Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Whispering Pines Lodge during CMS and state inspections, most recent first.
A resident with multiple cardiac and cognitive comorbidities, on a mechanically altered diet, began choking while eating in the dining room. An LVN responded by lightly patting the resident’s back, but appropriate back blows and the Heimlich maneuver were not performed for over a minute as the resident progressed to unresponsiveness. Additional staff, including an RN and a medication aide, then attempted the Heimlich on the now-limp resident and performed a sternal rub before moving the resident to a nearby room, delaying CPR initiation by about two minutes. Review showed the resident’s care plan did not address choking risk, the facility’s choking policy lacked guidance for when a resident becomes unconscious, and the LVN, RN, and medication aide involved did not have current BCLS certification, contrary to facility policy requiring current CPR/BCLS training.
The facility failed to ensure residents had access to warm water for bathing and showers, resulting in at least one resident receiving a cold bed bath during a winter storm and another receiving a cold shower when hot water was unavailable. A resident with fractures and chronic diastolic heart failure, who required substantial assistance with bathing, reported taking a cold bed bath when the facility lost power and had no warm water. Staff, including a SW, CNA, LVN, housekeeping staff, and supervisors, described ongoing problems with cold water on one hall, residents refusing showers, and staff transporting residents to other halls or carrying hot water between showers. A surveyor measured the shower water at 71°F on the affected hall, and the area maintenance specialist later found the hot water temperature had been turned down and that required weekly water‑temperature logs had not been completed for several weeks, despite a policy requiring water temperatures of 100–110°F and resident rights to care that promotes quality of life.
A resident with severe cognitive impairment, multiple neuropsychiatric diagnoses, and total dependence for ADLs was observed seated in a wheelchair near the nurse’s station with a white liquid spilled on his pants and on the floor beneath him for an extended period while staff walked past without changing his clothing. Although the spill on the floor was eventually cleaned, the resident’s pants remained visibly wet until later, when a CNA and a COTA used a mechanical lift to provide care and change his clothes, at which time the wheelchair and lift sling were also found to be wet. In interviews, CNAs, a CMA, an LVN, the ADON, the DON, and the administrator all acknowledged that all staff are responsible for keeping residents clean and dry and that leaving a resident in soiled clothing is a dignity issue, consistent with the facility’s Resident Rights policy.
A resident with COPD, acute respiratory failure, anxiety disorder, myopathy, and moderate cognitive impairment was observed sitting in her room with a prescribed Fluticasone Propionate nasal spray left on her bedside tray instead of being secured. The resident reported that staff usually kept the medication locked. A CMA admitted she had given the nasal spray, left the room, and later realized she had failed to return it to the med cart. Facility staff, including CMAs, an LVN, the ADON, the DON, and the administrator, all stated that residents were not permitted to have medications in their rooms, that no residents were authorized to self-administer medications, and that nursing staff were responsible for proper medication storage, in contrast to what occurred in this case.
Surveyors identified that staff failed to follow infection control practices for handling and storing trash and soiled linens in one hall and two shower rooms. Dirty linens were left on shower floors, trash bags were placed on the floor in a hallway and behind a shower door, and a staff member handled soiled linens without gloves. Trash was stored in clear bags and transported on top of gray linen barrels instead of in designated yellow barrels. Multiple CNAs, CMAs, housekeeping staff, the housekeeping supervisor, ADON, DON, and the administrator all acknowledged that these practices violated facility policy requiring proper containment, use of PPE, and appropriate transport of trash and linens to prevent contamination.
Surveyors identified that dirty linens were left on a shower floor, trash bags were stored on the floor in a hall and behind a shower door, and a toilet rim in a shower room remained broken with exposed porcelain edges. Staff interviews showed that facility expectations and policies required dirty linens to be bagged and placed in gray barrels, trash to be contained in yellow barrels, and no trash or linens to be stored on floors or behind doors. One CNA acknowledged placing trash bags on the hallway floor and misunderstanding that this was acceptable if bagged. A housekeeper reported the broken toilet months earlier via a maintenance system, while nursing and administrative staff, including an LVN, ADON, DON, and ADM, stated they were unaware of the damage and that any staff member who found such issues was responsible for reporting them immediately, consistent with the facility’s infection control and resident rights policies.
Call Lights Not Kept Within Reach for Multiple Residents: Four residents with severe cognitive impairment and varying ADL needs had call lights found on the floor, behind nightstands, or under beds instead of within reach. Observations showed the call lights were not accessible on the memory care and secure unit, and staff including a CNA, LVN, ADON, DON, and Administrator acknowledged that residents needed accessible call lights to contact staff for help.
Activities Program Not Directed by a Qualified Professional: The facility failed to ensure the activities program was overseen by a qualified AD. The AD had been in the role for about two months, was not certified, had not completed required classes, and had not done activity assessments. The Administrator acknowledged the AD was hired without certification, while a COTA said she only volunteered to call bingo and did not handle assessment or documentation duties.
An LVN continued working as a charge nurse and floor nurse after her TX BON license had expired and was later under enforced suspension. The facility had initially verified her license before hire, but did not recheck it when she gave notice, and she worked multiple shifts on units with a census of 65 to 66 residents. Interviews showed the DON and ADM learned later from corporate HR that the license was not valid, while the LVN said she believed she could work out a notice period based on her communication with the BON.
Failure to log and promptly resolve a resident grievance about a noisy roommate. A cognitively intact male resident with MS, HTN, and chronic pain told the DON his roommate was hollering, moaning, and groaning day and night, leaving him unable to sleep. Observations confirmed the roommate’s loud vocalizations, and the resident said he was turning his TV up to drown out the noise, but no grievance was found in the log and no resolution had been communicated to him.
A resident with cognitive impairment and ADL dependence did not receive a scheduled shower, even though he was waiting with his shower supplies ready, and the EHR was later documented as completed by a student aide who admitted she had not actually done it. Another resident with severe cognitive impairment and ADL dependence did not receive shaving assistance as outlined in the care plan because a CNA assumed the family would handle it. The DON and Administrator stated showers and personal hygiene were to be provided according to the care plan.
