident #180 was a cognitively intact male with diagnoses including malnutrition, bipolar disorder, and complications of diabetes affecting the eyes. His care plan directed staff not to administer or come in contact with the listed allergens and to make note of all allergies on the chart. On observation, Resident #180’s lunch tray contained two tomato ketchup packets, and the tray ticket identified allergies to red food color and tomatoes. During interview, Resident #180 stated the kitchen had placed the ketchup on his tray and that he would not eat it because he was allergic to it. He reported that if he ate ketchup he would itch all over, his throat would begin to close, and he would need an antihistamine to relieve the symptoms. He also stated he had told nursing staff multiple times about his allergies, but the foods continued to be served to him. The LVN stated nurses should check residents’ trays against the meal ticket and allergies before serving, but she did not check Resident #180’s tray that day and said she would have served it as received because of his high cognition. The Dietary Manager stated the serving staff was responsible for ensuring nothing with the allergen was placed on the tray, and the nurse should check the tray before it was served. The DON and the Registered Dietician both stated that kitchen staff and nursing staff were expected to verify the tray against the allergy information, and the DON noted that failure to do so could result in an allergic reaction.
Failure to Provide Dignified Dining Experience During Meal Assistance
Penalty
Summary
A certified nursing assistant (CNA) failed to provide a dignified dining experience for a male resident with spastic quadriplegic cerebral palsy, severe cognitive impairment, and major depressive disorder. The resident was dependent on staff for eating and required a regular puree diet with mildly thickened liquids. Due to his condition, he was unable to sit upright and remained in a supine position in his wheelchair, increasing his risk for choking and aspiration. During a lunch meal service, the CNA was observed standing over the resident while feeding him, with the food and drink placed behind her on the table. She alternated between giving the resident bites of food and drinks while standing, as she was unable to find a clean chair to sit on at the time. The CNA later stated that she typically sat while assisting the resident but could not locate a clean chair and did not want to delay feeding, as the resident became restless when not fed on time. The Director of Nursing (DON) and the Administrator both confirmed that staff are expected to sit at eye level with residents during meal assistance to promote dignity and a homelike environment. Facility policy also requires that all residents be treated with respect and dignity, with care provided in a manner that enhances quality of life and recognizes each resident's individuality. The failure to sit while feeding the resident was identified as not meeting these standards.
Failure to Protect Resident from Abuse Involving Unprescribed Methadone
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse when a male resident with a history of drug abuse, heart failure, stroke, and depression was found unresponsive in his room and subsequently tested positive for methadone, a medication for which he did not have a physician's order. The resident required emergency intervention, including Narcan administration, and was transported to the hospital where he was diagnosed with hypoxia likely due to acute-on-chronic systolic heart failure. Hospital records confirmed the presence of methadone and opiates in his system, and the resident later alleged that he had received methadone from a staff member, though he refused to identify the individual involved. Review of the resident's care plan and medication orders confirmed that methadone was not prescribed or available to him through legitimate medical channels within the facility. Staff interviews indicated that the resident had not signed out of the facility, and there was no evidence of him obtaining methadone from outside sources. Nursing staff reported finding the resident in respiratory distress and unresponsive, with no prior indication of nonprescription drug use or possession. The resident's care plan was updated to reflect his drug abuse history only after the incident, and interventions such as education on the facility's drug policy and psychological support were documented post-event. Despite the resident's initial admission to a state investigator that he received methadone from a staff member, he later denied this to facility staff, administration, and police. The facility's policies on abuse prevention and drug use were in place, but the investigation revealed that the required immediate reporting and thorough investigation of the incident were not initiated until after the state investigator's involvement. Prior to the identification of Immediate Jeopardy, the only evidence provided by the facility included staff in-services and care plan updates, with no documentation of medication audits, safe surveys, or timely self-reporting to the state agency.
