Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westpark Rehabilitation And Living during CMS and state inspections, most recent first.
A deficiency was cited when multiple residents receiving or potentially needing oxygen and suction therapy did not have their respiratory equipment stored and maintained according to facility policy and professional standards. Observations showed nasal cannulas hanging on wheelchairs and chairs, one cannula lying on the floor, and a suction tip left connected to a machine without being bagged. A humidifier bottle for oxygen was found on a nightstand, partially filled, cracked, and not connected to the concentrator. Residents involved had conditions such as COPD, chronic respiratory failure, acute respiratory failure, heart failure, and dementia. Staff, including CNAs, an RN, an LVN, a med tech, and the DON, stated that cannulas, nebulizer masks, suction tips, and humidifier bottles were supposed to be bagged or covered, dated, and changed on a regular schedule, and acknowledged that improper storage could lead to infection.
Surveyors found that the facility failed to secure medications and over-the-counter products and allowed residents to possess them without physician orders. A resident with severe cognitive impairment had Lumify eye drops at the bedside without an order, another resident with chronic respiratory failure and diabetes had Alka Seltzer and nasal saline spray on the over-bed table without orders, and a resident with dementia and macular degeneration had Vicks VapoRub stored in personal drawers without an order. Staff, including CNAs, a Med Tech, an LVN, and the DON, stated that facility policy prohibits residents from keeping medications, requires physician orders for all medications, and requires that medications be secured and administered by authorized personnel.
Two residents were not provided care in a manner that maintained their dignity. One resident with severe cognitive impairment and dysphagia, who required maximum assistance with feeding, was fed in bed by a CNA standing over her rather than sitting at eye level, despite staff acknowledging that feeding should be done while seated to observe swallowing. Another resident with moderate cognitive impairment and an indwelling catheter was observed in bed with her catheter bag visible from the hallway and not covered by a privacy bag, even though staff recognized that a privacy bag was required and that ensuring its use was a nursing responsibility.
A resident with severe cognitive impairment, difficulty swallowing, and an MDS indicating a need for maximum assistance with feeding did not have assisted feeding documented as an intervention on the comprehensive care plan, despite having a noted nutritional problem. The resident was observed being fed by a CNA, who stated the resident could not feed herself. The DON acknowledged the resident had a change in condition requiring assisted feeding and that this intervention should have been on the care plan, while the MDS Nurse reported being unaware of the need. This occurred despite a facility policy requiring comprehensive, person-centered care plans to be updated based on changing resident needs.
Two residents were not provided with an environment free of accident hazards. One resident with severe cognitive impairment, a fall history, and documented unsteadiness had a care plan requiring a fall mat at bedside, yet surveyors observed her lying in bed with the fall mat away from the bed and the bed in a raised position. Another resident with intact cognition, a mental disorder, lack of coordination, and an order for PRN Albuterol-Budesonide inhaler for respiratory symptoms was observed with a can of Lysol spray on his bedside table, despite staff and the DON stating that such sprays are not allowed in resident rooms due to potential respiratory and allergic effects and that all staff are responsible for removing such items.
Surveyors found that two residents with significant cognitive and physical impairments, including dementia, Alzheimer’s disease, contractures, and fall risk, did not have accessible call lights while in bed, despite care plans and facility policy requiring call devices to be within reach. One resident reported having no way to call staff and believed she did not have a call light, which was later observed attached to the roommate’s bed. The other resident reported long waits for assistance and that her call light was often not near her; surveyors observed her call light on the floor behind a mat rather than on her bed.
Unclean Resident Rooms and Shower Areas: Multiple resident rooms had built up dirt in floor corners, thick dark substances in bathrooms, dust and dirt on AC units, rust-like staining on furniture and door frames, and staining under sinks and around toilets. Two shower rooms also had dark stains and thick dirt around drains. Housekeeping staff stated they were responsible for cleaning the rooms and bathrooms, and the DON/Administrator acknowledged the expectation for a clean resident environment.
Respiratory equipment was found improperly stored for multiple residents with O2 or nebulizer orders. A nasal cannula and several breathing masks were observed unbagged on a wheelchair, shelf, chair, floor, bedside area, and nightstand, while staff stated the equipment should be bagged when not in use to prevent contamination and infection.
A resident with HTN, hospice services, and severe cognitive impairment missed the morning dose of propranolol ordered BID. MA G could not find the medication in the cart or emergency kit, and ADON A contacted hospice after the dose was already missed. The DON stated staff should reorder meds before the last pill was given and that residents should receive meds as ordered.
Medication Storage and Labeling Failures: Multiple meds and biologicals were found left in resident rooms or on unattended carts, including antifungal cream, zinc oxide, nasal spray, peroxide, wound cleanser, barrier cream, insulin, and liquid lorazepam. Residents involved included several with dementia, severe cognitive impairment, diabetes, and incontinence. Staff acknowledged the items should not have been left accessible, and some insulin lacked open dates while lorazepam ordered to refrigerate was stored in a cart lock box.
Food storage and sanitation practices were not maintained in the kitchen and dining areas. The Dietary Manager was observed near prepared food without a beard cover, uncovered tea and juice pitchers were present, and a tea dispenser was left uncovered. Surveyors also found multiple unlabeled or undated food items, a damaged package exposing food to air-borne contaminants, stained storage bins, and dirty ice equipment, steam trays, counters, sinks, and an ice chest. The DM acknowledged responsibility for dating, covering, and cleaning these items.
Infection control lapses were observed with EBP and glove use for multiple residents. A CNA changed linens for a resident with a g-tube without a gown despite an EBP sign, an RN disconnected and flushed a PICC line without a gown for a resident on EBP, and a MA entered vital signs into a laptop on the med cart while still wearing gloves after checking a resident’s BP. Staff acknowledged the PPE and hand hygiene errors.
A crash cart in a hallway had unsecured drawers that could be easily opened and contained a screwdriver and tubing. In separate observations, an RN and an MA left containers of germicidal wipes on top of unattended carts in hallways while residents were nearby. The DON, ADON, and Administrator stated the wipes should be locked inside the carts and the crash cart should be secured so residents could not access the drawers.
A resident with cerebral palsy, intact cognition, and a care plan noting fall risk and slide board transfers had a call light that was not positioned within reach while he was in bed. Staff observed the call light draped across an open nightstand drawer and acknowledged it did not reach the resident, while RN and CNA staff said they had not noticed it was out of reach. The facility policy required the call device to be placed within the resident’s reach before leaving the room.
Two residents had PASRR Level I screenings that were initially negative, but later developed new mental health diagnoses including depression, delusional disorder, dementia, and bipolar disorder. No new PASRR I, PASRR II, or PE was found in either record. The MDS Nurse confirmed a new PASRR I should have been completed after the new diagnoses, while the DON and ADON were unfamiliar with PASRR and the Administrator said a process should exist to identify when a new screening is needed.
Incomplete Care Plans for Skin Lesion and Midline IV Therapy: The facility failed to ensure two residents had comprehensive, person-centered care plans that reflected their current needs. One resident had a cancer lesion on the forehead, but the care plan did not include a specific plan for that condition even though staff said the lesion was being monitored and treated by the Wound Care MD. Another resident received IV cefepime through a midline catheter for a UTI, but the care plan did not include the midline or IV antibiotic therapy, despite staff confirming the device and treatment were in place.
Failure to provide and document scheduled showers for a resident with morbid obesity, paraplegia, and moderate cognitive impairment. The resident stated he was not receiving showers and had not refused them, while staff initially could not produce his shower sheets and later produced records showing inconsistent documentation of showers and bed baths. Interviews also showed staff uncertainty about whether the resident was actually receiving the ordered hygiene care.
Unsafe Chemical Found in Resident Room: A resident with major depressive disorder, schizophrenia, and moderate cognitive impairment was observed with a bottle of rubbing alcohol on his bedside table. RN C stated the chemical was not safe for him because he could drink it, and the DON stated he could not have possession of it because he could ingest it. The record also included an SDS noting acute toxicity - oral and flammable liquid hazards for a related product.
Expired medications were found in a nurse's cart, including Linzess for one resident, Clonidine for another resident, and an OTC gas relief product. RN D confirmed the medications were expired, and the DON and ADON stated expired medications should not remain in carts. One resident had no active order for Linzess, while the other had an active Clonidine order for HTN.
A resident with dementia and severe cognitive impairment received the influenza vaccine even though the immunization record documented family refusal. The RP stated she had told nursing staff not to give the shot because of concern for an allergic reaction, but later learned it was administered anyway. The ADON and DON said the vaccine was given in error because the resident had the same last name as another resident.
A resident with quadriplegia and a physician order for nebulizer treatments did not have the use of the nebulizer included in their care plan. Despite staff awareness of the order and the resident's use of the device, the care plan was not updated to reflect this need, resulting in a lack of documented interventions and guidance for staff.
A resident with severe cognitive impairment and muscle weakness, identified as a fall risk, did not have a physician order for a scoop mattress and had a fall mat observed leaning against the wall instead of being placed next to the bed as required by the care plan. Nursing staff confirmed the interventions were not properly implemented, resulting in a failure to provide adequate accident prevention measures.
