Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westward Trails Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not consistently check or document food temperatures before serving meals, as required by policy, resulting in missing or incomplete temperature logs for multiple meals. The Dietary Manager and cooks were responsible for these checks, but logs often lacked staff signatures and many days had no documentation at all. All residents, except two who were tube fed, received food from the kitchen during this period.
A resident with multiple medical conditions fell from a facility van when the van driver failed to ensure the wheelchair lift was flush with the van floor before unloading. The driver, distracted by retrieving a bag, did not follow proper procedures, resulting in both the resident and driver falling. The resident sustained minor injuries but declined hospital evaluation. Facility records confirmed the equipment was functioning properly and the driver had received prior training.
Two residents with significant physical limitations did not receive regular or as-needed nail care, resulting in long fingernails with visible debris and, for one, long toenails. Both residents were unable to perform their own nail care and reported that staff had not been checking or assisting with this aspect of personal hygiene, despite care plans indicating the need for staff assistance. Staff interviews revealed inconsistent practices and understanding regarding nail care responsibilities.
A facility failed to ensure a safe environment for a resident with severe dementia, who wandered outside due to a malfunctioning wander guard. Another resident with end-stage renal disease was not properly secured in a transport van, resulting in a fall and subsequent head and neck pain. Both incidents highlight inadequate supervision and failure to follow protocols, placing residents at risk of harm.
A long-term care facility failed to provide appropriate incontinence care by allowing the practice of double briefing, which was observed in four residents. This practice was not requested by the residents and was not part of their care plans. Staff interviews revealed a lack of awareness and understanding of the negative effects of double briefing, and the practice had become normalized within the facility. The facility's failure to adhere to proper care practices placed residents at risk for infections and skin breakdowns.
A resident with severe cognitive impairment was verbally threatened by another resident with a history of dementia and bipolar disorder. Despite staff intervention, the threatening behavior was not reported as abuse by the facility's DON and Administrator, who believed no harm was done. This failure to report the incident violated the facility's policy on abuse and neglect.
A resident with severe cognitive impairment was threatened by another resident with a history of dementia and bipolar disorder. Despite the threatening behavior, the facility did not report the incident immediately as required by state law. Staff intervened to de-escalate the situation, but the facility's administration did not consider the incident reportable, leading to a deficiency in handling the situation.
A resident with dementia and bipolar disorder was found to have stashed numerous pills in her room following psychotic episodes, indicating a failure in medication administration. Despite a care plan addressing medication refusal, the resident's records showed multiple refusals, and staff interviews revealed that medications were improperly left at the bedside, contrary to facility policy.
The facility failed to maintain an effective infection control program as two CNAs did not perform hand hygiene during incontinent care for two residents. Despite recent training, the CNAs did not follow proper procedures, potentially leading to the spread of infections.
The facility failed to ensure full visual privacy during incontinent care for a resident, leaving her unclothed and exposed. The incident occurred while two CNAs were preparing the resident for care, and the oversight was only corrected after noticing a male worker outside the uncovered window.
The facility failed to complete a significant change MDS assessment within 14 days after a resident's admission to hospice services. The resident, with multiple diagnoses including parkinsonism and schizoaffective disorder, was admitted to hospice, but the required assessment was not completed. Interviews revealed that the oversight was due to a lapse in communication and responsibility among staff.
The facility failed to refer a resident with newly evident serious mental disorders for a level II resident review upon a significant change of condition. The MDS Coordinators were unaware of the new diagnoses and did not submit the necessary forms, potentially resulting in the resident not receiving required services.
The facility failed to update a resident's care plan to include a PTSD diagnosis, despite it being documented in the Quarterly MDS assessment. The oversight by the MDS Coordinators and lack of awareness by the DON and Administrator led to the resident not receiving appropriate care for their mental health needs.
The facility failed to use a gait belt for a resident requiring a two-person assist during transfers and allowed another resident to keep smoking materials in their possession, contrary to facility policy. These actions were observed and confirmed through staff interviews and record reviews, highlighting lapses in adherence to safety protocols.
A resident with multiple health conditions did not receive the prescribed double portions at meals on two observed occasions, leading to potential risks of weight loss and malnutrition. Staff were unaware of the dietary order until the state surveyor's intervention, revealing a communication breakdown between nursing and dietary services.