Failure to Implement Abuse and Drug Prevention Policies Resulting in Resident Overdose
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, specifically in the case of one resident who was found unresponsive and later tested positive for Methadone, a medication for which he did not have a physician's order. The resident, who had a history of drug and alcohol abuse, was admitted with multiple medical conditions including acute systolic heart failure, stroke, and major depressive disorder. On the day of the incident, the resident was found in respiratory distress and was only responsive to sternal rub, with an oxygen saturation of 47% on room air. He was transported to the hospital, where he was diagnosed with hypoxia likely due to acute-on-chronic systolic heart failure, and laboratory results revealed the presence of Methadone and opiates in his system. Upon interview, the resident stated that he had received Methadone from a staff member, although he refused to identify the individual and later denied the incident during subsequent interviews. Facility records showed that the resident had not signed out to leave the facility, and there was no physician order for Methadone in his medication records. Staff interviews indicated that they were unaware of the resident having access to nonprescription drugs or staff providing such substances. The facility's policies required prompt investigation and reporting of abuse, neglect, and drug-related incidents, but there was a delay in initiating a provider investigation and submitting a self-report to the state agency. The facility's leadership, including the DON and Administrator, did not immediately act upon learning of the Methadone finding in the resident's hospital records. The investigation and required notifications were not initiated until after the state investigator became involved. There was no evidence provided of medication audits, safe surveys, or timely reporting to the state agency prior to the identification of Immediate Jeopardy. This lapse in following established policies and procedures resulted in a deficiency related to the facility's failure to protect residents from abuse and to ensure a safe, drug-free environment.
Removal Plan
- Alleged employee suspended pending investigation
- Attending Physicians was notified of the incident involving the resident
- Trauma screen was completed
- Police notified
- Resident referred to Deer OAKS for psychological assessment
- Care plans updated
- Reviewed out on pass
- Reviewed advance entry for visitors
- Reviewed facility medications for use of methadone
- Completed care plan conference with residents
- Resident seen by psychologist
- Drug abuse contract and policy discussed with residents and signed
- Staff in-service on facility drug policy, identifying intoxicated residents, Narcan administration, and will be completed. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff who are not in-serviced for any reason will receive it before the start of the shift
- Abuse and neglect in-service started and will be completed. All staff in services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee
- 1:1 in-service conducted for DON and Administrator on Abuse and Neglect Policy. In-service conducted by RDO and RNC
- Staff and resident questionnaires
- Safe surveys
- Offered drug rehab services to resident
- Audit of all residents who have a drug history or potential for drug use and have completed the drug policy acknowledgement form. This will be ongoing to ensure all new admits and changes are made where necessary. This will be conducted by the DON or Designee
- Appropriate interventions are being put in place as needed
- All staff were re-educated on identifying intoxicated residents and the resident drug and alcohol abuse policy. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee
- Staff (nurses) in-service on facility drug policy, identifying intoxicated residents, Narcan administration, abuse, and neglect. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee
- The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted and ongoing
- The Administrator/DON will review the effectiveness of this daily and weekly, then monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discovery
- The Medical Director met with the Interdisciplinary team and conducted an Ad HOC QAPI regarding resident drug use. The Medical Director was notified about the immediate Jeopardy, the Plan of removal was reviewed and accepted by Medical Director
- An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal
- The Director of Nursing and Administrator will be responsible for the implementation of Process
Failure to Ensure Adequate Oxygen Supply During Resident Outing
Penalty
Summary
A deficiency occurred when a resident who required continuous oxygen therapy was not provided with adequate respiratory care during a community appointment. The resident, who had a history of chronic obstructive pulmonary disease, emphysema, chronic respiratory failure, and chronic bronchitis, was sent to an outpatient appointment with a portable oxygen tank. Although the tank was reportedly full and set to 2 liters per minute before departure, the resident ran out of oxygen while at the appointment. The resident began experiencing shortness of breath and chest pain, prompting clinic staff to call 911, and the resident was subsequently transported to the hospital. The resident's care plan specified the need for continuous oxygen therapy, including interventions such as providing a portable oxygen apparatus, ensuring an extra tank for appointments, and monitoring for signs of respiratory distress. On the day of the incident, the resident was prepared for the appointment early in the morning and waited for transportation while using the portable oxygen tank. Staff interviews indicated that the appointment lasted longer than expected, and the resident may have used a significant portion of the oxygen supply while waiting at the facility and during transport. The staff did not send an extra oxygen tank, despite the potential for an extended appointment duration. Interviews with staff revealed that while nurses were responsible for checking and ensuring full oxygen tanks before appointments, there was a lack of clarity regarding the responsibility for monitoring oxygen levels during outings and ensuring adequate supply for longer appointments. The facility did not have a specific policy regarding portable oxygen tanks for community appointments at the time of the incident. The failure to provide adequate oxygen supply resulted in the resident running out of oxygen and requiring emergency medical intervention.