A resident with quadriplegia and a physician's order for nebulizer treatments was found to have her nebulizer mask left unbagged on a nightstand when not in use. Staff interviews confirmed that the mask should have been bagged to prevent infection, and the resident's care plan did not address nebulizer use. The facility's policy required proper respiratory care practices, which were not followed in this instance.
Surveyors found that a treatment cart was left unlocked and unattended, with all drawers and supplies accessible, while a resident in a wheelchair was nearby. The DON confirmed the cart was not secured and stated that staff are expected to keep treatment carts locked when not in use, in line with facility policy requiring all drugs and biologicals to be stored securely and accessible only to authorized personnel.
Two residents were not provided with their prescribed medications following admission, including a seizure medication and multiple inhalers for respiratory conditions. The facility did not obtain or document hospital discharge orders in a timely manner, and staff failed to administer or record the administration of these essential medications as required by policy.
A resident in an LTC facility suffered physical abuse by an LVN, resulting in fractures to her right elbow and wrist, necessitating surgery. The incident occurred during an altercation where the LVN pushed the resident, causing her to fall. The injuries were not immediately reported as abuse, and the LVN was later terminated following an investigation.
Two residents in the facility were found with inaccessible call lights, violating their right to reasonable accommodation of needs. One resident had his call light clipped to a privacy curtain, while another's was blocked by an oxygen concentrator. Both residents, who required assistance due to muscle weakness and cognitive impairments, were unable to call for help. Staff interviews confirmed the expectation for call lights to be within reach, as per facility policy.
A resident with a suprapubic catheter was found with the catheter bag and drain valve on the floor, risking infection. Staff interviews confirmed the importance of keeping the catheter bag off the floor to prevent contamination, aligning with facility policy on infection control.
A resident with COPD did not receive proper respiratory care as their nebulizer mask was left unbagged on a drawer, contrary to facility policy. The resident was not informed about the need to bag the mask, and the nurse failed to notice the oversight. Interviews with the ADON and DON confirmed the importance of bagging the mask to prevent infection.
A resident with cerebral palsy received care from staff who failed to perform proper hand hygiene and glove changes, leading to potential cross-contamination. COTA G and CNA F did not change gloves after handling soiled items, and COTA G continued using gloves contaminated with feces. The facility's policy requires hand hygiene and glove changes, which were not followed during this incident.
A resident with obstructive and reflux uropathy was not provided a privacy bag for her catheter bag, resulting in a failure to maintain her dignity. The catheter bag was observed exposed and visible, contrary to the facility's policies on dignity and catheter care. Staff, including an RN, DON, and ADON, acknowledged the oversight and the importance of using privacy bags to prevent embarrassment.
The facility failed to maintain a clean and sanitary environment in seven resident rooms and hallways, with observations of dirt, dust, and stains. Staff interviews revealed a lack of awareness and communication regarding these issues, despite the facility's cleaning policy requiring housekeeping to maintain equipment and areas as bacteria-free as possible.
The facility failed to properly store respiratory equipment for three residents, risking infection. A resident's nasal cannula was left unbagged on a stuffed rabbit, another's nebulizer mask was unbagged on a nightstand, and a third's nasal cannula was tangled and touching the floor. Staff failed to notice these issues, despite care plans requiring equipment to be bagged when not in use.
The facility's kitchen failed to meet food storage and sanitation standards, with unclean equipment and improperly labeled food items. The ice scoop and ice chest were dirty, and food in the refrigerator and freezer lacked proper date labeling. The tea dispenser was uncovered, and cooking equipment was stained. The dietary manager was on leave, and no temporary manager was designated, leading to a lack of accountability for kitchen cleanliness.
Two CNAs failed to follow infection control protocols during incontinent care for two residents, leading to potential cross-contamination. One CNA did not change gloves or perform hand hygiene after cleaning a resident's bottom, and placed a cleanser from her pocket onto a new brief. Another CNA did not sanitize hands before care and placed a new brief on soiled padding. Both CNAs admitted to not following proper procedures despite training.
A resident's call light was not answered for over an hour, highlighting a deficiency in the facility's response time to call lights. Interviews and observations revealed that staff often took 30 minutes to over an hour to respond, contrary to the facility's policy. This delay in response time was acknowledged by multiple staff members and noted in the facility's grievance log.
A resident's privacy was compromised when an LVN failed to close the door while checking blood sugar and administering insulin, leaving the resident visible from the hallway. The resident, diagnosed with type 2 diabetes and dementia, had a care plan that included closing the door to reduce distractions. Interviews with facility staff confirmed the expectation to maintain privacy during treatments.
A resident's Quarterly MDS Assessment failed to reflect her continuous use of oxygen therapy, despite her diagnosis of respiratory failure with hypoxia and a physician's order for oxygen. Staff interviews revealed a lack of awareness and oversight in the assessment process, with the MDS Nurse admitting to overlooking the resident's oxygen therapy. This discrepancy highlights a gap in the facility's adherence to its policy on accurate resident assessments.
A facility failed to obtain physician orders or conduct an assessment before using a scoop mattress for a resident with seizures and muscle weakness, potentially exposing the resident to accident hazards. The DON acknowledged the mattress was provided without proper authorization, sometimes at family request.
A facility failed to provide proper incontinent care for a resident with dementia and muscle weakness, risking urinary tract infection. A CNA reused wipes during cleaning, contrary to policy, which requires a new wipe for each stroke to prevent cross-contamination. Interviews confirmed the CNA's understanding of the error and the facility's policy on infection prevention.
A resident with severe cognitive impairment and dysphagia was not provided proper g-tube care, as a syringe used for medication administration was not replaced daily, and an abdominal binder was not applied as ordered. The LVN failed to check the syringe date, and there was no documentation of the resident refusing the binder. Interviews with the ADON and DON confirmed these lapses, which were against the facility's policy and physician's orders.
A non-verbal resident with severe cognitive impairments was sexually abused by a CNA in an LTC facility. Video evidence showed the CNA engaging in inappropriate conduct while providing care. The resident, dependent on staff for all activities, was unable to communicate the abuse. Despite staff awareness of reporting procedures, the incident occurred, revealing lapses in oversight and monitoring.
A resident with severe cognitive impairments was sexually abused by a CNA, despite the facility's policies prohibiting mistreatment and abuse. The incident was captured on video, and the resident, who was non-verbal and dependent on staff for care, was unable to communicate the abuse. The facility's investigation was ongoing, and the CNA was suspended. Staff interviews indicated awareness of abuse reporting procedures, but the incident revealed a failure in policy implementation.
The facility failed to implement a comprehensive care plan for a resident with a history of stroke, requiring two staff members for incontinence care. Despite the care plan's instructions, a CNA provided care alone, and the DON stated that the care plan was a guide, allowing for changes based on the resident's participation level.
A facility failed to maintain an infection prevention and control program when a CNA did not perform hand hygiene between glove changes and did not clean a urine-soiled mattress during incontinence care for a resident with a history of frequent UTIs. The DON confirmed the importance of these actions in preventing infection.
Improper Storage and Maintenance of Respiratory Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care and equipment management consistent with professional standards, residents’ care plans, and physician orders for multiple residents receiving or potentially needing oxygen and suction therapy. For one male resident with chronic respiratory failure and dementia, surveyors reviewed his face sheet and care plan and noted an active order to change oxygen tubing and humidifier bottle weekly. On observation, his nasal cannula connected to an oxygen tank was found hanging on his wheelchair while he was in bed using another nasal cannula connected to an oxygen concentrator, indicating that the unused cannula was not stored in a manner consistent with the facility’s oxygen equipment policy, which requires masks and cannulas to be covered loosely when not in use. Another male resident with dementia and severe cognitive impairment had a care plan and physician order for PRN oxygen via nasal cannula for shortness of breath. During observation, his suction machine tip was found connected to the suction machine and not bagged, contrary to staff statements and facility policy that suction tips, nasal cannulas, and nebulizer masks should be bagged, dated, and changed weekly. A female resident with COPD and no cognitive impairment, whose care plan included oxygen therapy as ordered and an order to elevate the head of bed due to shortness of breath, was observed with her nasal cannula connected to an oxygen concentrator lying on the floor, again not stored in a protected manner when not in use. A male resident with COPD and acute and chronic respiratory failure, who had a care plan for altered respiratory status and oxygen therapy and an order for oxygen via nasal cannula at 2–4 LPM to maintain saturation at or above 90%, was observed lying in bed awake with his nasal cannula connected to the oxygen concentrator but hanging on his chair. He stated he usually hangs it on the chair when not in use and that it is not bagged most of the time. Another male resident with acute and chronic respiratory failure and heart failure, with a terminal prognosis and care plan for oxygen therapy related to respiratory illness, had physician orders to change oxygen tubing and humidifier bottle weekly and to use oxygen PRN for respiratory distress. His oxygen concentrator humidifier bottle was observed sitting on the nightstand, not connected to the machine, one-quarter full, and with an open crack on the top right corner. Interviews with nursing and CNA staff, as well as the DON, confirmed that facility policy requires nasal cannulas, nebulizer masks, suction tips, and humidifier bottles to be bagged or covered, dated, and changed on a scheduled basis, and that failure to store respiratory equipment properly could result in infection. The facility’s written Oxygen Equipment Policy dated 05/17 specifies that oxygen therapy equipment must be maintained in a clean and sanitary manner, with disposable pre-filled humidifiers, tubing, masks, and cannulas used for residents receiving oxygen and discarded after use. The policy states that pre-filled humidifiers are to be dated and replaced every seven to ten days, tubing, masks, and cannulas replaced weekly, and that when a mask or cannula is temporarily not being used, it will be covered loosely to prevent contamination from airborne microorganisms. Despite this policy, surveyors observed multiple instances where nasal cannulas, suction tips, and a humidifier bottle were not stored or maintained according to these procedures. Staff interviews consistently acknowledged the policy requirements and the risk of infection from improperly stored respiratory equipment, confirming that the observed practices were inconsistent with facility policy and professional standards.