A resident requiring oxygen therapy was observed with an empty and undated humidifier bottle on two occasions, leading to discomfort due to nasal dryness. Staff interviews confirmed that the humidifier bottle should be filled and dated, especially for high-flow oxygen, as per facility policy.
The facility failed to ensure a resident's emergency call button in the bathroom had a pull cord, which is necessary for calling staff in case of an emergency. The Maintenance Supervisor was unaware of the requirement for the string to reach the floor, and the facility lacked a specific policy on call lights.
A resident was found with smoking materials in their possession multiple times, despite the facility's policy requiring such items to be stored in a secured area. Staff were aware of the policy and the risks but did not consistently enforce it.
Failure to Document and Monitor Food Temperatures in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. Specifically, there were multiple instances where food temperatures were not checked or documented as required for food safety. Review of temperature log forms revealed numerous days where no logs were provided or where temperatures were not documented for various meals, including breakfast, lunch, and supper. Additionally, the temperature logs that were available did not include staff names or signatures to indicate who was responsible for checking the temperatures. The Dietary Manager (DM) confirmed that cooks were responsible for checking food temperatures before serving and acknowledged that logs were missing or incomplete, indicating that temperatures were not checked or documented for those meals. Interviews with the DM and the Administrator confirmed that the responsibility for ensuring food temperatures were checked and documented fell on the DM and the cooks. The DM stated that thermometers were provided for staff use and that missing documentation meant the checks were not performed. The Administrator acknowledged the risk to residents if food was not cooked and served at appropriate temperatures. The facility's policy required that temperatures of all hot and cold food be taken prior to every meal service and recorded on the temperature log, but this was not consistently followed. All residents, except for two who were tube fed, received food from the facility kitchen.
Failure to Ensure Safe Use of Wheelchair Lift During Resident Transport
Penalty
Summary
A deficiency occurred when a facility failed to ensure a resident environment free from accident hazards and did not provide adequate supervision to prevent accidents for one resident. The incident involved a female resident with end stage renal disease, diabetes mellitus, heart failure, and mild cognitive impairment, who was mobile via wheelchair and required regular dialysis treatments. On the day of the incident, the resident was being transported to a dialysis center in the facility's van. During the unloading process, the van driver lowered the wheelchair lift to the ground but became distracted by a bag left by another resident. The driver then re-entered the van, unlatched the resident, and began backing her in her wheelchair out of the van, unaware that the lift was not flush with the van floor. As a result, both the resident and the van driver fell out of the van, landing on the lift platform positioned on the ground. The resident sustained a scratch to her finger and complained of a headache, but declined to go to the emergency room. X-rays and neuro checks performed later showed no injuries. The facility's records indicated that the van and lift were operating correctly at the time of the incident. The van driver had received training on the operation of the van and lift, as well as on abuse and neglect, prior to the event. However, the driver failed to follow established procedures for ensuring the lift was in the correct position before unloading the resident, which directly led to the fall. The incident was documented in progress notes, and statements from the resident, van driver, and facility staff confirmed the sequence of events that resulted in the deficiency.
Failure to Provide Regular Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary grooming and personal care services for two residents who required assistance with activities of daily living (ADLs). Both residents had significant physical limitations due to conditions such as hemiplegia and hemiparesis following strokes, which left them unable to perform their own nail care. Despite care plans indicating the need for staff assistance with all ADLs, including regular nail care, both residents were observed with long fingernails containing a visible black/brown substance underneath, and one resident also had long toenails. Both residents reported being unable to trim their own nails and stated that staff had not been checking or providing nail care as needed. Interviews with staff, including the administrator, DON, ADON, LVNs, and CNAs, revealed inconsistent understanding and implementation of nail care responsibilities. While some staff stated that nail care should be performed on shower days or as needed, others indicated it was not part of their daily routine. There was also confusion regarding the facility's nail care policy, with some staff unaware of its specifics. Documentation showed that in-service training on resident hygiene had occurred, but recent staff turnover and the hiring of new CNAs may have contributed to lapses in care. Record reviews confirmed that both residents had care plans and assessments documenting their need for assistance with personal hygiene and nail care. However, observations and resident interviews on the day of the survey indicated that these interventions were not being consistently implemented, resulting in unmet hygiene needs for residents who were unable to care for themselves.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to ensure a safe environment for a resident with severe dementia, who was wearing a wander guard. The resident managed to leave the facility through the front door, which did not alarm or lock as it should have. The resident was found walking down the road by another resident's family member, who then notified the facility. The wander guard had been checked the night before and was reported as functioning, but it malfunctioned, allowing the resident to exit the facility without triggering an alarm. Another incident involved a resident with end-stage renal disease who was not properly secured in a transport van. During transport to dialysis, the resident's wheelchair flipped over backwards, causing the resident to experience head and neck pain. The contract van driver did not secure the resident's wheelchair with the necessary tie-down straps, which led to the incident. The driver continued to transport the resident to dialysis without reporting the fall to the facility or the dialysis center. Both incidents highlight a lack of adequate supervision and failure to follow protocols, which could place residents at risk of harm and serious injuries. The facility's failure to maintain a safe environment and ensure proper procedures were followed for resident transport resulted in these deficiencies.