Failure to Timely Report Alleged Abuse and Drug Diversion Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime, abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but no later than 2 hours after the suspicion or allegation was made, to a law enforcement entity or State Agency in accordance with State law. This deficiency was identified in the case of a male resident with a history of drug and alcohol abuse, congestive heart failure, stroke, and major depressive disorder. The resident was found unresponsive in his room, required emergency intervention with Narcan, and was subsequently hospitalized, where he tested positive for Methadone, a medication for which he did not have a physician's order. Upon return to the facility, the resident alleged that he had received Methadone from a staff member, though he refused to identify the individual. Facility records and interviews confirmed that the resident had not signed out of the facility, and there was no evidence of an order for Methadone in his medical records. Staff interviews indicated that the resident was found in respiratory distress and that the cause of his condition was initially unclear, but later suspected to be a drug overdose based on hospital records. Despite the resident's allegation and the positive drug test, the facility did not immediately report the incident to law enforcement or the State Agency as required by policy and regulation. The Director of Nursing (DON) and Administrator were aware of the hospital findings and the resident's statements but delayed reporting the incident while they gathered more information. The facility's policies required immediate reporting of suspected abuse or criminal acts, but the only actions taken prior to the surveyor's intervention were staff in-services, a care plan meeting, and scheduling a Resident Council meeting. There was no evidence of timely notification to authorities, medication audits, or a formal investigation initiated within the required timeframe.
Failure to Investigate and Report Alleged Drug Diversion and Resident Overdose
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated and did not prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for one resident. Specifically, the facility did not implement its abuse, neglect, and exploitation policy or investigate suspected or alleged abuse when a resident alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for methadone, for which he did not have a physician's order. This failure was identified through observation, interviews, and record review. The resident involved had a history of drug and alcohol abuse, major depressive disorder, and other significant medical conditions, including heart failure and stroke. He was found unresponsive in his room, with low oxygen saturation, and was transferred to the hospital, where he responded to Narcan administration and tested positive for methadone and opiates. There was no evidence in facility records that the resident had an order for methadone or that he had left the facility to obtain it elsewhere. The resident later stated he received methadone from a staff member but refused to identify the individual and subsequently denied the incident in later interviews. Despite the resident's allegation and the positive drug test, the facility did not immediately initiate a thorough investigation or report the incident to the state agency as required by policy. Initial actions were limited to staff in-services and care plan updates, with no evidence of medication audits, interviews, or other investigative steps until prompted by external parties. The delay in investigation and reporting was confirmed through interviews with facility leadership and regional managers, who indicated that a provider investigation and self-report were only initiated after the issue was brought to their attention by a state investigator.
Failure to Document Use of Assistive Devices in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for four residents, specifically regarding the documentation and use of bed rails, grab bars, or mobility bars. This deficiency was identified through observations, interviews, and record reviews, which revealed that the care plans for these residents did not include the use of these assistive devices, despite their presence and use in the residents' rooms. The absence of this documentation in the care plans posed a risk to the residents, as it could lead to their individual needs not being met and a lack of continuity in care. Resident #41, a female with multiple diagnoses including type 2 diabetes, systemic lupus erythematosus, and morbid obesity, was observed using grab bars for repositioning and personal care. However, her care plan did not mention these bars as an intervention. Similarly, Resident #59, who has conditions such as metabolic encephalopathy and type 1 diabetes, was also using grab bars for personal care and repositioning, yet her care plan lacked documentation of these devices. Resident #76, a male with acute respiratory failure and morbid obesity, used grab bars and a trapeze for repositioning, but his care plan did not reflect this usage. Lastly, Resident #121, with acute and chronic respiratory failure and morbid obesity, was observed with raised grab bars, but her care plan did not include them as a focus or intervention. Interviews with the Director of Nursing (DON) and the Administrator (ADM) highlighted the importance of documenting the use of grab bars in care plans to ensure staff are aware of how to best perform care. The facility's policies on bed rails and care planning emphasize the need for individualized assessments and updates to care plans to reflect the use of such devices. The lack of documentation in the care plans for these residents indicates a failure to adhere to these policies, potentially placing residents at risk of harm.