Failure to complete activity assessments and provide scheduled in-room activities: Two residents did not receive activity programming consistent with their care plans and assessments. One resident with heart disease, prostate cancer, cardiomegaly, HTN, and back pain had no recent activity assessment and said he did not leave his room for facility activities, while a second resident with Alzheimer’s disease, severe malnutrition, and osteomyelitis was observed resting in bed throughout the day despite a care plan for 1:1 sensory visits at least 3 times weekly. The AD said she had not completed assessments or documented activity participation/refusals and was unaware of the documentation and quarterly assessment requirements.
An unlocked nurse medication cart on the B Hall was observed unattended across from a resident room, with a resident in bed in the room and another resident standing at the cart. The cart contained eye drops, insulin pens, a glucometer, liquid G-tube meds, multiple medication cards, topical meds, and other supplies. The LVN said she had been called away by an aide, and the DON, ADON, RN, and Administrator stated carts were supposed to be locked when staff stepped away.
Failure to use required PPE during EBP care: staff provided direct care to a resident with a PEG tube, severe cognitive impairment, and total dependence for ADLs without wearing gowns during a feeding tube/PEG tube connection, a mechanical lift transfer, incontinent care, and repositioning. Observations showed staff handling the resident and bedding while only using gloves or no PPE, and interviews confirmed staff understood gowns and gloves were required for these high-contact activities.
A resident with MS, HTN, chronic pain, and a BIMS of 15 required extensive assistance with ADLs and transfers, but his call light was not working. He reported pressing it and waiting without response, and when the surveyor had him test it, the hallway indicator did not activate. An SNA could not get it to work and said she was unaware it was malfunctioning; the DON and Administrator stated staff were responsible for ensuring call lights were accessible and functioning, and that no policy addressed the call light system.
Surveyors identified multiple instances of abuse, neglect, and inadequate care, including a nurse physically abusing a resident with severe cognitive impairment, another nurse verbally abusing a resident and refusing pain medication, and repeated resident-to-resident altercations resulting in injury. Additional deficiencies included improper positioning during tube feeding leading to aspiration, lack of wound care, insufficient feeding assistance, and inadequate supervision due to staffing shortages. Staff interviews confirmed ongoing concerns about inadequate staffing and lack of support.
Multiple residents experienced unwitnessed falls and resident-to-resident altercations due to inadequate supervision and insufficient staffing, with only one staff member often present on the secured unit. Staff interviews and observations confirmed that residents were frequently left unsupervised in common areas, and care plans did not consistently address fall risks or behavioral issues, resulting in injuries and unmonitored incidents.
A facility failed to provide adequate nursing staff with the necessary skills to meet resident needs, resulting in missed care interventions such as improper positioning during tube feeding that led to aspiration pneumonia, and incomplete wound care and documentation for multiple residents with complex medical conditions. The secured unit also lacked sufficient staff to prevent accidents and provide supervision during mealtimes, contributing to ongoing deficiencies in resident care and safety.
A resident with multiple comorbidities experienced repeated episodes of abnormal vital signs, including low blood pressure and heart rate, resulting in held antihypertensive medications over several days. Despite facility policy requiring physician notification for such changes, there was no consistent documentation or evidence that the physician was informed, and staff interviews revealed confusion about notification responsibilities. The resident was later hospitalized for a gastrointestinal hemorrhage after critical lab values were discovered.
A resident with severe cognitive and physical impairments, dependent on staff for all care, was left leaning over the armrest of a Geri-chair for an extended period during tube feeding, contrary to care plan and physician orders requiring head elevation. Despite a CNA's brief attempt to reposition, the resident remained improperly positioned until a nurse intervened much later. The incident resulted in aspiration, confirmed by hospital evaluation, and staff interviews cited inadequate staffing as a factor in the failure to provide appropriate monitoring and care.
Two residents experienced unmanaged pain due to missed and delayed administration of scheduled opioid and non-opioid pain medications, lack of required pain assessments, and failure to offer alternative or non-pharmacological interventions as ordered. Staff did not consistently document pain assessments or notify physicians when doses were missed, and PRN pain medications were not administered when residents displayed signs of pain during care. These actions were not in accordance with professional standards or the facility's pain management policy.
During a COVID-19 outbreak, the facility did not ensure staff consistently used required PPE, such as N-95 masks and face shields, when caring for residents with confirmed infections. PPE carts lacked necessary supplies, and staff were observed entering and exiting rooms without changing masks or performing hand hygiene due to missing sanitizer. Isolation signage was absent from affected residents' doors, and new symptomatic residents were not promptly tested. Facility leadership was unaware of these lapses, and infection control protocols were not properly followed or monitored.
A resident with chronic pain and mental health diagnoses did not receive scheduled pain medications on time and, during a subsequent interaction, an LVN spoke to her in a disrespectful and condescending manner, including raising her voice and using inappropriate gestures. A CNA witnessed the incident and confirmed the LVN's tone was not respectful. Facility leadership acknowledged that this conduct violated the resident's rights to dignity and respectful communication.
A resident with chronic pain conditions did not receive proper protection from misappropriation of her prescribed Oxycodone when staff documented an extra dose that was not administered, and the discrepancy could not be reconciled through medication records or staff interviews. The incident involved inconsistent documentation, staff concerns about possible drug diversion, and a lack of clear explanation from the nurse responsible.
The facility did not thoroughly investigate allegations involving two residents, including possible misappropriation of narcotic medication and failure to administer pain medication as requested. Despite reports from staff and family, there was no evidence of comprehensive investigation or immediate protective actions, and the nurse involved continued to work with residents after the incidents.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
A resident with spastic quadriplegic cerebral palsy and chronic kidney disease was not permitted to use his personal motorized wheelchair during his stay, despite prior use and intact cognition. Facility staff cited an outdated practice of disallowing motorized wheelchairs, and the resident was not assessed for safe use as required by policy. This resulted in the resident's loss of independence and increased reliance on staff for mobility.