Inappropriate Double Briefing Practice in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care for residents who are incontinent of bowel and bladder, as evidenced by the practice of double briefing. This was observed in four residents, who were found wearing two briefs at the same time. The residents did not request to be double briefed, and some were unaware of the number of briefs they were wearing. This practice was not in accordance with professional standards of care and was not part of the residents' care plans. Interviews with staff revealed a lack of awareness and understanding of the negative effects of double briefing. Some CNAs admitted to using two briefs on residents, while others were unaware of the practice. The RN and DON acknowledged the practice but had not reported it, indicating it had become normalized within the facility. The staff's actions were inconsistent with the facility's policies on abuse, neglect, and residents' rights, which emphasize the importance of individualized care and informed consent. The facility's failure to adhere to proper incontinence care practices placed residents at risk for infections and skin breakdowns. The report highlights the need for staff to follow care plans and professional standards to ensure the health and safety of residents. The facility's policies on resident rights and care planning were not effectively implemented, leading to the observed deficiencies.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to protect a resident from verbal abuse during an incident involving two residents. Resident #4, a female with severe cognitive impairment and dependent on others for mobility, was verbally threatened by Resident #3, who has a history of dementia, anxiety, and bipolar disorder. On the night of the incident, Resident #3 was found sitting on Resident #4's bed, threatening to kill her. Despite the intervention of staff, including an RN and a CNA, Resident #3 exhibited combative behavior and made threats towards both Resident #4 and the staff. The incident was not reported as abuse by the facility's Director of Nursing (DON) and Administrator, who believed that since Resident #4 did not appear to be upset or harmed, the situation did not constitute reportable abuse. The facility's policy on abuse and neglect requires all allegations of abuse to be reported immediately, but this protocol was not followed. The DON and Administrator did not consider the verbal threats as abuse due to the lack of physical or emotional harm to Resident #4, despite the facility's policy defining verbal abuse as any threatening language. Interviews with staff revealed that the incident was discussed in a morning meeting the following day, but it was not reported to the appropriate authorities as required. The facility's failure to report the incident and protect Resident #4 from verbal abuse represents a deficiency in ensuring residents' rights to be free from abuse and neglect. The facility's policy clearly outlines the need for immediate reporting of any abuse allegations, which was not adhered to in this case.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving two residents within the required timeframe. Resident #4, who has severe cognitive impairment and is dependent for all bed mobility, was found in a vulnerable situation when Resident #3, who has a history of dementia, anxiety, and bipolar disorder, was discovered sitting on Resident #4's bed and threatening to kill her. This incident occurred in the early hours of the morning, and despite the threatening behavior, the facility did not report the incident immediately as required by state law. The incident was witnessed by RN D, who intervened by calming Resident #3 and removing Resident #4 from the room. Despite the severity of the threats, the Director of Nursing (DON) and the Administrator did not consider the incident reportable, as they believed Resident #4 was not physically or emotionally harmed due to her cognitive state. The facility's policy requires all allegations of abuse to be reported immediately, but this was not adhered to in this case. Interviews with staff revealed a lack of understanding of the reporting requirements, as the DON and Administrator both stated that they did not report the incident because they did not perceive it as abuse. The facility's policy clearly outlines the need to report all allegations of abuse, neglect, and mistreatment, but this protocol was not followed, leading to a deficiency in the facility's handling of the situation.