Failure to Ensure Appropriate Self-Administration of G-Tube Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined the clinical appropriateness of self-administration of medications for a resident. Specifically, the facility did not assess, obtain physician orders, or secure interdisciplinary team approval for a resident to self-administer medications and feedings via a gastrostomy tube (G-tube). This oversight involved a resident with a history of malignant neoplasm of the head, face, and neck, gastrostomy status, dysphagia, and moderate cognitive impairment. On the day of the incident, a Licensed Vocational Nurse (LVN) allowed the resident to self-administer medications and feedings through the G-tube without verifying the tube's placement. The LVN did not aspirate gastric content or check for abdominal distention before the resident administered his medications and feedings. The LVN stated that she had been informed during training that the resident would self-administer under supervision, but she did not check the G-tube placement due to being caught off guard by a surveyor's presence. The Director of Nursing (DON) confirmed that staff are expected to check G-tube placement before administering medications or feedings. The facility's policy requires a written order from the prescriber and an assessment by the interdisciplinary team before residents can self-administer medications. The failure to adhere to these protocols placed the resident at risk of not receiving the proper medication or therapeutic benefits.
Resident Dignity Compromised Due to Laundry Distribution Issues
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not providing personal clothing for two consecutive days. This deficiency affected a resident who was dependent on staff for dressing and other activities of daily living. The resident, who had intact cognitive function, was unable to participate in preferred activities over the weekend due to the lack of personal clothing, which led to him remaining in bed. The resident expressed that he likes to engage in group activities but was unable to do so because his clothes were not available. The issue arose because the facility's laundry process did not distribute personal clothing on weekends. The laundry aide, who worked only on weekdays, confirmed that resident clothing was not distributed during weekends, leading to a backlog of laundry on Mondays. The Environmental Services Supervisor noted that while residents' belongings were washed over the weekend, they were not distributed to avoid misplacement by the weekend staff. This practice resulted in the resident wearing clothes from the lost and found and feeling disrespected due to the lack of access to his personal belongings.
Failure to Verify G-Tube Placement Before Administration
Penalty
Summary
The facility failed to ensure that enteral feeding physician orders were followed for two residents, leading to deficiencies in the care provided. For one resident, a Licensed Vocational Nurse (LVN) did not check the gastrostomy tube (G-tube) placement by aspirating gastric content or listening for bowel sounds before administering water, medications, and enteral feeds. The LVN admitted to forgetting to check the placement due to nervousness from being observed, acknowledging the risk of the tube not being in the correct position. Another resident, who self-administered medications and feeds, also did not have their G-tube placement checked by the attending LVN. The LVN stated that she was caught off guard by a surveyor and did not perform the necessary checks. The resident had been educated on the risks of putting additional fluids in the G-tube, but the LVN was responsible for ensuring the tube's placement was correct before the resident administered his own medications and feeds. The Director of Nursing (DON) confirmed that the expectation was for staff to check G-tube placement before administering medications or feeds. The facility's policy required verification of G-tube placement by a licensed nurse, including assessing the resident's abdomen for bowel sounds and distention and aspirating gastric contents. The failure to follow these procedures could place residents at risk, as noted in the report.
Failure to Secure Medications in Resident's Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. This deficiency was observed in the case of a resident who had two bottles of medication, a Complete Mineral Complex dietary supplement and Advanced Multivitamins, stored on her bedside table. The resident, who had been readmitted to the facility following multiple injuries from a vehicle collision, was not permitted to self-administer medications, and there was no order or care plan reflecting self-administration. The resident, who had impaired visual function, stated that the facility was aware of her having the medication at her bedside. She mentioned that she preferred her own supplements because they did not contain mercury. Despite the facility's policy requiring medications to be locked in the medication cart or room, the resident's supplements remained unsecured on her bedside table for several days. Staff members, including an LVN, MA, ADON, and DON, were unaware of the medications at the bedside until notified by the surveyor. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's possession of medications. The LVN and ADON admitted to not noticing the medications during their visits to the resident's room. The DON confirmed that education was provided to the resident and her friend about turning in medications to the nurse, but the medications were not secured as required. The facility's policy allows bedside medication storage only for residents with a prescriber's order and an assessment for self-administration, which was not in place for this resident.