An oxygen cylinder was found stored upright on the floor in a resident's room, rather than in a caddy or secured area as required by facility policy. The resident, who had multiple serious medical conditions, was present in the room with the unsecured tank. Staff interviews confirmed that the tank should have been properly stored to prevent accidents, and the facility's policy prohibits leaving cylinders free-standing.
A resident with severe cognitive and physical impairments was unable to call for staff assistance due to a non-functional call light, which had been inoperative for approximately two weeks. The issue was only discovered during a surveyor's visit, with the resident's roommate confirming the ongoing problem and staff acknowledging that maintenance had not been notified. Facility records indicated that routine checks had not identified the issue prior to the survey.
A resident with severe cognitive impairment and a history of wandering eloped from a secured unit in an LTC facility. The resident was found at a local hospital after being taken there by police. The facility was unaware of the resident's absence for four hours. The resident had previously demonstrated exit-seeking behavior, and staff were not aware of the resident's ability to disable window alarms and remove thumb locks, leading to the elopement.
A resident with Huntington's Disease was improperly restrained by a CNA in a LTC facility, violating resident rights. The CNA tied the resident's legs to the bed using leggings, despite having received training on the facility's restraint-free policy. The incident was discovered by another CNA, leading to an investigation by the facility's administration.
Two residents in a facility were involved in separate incidents due to inadequate supervision and failure to follow safety protocols. One resident, with severe cognitive impairment, was found with an unattended spray bottle of cleaner, suggesting possible ingestion. Another resident, requiring dialysis, was not properly secured in a transport van, resulting in a fall and head abrasions. The facility failed to ensure proper training and adherence to safety procedures, leading to these deficiencies.
The facility failed to ensure proper management of psychotropic medications, including gradual dose reductions and behavioral interventions, for several residents. One resident experienced lethargy, falls, and weight loss due to medication side effects, and the facility did not notify the physician of significant weight loss or accurately report behaviors. Additionally, PRN Lorazepam use was not limited to 14 days for other residents, lacking necessary documentation for extended use, placing residents at risk for adverse side effects.
The facility failed to accurately complete PASRR Level I screenings for four residents, omitting diagnoses of mental illnesses such as PTSD and major depressive disorder. This oversight could prevent residents from receiving necessary assessments and specialized services. Interviews with staff revealed a lack of awareness regarding the need to update PASRR screenings upon admission or re-admission with mental health diagnoses.
The facility failed to provide meaningful activities for residents in the memory care unit, as observed during a survey. Despite having an activity schedule, no dementia-focused activities were implemented, and the activity director was infrequently present. Staff reported that the lack of activities might contribute to falls and incidents, and the absence of a specific activity calendar for the memory care unit was noted.
Three residents experienced inadequate hydration due to insufficient fluid intake and inconsistent staff practices. One resident with multiple sclerosis reported a dry mouth, another with cerebral infarction had to request water, and a third with Alzheimer's had elevated BUN levels. Staff interviews revealed dissatisfaction with the hydration system, highlighting potential health risks.
The facility failed to provide adequate pharmaceutical services, resulting in missed medication doses and improper administration for several residents. A resident did not receive Niacin, Ativan, and Nicotine Patch due to unavailability, while another received crushed Aspirin EC against orders. Two other residents experienced medication shortages, with Lorazepam and Lomotil not being available. Staff interviews revealed communication issues with the pharmacy and inadequate emergency kit stocking.
A facility reported a medication error rate of 61.76%, involving late administration and incorrect dosing for residents with complex medical conditions. Errors included late administration of anxiety and pain medications, incorrect IV infusion rates, and failure to apply a prescribed patch. Staff interviews revealed issues with adherence to medication schedules and physician orders.
Two residents received losartan despite vital signs being outside prescribed parameters. Staff interviews revealed a lack of adherence to medication protocols, with MAs administering medication based on nurse instructions. The facility's policy emphasizes the ten rights of medication administration, but these were not followed, risking adverse effects.
A facility failed to provide a baseline care plan to the responsible party (RP) of a resident with severe cognitive impairment and multiple diagnoses. Although the resident received a copy, the RP did not, which could lead to a lack of understanding of the care being provided. Interviews with staff revealed inconsistencies in executing the responsibility of providing the baseline care plan to the RP, despite the facility's policy requiring it.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. A resident's care plan did not include her prescribed psychotropic medication, another resident's behavioral symptoms were not addressed, and a third resident's limited range of motion and music preferences were omitted. Staff interviews highlighted the importance of care planning to ensure residents' needs and preferences are met.
The facility failed to provide scheduled baths for three residents, leading to missed hygiene care. A resident with cerebral palsy and heart failure, another with severe cognitive impairment, and a third with Alzheimer's disease did not receive baths as per their care plans. Documentation was lacking, and staff turnover was cited as a reason for the missed baths.
A resident with COPD and other health issues was found to have an oxygen concentrator with a 90% missing filter, which was not replaced as required by facility policy. Interviews revealed that the facility had procedures for maintaining clean and functioning filters, but these were not followed, potentially exposing the resident to respiratory risks.
The facility failed to ensure the safe and sanitary storage of food in the personal refrigerators of two residents. One resident had expired protein drinks, while another's refrigerator contained a brown and black substance with dead gnats. Despite the facility's policy requiring family or staff to maintain cleanliness, there was confusion among staff about their responsibilities, leading to unsanitary conditions and potential health risks for the residents.
A facility failed to maintain an effective infection prevention and control program, as a medical assistant entered and exited a COVID-19 positive resident's room wearing only a surgical mask instead of the required full PPE. The resident, with multiple health conditions, was on isolation precautions. Despite clear signage and staff understanding of PPE protocols, the assistant did not adhere to them, risking cross-contamination and infection spread.
The facility failed to report the results of an investigation into an alleged abuse incident between two residents to the state survey agency within the required timeframe. The administrator admitted to forgetting to send the report, despite being solely responsible for its submission. The facility's policy mandates that such reports be sent within 5 working days, which was not followed in this instance.
