Above average — CMS composite of the measures below.
The next survey window likely opens around May 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 Westover Hills Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident had a pharmacy-labeled Mupirocin ointment at the bedside without an order, a medication aide cart was left unlocked and unattended, and another resident had Vapor Rub in an open bedside container. Staff and the DON stated residents were not allowed to keep medications at the bedside or in rooms unless properly authorized, and the facility policy required drugs and biologicals to be stored in locked compartments accessible only to authorized personnel.
Food storage and hot-holding practices were deficient when surveyors found expired taco shells in dry storage and frozen cookie dough with the manufacturer's use-by date removed, leaving the discard date unknown. Surveyors also observed pureed bread and baked beans on the steam table below the required 135 F hot-holding temperature, and the Dietary Manager acknowledged the correct standard.
Two residents had no Advance Directive Acknowledgement document in their records despite being admitted with Full Code orders and care plans reflecting elected code status. One resident with osteomyelitis, DM, kidney transplant status, and PVD and another resident with DM, COPD, CHF, PVD, and an above-knee amputation both had interviews indicating advance directive discussions may have occurred, but neither record contained the required acknowledgment. The SW stated she was responsible for providing and uploading the document but did not generate it for these residents.
A resident with depression and memory deficit had a pair of nail clippers stored in a clear container on his dresser, despite staff stating residents were not allowed to keep harmful items in their rooms. The resident said staff knew about the clippers and that his family handled nail care, while the DON stated the resident should not have had the item and no safety assessment was found.
Incorrect Code Status Documented in Resident Record: A resident with chronic respiratory failure and heart failure had signed an OOH-DNR and advance care planning form indicating DNR wishes, and the care plan reflected DNR status. However, the order summary still showed an active full code order after readmission, and interviews with the DON, SW, ADON, and the resident confirmed the code status in the record was inconsistent.
The facility failed to maintain infection control practices for two residents. One resident with a urinary catheter was observed with the catheter tubing and urine bag resting on the floor, despite orders and care plan directions to secure the catheter and keep it off the floor. Another resident receiving oral meds and eye drops was observed with an aide who did not perform hand hygiene before donning gloves, moved between the med cart and bedside while gloved, and administered eye drops without proper hand hygiene, which the DON identified as a break in basic infection control practice.
Failure to Report Allegation of Neglect: A resident admitted for rehab after a left knee wound was dependent on staff for all ADLs and had skin breakdown noted on admission. The family reported staff often did not provide repositioning or incontinent care, and after the resident was hospitalized for lethargy and infection, hospital staff reportedly identified ulcers on the buttocks and neck that may have contributed to systemic infection. The DON and Administrator decided the allegation did not need to be self-reported because they believed there was no evidence, and the allegation was not reported to the state agency.
Failure to investigate allegation of neglect and skin breakdown: A resident admitted for rehab with a left knee wound, UTI, and dependence for all ADLs was later sent to the hospital for lethargy. The family reported staff often did not provide repositioning or incontinent care, and hospital staff later told the family the resident had ulcers to the buttocks and neck that may have contributed to systemic infection. The DON and Administrator decided the allegation lacked merit based on an enema care note and did not report it as ANE.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 16.12% error rate when an LPN administered five scheduled medications (Docusate Sodium, Fluoxetine, Meloxicam, Methenamine Hippurate, and Polyethylene Glycol) to a resident more than an hour after the end of the ordered administration window. The resident, an elderly female with a carpal fracture, constipation, depression, and UTI, had care plans and active orders requiring timely administration of bowel, antidepressant, analgesic, and UTI prophylaxis medications, but these were not given within the prescribed time frame during the observed medication pass.
A resident with pain related to a fracture and other conditions had an active order for a daily 5% Lidoderm patch to the lower back, to be removed each evening per physician order and manufacturer directions. During a med pass observation, an LPN found an existing Lidoderm patch on the resident’s lower back that was still in place, dated two days earlier and lacking staff initials, despite documentation that a medication aide had administered the patch the previous day. The medication aide later reported she applied the patch and knew it should be removed after about 12 hours but did not recall removing it and acknowledged she might have misdated the patch. The DON stated staff were expected to date and initial lidocaine patches and remove them after 12 hours unless otherwise ordered, consistent with facility policy requiring meds to be administered per physician orders.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Surveyors found loose, unlabeled pills in three medication carts, with staff including RNs and medication aides confirming the pills' identities were unknown and that such occurrences could lead to contamination or medication errors. The DON stated that loose pills should be destroyed, and the facility's policy requires proper labeling of all medications and biologicals.
The facility failed to provide appropriate pharmacological services, leading to medication errors for two residents. An LVN administered Cefazolin in the wrong concentration due to a pharmacy oversight, but no harm occurred. Additionally, a discrepancy in the narcotic count for Ativan was found due to outdated counting practices, with missing medication discovered during a drug destruction by the DON. Both incidents were corrected before the survey began.