Unsecured Resident Possession of Unordered Medications and OTC Products
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that drugs and biologicals were stored in locked compartments and that residents did not possess medications without physician orders, as required by State and Federal laws and facility policy. During observations on 04/01/26, surveyors found multiple over-the-counter medications and products in resident rooms and on bedside furniture. These items were not secured, were not stored under proper controls, and did not have corresponding physician orders in the residents’ active medication records. For Resident #1, a [AGE] year-old female with diagnoses including limitation of activity due to disability, primary generalized osteoarthritis, and generalized muscle weakness, the MDS dated 02/06/26 showed a BIMS score of 7, indicating severe cognitive impairment. Her care plan noted impaired cognition with an intervention to provide step-by-step instructions. On 04/01/26 at 8:50 a.m., surveyors observed a bottle of Lumify eye drops on her bedside table while she was asleep in bed. Review of her active physician’s orders on 04/01/26 revealed no order for Lumify eye drops. For Resident #7, a [AGE] year-old male with chronic respiratory failure and type 2 diabetes, the care plan indicated risk for impaired cognitive function/dementia or impaired thought process. On 04/01/26 at 8:35 a.m., Alka Seltzer and nasal saline spray were observed on his over-bed table, and review of his active physician’s orders showed no orders for these items. For Resident #10, a [AGE] year-old female with dementia and intellectual disability, the MDS dated 03/10/26 showed a BIMS score of 13 (intact cognition) and an active diagnosis of dementia, with a care plan noting risk for impaired visual function related to macular degeneration. On 04/01/26 at 8:30 a.m., Vicks VapoRub was found in her plastic chest of drawers, and she did not answer when asked if nurses knew she had it. Her active physician’s orders contained no order for Vicks VapoRub. Multiple staff interviews, including with CNAs, a Med Tech, an LVN, and the DON, confirmed that facility policy does not allow residents to keep medications in their possession and that all medications require physician orders and must be secured and administered by licensed staff or Med Techs.
Failure to Maintain Resident Dignity During Feeding and Catheter Care
Penalty
Summary
The deficiency involves failure to ensure residents were treated with dignity and respect in their daily care. One resident, an elderly female with severe cognitive impairment, difficulty swallowing, and requiring maximum assistance with feeding, was observed being fed in bed by a CNA who was standing over her. The resident’s comprehensive care plan noted a nutritional problem but did not include an intervention indicating the need for assisted feeding. During the observation, the CNA stated that staff were expected to sit while feeding residents and be at eye level to observe for swallowing issues, but she did not do so because the chair was too low. The DON later confirmed that CNAs should be sitting while feeding residents to monitor eating and swallowing and acknowledged this as a dignity concern. Another resident, an elderly female with moderate cognitive impairment, a weak bladder, and an indwelling catheter, was observed lying in bed with her catheter bag visible from the hallway and not covered by a privacy bag. Her comprehensive care plan included a plan of care for the indwelling catheter. The MDS nurse observed that the resident did not have a privacy bag over the catheter bag and stated that a privacy bag was needed for the resident’s dignity and that it was the nursing staff’s responsibility to ensure its use. The DON was informed that the catheter bag was not covered and stated that the resident needed a privacy bag for dignity. The facility’s Resident Rights policy states that residents have the right to a dignified existence, self-determination, and communication, and to exercise their rights without interference, coercion, discrimination, or reprisal.
Failure to Include Assisted Feeding in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes. Record review showed that a female resident with a diagnosis of difficulty swallowing and a BIMS score of 00, indicating severe cognitive impairment, required maximum assistance with feeding per her Quarterly MDS assessment. Her comprehensive care plan, dated 03/09/26, documented a nutritional problem but did not include an intervention specifying that she required assisted feeding, despite her assessed need for maximum assistance with feeding. During observation, a CNA was seen feeding the resident while she was lying in bed and stated the resident was unable to feed herself and required staff to feed her. In interviews, the DON acknowledged that the resident had experienced a change in condition and now required assistance with feeding, and that assisted feeding should have been included on the care plan as part of her plan of care. The DON stated that updating care plans was the responsibility of the MDS Nurse, ADON, and DON. The MDS Nurse reported being unaware that the resident required assistance with feeding and confirmed that care plan updates were a collaborative effort. The facility’s policy on Comprehensive Care Planning stated that care plans would be developed and implemented to meet identified needs and revised based on changing goals, preferences, and needs, but this was not carried out for the resident’s need for assisted feeding.
Failure to Maintain Safe Environment Related to Fall Prevention and Hazardous Spray
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards for two residents identified as being at risk. For one resident with a documented history of falls, severe cognitive impairment (BIMS score of 6), lack of coordination, and unsteadiness on her feet, the comprehensive care plan required a fall mat at the bedside as a fall prevention intervention. During observation, this resident was found lying in bed with the fall mat positioned away from the bed rather than alongside it, and the bed itself was in a raised position instead of being in the lowest position. Staff, including a CNA and the DON, acknowledged that the resident was a fall risk, needed the fall mat placed alongside the bed, and that the resident often raised her bed and did not allow staff to lower it. The second resident involved was an adult male with diagnoses including a mental disorder and lack of coordination, and an MDS indicating intact cognitive function (BIMS score of 14). His care plan addressed altered respiratory status related to cough, and active physician orders included PRN Albuterol-Budesonide inhalation aerosol for wheezing. During observation, this resident was noted to have a can of Lysol spray on his bedside table. Multiple staff members, including an RN, CNAs, a Med Tech, an LVN, and the DON, stated that residents should not have Lysol spray in their rooms and that any such items found should be removed and reported to the nurse. Staff interviews consistently reflected that Lysol spray was not allowed in resident rooms and that all staff were responsible for ensuring harmful items were removed. Staff described that use of Lysol spray in resident areas could exacerbate respiratory issues, cause allergic reactions, or other harm. The DON reported that the resident obtained Lysol spray when going out on medical passes and that staff would continue to educate him and monitor through rounds. The facility’s resident rights policy stated that residents have the right to a safe, clean, comfortable, and homelike environment and to receive treatment and supports for daily living safely, which contrasted with the observed presence of the Lysol spray and the improperly positioned fall mat and bed for the identified residents.
Failure to Keep Call Lights Accessible for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs by ensuring call lights were accessible to residents while in bed. For one resident, an older female with multiple diagnoses including cerebral infarction, type 2 diabetes, vascular dementia, Alzheimer’s disease, mood disorder, insomnia, hypertension, muscle weakness, lack of coordination, cognitive communication deficit, aphasia, and a history of adult failure to thrive, the MDS showed severe cognitive impairment and a need for assistance with activities of daily living. Her care plan identified fall risk with interventions that included keeping the call light within reach and educating her to use it for assistance, especially after an actual fall. Despite these documented needs and interventions, surveyor observation found that this resident did not have a call light within reach on her side of the room. During interview and observation, this resident stated she could not call staff when she needed assistance and that she did not have a way to call staff because she did not have a call light. She reported having asked an unidentified staff member about her call light and being told she did not have one, and that she had been without a call light for some time, though she could not specify how long. Observation revealed that her call light was not on her bed or within her side of the room but was instead intertwined with her roommate’s call light on the roommate’s bed, contrary to the care plan intervention that required a working and reachable call light. A second resident, an older female with Alzheimer’s disease, dementia, muscle weakness, osteoporosis, unsteadiness on feet, cognitive communication deficit, dysphagia, multiple contractures, normal pressure hydrocephalus, constipation, major depressive disorder, insomnia, seizures, cataract, generalized anxiety disorder, hypothyroidism, GERD, and visual hallucinations, had an MDS indicating moderate cognitive impairment and a need for assistance with ADLs. Her care plan for musculoskeletal alteration and contractures included anticipating and meeting needs and ensuring the call light was within reach. In interview, she reported having to wait a long time for staff assistance when she did use her call light and stated she was not always able to use it because it was not near her, sometimes relying on her roommate to get staff. Observation confirmed that her call light was not in her bed but was on the floor behind a mat against the wall, making it inaccessible, in violation of both her care plan and the facility’s call light policy requiring the call device to be placed within residents’ reach before staff leave the room.