Failure to Provide Timely BLS/CPR and Appropriate Choking Response
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support (BLS), including CPR and appropriate choking interventions, to a resident in distress prior to EMS arrival, in accordance with AHA/BCLS guidelines, physician orders, and the resident’s advance directives. The resident was an elderly female with diagnoses including senile degeneration of the brain, CHF, type 2 diabetes, atrial fibrillation, respiratory failure, muscle weakness, and a cardiac pacemaker. Her MDS indicated severe cognitive impairment, need for assistance with eating and mobility, incontinence, and a mechanically altered diet. Her care plan noted a diet other than regular but did not address choking risk. On the morning of the incident, video footage showed the resident seated in the dining room in a wheelchair, eating breakfast when she began to choke. LVN A responded promptly after the resident gestured to her back, and LVN A began lightly tapping the resident’s back. The resident violently shook her head "no" and later appeared to vomit, then nodded "yes". LVN A continued lightly patting the resident’s back and appeared to yell for help. The resident’s body then became limp and unresponsive while still in the wheelchair. LVN A briefly left toward the edge of the dining room, then returned, and RN B entered the dining room. LVN A resumed lightly patting the resident’s back, then positioned the resident’s limp body forward with her head on the table and began more aggressive back patting. During this period, appropriate back blows and the Heimlich maneuver were not performed for over a minute while the resident was in distress and then unresponsive. MA C then attempted the Heimlich maneuver while the resident remained limp in the wheelchair, followed by RN B attempting the Heimlich maneuver after the wheelchair was moved away from the table. RN B also attempted to shake the resident’s shoulder while MA C appeared to perform a sternal rub. Staff then pushed the resident in the wheelchair out of the dining room toward a nearby room to initiate CPR. The facility’s own timing and observations indicated that CPR initiation was delayed by approximately two minutes after the resident became unresponsive. The facility’s choking/aspiration policy addressed signs of choking and use of the Heimlich maneuver, including abdominal thrusts if the resident was on their back, but did not address what to do if the resident became unconscious or non-responsive. The facility’s CPR policy required at least one staff member trained in CPR/BCLS at all times and that trained staff maintain current certification. Record review showed that LVN A’s BCLS certification had expired, RN B’s BCLS certification had expired, and MA C was not currently certified in BCLS. Interviews confirmed that LVN A believed back slapping was the right action when she suspected choking and that she was scared and felt the event "felt like an eternity". RN B reported that when she arrived the resident was already blue and purple and unresponsive, that she checked the code status, called 911, and then attempted the Heimlich maneuver even though the resident was unconscious, acknowledging she panicked and knew CPR should be initiated when a choking victim becomes unresponsive. These actions and inactions—failure to promptly perform appropriate back blows and Heimlich on a conscious choking resident, failure to initiate CPR immediately once the resident became unresponsive, and allowing staff to work with expired or absent BCLS certifications—resulted in the resident not receiving basic life support while choking and constituted the cited deficiency.
Removal Plan
- Conduct an audit of all residents who expired in the facility during the last 30 days to ensure CPR was performed according to AHA/BCLS guidelines, including the Heimlich maneuver.
- Conduct an audit of all charge nurses for current CPR/BCLS certifications.
- Provide CPR/BCLS classes for all charge nurses to ensure current certifications, including return demonstration of skills (including the Heimlich maneuver).
- Provide 1:1 in-service training for the Administrator and ADON (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect), Cardiopulmonary Resuscitation (initiate CPR immediately when unresponsive with no pulse), and Choking/Heimlich per AHA/BCLS guidelines.
- Provide 1:1 in-service training for LVN A, RN B, and MA C (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect), Cardiopulmonary Resuscitation (initiate CPR immediately when unresponsive with no pulse), and Choking/Heimlich per AHA/BCLS guidelines.
- Notify the Medical Director of the Immediate Jeopardy citation.
- Hold an ADHOC QAPI meeting to review the Immediate Jeopardy citation(s) and the plan of removal.
- In-service all medication aides and CNAs (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect) and Notification of change in condition (universal signs of choking and immediate Heimlich per AHA/BCLS; notify nurse; respond immediately); prohibit staff from working their next shift until completed; include new hires during orientation and agency staff prior to shift.
- In-service all charge nurses (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect), Notification of change in condition (universal signs of choking and immediate Heimlich per AHA/BCLS), Cardiopulmonary Resuscitation (initiate CPR immediately when unresponsive with no pulse), and Choking/Heimlich per AHA/BCLS guidelines; prohibit staff from working their next shift until completed; include new hires during orientation and agency staff prior to shift.
Failure to Ensure Warm Water for Resident Bathing and Showers
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with warm water for bathing and showers, resulting in cold bed baths and showers for at least two residents. One resident, an older female with fractures of the right tibia and fibula and chronic diastolic heart failure, had an admission MDS showing moderate cognitive impairment and a need for substantial assistance with bathing and total assistance with lower body dressing. Her care plan indicated she required two staff for bathing and that staff could provide a sponge bath when a full bath or shower could not be tolerated. She reported that during a winter storm, when the facility lost power and did not have warm water, she received a cold bed bath because she wanted to feel clean. A social worker reported that the Hall A shower water was cold and stated she discovered this when she stayed in the facility over a winter storm weekend and attempted to take a shower. She said she did not think the facility was aware of the cold water until she tried to shower. On observation, the Hall A shower water was run for approximately three minutes and measured 71°F, never reaching the recommended 100–110°F. The social worker stated that six residents resided on Hall A and were using Hall B and D showers until the water was fixed, without specifying a timeframe for repair. An anonymous resident reported receiving a cold shower because the facility did not have hot water. Multiple staff interviews showed ongoing awareness of hot water problems on Hall A (and at times Hall B) without consistent resolution or documentation. A CNA stated she knew the Hall A shower water was cold for 1–2 months, had reported it to maintenance and the DON, and that no one was taking showers in the Hall A shower room. Housekeeping staff and the housekeeping supervisor reported hearing CNAs complain about cold water, residents refusing showers, and staff having to take residents to other halls or carry hot water from one shower to another. An LVN reported that Hall A did not have hot water on and off, that residents had complained about not having hot water for hot beverages or to sponge off at their sinks, and that residents were taken to other halls for showers. The ADON and DON both stated that staff were expected to report water temperature issues immediately and ensure comfortable water temperatures, and the administrator acknowledged concerns with water not getting as hot as it should. When the area maintenance specialist was interviewed, he stated he was not aware that Hall A water was running cold and noted that the prior maintenance man had been terminated. On testing with the facility’s thermometer, the Hall A shower water measured 98.7°F and the sink water was warm, and he stated that somehow the hot water temperature had been turned down. He presented temperature logs and stated the expected range was 100–110°F, but the last recorded weekly temperature checks were dated more than a month earlier, with no logs documented since. Facility grievance records over a several‑month period did not show any complaints about water temperature. The facility’s resident rights policy required care in a manner and environment that promotes or enhances quality of life, and a facility checklist required weekly testing and logging of hot water temperatures in resident rooms and showers to ensure they remained between 100°F and 110°F, but these checks were not documented as completed during the period when residents and staff reported cold water and residents received cold baths and showers.