A resident with a history of depression and under hospice care was readmitted to the facility without adequate mental health interventions. Despite previous self-harm attempts communicated by hospice, the facility did not implement a care plan for depression or coordinate effectively with hospice. The resident's PHQ-9 scores indicated minimal depression, but no psychiatric services were pursued. The resident was found deceased after using a gait belt to hang himself, highlighting the facility's failure to address his mental health needs.
A facility failed to create a comprehensive care plan for a resident's depression and the use of Zoloft, despite the resident's history of stroke and severe cognitive impairment. The care plan only addressed Trazodone for insomnia, missing the resident's depression diagnosis. Interviews with staff revealed the oversight, and the facility's policy mandates a care plan within 48 hours of admission, which was not followed.
Two residents in an LTC facility did not receive timely IV dressing changes as ordered by physicians, placing them at risk for infection. One resident's dressing was not changed due to an LPN documenting the change before performing it and then failing to complete the task. Another resident's dressing was overdue despite documentation indicating a change, with the facility lacking a specific policy for dressing change timeframes. The ADON and Administrator acknowledged the importance of clean dressings but could not explain the oversight.
The facility failed to maintain accurate clinical records for two residents due to LVN A and LVN B's inability to properly document and perform IV dressing changes. A resident with multiple diagnoses had a midline care order for dressing changes every seven days, but the schedule was not followed. Another resident with sepsis and heart failure had a PICC line dressing that was not updated as required. Despite having completed training, the LVNs did not adhere to the physician's orders, potentially increasing infection risk.
The facility failed to adhere to food safety standards, including improper labeling of opened food containers, staff wearing wristwatches during food preparation, and a cook not wearing a facial hair restraint. These actions could lead to foodborne illnesses among residents.
The facility failed to maintain an infection prevention and control program. A medication aide did not use appropriate hand hygiene during a medication pass, an LVN did not sanitize hands between glove changes, and another medication aide did not sanitize a wrist blood pressure cuff between resident uses.
The facility failed to ensure the PASRR Level 1 was completed accurately for a resident with a mental health diagnosis of PTSD. The initial screening form had both 'yes' and 'no' boxes checked for mental illness, and the responsible staff did not follow up for clarity. The facility lacked a specific policy for PASRR screenings, and the MDS Coordinator acknowledged the oversight.
The facility failed to provide timely assistance to a resident with Alzheimer's disease who required help with toileting. Despite the resident's call light being deactivated by an unknown staff member, no assistance was provided for 29 minutes. Interviews with staff revealed a breakdown in communication and adherence to facility protocols.
The facility failed to update the care plans for two residents, leading to inaccuracies in their documented care needs. One resident's care plan incorrectly showed they were still receiving hospice services, while another's care plan did not reflect the discontinuation of a harmful leg/foot brace. Interviews with staff and family confirmed these discrepancies.
A facility failed to ensure a resident's environment was free of accident hazards by leaving a syringe with an open needle in the room of a resident who did not have any orders for medications administered via syringe. The resident received insulin via an insulin pen, and the LVN and DON were unaware of how the syringe ended up in the room.
A facility failed to ensure a resident received the correct water flushes before and after medication administration through a g-tube, as per physician's orders. The LVN used incorrect water volumes, and the DON confirmed the expectation to follow orders, highlighting a lapse in adherence to the facility's policy.
A resident was administered Zoloft without a completed informed consent form. The consent form in the resident's EHR had empty fields for critical information and was uploaded without proper review. Interviews revealed that the standard protocol for obtaining consent was not followed, and multiple staff members failed to ensure the form's completion.
The facility failed to ensure proper storage and security of medications, leaving a medication cart unlocked and unattended in a high-traffic area and allowing an LVN to leave medications unattended at a resident's bedside. This compromised resident safety and medication security.
Medication Storage and Access Lapses
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and accessible only to authorized personnel. During observation, Resident #162 was found with a pharmacy-labeled tube of Mupirocin Ointment 2% on the bedside table, even though the resident did not have a physician order for that medication and staff stated she was not allowed to keep medications at the bedside. Resident #162 stated the ointment had been given to her by the hospital and had remained on the bedside table since admission, and she did not know what it was for. The 100 Hall Medication Aide cart was also observed unlocked and unattended next to the medication room and facing the walkway in front of the nurse’s station. The assigned medication aide stated she had last used the cart minutes earlier and had forgotten to lock it. An RN observed the cart and stated that an unlocked, unattended cart could allow anyone to access medications that did not belong to them. Resident #118 was observed with a container of Vapor Rub in an open storage container on the bedside table. The resident stated he used it for allergies and that staff knew he had it. Staff interviews reflected uncertainty about whether Vapor Rub was considered a medication, while the DON stated residents should not have medication in their rooms unless there was a physician order and a safe administration of drug assessment. The facility policy stated that all drugs and biologicals were to be stored in locked compartments under proper temperature controls and accessible only to licensed nursing personnel, pharmacy personnel, or other authorized staff.