Unclean Resident Rooms and Shower Areas
Penalty
Summary
The facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 11 of 20 resident rooms and 2 of 2 shower rooms observed for cleanliness. During observations, multiple resident rooms had built up dirt in the corners of door frames and floors, thick dark substances in bathroom corners and behind toilets, black dirt and dust on air conditioning units and between vents, rust-like substances on door frames and bedside table frames, thick black dirt under sinks, yellowish staining at an entryway, and reddish substances along bathroom wall edges, near showers, behind toilets, and under sinks. The shower rooms also had cleanliness concerns. One shower room on the 100-hall was observed with dark stains and thick dirt around the drain, and another observation of the same shower room noted the same conditions. In one resident room, the shower floor had dark stains near the rear wall and thick dirt around the drain. The observations were made across rooms identified as [ROOM NUMBER], #2 through #11. During interviews, housekeeping staff stated they were responsible for cleaning the rooms, bathrooms, and air conditioning units, and that they were to clean everything in the room. One housekeeper stated not cleaning thoroughly could result in the spread of bacteria and that some stains required something stronger to remove. Another housekeeper stated she cleaned the shower rooms and bathrooms daily but was not sure what the impact would be if rooms were not thoroughly cleaned. The housekeeping supervisor stated staff were trained to clean from the windows to the front door, including bathing rooms, and said not thoroughly cleaning the rooms could cause infections. The Administrator stated he expected housekeeping to provide a clean environment for residents and said this was the resident's home and it could also cause an infection. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment, including cleanliness and order.
Respiratory equipment left unbagged when not in use
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored properly when not in use for six residents who had orders and care plan interventions for oxygen therapy or nebulizer treatments. During observations on 02/04/2026, a nasal cannula for one resident was hanging on a wheelchair without a bag and no bag was present on the wheelchair. Another resident’s breathing mask was observed on top of a shelf and was not bagged, and a third resident’s breathing mask was observed on a chair and was not bagged. A fourth resident’s nasal cannula was attached to an oxygen concentrator, with the tubing on the floor and not bagged. A fifth resident’s nasal cannula was attached to an oxygen concentrator at the bedside, with the prongs on the floor. A sixth resident’s nebulizer mask was observed on a nightstand and was not bagged. The residents involved had respiratory diagnoses and orders for oxygen or nebulizer treatments. One resident was diagnosed with chronic obstructive lung disease and respiratory failure and had an order for oxygen via nasal cannula at 3-5 LPM continuous. Another resident had shortness of breath and an order for ipratropium-albuterol via nebulizer as needed. A third resident had severe cognitive impairment and an order for ipratropium-albuterol three times a day for shortness of breath and wheezing. Additional residents had asthma, COPD, or respiratory failure, and their care plans included oxygen therapy or breathing treatments as ordered. During interviews, nursing staff stated that nasal cannulas and breathing masks should be kept in a bag when not in use to prevent infection and cross contamination. The charge nurse stated he was responsible for ensuring the equipment was bagged and said the items observed were already dirty because they had been in contact with the shelf, chair, wheelchair, and floor. Other staff and leadership stated that respiratory equipment should be bagged when not in use, and the facility policy stated that when a mask or cannula is temporarily not being used, it should be covered loosely to prevent contamination from airborne microorganisms, and nebulizer equipment should be stored, cleaned, and dried until next use.
Missed Propranolol Dose
Penalty
Summary
Resident #51 did not receive the ordered morning dose of propranolol 20 mg by mouth on 02/05/2026. The resident was a [AGE]-year-old female with hypertension, was on hospice services, and had severe cognitive impairment with a BIMS score of 00. Her care plan included an intervention to administer anti-hypertensive medication as ordered, and the physician's order directed propranolol 20 mg twice daily for hypertension. Review of the medication administration record showed the morning dose was not given. During observation and interview at 8:37 AM, MA G stated she did not see the propranolol in the medication cart and checked the emergency kit, but the medication was not there either. MA G then spoke with ADON A, who said she would call the hospice nurse about the medication. Later that day, ADON A stated she called hospice and was told the medication would be delivered that afternoon. The DON stated staff should reorder medication before the last pill was given and that it was important to ensure residents received medication as ordered.
Medication Storage and Labeling Failures
Penalty
Summary
The facility failed to keep multiple drugs and biologicals stored in locked compartments and under proper control, as evidenced by medications and topical products being left inside resident rooms and on unattended carts. On 02/04/2026, Resident #10, who had dementia and diabetes with severe cognitive impairment, was observed without an order for antifungal cream while a tube of antifungal cream was sitting on top of her side table. The same day, Resident #102, who had dementia and severe cognitive impairment, was observed with a tube and sachet of zinc oxide on top of her side table, and Resident #21 had two containers of zinc oxide on her shelf. Resident #73, who had dementia and severe cognitive impairment, had a cup of white cream on top of his overbed table, and Resident #18, who had cerebral infarction and cognitive communication deficit with severe cognitive impairment, had a container of nasal spray on top of her overbed table despite no order for it. Resident #68, who had dementia and severe cognitive impairment, had a bottle of peroxide on her bedside table with no physician order for peroxide. The report also documented medication storage problems involving staff handling and cart security. Resident #31, who had diabetes and severe cognitive impairment, had an insulin pen left on top of an unattended cart in the hallway. RN D was observed leaving a bottle of wound cleanser and barrier cream on top of an unattended cart in the hallway of the wander unit while residents were walking nearby. For Resident #103, who had obesity, delusional disorder, anxiety, and diabetes, two cups of white cream were found on the side table in the room, and later three insulins were observed inside the cart without dates showing when they were opened. The same resident also had liquid lorazepam, ordered as a controlled drug and labeled to refrigerate, stored inside the cart's locked box rather than in refrigeration. The record review showed that several of the affected residents had cognitive impairment, incontinence, or diabetes-related needs, and the facility's own policies required medications and biologicals to be stored in locked compartments under proper temperature controls, with opened multi-dose vials dated and discarded within 28 days unless otherwise specified. During interviews, staff acknowledged that zinc oxide, antifungal cream, nasal spray, wound cleanser, barrier creams, insulin pens, peroxide, and liquid lorazepam should not have been left in resident rooms or unattended on carts, and that the undated insulin and improperly stored lorazepam were not in compliance with the facility's stated storage expectations.
Food Storage and Sanitation Deficiencies in Kitchen and Dining Areas
Penalty
Summary
Food service sanitation and storage practices were not maintained in the facility’s kitchen and dining areas during survey observations. The Dietary Manager was observed walking around the kitchen near prepared and uncovered food without a beard cover, and his beard was approximately a quarter of an inch in length. At the same time, the kitchen contained uncovered pitchers of tea and juices in the walk-in cooler, and a large tea dispenser filled with tea was left uncovered. The DM stated his team prepared the tea at about 7:00 a.m. and acknowledged that the uncovered dispenser was visible while food was being prepared nearby. Surveyors also found multiple food storage and labeling issues in the kitchen. One freezer bag of frozen chicken nuggets was not labeled with the date stored, packages of hamburger buns and croissants in the walk-in cooler were not dated, and several vendor-supplied items, including deli meat, grilled mixed vegetables, sliced zucchini squash, and tater tots, were not dated with the month, day, and year received. The package of tater tots also had a 1-inch hole exposing the food to air-borne contaminants. In dry storage, two large bins containing sugar and flour had brownish stains on the inside and outside, and the DM stated it was his responsibility to ensure items were properly dated and stored. Additional observations showed sanitation concerns in food preparation and serving areas. The ice machine in the kitchen had stains on the inside panel wall, and the ice scoop holder had brown dirt particles on the inside bottom. Three steam trays on the serving table had brownish stains and water with light brownish particles floating in it, and no sanitizer container was observed on the serving table while lunch was being plated. In the dining area, the ice dispenser had thick white substances, black dirt, and rust-like buildup, and the dining room counter and sink had brownish stains and white substances around the faucet area. On the 300-hall, an ice chest containing ice had light brownish stains on the lower portion, which the DM stated was cleaned daily before filling with ice.
Infection Control Lapses During EBP and Glove Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents reviewed for infection control. Resident #10 had dysphagia, severe cognitive impairment with a BIMS score of 00, and a g-tube with an order for Enhanced Barrier Precautions due to an implanted feeding device. On 02/04/2026, CNA K was observed changing the resident’s bed linens without wearing a gown, even though a sign outside the room indicated that a gown was required for EBP during linen changes. CNA K stated she was not aware she still needed to wear a gown while changing the linens, then acknowledged the resident still had a g-tube and that the gown was meant to prevent cross contamination. Resident #150 had pneumonia, severe cognitive impairment with a BIMS score of 00, and orders for IV Meropenem and PICC line flushing. On 02/05/2026, RN E was observed disconnecting the resident’s IV via the PICC line and flushing the line after washing her hands and putting on gloves, but she did not wear a gown. A sign outside the room indicated the resident was on EBP and PPE was required during device care and use of the central line. RN E stated she knew she was supposed to wear a gown to prevent spread of infection but did not know why she forgot to wear one. Resident #60 had hypertension and diabetes, severe cognitive impairment with a BIMS score of 7, and required assistance with all self-care needs. During an observation on 02/05/2026, MA G obtained the resident’s blood pressure while wearing gloves, then returned to the medication cart and entered the vital signs into the laptop without removing the gloves. She removed the gloves and used hand sanitizer only after touching the laptop, then applied clean gloves before sanitizing the blood pressure cuff. MA G stated she should have removed her gloves before touching the laptop to prevent cross contamination and infection. The ADON stated staff should not leave a room with gloves on and should remove gloves and sanitize hands when finished.