Resident Left in Soiled Clothing for Extended Period, Violating Dignity
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s dignity by allowing him to remain in soiled clothing for an extended period and to be taken toward the dining hall without timely changing his clothes. The resident was an elderly male with unspecified dementia, epilepsy, schizophrenia, major depressive disorder, and cerebrovascular disease. His MDS showed a BIMS score of 5, indicating severe cognitive impairment, and he was wheelchair-bound and dependent on staff for bed mobility, transfers, dressing, and toileting, requiring 1–2 staff assistance and a mechanical lift per his care plan. On the morning in question, surveyors observed the resident seated in his wheelchair in front of the nurse’s station with a clear cup of white liquid spilled on his dark gray pants at 8:50 a.m. At 9:15 a.m., he remained in the same location with the white liquid still on his pants and a small puddle of the substance under his wheelchair, while multiple staff members walked past him and sat at the nurse’s station. At 9:23 a.m., the resident was still in front of the nurse’s station with the absorbed white substance visible on his pants and under his wheelchair. By 9:51 a.m., the spill on the floor had been cleaned, but the resident’s pants still had a wet area on the left upper thigh. Later that morning, at 11:45 a.m., a CNA wheeled the resident toward the dining hall, stating his pants were dry but then took him to his room to change his clothing. At 11:55 a.m., the CNA and a COTA used a mechanical lift to transfer the resident, provided incontinent care, and changed his clothes. During this process, surveyors observed a white substance on the wheelchair and noted the lift sling was wet, requiring a clean sling before transferring the resident back. In interviews, the CNA reported she had gotten the resident up, dressed, and fed breakfast earlier, believed he had a health shake, and acknowledged that aides were responsible for ensuring he was clean and dry. Other staff, including a CMA, CNA, LVN, ADON, DON, and the administrator, all stated that residents should be kept clean and dry, that all staff share responsibility for addressing soiled clothing, and that leaving a resident in dirty clothes is a dignity issue. The facility’s Resident Rights policy states that residents have the right to be treated with respect and dignity.
Unsecured Nasal Spray Left at Bedside Contrary to Medication Storage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and biologicals were stored in locked compartments in accordance with state and federal requirements. Surveyors observed that a prescribed Fluticasone Propionate nasal spray, ordered as 50 mcg/ACT, one spray in each nostril once daily for allergies, was left on the bedside tray table of a resident. The resident, an elderly female with COPD, acute respiratory failure, anxiety disorder, and myopathy, had a BIMS score of 9 indicating moderate cognitive impairment, though she was able to make herself understood and understand others. Her care plan identified potential for impaired cognitive function and thought processes related to oxygenation status and COPD. During observation, the resident was seated in a chair with oxygen in use and the nasal spray was visible on her bedside tray. The resident stated that staff normally kept the medication locked up and she did not know why it remained on her table. Review of the facility’s policies showed that medications and biologicals were to be stored safely and securely, accessible only to licensed nursing personnel, pharmacy personnel, or staff authorized to administer medications. The facility’s self-administration policy required an interdisciplinary assessment and specific conditions, including lockable bedside storage, before residents could keep medications at bedside; the policy also required staff to report any unauthorized bedside medications. Interviews with staff confirmed that the facility did not currently allow residents to self-administer medications and that residents were not supposed to have medications in their rooms. A CMA acknowledged that she had given the resident her nasal spray, left the room, and later realized she had left the medication in the resident’s room, stating she was responsible for returning it to the medication cart. Other CMAs, an LVN, the ADON, the DON, and the administrator all stated that medications should not be left in resident rooms, that no residents were authorized for self-administration at that time, and that the nurse or medication aide in charge of the medication cart was responsible for ensuring medications were properly stored. This sequence of actions and inactions led to the medication being left unsecured at the resident’s bedside in violation of facility policy and regulatory requirements.
Improper Handling and Storage of Trash and Soiled Linens Compromises Infection Control
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program related to the handling and storage of trash and soiled linens in one hall and two shower rooms. Surveyors observed dirty linens on the floor and a bag of trash in a clear bag behind the door in Shower #4. In Shower #2, dirty linens were also observed improperly stored. Staff interviews confirmed that dirty linens should not be on the floor and should be kept in designated linen barrels or bags, and that gloves should be worn when handling soiled linens. Surveyors further observed two bags of trash in clear bags placed on the floor in front of the shower room on Hall #2. A CNA was seen picking up these trash bags, placing them on top of a gray barrel, and rolling the barrel down the hall toward the outside. Multiple staff members, including CNAs, CMAs, housekeeping staff, the housekeeping supervisor, the ADON, DON, and the administrator, stated that trash should not be stored on the floor in hallways or behind shower doors, should be placed in yellow barrels, and should not be transported on top of gray barrels used for linens. They also stated that dirty linens should be bagged and placed in gray barrels or taken to the laundry, and that gloves should be worn when handling soiled linens. Record review of the facility’s infection control policy, "Fundamentals of Infection Control Precautions," indicated that hand hygiene is required after handling soiled linens and that gloving is used to prevent contamination when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. The policy also stated that soiled linen should be handled, transported, and laundered in a manner that avoids transfer of microorganisms, including double-bagging soiled linen at the site where it is generated and transporting it by cart with appropriate PPE. The observed practices of leaving trash and soiled linens on floors, using clear trash bags, placing trash on top of gray barrels, and handling dirty linens without gloves were inconsistent with the facility’s stated infection control policies and procedures.