Food Storage and Hot-Holding Temperature Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards when surveyors found a box of taco shells in the dry storage area with a manufacturer's use-by date of 03/19/2026 and a box of frozen cookie dough in the freezer with the manufacturer's use-by date removed from the packaging. The cookie dough was labeled only with a handwritten date of 02/03/2026, and the Dietary Manager stated the handwritten date represented when staff opened the product. He confirmed the use-by date had been removed and said he could not determine the manufacturer's discard date, when the product should be discarded, when it was last used, or whether it remained suitable for use. The facility also failed to maintain hot-held foods at the required temperature during meal service. During observation, pureed bread measured 118 F and baked beans measured 121 F on the steam table, and the Dietary Manager stated the required hot-holding temperature was 135 F or higher. The Dietary Manager stated the food items would be reheated prior to service, and the items were removed from the steam table and reheated. The report also noted that dietary staff training records showed the Dietary Manager had current ServSafe Food Safety Certification and [NAME] A had completed ServSafe Food Safety training.
Missing Advance Directive Acknowledgements for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had the opportunity to formulate an advance directive upon admission. For Resident #153, the record showed admission with diagnoses including acute osteomyelitis of the left foot and ankle, diabetes, kidney transplant status, and peripheral vascular disease. The record included a CPR/Full Code order and a care plan reflecting Full Code status, but there was no Advance Directive Acknowledgement document in the clinical record. For Resident #162, the record showed admission with diagnoses including diabetes, COPD, CHF, peripheral vascular disease, and acquired absence of the right leg above the knee. The record also included a CPR/Full Code order and a care plan reflecting Full Code status, but there was no Advance Directive Acknowledgement document in the clinical record. During interview, Resident #162 stated she recalled a discussion about an advance directive but was not sure with whom, and stated she did not sign a document referencing advance directives. Resident #153 stated he recalled discussing an advance directive with a family member and wanted to remain Full Code, though he had discussed the possibility of DNR if he became brain dead. His family member stated she possibly discussed an advance directive with the SW but was not sure about signing a document. The DON stated the opportunity to formulate an advance directive was provided by the SW at admission and reviewed during care plan meetings, and the SW stated she was responsible for providing and uploading the Advance Directive Acknowledgement document but did not generate it for these two residents because she had been busy. Facility policy required staff to provide written information about advance directives prior to, upon, or immediately after admission and to document that the resident and/or representative received it.
Nail Clippers Left in Resident Room
Penalty
Summary
The facility failed to ensure Resident #118’s environment remained as free of accident hazards as possible when a pair of nail clippers was found in the resident’s room. Resident #118 was a [AGE]-year-old male readmitted to the facility with diagnoses including major depressive disorder, recurrent, mild, and memory deficit following nontraumatic subarachnoid hemorrhage. His MDS dated [DATE] showed a BIMS score of 14 out of 15 and indicated substantial/maximal assistance was needed with personal hygiene. His care plan included an ADL self-care performance deficit related to UTI with personal hygiene set-up as an intervention. During observations on 06/09/2026 and 06/10/2026, the resident had 1 pair of nail clippers in a clear storage container on his dresser. The resident stated staff knew he had the nail clippers and that if he was not allowed to have them, staff would have taken them away. He also stated he could not cut his nails and that his family comes and does it. Staff interviews showed CNA B and LVN C stated residents were not allowed to have harmful items such as nail clippers in their rooms, and the DON stated Resident #118 should not have nail clippers in his room and that no safety assessment was found for him. The DON also stated staff were supposed to remove prohibited items if seen in residents’ rooms, and that rotating staff were assigned daily rounds to look for such items.
Incorrect Code Status Documented in Resident Record
Penalty
Summary
The facility failed to maintain Resident #11’s clinical record in accordance with accepted professional standards because the resident’s code status was documented inconsistently. Record review showed the resident was a [AGE] year-old male with diagnoses including chronic respiratory failure and heart failure, had a BIMS score of 14 out of 15, and had signed an out-of-hospital do-not-resuscitate (OOH-DNR) form and advance care planning acknowledgement on 1/11/2024 indicating his wish for DNR status. The care plan also reflected that he had elected DNR status and that an OOH-DNR had been scanned into the record. Despite this documentation, the order summary dated 06/10/2026 showed an active full code order with an order date of 04/02/2026. Interviews with the DON, SW, ADON, and the resident showed that the resident had changed his code status to DNR and that staff were responsible for ensuring the order was changed, but the full code order remained in place after readmission. The DON confirmed the record contained a full code order while the care plan reflected DNR status, and the SW stated the resident should have been DNR when readmitted.