Unsecured crash cart and germicidal wipes left accessible to residents
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment when a crash cart parked at the entry of hall 100 had drawers that were not secured and could easily be opened. During the observation, the first drawer contained a screwdriver and the other drawers contained tubing. The Administrator stated the crash cart should not be locked, while the DON stated the cart was not locked. ADON A later stated the cart should be accessible in an emergency but secured enough that residents could not open the drawers when it was not in use. The facility also failed to ensure that a container of germicidal wipes was not left on top of an unattended treatment cart in the memory care unit. During the observation, several residents were walking in the hallway while the cart was unattended with the wipes on top. RN D stated she had gone into a resident room to assess a wound and should have placed the wipes inside the cart before leaving because confused residents might use them to clean their faces and eyes. She later stated she would put the wipes inside the cart. A similar event occurred when MA G left a container of germicidal wipes on top of her cart in a hallway while the cart was unattended and residents were walking nearby. MA G stated she walked away because the DON called her and that she should have secured the wipes before leaving because residents might use them improperly or even eat them. The DON, ADON B, and the Administrator stated the wipes should be locked inside the carts and not left on top where residents could access them. Record review showed the facility policy required potentially harmful substances to be clearly identified and stored in a locked area separately from medications, and the SDS for the wipes identified them as an acute oral toxin and eye irritant with storage instructions to keep out of the reach of children.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure the call light system in Resident #6’s room was positioned so it was accessible to the resident. Resident #6 was a [AGE]-year-old male with cerebral palsy, intact cognition with a BIMS score of 15, and a care plan noting he was at risk for falls related to impaired transition during transfers and could use a slide board for transfers. The care plan also included an intervention to ensure he had a working and reachable call light. During an observation, Resident #6 was lying in bed asleep with a fall mat beside the bed and the nightstand positioned approximately 18 inches to the right of the bed. The top drawer of the nightstand was open, and the call light was draped across the drawer and hung over the side closest to the bed, but it was not within the resident’s reach. The Assistant Business Office Manager pulled on the cord and stated that was as far as it would reach. RN C stated she had seen maintenance in the room that morning but did not know if it was related to the call light and had not noticed it was out of reach. CNA L also stated she did not notice the call light was not close enough for the resident to reach. The ADON and DON stated the expectation was for call lights to be within reach, and the Administrator stated the roommate had a longer call light so they were swapped. The facility policy stated the call device should be placed within the resident’s reach before leaving the room.
Failure to Complete New PASRR Screening After New Mental Health Diagnoses
Penalty
Summary
The facility failed to notify the State Mental Health Authority when two residents had significant changes in mental condition and required new PASRR Level I screening. Resident #2 was admitted with a PASRR Level I screening that was negative for mental illness, intellectual disability, and developmental disability, but later developed major depressive disorder, delusional disorder, and dementia. Resident #3 was also admitted with a PASRR Level I screening that was negative, and later was diagnosed with major depressive disorder and bipolar disorder. Record review showed Resident #2’s care plans addressed depression, occasional hallucinations, impaired cognitive function, and mood problems, and the resident did not have a PASRR II, PE, or a new PASRR I on file. Resident #3’s care plan addressed bipolar disorder, and the resident also did not have a PASRR II, PE, or a new PASRR I on file. During observation, Resident #2 was awake in a wheelchair after breakfast, and Resident #3 was awake in bed and said he wanted to sleep more. The MDS Nurse stated that if a resident who was initially PASRR negative was later diagnosed with a new mental illness such as depression, anxiety, dementia, bipolar disorder, or delusional disorder, a new PASRR I should have been completed. She reviewed both residents’ records and confirmed that no new PASRR I had been done for either resident. The DON stated she was not familiar with PASRR, the ADON said he did not know how PASRR worked, and the Administrator stated there should be a process to determine when a new PASRR was needed after a new mental illness diagnosis.
Incomplete Care Plans for Skin Lesion and Midline IV Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #22 that included measurable objectives and timeframes for her medical and nursing needs. Resident #22 was a [AGE]-year-old female admitted to the facility with left-sided paralysis and a quarterly MDS showing moderate cognitive impairment. Her comprehensive care plan, dated 02/05/26, included an intervention for actual skin impairment to the forehead and stated that the Wound Care MD would evaluate and treat weekly until the wound resolved, but it did not reflect a plan of care for the cancer lesion on her forehead. During interviews on 02/05/26, the ADON stated Resident #22 was required to receive weekly skin assessments from the Wound Care Doctor and acknowledged that the resident had a cancer lesion on her forehead that had been present for a while. The ADON and DON stated the resident received weekly head-to-toe assessments and that nursing staff checked her skin for the condition of the cancer lesion, and the DON stated the cancer lesion should have been care planned to ensure the resident received the care. The DON stated it was the ADON's and DON's responsibility to ensure the care plan was updated. The facility also failed to ensure Resident #36's comprehensive care plan reflected her midline intravenous catheter for antibiotic administration. Resident #36 was a [AGE]-year-old female with neuromuscular dysfunction of the bladder and a quarterly MDS showing intact cognition with a BIMS score of 15 and indicating she received intravenous medications. Her comprehensive care plan dated 12/10/2025 did not include the midline, even though physician orders dated 01/29/2026 showed Cefepime 1 gm/50 ml IV twice daily for 7 days for a urinary tract infection. Staff interviews confirmed the resident had an IV for antibiotics, that the midline should have been included in the care plan, and that it was important to monitor the resident for complications and signs of infection.
Failure to Provide and Document Scheduled Showers
Penalty
Summary
The facility failed to ensure Resident #114 received scheduled showers for January 2026, and there was no indication that the resident refused them. Resident #114 was a 48-year-old male with morbid obesity and paraplegia, and his MDS reflected a BIM score of 12 with moderate cognitive impairment and a need for maximal assistance with ADL care. His comprehensive care plan identified an ADL self-care deficit and stated that he was totally dependent on staff for ADL care, with no mention of shower refusal. Record review and interviews showed no documentation of shower refusal in the resident’s January 2026 progress notes, and the initial shower sheets provided to surveyors did not include any sheets for the resident. The resident stated he was not receiving showers and had not refused them, though he sometimes received bed baths and wanted showers. Later, additional shower sheets were produced showing some showers, bed baths, one refused bed bath, and one date with nothing marked, but the resident stated he did not receive any showers and could not verify all of the bed baths documented. Staff interviews reflected uncertainty about whether he was receiving showers, and the facility policy required showers and bed baths to be provided according to the resident’s schedule and documented on shower sheets.
Unsafe Chemical Found in Resident Room
Penalty
Summary
The facility failed to ensure that Resident #114's environment remained free from accident hazards when a bottle of rubbing alcohol was observed in the resident's room on 02/04/2026 at 10:43 AM. Resident #114 was a [AGE]-year-old male admitted on [DATE] with diagnoses of major depressive disorder and schizophrenia, and his MDS assessment dated 11/25/25 reflected a BIM score of 12, indicating moderate cognitive impairment. During an interview on 02/04/26 at 2:24 PM, RN C stated the resident was not allowed to have the chemical in his room because it was not safe for him and he could drink it. During an interview on 02/06/26 at 10:02 AM, the DON stated the resident could not have possession of the item because he could ingest it. Record review of the SDS for Medline Micro-Kill Two Germicidal Wipes dated 01/21/2026 reflected hazard information including acute toxicity - oral, eye irritant, flammable liquids, and storage instructions to keep out of the reach of children.
Expired Medications Found in Nurse's Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles when expired medications were found in a nurse's cart. During an observation on 02/06/2026, surveyors found Linzess capsules for Resident #16 with an expiration date of 12/2025, Clonidine tablets for Resident #32 with a discard-after date of 04/30/2024, and an over-the-counter gas relief product with an expiration date of 12/2025. RN D confirmed the medications were already expired and stated expired medications should not be kept in the cart because staff could mistakenly use them. Resident #16 was a cognitively intact female with rheumatoid arthritis and chronic pain. Her care plan included administering medications as ordered, and her physician order showed Percocet for pain, which could cause constipation. The record review showed she did not have an active order for Linzess on 02/05/2026, yet expired Linzess capsules remained in the cart. Resident #32 was a cognitively intact female with hypertension. Her physician order directed Clonidine 0.1 mg twice daily for essential hypertension, with instructions to hold for blood pressure less than 110/60. Although RN D stated the resident used clonidine in blister packs and not the bottle found in the cart, the expired clonidine tablets were still present. The DON and ADON stated expired medications should not be in carts and that nurses, medication aides, and leadership staff were responsible for checking carts for expired medications.