Improper Trash/Linen Handling and Unrepaired Broken Toilet in Shower Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment on one resident hall and in two shower rooms. Surveyors observed dirty linens on the floor and a bag of trash in a clear bag behind the door in one shower room. Laundry staff stated that dirty linens should not be on the shower floor but in a linen barrel, and a housekeeper, who was not wearing gloves, picked up the dirty linens and placed them in the designated barrel, later acknowledging that gloves should have been worn when handling dirty linens. The ADON, a CNA, and other staff members consistently stated that dirty linens should be bagged and placed in gray barrels, trash should be placed in yellow barrels, and that linens and trash should not be stored on the floor. Surveyors also observed two bags of trash in clear bags on the floor in front of a shower room on one hall. A CNA was seen picking up the trash and placing it on a gray barrel to roll it down the hall. Multiple staff members, including a CMA, housekeeper, housekeeping supervisor, LVN, ADON, DON, and ADM, stated that trash should not be left on the floor in hallways or behind shower doors, should not be placed on top of gray linen barrels, and should instead be properly contained in yellow barrels and taken directly to the dumpster. One CNA admitted she was the person who placed the trash bags on the hallway floor and believed it was acceptable if the trash was bagged or combined with dirty linens for transport, which conflicted with the facility’s stated practices and staff expectations. In addition, surveyors observed that the toilet rim in one shower room was broken at the back, with exposed rigid porcelain edges. The broken toilet had been present for an extended period, as a housekeeper reported having submitted a maintenance request months earlier through a mobile QR application and stated that the toilet rim had been broken for a while. Nursing and administrative staff, including an LVN, ADON, DON, and ADM, reported they were not aware of the broken porcelain until it was brought to their attention during the survey. They each stated that any staff member who identified such damage would be responsible for reporting it immediately to maintenance or administration. The facility’s infection control policy required proper handling and transport of soiled linens with appropriate PPE and hygienic storage, and the resident rights policy required care in an environment that promotes quality of life, but the observed conditions in the hall and shower rooms did not align with these policies.
Call Lights Not Kept Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences by not keeping call lights within reach for 4 of 21 residents reviewed: Resident #16, Resident #24, Resident #37, and Resident #60. Each of these residents had care plans that included keeping the call light within reach and encouraging use of it for assistance as needed. The report identified these residents as having significant cognitive impairment and needing varying levels of assistance with activities of daily living and toileting, with several also being incontinent and at risk for falls. Resident #16 was a female with diagnoses including severe dementia with psychotic disturbances, severe protein-calorie malnutrition, depression, and right knee osteoarthritis. Her MDS reflected severe impaired cognition, dependence for toileting, partial or moderate assistance with all ADLs, and bowel and bladder incontinence. Resident #24 was a male with diagnoses including cerebral ischemia, dysphagia, extrapyramidal movement disorder, convulsions, and vascular dementia; his MDS reflected severe impaired cognition, substantial or maximal assistance with toileting, partial or moderate assistance with ADLs, and bladder and bowel incontinence. Resident #37 was a male with dementia, malignant neoplasm of the head, face and neck, and major depressive disorder; his MDS reflected severe impaired cognition, independence with ADLs, and occasional incontinence. Resident #60 was a female with dementia, COPD, and overactive bladder; her MDS reflected severe impaired cognition, set-up or clean-up assistance with ADLs, and occasional incontinence. During observations, Resident #37's call light was found on the side of the nightstand on the floor and later not within reach; Resident #16's call light was tucked behind the nightstand on the opposite side of the bed and she stated she could not reach it; Resident #60's call light was observed under the bed and later not within reach; and Resident #24's call light was on the floor on the opposite side of the nightstand and later not within reach. Staff interviews confirmed that call lights should be accessible, that all staff were responsible for ensuring accessibility, and that the call lights on the secured unit were not accessible for residents. The DON, ADON, LVN, CNA, and Administrator all acknowledged that accessible call lights were necessary for residents to contact staff for help.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional. Record review of the Activity Director’s personnel file did not show an Activity Director certification or documentation that the individual had 2 years of experience in a social or recreational program. During interview, the Activity Director said she had been in the position for about two months, was not certified, and had not completed the required activity director classes. She also stated she had not completed any activity assessments and had only learned that morning that she was responsible for doing them. The Activity Director said she was still learning and was not aware of the frequency for completing activity assessments. She stated that another person from a sister facility was supposed to train her, but that person had a stroke and did not come. A Certified Occupational Therapist Assistant said she was a certified activity director but had only volunteered to call bingo and knew nothing about assessment requirements or documenting activities. The Administrator said he expected activity assessments to be completed quarterly and acknowledged that the Activity Director had been hired without certification. The facility policy stated that the Activity Director determines the need for individual programming through the resident assessment process and that the Activity Director and staff assess residents’ ability or interest at least quarterly, but the policy did not list required qualifications for the Activity Director.
Unlicensed LVN Worked as Charge Nurse After License Suspension
Penalty
Summary
The facility failed to ensure that LVN A was licensed, certified, or registered in accordance with state law while she continued to work as a charge nurse and floor nurse. Record review showed the facility initially verified LVN A’s unencumbered license before hire, and her employee file included a charge nurse job description requiring an RN or LVN in good standing. The file also contained a handwritten notice from LVN A stating she was turning in her notice and would continue working until the end of December, with the option of another position in the facility. Record review of the Texas Board of Nursing license lookup showed LVN A’s license was expired and later listed as under enforced suspension. The report also included a Board of Nursing order stating her vocational nurse license was suspended, with the suspension enforced effective a specified date. Facility time punch records showed LVN A worked multiple shifts after the suspension date, and daily staffing sheets identified her as the Charge Nurse for the 6 AM to 6 PM shift on Halls C and D on several dates. Daily census records showed the unit census during those shifts ranged from 65 to 66 residents. During interviews, the DON stated LVN A told her she would need to put in her notice because of issues with the BON and that the DON did not check LVN A’s license when she turned in her notice. The DON said corporate HR later informed her that LVN A’s license was not good and she was then removed from the schedule. LVN A stated she believed she could work out a two-week notice based on her communication with the BON representative, but she also acknowledged she knew she could not work as a nurse once her license was suspended. The ADM stated the facility expected LVN A to communicate the status of her license and said the facility used job descriptions as requirements for the position.