Infection Control Lapses During Catheter Care and Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program for two residents. Resident #10, a severely cognitively impaired female admitted with diagnoses including sepsis, kidney failure, urinary tract infection, uterovaginal prolapse, and need for assistance with personal care, had an indwelling urinary catheter ordered to be secured with a leg strap or anchor and checked every shift. Her care plan also directed staff to secure the catheter to facilitate urine flow, prevent kinking, and prevent accidental removal. During an observation in the dining room, Resident #10 was sitting in a wheelchair eating lunch while her indwelling urinary tube and urine bag were resting on the floor. An ADON observed this and stated the tubing and bag should not be on the floor because they could leak, cause injury if dislodged, and were an infection control issue involving cross contamination. The ADON stated nursing and medical staff were responsible for keeping the tubing and bag off the floor. Resident #31, a cognitively intact female with impaired vision and orders for Systane eye drops, was observed during medication administration when Medication Aide E gave oral medications, returned to the medication cart, did not wash or sanitize his hands, put on gloves, unlocked the cart, retrieved the eye drops, and then returned to the resident while still wearing the gloves to instill the drops. The aide stated he had not realized hand hygiene was not performed before glove use or when moving from a clean area to a dirty area. The DON stated the aide should have sanitized his hands before gloves and that gloves should have been removed and hand hygiene performed before administering the eye drops.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to ensure that an allegation of abuse, neglect, exploitation, or mistreatment was reported immediately, and no later than the required time frame, after a family member alleged that a resident had been neglected and developed a skin ulcer. The resident was admitted for rehabilitation after a left knee wound and had diagnoses including a laceration of the left knee, urinary tract infection, and a history of infections. The resident was dependent on staff for all ADLs, and the skin assessment on admission documented skin breakdown to the right big toe and a left knee surgical wound. The resident’s family member stated that staff often did not assist with repositioning or incontinent care and that family members sometimes had to intervene to get care provided. After the resident was sent to the hospital for lethargy and infection, the family member was told by hospital nurses that the resident had ulcers to the backside/buttocks and neck areas and that these may have contributed to systemic infection. The family member complained to the DON, who discussed the concern with the Administrator; they concluded the allegation did not need to be self-reported because they believed there was no evidence of abuse or neglect. The DON stated the facility would report allegations of ANE within 2 hours if involving injury and within 24 hours if without injury, but the allegation was not reported to the state agency.
Failure to Investigate Allegation of Neglect and Skin Breakdown
Penalty
Summary
The facility failed to ensure that an allegation of abuse, neglect, exploitation, or mistreatment was thoroughly investigated for one resident. The resident was admitted for rehabilitation after hospitalization with diagnoses including a left knee wound, urinary tract infection, and a history of recurrent infections. Records showed the resident was dependent on staff for all ADLs, had skin breakdown to the right big toe and a left knee surgical wound on admission, and later received an enema from two LVNs on the evening before being discharged to the hospital for lethargy. The resident’s family member stated that during visits he observed staff not assisting with repositioning or incontinent care and that family members often had to intervene to get care provided. He later learned from hospital staff that the resident had an ulcer to the backside/buttocks and neck areas and may have contributed to systemic infection. He reported the concern to the DON, who stated she and the Administrator reviewed the complaint, concluded it lacked merit because the two LVNs did not observe skin breakdown during the enema care, and decided the allegation did not need to be reported to the state agency. The facility policy required all possible incidents of abuse, neglect, mistreatment, and misappropriation to be identified and investigated, and allegations to be investigated and reported within required time frames.
Medication Pass Error Rate Exceeds 5% Due to Late Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, as surveyors identified a 16.12% error rate during a medication pass. During observation of a medication administration by one LPN, five of thirty-one medication opportunities were administered late to one resident. Specifically, the LPN administered Docusate Sodium, Fluoxetine HCl, Meloxicam, Methenamine Hippurate, and Polyethylene Glycol at 12:12 p.m., which was one hour and twelve minutes after the end of the scheduled administration window of 7:00 a.m. to 11:00 a.m. This late administration was identified through observation, interview, and record review. The resident involved was an elderly female with diagnoses including a left wrist carpal fracture, constipation, depression, and urinary tract infection. Her 5-Day MDS showed a BIMS score of 11, indicating moderate cognitive status, and documented frequent pain rated 5 out of 10, need for substantial/maximal assistance with mobility and transfers, and active UTI, fracture, and depression. Her care plan included interventions to administer medications as ordered for constipation, UTI prophylaxis with Methenamine Hippurate, pain management with analgesics, and depression treatment with Fluoxetine. The active medication orders confirmed scheduled dosing for the medications that were administered late, including bowel maintenance, antidepressant therapy, pain control after breakfast, and chronic UTI management.