Influenza Vaccine Given Despite Family Refusal
Penalty
Summary
The facility failed to follow its policies and procedures for flu and pneumonia vaccinations when Resident #33 received the influenza vaccine despite a documented family refusal. Resident #33 was a [AGE]-year-old female admitted [DATE] with diagnoses of dementia and anemia. Her Quarterly MDS Assessment dated 11/20/25 reflected a BIM score of 3, indicating severe cognitive impairment, and noted an active diagnosis of dementia. The immunization record for the influenza vaccine dated 10/17/25 documented "Family refused," yet the resident later received the vaccine. A progress note dated 10/18/25 stated that Resident #33 received the influenza vaccine and tolerated it well without an allergic reaction, with vital signs within normal limits. During interview, the resident's RP stated she had told nursing staff not to give the resident the influenza vaccine and later learned it had been given anyway; she said she was concerned about an allergic reaction. The ADON and DON stated the vaccine was accidentally given because Resident #33 and another resident had the same last name, and they reported that an in-service was completed with nursing staff to verify consent and use a second person to verify the correct resident for future vaccinations.
Failure to Care Plan Nebulizer Use for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing all of a resident's needs, specifically omitting the care planning for the use of a nebulizer device for one resident. The resident, a female with quadriplegia requiring total assistance for activities of daily living and with an intact cognitive status, had a physician order for Ipratropium-Albuterol via nebulizer as needed for shortness of breath or wheezing. Despite the physician order being present in the resident's records, the comprehensive care plan did not include any information or interventions related to the nebulizer use. Observations confirmed the resident was using a nebulizer, and interviews with nursing staff, including the RN, ADON, MDS nurse, and DON, revealed that the omission was due to a lack of communication and failure to update the care plan when the physician order was received. Staff acknowledged that the care plan should have been updated to reflect the new order, and that the interdisciplinary team is responsible for ensuring care plans are comprehensive and current. The facility's policy requires care plans to be reviewed and revised as needed, but this was not followed in this instance.
Failure to Implement Fall Prevention Interventions and Obtain Required Physician Orders
Penalty
Summary
The facility failed to ensure that a resident identified as a fall risk was provided with adequate accident prevention measures as outlined in his care plan. Specifically, the resident, who had severe cognitive impairment, muscle weakness, and required extensive assistance with activities of daily living, did not have a physician order for the scoop mattress used on his bed. Additionally, the fall mat, which was an intervention listed in his care plan to prevent injury from falls, was observed leaning against the wall rather than being placed alongside the bed while the resident was in it. Interviews with nursing staff, including an RN, the DON, and the ADON, confirmed that the fall mat should have been positioned next to the resident's bed whenever he was lying in it, and that a physician order was required for the scoop mattress. The facility's policy on physical restraints also indicated that such devices should only be used with appropriate medical justification and orders. The lack of proper placement of the fall mat and absence of a physician order for the scoop mattress constituted a failure to provide an environment free from accident hazards and to implement necessary interventions for accident prevention as specified in the resident's care plan.
Failure to Properly Store Nebulizer Mask for Resident Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required the use of a nebulizer. Specifically, a resident with quadriplegia and a physician's order for Ipratropium-Albuterol via nebulizer every four hours as needed was observed to have her nebulizer mask left unbagged on a nightstand when not in use. The resident's comprehensive care plan did not include a plan for nebulizer use, and her MDS assessment did not reference the need for a breathing device. Multiple staff members, including an RN, ADON, and DON, confirmed that the mask should have been bagged when not in use to prevent infection and that this was an expected practice during nursing rounds. The facility's policy on respiratory nurse training outlines the need for skilled nursing services and proper respiratory care interventions, but this was not followed in the case of the resident observed. The failure to properly store the nebulizer mask was identified through observation, interviews, and record review, and staff acknowledged that not bagging the mask could lead to bacterial buildup and infection risk.
Unattended Unlocked Treatment Cart Found Accessible to Resident
Penalty
Summary
Surveyors observed that treatment cart #1 was left unlocked and unattended, with all drawers accessible and supplies such as bandages, gauze, and scissors easily reachable. During this time, a resident in a wheelchair was seen within approximately five feet of the unattended cart. The Director of Nursing (DON) confirmed during an interview and observation that the cart was unlocked and unattended, stating that a staff member had just stepped away. The DON also acknowledged that her expectation was for the treatment cart to be locked when not in use to prevent unauthorized access. A review of the facility's policy on Medication Access and Storage indicated that all drugs and biologicals are to be stored in locked compartments, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. The policy further specifies that medication carts and supplies must be locked or attended by authorized persons at all times. The observed failure to lock the treatment cart while unattended was not in accordance with this policy.
Failure to Provide Timely Pharmaceutical Services Upon Admission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring the accurate acquisition, receipt, and administration of prescribed medications following their admission. One resident, with a history of seizures, congestive heart failure, diabetes, morbid obesity, hypertension, and hemiplegia, was admitted from the hospital without his discharge medication orders being obtained or available in the facility's records. As a result, he did not receive his prescribed seizure medication, Levetiracetam (Keppra), on the evening of admission and the following morning. Nursing documentation did not reflect administration of the medication or provide an explanation for the missed doses, and the resident expressed concern and distress over the missed medication, fearing the risk of seizure activity. Another resident, with diagnoses including COPD, respiratory failure with hypoxia, morbid obesity, asthma, sleep apnea, and dependence on supplemental oxygen, was also admitted without timely access to her prescribed inhalers. Despite physician orders for multiple inhalers to manage her respiratory conditions, the resident did not receive these medications as scheduled on the evening of admission and the following day. Nursing progress notes did not document administration of the inhalers or reasons for omission. The resident reported that her inhalers were not available and expressed frustration and concern, although she did not experience acute respiratory distress during the period in question. Facility policy required medications to be administered in accordance with physician orders and for staff to document any withheld or missed doses on the medication administration record (MAR), including reasons for such occurrences. The policies also outlined the need for accurate review and verification of medications upon admission. In both cases, the facility did not follow these procedures, resulting in residents not receiving essential medications as ordered by their physicians.
Resident Abuse Incident Leading to Surgery
Penalty
Summary
The facility failed to protect a resident from physical abuse by an LVN, which resulted in significant injuries requiring surgery. The incident involved a resident who was cognitively intact and had a history of mental health issues, including schizophrenia and anxiety disorder. During an altercation, the LVN reportedly pushed the resident, causing her to fall and sustain fractures to her right elbow and wrist. The resident later required surgery to address these injuries. The incident was documented in a progress note by the LVN, who claimed the resident punched her, prompting a defensive response that led to the resident's fall. The resident's injuries were not immediately reported as abuse, and it was only after another LVN noticed bruising and reported it that the facility began to address the situation. The Director of Nursing (DON) and the Administrator were informed, and the LVN involved was suspended pending investigation. Interviews with staff revealed that the LVN had previously been in-serviced on preventing and de-escalating crisis situations, as well as on abuse and neglect policies. Despite this training, the LVN's actions were deemed inappropriate, leading to her termination. The facility's policies on resident rights and abuse prevention were reviewed, highlighting the requirement for immediate reporting of any suspected abuse or neglect.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of two residents were accessible, which is a violation of their right to reasonable accommodation of needs and preferences. Resident #3, a male with severe cognitive impairment and muscle weakness, was found with his call light clipped to the privacy curtain, out of his reach. This resident required maximal assistance for daily activities and was at risk for falls due to an unstable gait. Similarly, Resident #4, who also had muscle weakness and difficulty walking, could not locate his call light, which was obstructed by his roommate's oxygen concentrator. Both residents were unable to access their call lights to request assistance, which could lead to unmet needs and potential emergencies. Interviews with staff, including RN D, the ADON, the DON, and the Administrator, revealed a consensus that call lights should always be within reach of residents to ensure their needs are met and to prevent potential emergencies. RN D acknowledged the oversight and took immediate action to place Resident #3's call light within reach. The ADON and DON both emphasized the importance of staff ensuring call lights are accessible during rounds and before leaving residents' rooms. The facility's policy also mandates that call devices be placed within residents' reach before staff leave the room. The deficiency was identified during observations and interviews conducted on the same day, highlighting a lapse in staff adherence to the facility's policy and procedures regarding call light accessibility. The staff, including CNA F, admitted to not noticing the inaccessibility of the call lights for the two residents, which could result in their needs not being communicated or met. The facility's policy, revised in 2021, clearly outlines the requirement for call lights to be within reach, yet this was not followed, leading to the deficiency noted in the report.