Failure to Log and Resolve Resident Grievance About Noisy Roommate
Penalty
Summary
The facility failed to promptly resolve a grievance for Resident #12, a cognitively intact male with multiple sclerosis, hypertension, and chronic pain who required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, transfers, and bathing. Resident #12 reported to the DON that his roommate was loud, hollering, moaning, and groaning throughout the day and night, and that he could not sleep. He stated he had spoken with the DON during the Christmas holidays about wanting a new roommate, but no follow-up had occurred by the time of the surveyor interview. During observations, the roommate was heard hollering, talking randomly, and moaning loudly while lying in bed, and Resident #12 stated he was using his television at a very loud volume to drown out the noise. He again asked for an update and said he had become more frustrated from lack of rest, but still had not heard of any plan or resolution. Review of the grievance log did not show any grievance filed by Resident #12. The DON stated she was aware of the complaint, believed she had made notes and given them to the Social Worker, but could not locate the documentation, and the Administrator stated he was not aware of the grievance until the surveyor interview.
Missed Shower and Incomplete Grooming Care
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received the assistance needed for grooming and personal hygiene. For one resident with diagnoses including atherosclerotic heart disease, prostate cancer, cardiomegaly, hypertension, and back pain, the quarterly MDS showed a BIMS score of 11 and need for supervision and partial assistance with all ADLs. The care plan identified a need for limited assistance with showering, and the resident was observed waiting for the aide on his shower day with a shower bag ready. The resident later stated he did not receive the shower and that the aide never returned to get him, despite his reminders throughout the day. Record review showed a completed bath documented for that resident on the same day, but the student nursing aide later stated she had documented the shower even though she had not completed it. She said she had been assigned to the resident, but the shower was not done because she was pulled to another hall. She acknowledged she needed re-education to document only tasks she personally completed. The resident stated the missed shower was upsetting and said assistance with scheduled showers was important to decrease the chances of infection. A second resident with diagnoses including Alzheimer's disease, chronic atrial fibrillation, subdural hemorrhage, hypertension, and repeated falls had a BIMS score of 05 and required substantial and partial assistance for all ADLs. The care plan identified a need for assistance with personal hygiene, including hair, shaving, and oral care. The resident's family member stated she shaved him on shower days and that if she did not do it, he would not be shaved. During interview, a CNA said she gave the resident a shower but did not shave him because she assumed the family wanted to do that task and had not asked about it. The DON and Administrator stated showers and personal hygiene were expected to be provided according to the plan of care, and the DON said staff were responsible for ensuring residents were bathed and showered appropriately.
Failure to Complete Activity Assessments and Provide Scheduled In-Room Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet residents’ interests and physical, mental, and psychosocial well-being for 2 of 6 residents reviewed for activities. One resident, a male with diagnoses including atherosclerotic heart disease, malignant neoplasm of the prostate, cardiomegaly, hypertension, and back pain, had a quarterly MDS showing a BIMS score of 11 and a care plan calling for out-of-room social, spiritual, and stimulus activities, mental stimulation, TV, reading, and socialization. His electronic record showed the last activity assessment was completed on 08/18/2025, and he stated during interview that he did not get out of his room for facility-related activities and enjoyed in-room Bible conversations. Another resident, a female with Alzheimer’s disease, severe protein-calorie malnutrition, and osteomyelitis, had a quarterly MDS showing a BIMS score of 0 and a care plan calling for in-room socialization and sensory stimulation, including one-on-one in-room visits at least 3 times per week. Observations on 01/06/2026 showed her lying in bed resting at 08:30 AM, 02:10 PM, and 05:45 PM. The record review and interviews showed the Activity Director had not completed activity assessments, had not documented attendance or refusals in the computer charting system or on a log, and was not aware she was supposed to document who attended activities or when one-on-one activities were provided. During interviews, the Activity Director stated she had been in the position for approximately two months, had not done any activity assessments, and had just learned she was responsible for completing them. She also stated she was not aware of the frequency for completing activity assessments and had not been trained as expected. The Administrator stated he expected activity assessments to be done quarterly and that the Activity Director was responsible for completing them. The facility policy titled Activity Programming stated the Activity Director determines the need for individual programming through the resident assessment process and that the Activity Director and staff regularly assess residents’ ability or interest at least quarterly.