Failure to Remove and Properly Document Lidoderm Patch Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate dispensing and administration of a prescribed Lidoderm (lidocaine) patch for one resident. The resident was an elderly female with diagnoses including a left wrist fracture, constipation, depression, and a urinary tract infection. Her 5-Day MDS showed a BIMS score of 11 (moderately cognitively intact), frequent pain rated 5/10, and use of scheduled and PRN pain medications. Her care plan included administration of analgesics as ordered and monitoring for side effects and effectiveness. An active physician order directed that a 5% Lidoderm patch be applied to the lower back once daily for back pain and removed every evening before bedtime, consistent with manufacturer directions to use the patch for up to 12 hours within a 24-hour period. On the medication administration record for the month, the Lidoderm patch was documented as administered on 03/07/2026 by a medication aide. During a medication pass observation the following day, an LPN entered the resident’s room to administer the scheduled Lidoderm patch and, upon exposing the resident’s lower back, observed an existing Lidoderm patch still in place. The patch was dated 03/06/2026 and had no staff initials. The LPN stated the resident should not have had the previous patch on, that she had not worked the prior two days and therefore had not seen the resident’s back, and that she believed the patch should only be on for 12 hours. She expressed uncertainty as to whether the prior day’s administration had been missed or if the patch had been misdated, and stated that such an error was unacceptable because it placed the resident at risk of receiving more medication or a higher dose than intended. When questioned, the resident reported she was not in pain and believed the patch had been applied the day before but was unsure. In a subsequent interview, the medication aide reported working from 06:00 a.m. to 10:00 p.m. on 03/07/2026 and recalled administering the resident’s medications and applying the Lidoderm patch that day. She stated that if she applied the patch, she knew it needed to be removed in the afternoon but did not recall removing it. She remembered giving the resident evening medications and asking her to turn on her side, at which time the resident complained of arm pain; the aide believed she likely told the resident she would return and then forgot to remove the patch. She stated the patches were expected to be on for 11.5 to 12 hours and acknowledged she could have put the wrong date on the patch, noting she had previously discovered and corrected wrong dates on patches. The DON stated her expectation that staff date and initial lidocaine patches on administration and remove them after 12 hours unless the provider changed the order, and that leaving a patch on longer than expected could cause lidocaine toxicity, while not providing the patch per order could result in pain. The facility’s medication administration policy required medications to be administered in accordance with written physician orders.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Unlabeled Loose Pills Found in Multiple Medication Carts
Penalty
Summary
Surveyors observed that three of eight medication carts in the facility contained loose, unlabeled pills in the drawers. Specifically, the 200 hall nurse cart had two unlabeled pills, the 200 hall medication aide cart had one unlabeled pill, and the 400 hall medication aide cart had four unlabeled pills. These pills were not labeled in accordance with professional guidelines, and staff interviewed acknowledged that the identity of the pills was unknown and that they would dispose of them due to safety concerns. Interviews with nursing and medication aide staff confirmed that the presence of loose, unlabeled pills could lead to contamination, medication errors, or the possibility that a patient might not receive their prescribed medication. The Director of Nursing also stated that loose pills could be accessed by unauthorized individuals and should be destroyed. The facility's policy requires medications and biologicals to be labeled according to facility, state, and federal requirements, which was not followed in these instances.
Medication Administration and Security Deficiencies
Penalty
Summary
The facility failed to provide appropriate pharmacological services for two residents, leading to medication errors. For one resident, a Licensed Vocational Nurse (LVN) administered Cefazolin 6 GM in 250 ML instead of the prescribed 6 GM in 1000 ML. This error was identified as a pharmacy oversight, where the incorrect concentration was sent. The LVN realized the mistake after administration and reported it to the Director of Nursing (DON), who instructed her to contact the facility nurse practitioner and pharmacy. Fortunately, no harm occurred to the resident as the medication was administered via a PICC line, which is non-irritant to veins. In another incident, the facility failed to secure controlled medications properly. A discrepancy was found in the narcotic count for Ativan 1 MG prescribed to another resident. The narcotic sheet indicated that 24 Ativan tablets were received, but only 14 were present, and the blister pack was missing. This discrepancy was discovered during a monthly drug destruction by the DON. The issue arose due to outdated controlled drug counting practices, where nurses only counted the medication in the blister pack without verifying the resident's name or the medication details. Both incidents were identified as past non-compliance, with the facility having corrected the issues before the survey began. The deficiencies could have affected all residents receiving medication from the facility, placing them at risk for adverse reactions and a decline in physical health.