Medication Mismanagement and Resident Safety
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, leading to the unsafe administration of medications. The resident, who had a history of dementia, anxiety, and bipolar disorder, was found to have stashed a significant number of pills in her room on two separate occasions following psychotic episodes. On one occasion, 40 to 50 pills were discovered on the floor, and on another, 10 to 15 pills were found. These incidents indicate that the resident was not ingesting all medications as prescribed, which could compromise her therapeutic treatment. The resident's comprehensive care plan noted her tendency to refuse medications, and interventions were in place to administer medications as ordered and monitor for side effects. Despite this, the resident's medication administration records showed multiple instances of medication refusal, including omega-3, linzess, probiotic, Wellbutrin, amantadine, and baclofen. Interviews with staff revealed that medications were left at the resident's bedside, contrary to facility policy, which contributed to the resident's ability to stash pills. Interviews with various staff members, including nurses and the Director of Nursing, confirmed the presence of pills in the resident's room and the failure to adhere to medication administration procedures. The facility's policy clearly stated that medications should not be left at the bedside and should be administered and charted immediately. However, a nurse admitted to leaving medications at the resident's bedside, which was against the policy, and this oversight was not adequately addressed, leading to repeated incidents of medication mismanagement.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during incontinent care for two residents. CNA A did not perform hand hygiene after changing gloves multiple times while providing care to a resident with end-stage renal disease, diabetes, and morbid obesity. This resident required total assistance with toileting and had mildly impaired cognition. CNA A admitted to not using sanitizer because it was not brought into the room, despite having received training on incontinent care. In another instance, both CNA A and CNA B failed to change gloves or perform hand hygiene while providing incontinent care to a male resident with fluid overload. This resident had intact cognition and was dependent on staff for toileting. The CNAs continued to provide care, including dressing the resident and transferring him to a wheelchair, without changing their soiled gloves or performing hand hygiene. Both CNAs acknowledged their failure to follow proper procedures, despite having received training. Interviews with the DON, Administrator, and ADON revealed that the facility had recently conducted in-services on hand hygiene and peri care. However, the CNAs did not adhere to the established protocols, which could lead to the spread of infections. The facility's policies on hand hygiene and perineal care were not followed, as evidenced by the CNAs' actions during the observed care.
Failure to Ensure Resident Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure full visual privacy during incontinent care for a resident. During an observation on 04/22/2024, the privacy curtain was not pulled around the resident, leaving her unclothed from the neck down and exposed. The incident occurred while two CNAs were preparing the resident for incontinent care. A male worker was observed outside the window, which was not covered, and one of the CNAs acknowledged the oversight and closed the blind only after noticing the worker. The privacy curtain was then drawn around the resident. Interviews with the resident, the DON, the Administrator, and the ADON revealed that the resident did not realize the privacy measures were not in place but acknowledged that it could embarrass some residents. The DON and ADON expressed disappointment and confirmed that the CNAs had been trained on maintaining privacy during personal care. The facility's policies on resident rights and personal care were reviewed, indicating the requirement to provide privacy and modesty by closing the door and/or curtain.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for one resident. Specifically, the facility did not reassess a resident following their admission to hospice services. The resident, who had diagnoses including parkinsonism, schizoaffective disorder, bipolar type, mild intellectual disabilities, and hypertension, was admitted to hospice services on 12/15/2023. However, the significant change MDS assessment was not completed within the required timeframe, and the resident's quarterly MDS assessment dated 1/5/2024 did not reflect the hospice admission. Interviews with the MDS Coordinators revealed that they were unaware of the missed assessment and attributed the oversight to the previous MDS Coordinator, who was no longer employed at the facility. The DON and Administrator confirmed that the MDS Coordinators were responsible for resident assessments and acknowledged the oversight. They discussed significant changes in morning meetings but were unsure how this particular assessment was missed. The facility's policy mandates that a comprehensive assessment be completed within 14 days of admission and promptly after a significant change in the resident's condition, which was not adhered to in this case.