Non-Functioning Call Light in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that the call system in a resident's bathroom was functioning properly, which is essential for residents to communicate with staff for assistance. Specifically, the call light in the bathroom of a resident did not activate the corresponding light in the hallway above the resident's door when tested. This issue was identified during an observation and interview with the resident, who confirmed that the emergency call light was not working. The housekeeper and LVN interviewed were unaware of the malfunction, and the maintenance staff was not informed of the issue until the surveyors brought it to their attention. The resident involved was a female with a history of a fractured fibula, Type 2 Diabetes, and anxiety, requiring extensive assistance with bed mobility, transfers, and total dependence on staff for toilet use. The resident's cognitive function was intact, as indicated by a BIMS score of 14. The facility's policy requires that any inoperable call system should be reported and that alternative measures, such as providing a bell and conducting hourly safety checks, should be implemented until the system is repaired. However, these procedures were not followed, as the malfunction was not reported or addressed until the surveyors intervened.
Failure to Maintain Sanitary Conditions in Shower Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of the shower rooms at station 2. During an observation, a musty, moldy odor was detected, and round specks of a black substance were found on the ceiling above the shower. The Housekeeping Supervisor indicated that the ceiling was not properly primed before painting, which allowed the substance to bleed through the paint. Additionally, the tiles on the wall and floor had a brown and black slimy substance on the grout, which was not noticed by the CNA responsible for cleaning the room after resident use. Interviews with the Director of Nursing (DON) and the Interim Administrator revealed that the shower room was not being adequately cleaned and disinfected. The DON acknowledged the presence of brown grout and discoloration on the tiles, and the Interim Administrator confirmed the presence of black spots on the ceiling. The facility's policy on maintaining a clean and homelike environment was not adhered to, as evidenced by the unsanitary conditions in the shower room, which could potentially place residents at risk for respiratory infections.
Failure to Complete Significant Change of Condition Assessment
Penalty
Summary
The facility failed to complete a significant change of condition assessment within 14 days for a resident who attempted to leave the facility. The resident, a male with diagnoses including major depressive disorder, unspecified dementia, and anxiety insomnia, attempted to exit the facility on 01/30/24. Despite this significant change in behavior, the facility did not update the resident's elopement assessment or complete a new Minimum Data Set (MDS) assessment to reflect the change in condition. The resident was subsequently moved to a secure unit for safety, but the necessary assessments and documentation were not completed in a timely manner. Interviews with staff revealed that the resident's attempt to leave the facility was promptly addressed by redirecting him back inside and notifying the appropriate personnel. The resident's family was informed, and the decision was made to move him to a secure unit. However, the facility did not update the resident's elopement risk assessment or complete a significant change MDS assessment, which are required to ensure that the resident's care plan accurately reflects his current condition and needs. The facility's policy on wandering and elopement risk assessment requires that residents be reassessed upon identification of a significant change in condition. This policy was not followed in the case of this resident, leading to a deficiency in the facility's compliance with regulatory requirements. The failure to complete the necessary assessments could have placed the resident at risk for further incidents and potentially compromised his safety and well-being.
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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 White Settlement
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Ridge Wellness & Rehabilitation | 0.6 mi | ★★★★★ | 3 | 1 |
| White Settlement Nursing Center | 1.5 mi | ★★★★★ | 6 | 0 |
| Ridgmar Medical Lodge | 2.1 mi | ★★★★★ | 10 | 1 |
| Benbrook Nursing & Rehabilitation Center | 4.4 mi | ★★★★★ | 30 | 0 |
| Arlington Heights Health And Rehabilitation Center | 4.5 mi | ★★★★★ | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.