Failure to Address Mental Health Needs Leads to Resident's Death
Penalty
Summary
The facility failed to coordinate care with hospice and implement interventions to address a resident's mental health needs, leading to a tragic incident. The resident, who had a history of depression and was under hospice care, was readmitted to the facility with a diagnosis of depression. Despite hospice communication indicating the resident had previously attempted self-harm, the facility did not coordinate effectively with hospice or implement a care plan addressing the resident's mental health needs. The resident's care plans lacked specific interventions for depression, and there were no orders for mental health services from the time of readmission until the incident. The resident was on medications for depression, including Zoloft and Trazodone, but the facility's monitoring of the resident's mental health was inadequate. The resident's PHQ-9 assessments indicated minimal depression, but there was no follow-up or referral for psychiatric services despite a noted increase in the PHQ-9 score. The facility's social services staff did not probe further into the resident's mental health status or communicate the increased score to other healthcare providers. On the day of the incident, the resident was observed by multiple staff members and appeared to be in good spirits, showing no overt signs of distress. However, later that day, the resident was found deceased in his closet, having used a gait belt to hang himself. The facility's failure to address the resident's mental health needs and ensure a safe environment contributed to this tragic outcome.
Failure to Develop Comprehensive Care Plan for Resident's Depression
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included addressing the resident's diagnosis of depression and the use of the anti-depressant medication Zoloft. The resident, an elderly male with a history of stroke, hemiplegia, dysphagia, dysarthria, and depression, was admitted to the facility and had been receiving Zoloft and Trazodone as part of his treatment. However, the care plan only included interventions related to the use of Trazodone for insomnia and did not address the resident's depression or the use of Zoloft. Interviews with facility staff, including the MDS Nurse and the DON, revealed that the care plan for the resident's depression and Zoloft medication was overlooked. The MDS Nurse acknowledged missing the creation of the care plan when the medication was ordered, and the DON confirmed the absence of a care plan for the resident's depression and Zoloft. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan within 48 hours of admission, but this was not adhered to, potentially impacting the continuity of care for the resident.
Failure to Perform Timely IV Dressing Changes
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident preferences, specifically in the case of two residents who did not receive timely intravenous (IV) dressing changes. Resident #1, a male with multiple health conditions including cytomegaloviral disease, diabetes, and acute kidney failure, was supposed to have his IV dressing changed every 7 days. However, it was observed that his dressing was old, dirty, and not changed as documented by LVN A, who admitted to documenting the change before actually performing it and then failing to complete the task due to being busy. Resident #2, a male with conditions such as sepsis, MRSA, and heart failure, also did not receive timely IV dressing changes. His physician orders required a PICC line dressing change every 7 days, but observations revealed that the dressing had not been changed since the date of 6/28/2024, despite documentation indicating a change on 7/14/2024 by LVN B, who could not be contacted for verification. The treatment nurse and LVN A confirmed the dressing was overdue for a change, and the facility's ADON acknowledged the lack of a specific policy for dressing change timeframes, relying instead on physician orders. The facility's failure to adhere to the prescribed dressing change schedule for both residents placed them at risk for infection. The facility's ADON and Administrator both recognized the importance of maintaining clean IV dressings to prevent infection but could not explain why the orders were not followed. The absence of a clear policy and oversight in checking new orders contributed to the oversight in care for these residents.
Failure to Maintain Accurate IV Dressing Change Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, as LVN A and LVN B did not demonstrate competency in documenting and performing IV dressing changes. Resident #1, a male with multiple diagnoses including cytomegaloviral disease, diabetes mellitus, and acute kidney failure, had a physician's order for midline care with dressing changes every seven days. However, the documentation by LVN A indicated a dressing change on a date that did not align with the required schedule. Similarly, Resident #2, a male with conditions such as sepsis, MRSA, and heart failure, had a physician's order for a PICC line dressing change every seven days. Despite this, the dressing on Resident #2's IV site was observed to be outdated, with a date indicating it had not been changed as per the order. Interviews and observations revealed that LVN A, who was responsible for Resident #2's care, acknowledged the discrepancy in the dressing change schedule but could not explain why the dressing had not been updated. The facility's Assistant Director of Nursing (ADON) also confirmed the importance of maintaining clean IV dressings to prevent infections but was unaware of why the orders were not followed. Both LVN A and LVN B had completed training in intravenous therapy, including dressing changes for IV sites, yet failed to adhere to the physician's orders, potentially increasing the risk of infection for the residents.