Failure to Refer Resident for Level II PASSAR Review
Penalty
Summary
The facility failed to refer a resident with newly evident serious mental disorders for a level II resident review upon a significant change of condition. Specifically, Resident #32, who had diagnoses of Huntington's disease, PTSD, major depressive disorder with psychotic symptoms, and heart failure, did not have a new level 1 PASSAR completed after receiving new diagnoses of PTSD and major depressive disorder. The MDS Coordinators were unaware of these new diagnoses and did not submit the necessary forms for a new PASSAR evaluation, which could result in the resident not receiving the required services to meet her needs. Interviews with the MDS Coordinators and the DON revealed that there was a lack of communication and awareness regarding the new mental illness diagnoses for Resident #32. The facility's policy on PASSAR was not followed, as the new diagnoses were not entered into the system, and a new PL1 form was not completed. This oversight was acknowledged by the MDS Coordinators and the DON, who admitted that the resident could be at risk of missing essential services due to this failure.
Failure to Update Care Plan for PTSD Diagnosis
Penalty
Summary
The facility failed to review and revise the person-centered care plan to reflect the current condition for a resident diagnosed with PTSD. The resident, who was admitted with multiple diagnoses including Huntington's disease, major depressive disorder with psychotic symptoms, and heart failure, had a care plan that did not include PTSD. The Quarterly MDS assessment indicated the presence of PTSD, but this diagnosis was not reflected in the care plan. The MDS Coordinators responsible for updating the care plans were unaware of the PTSD diagnosis, leading to a lack of appropriate care planning for the resident's mental health needs. During interviews, the MDS Coordinators, DON, and Administrator acknowledged the oversight and the potential risk it posed to the resident's well-being. The facility's policy on comprehensive care planning mandates the inclusion of all relevant diagnoses and specialized services, but this was not adhered to in this case. The failure to update the care plan could result in the resident not receiving the necessary support and interventions for PTSD, potentially worsening their mental health condition.
Failure to Follow Safety Protocols for Transfers and Smoking Materials
Penalty
Summary
The facility failed to ensure Resident #65 was transferred using a gait belt on multiple occasions. Despite being trained and competent in proper transfer techniques, CNAs A and B manually lifted Resident #65 without using a gait belt, which was against the resident's care plan that required a two-person assist with a gait belt. Both CNAs acknowledged their mistake and admitted to being nervous or uncomfortable with the gait belt, although they had been properly trained. The resident himself mentioned that he found the gait belt uncomfortable but had not communicated this to the staff prior to the incident. The ADON and DON confirmed that the CNAs were trained and competent in using gait belts and that improper transfers could lead to injuries. The Administrator also emphasized the importance of following transfer policies to ensure resident safety. The facility also failed to ensure Resident #62 did not have smoking materials in his possession, which was against the facility's smoking policy. Resident #62, who was deemed a safe smoker, was observed with lighters and cigarettes in his room and on his person on multiple occasions. Despite the policy requiring smoking materials to be stored in a secure area and only accessed during supervised smoking sessions, staff found Resident #62 with these items several times. Interviews with CNAs and an LVN revealed that they were aware of the policy and had previously confiscated smoking materials from Resident #62. However, the resident continued to keep these items, posing a risk of fire and injury. The DON and Administrator acknowledged the issue and stated that staff were responsible for ensuring smoking materials were returned to the secure area after use. The facility's policies on resident transfers and smoking were not consistently followed, leading to potential risks for falls, injuries, and fires. Both deficiencies highlight lapses in adherence to established safety protocols, despite staff being trained and aware of the correct procedures. The failure to use a gait belt for Resident #65 and the improper handling of smoking materials for Resident #62 were directly observed and confirmed through staff interviews and record reviews.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident diagnosed with Parkinsonism, dementia, dysphagia, protein calorie malnutrition, and GERD. The resident, who was dependent on staff for all activities of daily living (ADLs), had a significant impairment in thinking and was on a mechanically altered diet. Despite physician orders for double portions at all meals, the resident did not receive the prescribed therapeutic diet on two observed occasions, which could place the resident at risk for unplanned weight loss, malnutrition, and failure to thrive. Observations and interviews revealed that on 4/22/2024 and 4/23/2024, the resident's meal trays did not contain double portions as ordered. Staff assisting the resident with meals confirmed that the resident was supposed to receive double portions but did not on these dates. The dietary manager and cook were unaware of the double portion order until it was brought to their attention by the state surveyor. The dietary manager admitted that the resident's tray card did not reflect the double portion order, and the cook confirmed that double portions were not provided on the specified dates. Interviews with the ADON and other staff indicated that the resident had been on double portions for a while due to weight loss concerns. However, there was a communication breakdown between nursing and dietary services, resulting in the resident not receiving the prescribed diet. The DON and Administrator acknowledged the oversight and stated that they were not aware of the issue until the state surveyor's intervention. They recognized that residents could be at risk for weight loss if diet orders were not correctly followed.