Failure to Prevent Catheter Bag Contamination
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary Foley catheter, which resulted in the catheter bag coming into contact with the floor. This incident involved a male resident diagnosed with neuromuscular dysfunction of the bladder, who had a suprapubic catheter in place. During an observation, it was noted that the catheter bag and its drain valve were on the floor, which was confirmed by a registered nurse who acknowledged that the floor was dirty and that the catheter bag should be secured to prevent infection. Interviews with the facility's staff, including the RN, ADON, DON, and a CNA, revealed a consensus that the catheter bag should not be on the floor to prevent potential contamination and infection. The staff acknowledged the importance of keeping the catheter bag below the bladder but off the floor, and the DON emphasized the responsibility of nurses to monitor and ensure the catheter bag's proper placement. The facility's policy on catheter care also highlighted the importance of infection control to prevent catheter-associated urinary tract infections.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident's face mask for the nebulizer was not stored correctly when not in use, as it was found on top of a semi-open drawer without being bagged. The resident mentioned that the nurse did not return after the breathing treatment, and she was not informed about the necessity of bagging the mask. The nurse, RN D, acknowledged that the mask should have been bagged and admitted to not noticing the mask was left unbagged after checking the resident's oxygen saturation. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the breathing mask should be cleaned and bagged after use to prevent cross-contamination and infection. The facility's policy also indicated that respiratory equipment should be stored in a plastic bag marked with the date and resident's name. The Administrator emphasized the importance of keeping residents' equipment clean to prevent infection, although he was not a clinician. This oversight in respiratory care could potentially place residents at risk for respiratory infections.
Inadequate Infection Control During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of staff members during the care of a resident with cerebral palsy. The resident, who was always incontinent for both bowel and bladder, was observed receiving care from COTA G and PTA H. During the process, COTA G did not perform hand hygiene before donning gloves and failed to change gloves after handling soiled items, such as a soiled brief and the resident's perineal area. This lack of proper glove use and hand hygiene was observed during the transfer and cleaning of the resident, which involved contact with feces. COTA G continued to use the same gloves after they became contaminated with feces, merely wiping them off instead of changing them. This improper practice was acknowledged by COTA G, who admitted that her actions could lead to cross-contamination and infection. Similarly, CNA F, who assisted in the care, did not sanitize her hands before putting on a new pair of gloves after removing the soiled ones. Both staff members recognized the importance of changing gloves and performing hand hygiene to prevent the transfer of germs. Interviews with the ADON, DON, and the Administrator confirmed that the facility's policy required hand hygiene before and after resident care, and glove changes after contact with soiled items. The failure to adhere to these protocols during the care of the resident was acknowledged by the staff, who understood the potential for cross-contamination and infection due to their actions.
Failure to Provide Privacy Bag for Catheter
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not providing a privacy bag for her catheter bag. The resident, an elderly female with obstructive and reflux uropathy, was observed with her catheter bag exposed and visible upon entering her room. This was noted during an observation and interview, where the resident did not respond to questions about her awareness of the exposed catheter bag. The facility's staff, including a registered nurse (RN), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), acknowledged the importance of using a privacy bag to maintain the resident's dignity. The RN admitted to not noticing the exposed catheter bag during her rounds, while the DON and ADON emphasized the expectation for staff to ensure catheter bags are covered to prevent embarrassment and maintain dignity. The facility's policy on dignity and respect, as well as its policy on indwelling urinary catheter care, both require the use of privacy bags for catheter drainage bags. Despite these policies, the resident's catheter bag remained uncovered, indicating a lapse in adherence to the facility's procedures and a failure to uphold the resident's right to a dignified existence.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in seven out of ten rooms and the hallway floors reviewed for cleanliness and sanitization. Observations revealed thick dirt and reddish stains along the borders of the hallway floors. In several resident rooms, air conditioning units had vents filled with black dirt debris and thick dust, and air filters were covered in dust. Additionally, there were brownish stains on walls and bathroom floors, thick dirt debris in bathroom corners, and significant ice buildup in mini fridge freezer sections. Interviews with facility staff, including the Operations Manager, Housekeeping Supervisor, and a newly hired housekeeper, indicated a lack of awareness and communication regarding the cleanliness issues. The Operations Manager was unaware of the concerns until shown photos, and the Housekeeping Supervisor acknowledged that housekeeping was responsible for cleaning the areas in question. The newly hired housekeeper stated she was not informed about the need to clean air filters until recently. The facility's cleaning policy from May 2023 states that housekeeping is responsible for maintaining equipment and keeping it as bacteria-free as possible, which was not adhered to in this instance.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for three residents, leading to potential risks of respiratory infection. Resident #35's nasal cannula was observed unbagged and improperly stored on a stuffed rabbit, contrary to the care plan that required it to be kept in a plastic bag when not in use. This oversight was confirmed by the Director of Nursing (DON), who acknowledged the risk of infection control due to the improper storage. Resident #55's face mask for his nebulizer was also found unbagged on his nightstand, despite the resident's acknowledgment of not using it for a few days. The Assistant Director of Nursing (ADON) confirmed that the mask should have been bagged to prevent infection. This lack of adherence to proper storage protocols was noted during an interview and observation. Resident #45's nasal cannula was found tangled and touching the floor, with no plastic bag available for storage when not in use. Multiple staff members, including a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), failed to notice the improper storage during their rounds. The ADON and DON both stated that the nasal cannula should be bagged to prevent cross-contamination and infection, highlighting a lapse in staff awareness and adherence to infection control procedures.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to maintain food storage, preparation, and sanitation standards in its only kitchen, as observed during a survey. Specific deficiencies included unclean equipment such as the ice scoop and ice chest, which had visible dirt and stains. Additionally, food items in the refrigerator and freezer were not properly labeled with storage dates, lacking either the complete date or any date at all. This included fish filets, sandwiches, sliced ham, turkey, croissants, vegetable soup, mixed vegetables, gravy, diced vegetables, beef enchiladas, stir fry vegetables, and sliced carrots. Furthermore, the tea dispenser was left uncovered, and the kitchen's cooking equipment, including the fryer and warming table, was found to be dirty and stained. Interviews with the consultant dietitian and the Operations Manager revealed that the dietary manager was on leave, and there was no designated temporary manager for the kitchen. The consultant dietitian acknowledged the issues and stated that the kitchen equipment was cleaned weekly, but could not identify specific staff responsible for the kitchen's cleanliness. The Operations Manager was aware of the concerns and recognized the potential risk of illness to residents due to these deficiencies. The facility's policy on dietary services and infection control emphasized preventing food contamination, but the observed practices did not align with these standards.
Infection Control Deficiencies in Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinent care to two residents. CNA C did not change gloves or perform hand hygiene after cleaning the resident's bottom and before handling a new brief, which could lead to cross-contamination. Additionally, CNA C placed a pericare cleanser from her pocket onto a new brief, which she acknowledged could introduce contaminants from her pocket to the clean brief. These actions were observed during care for a resident with dementia and muscle weakness, who was always incontinent for both bowel and bladder. Similarly, CNA B did not perform hand hygiene before starting incontinent care for another resident and failed to change gloves after cleaning the resident's bottom and before handling new padding and a new brief. CNA B also placed a new brief on top of an old, soiled padding, which could result in contamination of the new brief. This resident had a history of urinary tract infection and paraplegia and was always incontinent for bladder and bowel. Both CNAs admitted to not following proper hand hygiene and glove-changing protocols, despite having received in-service training on these procedures. Interviews with the ADON and DON confirmed that the facility's policy required hand hygiene before and after care, and glove changes when transitioning from dirty to clean tasks. The DON emphasized that hand hygiene is the most effective way to prevent cross-contamination and infection. The facility's policy on hand hygiene, revised in December 2023, outlines the necessity of washing hands before and after direct contact with residents, after contact with bodily fluids, and after removing gloves.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident #35 by not responding to her call light within a reasonable time. Observations on 11/20/2024 showed that Resident #35's call light was in use from 11:23 am until 12:30 pm, indicating a delay of over an hour before it was addressed. Interviews with the resident and other residents revealed that staff response times to call lights ranged from 30 minutes to over an hour on weekdays and even longer on weekends. This delay in response time was corroborated by multiple staff members, including LVN-A, CNA-I, ADON G, the DON, ADM, and ADON H, who all acknowledged that call lights should be answered promptly to prevent potential harm to residents. The facility's grievance log also reflected concerns from the resident council about call lights not being answered in a timely manner, with entries dated 8/12/2024 and 9/9/2024. The facility's policy on call lights, revised on 8/3/2021, states that call lights should be answered within a reasonable time, and staff should listen to and respond to residents' requests. Despite this policy, the facility's failure to adhere to it resulted in a deficiency, as it placed residents at risk of being unable to obtain assistance when needed, potentially leading to emergencies.
Failure to Maintain Resident Privacy During Medical Treatment
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during medical treatment. Specifically, a Licensed Vocational Nurse (LVN) did not close the door while checking the resident's blood sugar and administering insulin. This oversight was observed during a survey, where the resident was visible from the hallway, compromising her privacy. The resident involved was an elderly female diagnosed with type 2 diabetes mellitus and unspecified dementia with agitation. Her care plan included interventions to reduce distractions, such as closing the door during treatments. Despite this, the LVN admitted to forgetting to close the door, acknowledging that it should be done to provide privacy and dignity to the resident. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator confirmed that the expectation was for staff to close the door or draw the privacy curtain during treatments to prevent embarrassment and maintain dignity. The facility's policy on dignity and respect also emphasized the importance of maintaining residents' privacy during examinations and treatments.