Food Safety Violations in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. An observation revealed a gallon-sized container of sweet tea in the walk-in cooler that had been opened and was not labeled with a use-by date. The DS confirmed that the container should have been labeled by the staff member storing it in the cooler. This oversight could lead to the consumption of expired or unsafe food by residents. Further observations showed that both the DS and DA C wore wristwatches while engaged in food preparation, which is against the Texas Food Establishment Rules (TFER). The DS was seen handling meatloaf and raw beef, while DA C was observed filling cups with beverages and placing food items on trays. Both individuals acknowledged that they should not have worn jewelry while preparing food, but the DS mentioned he forgot to remove his watch due to the busy nature of the day's menu. Additionally, Cook D was observed with facial hair on his upper lip and was not wearing a facial hair restraint while preparing food. Cook D stated he was unaware of the requirement for a facial hair restraint. The DS confirmed that Cook D should have worn a facial hair restraint and mentioned that staff were trained during their orientation. The facility's reliance on the TFER as their policy manual was noted, but the lack of adherence to these standards was evident in the observed deficiencies.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies. Medication Aide G did not utilize appropriate hand hygiene during the medication pass for Resident #17. After administering oral medications, the aide put on gloves without washing or sanitizing her hands, then proceeded to handle the resident's belongings and apply a new Lidocaine patch without changing gloves. This was acknowledged by the aide as cross-contamination, which could lead to infection. LVN A also failed to practice proper hand hygiene during the medication pass for Resident #80. After cleaning the resident's g-tube site, the LVN removed her gloves but did not wash or sanitize her hands before putting on a new pair of gloves and continuing with the medication administration. The LVN admitted to not being aware of the lapse in hand hygiene, which was confirmed as an infection control issue by the DON. Additionally, Medication Aide F did not sanitize the wrist blood pressure cuff between uses on different residents. The aide used the same cuff on Resident #253 and Resident #80 without cleaning it in between, which he later acknowledged as an oversight due to nervousness. The DON confirmed that the expectation was to sanitize equipment between residents to prevent cross-contamination and potential infections.
Failure to Complete Accurate PASRR Screening for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level 1 was completed accurately for Resident #84 upon admission. The resident, who had a mental health diagnosis of post-traumatic stress disorder, did not receive the proper PASRR screening. The initial PASRR screening form received from the referring entity had both 'yes' and 'no' boxes checked for mental illness, which should have triggered a follow-up for clarity. However, the responsible staff member did not ensure the accuracy of the received or transmitted data at the time of admission and did not follow up with the referring entity for clarification. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the facility did not have a specific policy related to the completion of PASRR screenings, and the staff member responsible for the initial screening was no longer employed at the facility. The MDS Coordinator acknowledged that Resident #84 should have received a PASRR screening from the local authority to determine eligibility for PASRR services. The DON confirmed that the PASRR screening was incorrect and that the MDS Coordinator should have followed up with the referring entity for a new screening. Despite this, the DON believed that the resident not receiving the PASRR screening did not affect the resident's care.
Failure to Provide Timely Assistance to Resident
Penalty
Summary
The facility failed to provide necessary care and services to Resident #251, who was admitted for short-term rehabilitation with a primary diagnosis of Alzheimer's disease. The resident required assistance with toileting and preferred not to use an adult brief. On the day of the incident, the resident's family member reported that an unknown staff member responded to the resident's call light, deactivated it, and left the room without providing the needed assistance, promising that another staff member would arrive shortly. However, no staff responded to the resident's need for assistance over the next 29 minutes, despite the facility's protocol requiring immediate assistance or informing another staff member who could help promptly. Interviews with various staff members, including LVN I, CNA J, CNA K, the DOR, and the DON, revealed that none of them responded to the call light or were informed of the resident's need for assistance. The DON acknowledged the issue and stated that it was her expectation that any staff member responding to a call light should either assist the resident or inform another staff member who could. The facility's policy on rounds and staffing emphasized the importance of checking residents frequently and answering call lights in a timely manner, which was not adhered to in this case.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. For Resident #16, the care plan inaccurately reflected that the resident was still receiving hospice services, despite hospice services being terminated on 2/16/24. This discrepancy was noted during interviews with the resident's family, the social worker, and the Director of Nursing (DON), all of whom confirmed that the care plan should have been updated to reflect the termination of hospice services. The social worker admitted responsibility for updating the care plan but acknowledged that nursing staff could also have made the necessary updates. For Resident #8, the care plan did not reflect that the resident was no longer using a leg/foot brace (podus boot). The resident was observed wearing soft offloading boots instead of the podus boot, which was causing more harm than benefit. Interviews with the treatment nurse and physical therapist confirmed that the podus boot should have been discontinued and the care plan updated accordingly. The DON also acknowledged that the care plan should have been updated to reflect the current use of soft offloading boots. The facility's policy on comprehensive person-centered care planning, revised in 12/2023, mandates that the interdisciplinary team (IDT) develop and update care plans to meet residents' needs. However, the failure to update the care plans for Residents #16 and #8 indicates a lapse in adhering to this policy, potentially leading to inconsistent and inadequate care for the residents.