Failure to Provide Proper Oxygen Humidification
Penalty
Summary
The facility failed to ensure that a resident who required oxygen therapy received appropriate respiratory care, specifically oxygen humidification. Resident #65, a male with a diagnosis of fluid overload, was observed on two separate occasions with an empty and undated humidifier bottle while receiving oxygen at 5 liters per nasal cannula. The resident reported discomfort due to nasal dryness when the humidifier bottle was empty. Interviews with staff, including an LVN, ADON, DON, and the Administrator, confirmed that the humidifier bottle should be filled and dated, especially for residents on high-flow oxygen to prevent nasal dryness and potential respiratory infections. The facility's policy on oxygen administration, which requires humidification to prevent drying of mucous membranes and thickening of respiratory secretions, was not followed. The nursing staff, responsible for checking the oxygen setup during rounds, failed to ensure the humidifier bottle was filled and dated. This oversight was acknowledged by the nursing administration, who confirmed that proper oxygen setup checks were part of their training and competency checks. The deficiency was identified through observations, interviews, and record reviews, highlighting a lapse in adherence to the facility's established protocols for oxygen therapy.
Failure to Ensure Emergency Call Button Accessibility
Penalty
Summary
The facility failed to ensure that Resident #77's emergency call button in the bathroom had a pull cord, which is necessary for residents to call for staff assistance. During an observation, it was noted that the call button was attached to the wall by the grab bar without a pull string. Resident #77, a 94-year-old female with diagnoses including CKD Stage 3, age-related osteoporosis, and neuromuscular dysfunction of the bladder, was observed to use the bathroom independently. The absence of a pull cord could prevent her from calling for help in case of a fall or emergency. Interviews with staff revealed that the Maintenance Supervisor, who had been employed for two months, was responsible for checking call lights weekly but was unaware that the strings needed to be long enough to reach the floor. The CNA assigned to Resident #77's hall confirmed that the resident was independent in using the bathroom. The DON and Administrator acknowledged that call light strings should be long enough to reach the floor and that the facility lacked a specific policy on call lights. The call light log indicated that Resident #77's room was checked, and no issues were noted, despite the missing pull cord.
Failure to Follow Smoking Policy
Penalty
Summary
The facility failed to follow their established smoking policy for one resident, who was found with smoking materials including a lighter and cigarettes in his possession. Despite being deemed a safe smoker, the resident was not allowed to keep smoking materials in his room according to the care plan. Observations and interviews revealed that the resident had smoking materials in his room on multiple occasions, and staff were aware but did not consistently enforce the policy. The resident was seen using a lighter and cigarettes from his pocket during a smoke break, contrary to the facility's policy that smoking materials should be stored in a designated, secured area. Interviews with staff indicated that they were aware of the policy and the risks associated with residents keeping smoking materials, yet the resident continued to have access to these items. The Director of Nursing and the Administrator confirmed that the resident had smoking materials confiscated in the past and acknowledged the need for staff education on the smoking policy. The facility's policy clearly stated that smoking paraphernalia should not be kept in residents' rooms and should be returned to a secured area after use, which was not consistently followed in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Nacogdoches
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrook Nursing Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Stallings Court Nursing And Rehabilitation | 2.4 mi | ★★★★★ | 4 | 0 |
| Garrison Nursing Home & Rehabilitation Center | 16.5 mi | ★★★★★ | 0 | 0 |
| Wells Ltc Nursing & Rehabilitation | 18.5 mi | ★★★★★ | 17 | 4 |
| Southland Rehabilitation And Healthcare Center | 21.5 mi | ★★★★★ | 9 | 0 |
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