Inaccurate Assessment of Oxygen Therapy for a Resident
Penalty
Summary
The facility failed to ensure that Resident #45 received an accurate assessment reflective of her current status, specifically regarding her use of oxygen therapy. The Quarterly MDS Assessment for Resident #45, dated 11/10/2024, did not indicate that she was on oxygen therapy, despite her medical condition of respiratory failure with hypoxia and a physician's order for continuous oxygen use. This discrepancy was identified through observations, interviews, and record reviews, which showed that the resident was indeed using oxygen therapy continuously, as confirmed by both the resident and the nursing staff. Interviews with various staff members, including LVN A, ADON G, the DON, and the MDS Nurse, revealed a lack of awareness and oversight in the assessment process. LVN A confirmed the resident's continuous use of oxygen due to her respiratory issues. ADON G and the DON both acknowledged the importance of accurate assessments in ensuring appropriate care and interventions for residents. The MDS Nurse admitted to overlooking the resident's oxygen therapy in the MDS assessment, despite the presence of a physician's order and a care plan indicating the need for continuous oxygen. The facility's policy on resident assessments emphasizes the need for comprehensive, accurate, and standardized assessments documented in the clinical health record. However, the failure to accurately reflect Resident #45's oxygen therapy in the MDS assessment highlights a gap in the facility's adherence to this policy. This oversight could potentially lead to confusion in the care provided to the resident, as the MDS assessment serves as a basis for determining the necessary care and interventions.
Failure to Obtain Physician Orders for Scoop Mattress
Penalty
Summary
The facility failed to ensure the resident environment was as free of accident hazards as possible for a resident reviewed for accident hazards. Specifically, the facility did not obtain physician orders or conduct a physician assessment for the use of a scoop mattress for fall prevention before its installation for the resident. This oversight was identified during an observation where the resident was found lying on a scoop mattress without the necessary physician orders or assessment. The resident involved was an elderly male with diagnoses including seizures, syncope and collapse, and muscle weakness. He was totally dependent on assistance for activities of daily living such as transfers, toileting, and bathing. The Director of Nursing (DON) acknowledged that the scoop mattress was provided without a physician's order or assessment, sometimes at the request of family members, and recognized the potential risk of injury to the resident if he attempted to get out of bed without proper assessment.
Inappropriate Incontinent Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a potential risk of urinary tract infection. The resident, an elderly female with dementia and muscle weakness, was always incontinent of both bowel and bladder. During an observation, a CNA was seen performing incontinent care on the resident. The CNA initially used the correct front-to-back technique to clean the resident's front part but then reused the same wipe to clean different areas of the resident's front part, which is against the facility's policy and could lead to cross-contamination. Interviews with the CNA, ADON, and DON revealed that the CNA acknowledged the mistake and understood the risk of infection from improper cleaning. The ADON and DON confirmed that the facility's policy requires using a new wipe for each stroke to prevent cross-contamination. The DON mentioned that sometimes wipes could be reused if not heavily soiled, but to ensure safety, they should not be reused. The facility's policy emphasizes cleaning from the cleanest to the dirtiest area to prevent infection.
Failure in G-Tube Care and Management
Penalty
Summary
The facility failed to ensure proper care and management of a resident with a gastrostomy tube, leading to potential risks of infection and accidental dislodgement of the tube. The resident, a female with severe cognitive impairment and dysphagia, was observed to have been administered medication via a g-tube using a syringe that had not been replaced daily as required. The LVN responsible for the medication administration did not check the date on the syringe, which was supposed to be changed every 24 hours to prevent infection. The syringe used was dated two days prior, indicating a lapse in following the physician's order and facility policy. Additionally, the facility did not ensure the resident wore an abdominal binder as per the physician's order. The binder is intended to secure the gastrostomy tube and prevent accidental pulling. During the observation, the resident was not wearing the binder, and there was no binder present in the room. The LVN mentioned that the resident refused to wear the binder, but there was no documentation of such refusal, and the resident herself stated she was never asked about it. This lack of adherence to the physician's order and absence of documentation further contributed to the deficiency. Interviews with the ADON and DON confirmed the expectation for syringes to be changed daily and for the abdominal binder to be worn if ordered. The ADON acknowledged the failure of the night nurse to replace the syringe and the LVN's responsibility to verify its replacement. The DON emphasized the importance of following the correct procedures for g-tube care to prevent infection and ensure the safety of the resident. The facility's policy on gastrostomy tube care clearly outlines the need for daily syringe replacement and the use of an abdominal binder, which were not adhered to in this case.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by video footage showing inappropriate conduct by a CNA. The resident, who was non-verbal and had severe cognitive impairments, was observed trying to cover herself while the CNA undressed her and engaged in inappropriate touching for over eight minutes. This incident was reported to the facility's Administrator in Training and law enforcement, leading to the resident's removal from the facility. The resident had a history of multiple diagnoses, including dementia, major depressive disorder, and muscle weakness, and was dependent on staff for all activities of daily living. The facility's records indicated that the resident was unable to communicate verbally and required complete assistance with personal care. Despite these vulnerabilities, the facility did not ensure the resident's safety, resulting in a serious breach of her rights and dignity. Interviews with facility staff revealed that they were aware of the procedures for reporting abuse but failed to prevent the incident. The CNA involved had no prior incidents or warnings and was even recognized as employee of the month. The facility's investigation was ongoing at the time of the report, and the CNA was suspended pending the outcome. The failure to protect the resident from abuse highlighted significant lapses in the facility's oversight and monitoring of staff interactions with residents.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, as evidenced by an incident involving a resident who was sexually abused by a Certified Nursing Assistant (CNA). The incident was captured on video, showing the CNA undressing the resident and inappropriately touching her for over eight minutes. The resident, who was non-verbal and had severe cognitive impairments, was unable to communicate the abuse, which was reported by a confidential interviewee to the facility's Administrator in Training and law enforcement. The resident involved in the incident had multiple diagnoses, including dysphagia, cognitive communication deficit, dementia, psychotic disorder with delusions, paranoid schizophrenia, major depressive disorder, and muscle weakness. She was dependent on staff for all activities of daily living and was incontinent of bowel and bladder. The facility's care plan for the resident required staff to provide incontinent care after each episode, indicating her vulnerability and reliance on staff for personal care. Despite the facility's policy on abuse prevention and prohibition, the staff failed to protect the resident from abuse. The facility's investigation was ongoing at the time of the report, and the CNA involved was suspended pending the investigation. Interviews with various staff members revealed that they were aware of the procedures for reporting abuse and had received training on the facility's abuse policy. However, the incident highlighted a significant lapse in the implementation of these policies, resulting in the resident's abuse and the facility's failure to ensure a safe environment for its residents.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, a [AGE] year-old female with a history of stroke, who was always incontinent of bladder and bowel and required extensive assistance from two staff members for incontinence care and bed mobility. Despite the care plan indicating the need for two staff members, an observation revealed that CNA A provided incontinence care alone. During an interview, CNA A acknowledged that Resident #1 was a two-person assist but proceeded alone as the other staff member left. The Director of Nursing (DON) stated that the care plan was a guide and the number of staff required could change based on the resident's participation level during care. The facility's policy on Comprehensive Resident Centered Care Plan, revised in January 2022, mandates the development and implementation of a baseline care plan that includes instructions for effective and person-centered care. However, the facility did not adhere to this policy, as evidenced by the failure to ensure two staff members performed incontinence care for Resident #1, potentially placing residents at risk for not receiving care consistent with their care plan.
Infection Control Deficiency During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of CNA A during incontinence care for a resident. The resident, who was always incontinent of bladder and bowel and had a history of frequent urinary tract infections, was observed to be soiled with urine that had gone through the bed sheets to the mattress. CNA A did not perform hand hygiene between glove changes and did not clean the urine on the mattress before placing clean sheets and a brief on the resident. CNA A admitted to not performing hand hygiene due to the lack of hand sanitizer and not cleaning the mattress because it would have been difficult without additional help, despite being trained to do so. The Director of Nursing (DON) confirmed that staff were expected to perform hand hygiene between glove changes and clean the mattress if it had urine on it, emphasizing the importance of these actions in preventing infection. The facility's policy on incontinence care, dated March 2017, also required staff to remove gloves and wash hands. This failure to adhere to infection control protocols could place residents at risk for infection during incontinence care.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,394 citations issued within 25 miles in the last 12 months — including the 61 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Euless
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkwood Village | 0.4 mi | ★★★★★ | 1 | 0 |
| Forum Parkway Health & Rehabilitation | 1.3 mi | ★★★★★ | 4 | 0 |
| Bedford Wellness & Rehabilitation | 1.5 mi | ★★★★★ | 16 | 0 |
| La Dora Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 6 | 0 |
| Hurst Plaza Nursing & Rehab | 2.4 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.