Failure to Remove Syringe with Open Needle from Resident's Room
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards for one resident reviewed for accidents and hazards. Specifically, a syringe with an open needle attached was found in the room of a resident who did not have any orders for medications administered via syringe or injection. The resident, who was independently ambulatory and received medications administered by nursing staff, stated he had not seen the syringe and confirmed he received his insulin injection via an insulin pen that morning. An LVN who had rounded on the resident earlier that morning confirmed the resident received his insulin via an insulin pen and was unaware of the syringe in the room. The LVN disposed of the syringe immediately upon discovery. The DON was informed of the incident but could not identify which staff member left the syringe in the room. The facility's policy on rounds and staffing emphasized the importance of ensuring personal items at the bedside are safe for the resident.
Failure to Follow Physician's Orders for G-Tube Water Flushes
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not provide the correct water flushes before and after medication administration through a gastrostomy tube (g-tube) for a resident. The resident, who had multiple diagnoses including type 2 diabetes, muscle wasting, gastroparesis, and dysphagia, required a feeding tube and had specific orders for water flushes that were not followed by the nursing staff. During a medication pass, the Licensed Vocational Nurse (LVN) attempted to flush the g-tube with 5 ml of water instead of the ordered 30-50 ml, and subsequently administered a final flush of 180 ml instead of the ordered 30-50 ml after medication administration. The LVN acknowledged the error upon reviewing the physician's orders and realized the mistake in the volume of water used for flushing the g-tube. The Director of Nursing (DON) confirmed that it was the expectation for nursing staff to follow the physician's orders and that failure to do so could result in improper hydration for the resident. The facility's policy on medication administration via feeding tube also specified the need to follow the physician's orders for water flush volumes, which was not adhered to in this case.
Failure to Obtain Proper Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were given psychotropic medications with proper consent. Specifically, Resident #55 was administered Zoloft, an antidepressant, without a completed informed consent form. The consent form within Resident #55's electronic health record (EHR) was found to have empty fields for critical information such as the medication ordered, the related diagnosis, conditions treated, expected benefits, clinically significant side effects, and the purpose and course of therapy. This incomplete form was uploaded into the EHR without being properly reviewed for completion by the admitting nurse, the medical records staff, or the Director of Nursing (DON). Interviews with the Licensed Vocational Nurse (LVN), Medical Records staff, and the DON revealed that the standard protocol for obtaining consent for psychotropic medications was not followed. The LVN admitted that the psychotropic medications should not have been provided until consent was obtained, and the Medical Records staff acknowledged that the incomplete form should have been returned to the nurse for completion before uploading. The DON confirmed that it was the responsibility of multiple staff members, including the admitting nurse, charge nurse, medical records, and the Interdisciplinary Team (IDT), to review and ensure the completion of consent forms before uploading them to the EHR. The facility's psychotropic medication policy also required obtaining consent prior to the initiation of new psychotropic medications, which was not adhered to in this case.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permitted only authorized personnel to have access to the keys. Specifically, the 300 Hall Med Aide Medication Cart was left unlocked and unattended in a high-traffic area outside the main dining room and near the nurse's station. The Director of Nursing (DON) acknowledged the issue and locked the cart upon noticing it, revealing that Med Aide F was responsible for the cart and was likely on another hall at the time. The DON confirmed that the cart should not have been left unlocked and unattended, as residents with dementia could access it, posing a risk of medication misuse and diversion. Additionally, during a medication pass, LVN A left medications unattended at Resident #80's bedside on three separate occasions while gathering supplies from the medication cart. Resident #80, a [AGE] year-old female with multiple diagnoses including type 2 diabetes, muscle wasting, gastroparesis, and moderate cognitive impairment, had her medications placed in separate cups on her bedside table. LVN A admitted that she should not have left the medications unattended, as they could have been accidentally knocked over or taken by someone else. The DON reiterated that staff should not leave medications unattended to prevent accidental ingestion by residents with dementia or unauthorized individuals. The facility's policy and procedure on medication access and storage, revised in August 2020, mandates that all drugs and biologicals be stored in locked compartments and accessible only to authorized personnel. The policy specifies that medication rooms, carts, and supplies must be locked or attended by authorized individuals. The facility's failure to adhere to this policy resulted in the observed deficiencies, potentially compromising resident safety and medication security.
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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 San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windemere At Westover Hills | 1.1 mi | ★★★★★ | 6 | 0 |
| Las Colinas Of Westover | 1.3 mi | ★★★★★ | 18 | 0 |
| Lakeside Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Silver Creek Nursing And Rehabilitation | 2.9 mi | ★★★★★ | 0 | 0 |
| Legend Oaks Healthcare And Rehabilitation - West S | 3.7 mi | ★★★★★ | 13 | 0 |
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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.