Unlocked Medication Cart Left Accessible
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments for 1 of 4 medication carts reviewed. During an observation on 1/06/26 at 7:56 A.M., the nurse medication cart for the B Hall was found unlocked and sitting across the hall from room [ROOM NUMBER]. The cart door was open while the resident in that room was lying in bed, and another resident was standing at the cart leaning on a walker. No staff were present at the cart. The top drawer contained eye drops, lancets, alcohol pads, 3 insulin pens, and a glucometer. The second drawer contained liquid G-tube medications, 34 cards of various medications including Metoprolol, Metformin, Lisinopril, Keppra, and Digoxin, along with Geri-Lanta, MiraLAX, Tums, Ready Care, 1 bottle of Liquid Protein, and 1 bottle of Lactulose. Drawer 3 contained topical medications, and Drawer 4 contained oxygen tubing and plastic cups. During interviews, LVN D stated the cart was supposed to be in her possession and locked, but she had been called away by an aide. RN J, the ADON, the DON, and the Administrator all stated medication carts were supposed to be locked when staff walked away from them, and the facility policy stated medications and biologicals are to be stored securely and that medication rooms, carts, and supplies are locked or attended by authorized staff.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident who was on Enhanced Barrier Precautions (EBP). Resident #22 was admitted with diagnoses including Alzheimer’s disease and gastrostomy/PEG tube, was severely cognitively impaired, dependent on staff for most ADLs, always incontinent of bowel and bladder, and had a feeding tube. His care plan and order summary indicated he was on EBP with instructions for staff to don gloves and a gown for transfer, toileting/incontinent care, enteral feeding care, and other high-contact activities. During an observation, LVN D entered the resident’s room, put on gloves, and disconnected the feeding tube from the PEG tube without wearing a gown. Later, CNA C and SNA B performed a mechanical lift transfer from chair to bed, repositioned the resident, and provided incontinent care without wearing gowns. The observation described both staff leaning over the resident and his bed, contacting bedding and the resident’s body while handling the lift straps, brief, wipes, heel protectors, pillows, and repositioning tasks. A red sign and PPE cart outside the room indicated the resident was on EBP and that staff were required to wear a gown and gloves while providing direct care. A second observation showed LVN D reconnected the feeding tube to the PEG tube without wearing a gown or gloves. Interviews with SNA B, CNA C, RN E, LVN D, RN F, the DON, and the ADM confirmed that EBP required gown and glove use for direct care, including mechanical lift transfers, incontinent care, and feeding tube/PEG tube care. Staff stated they did not wear the required PPE during the observed care, and the facility policy stated gowns were worn to reduce the opportunity for transmission of microorganisms and that EBP included gown and glove use during high-contact resident care activities such as transfer, toileting, turn and reposition, bed mobility, and feeding tube care.
Call Light Not Functioning for Resident Needing Extensive Assistance
Penalty
Summary
The facility failed to ensure that Resident #12’s call light was functioning properly. Resident #12 was a male admitted with diagnoses including multiple sclerosis, hypertension, and chronic pain. The quarterly MDS indicated he was understood by others, able to understand others, had a BIMS score of 15, and required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, transfer, and bathing. His care plan identified multiple sclerosis as a chronic condition and included interventions related to discussing concerns and encouraging rest periods. During an observation and interview, Resident #12 stated he had pressed the call light about 15 minutes earlier and no one had come to answer it. When the surveyor asked him to press it again, the hallway light did not come on. A student nursing aide entered the room and attempted to turn on the call light without success and stated she was not aware it was not working. She said she thought the call light had been checked when the resident was relocated into the room the night before. The DON and Administrator stated that call lights should be accessible and working properly, that staff were responsible for ensuring they were in working condition, and that there was no policy to address the call light system.
Widespread Abuse, Neglect, and Inadequate Supervision Identified
Penalty
Summary
The facility failed to protect multiple residents from abuse, neglect, and inadequate care, as evidenced by several documented incidents. One incident involved a nurse physically abusing a resident with Huntington's disease and severe cognitive impairment by lifting her from a wheelchair and throwing her onto a mattress on the floor, resulting in visible bruising and redness. Another incident involved a nurse verbally abusing a resident by yelling, cursing, and refusing pain medication, as corroborated by the resident, her family member, and other staff who witnessed the nurse's erratic and inappropriate behavior. Additionally, the facility did not prevent resident-to-resident physical abuse, as one resident with dementia and behavioral issues shoved another resident on two occasions, resulting in scratches and a fall. The care plans for these residents did not adequately address behavioral risks, and supervision was insufficient to prevent these altercations. The facility also failed to ensure proper positioning during tube feeding for a resident with severe cognitive and physical impairments, leading to aspiration pneumonia and hospitalization. Video evidence showed the resident left in an unsafe position for an extended period, with minimal staff intervention. Further deficiencies included inadequate staffing to provide necessary wound care, feeding assistance, and supervision during meals and on the secured unit. Multiple residents did not receive timely or appropriate care for pressure ulcers, feeding, and fall prevention. Staff interviews revealed ongoing concerns about insufficient staffing, lack of support from management, and inadequate training, which contributed to the inability to meet residents' needs and prevent harm.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for multiple residents, resulting in both resident-to-resident altercations and unwitnessed falls. On two separate occasions, one resident physically pushed another, resulting in scratches and a fall, with both incidents occurring without staff witnessing the events. The care plan for the resident exhibiting physical behaviors did not address these behaviors, and the secured unit was inadequately supervised, as only one staff member was often present to oversee all residents. Staff interviews confirmed that the staffing was insufficient to provide proper supervision, with staff unable to monitor all residents while performing other care duties. Several residents experienced unwitnessed falls, some resulting in significant injuries such as fractures, lacerations, and emergency room visits. These incidents occurred in various locations, including hallways, dining rooms, and other residents' rooms, and were not observed by staff at the time. Care plans for some residents did not address fall risks, and interventions such as fall mats and supervision were inconsistently implemented or not effective due to lack of staff presence. Staff reported being overwhelmed and unable to complete all assigned tasks, including supervision and documentation, due to being the only staff member on the secured unit. Observations and interviews revealed that residents were frequently left unsupervised in common areas, including the dining room and hallways, sometimes for extended periods. Staff, including nurses and CNAs, reported that the nurse assigned to the secured unit often had to cover other areas, leaving only one person to supervise multiple residents with high care needs. The Director of Nursing and other staff acknowledged ongoing staffing shortages and the inability to provide adequate supervision, which contributed to the pattern of unwitnessed incidents and altercations among residents.
Failure to Provide Sufficient Nursing Staff and Care Interventions
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of its residents, as determined by resident assessments and individual care plans. This deficiency was observed through multiple incidents, including inadequate assistance with positioning during tube feeding, insufficient staff to provide wound care and documentation, and lack of adequate supervision and staffing on the secured unit, particularly during mealtimes. These failures were identified for a significant number of residents, with specific examples including a resident who was left leaning over the armrest of a Geri-chair for approximately 1 hour and 30 minutes during tube feeding, resulting in aspiration pneumonia, and several residents who did not receive required wound care treatments or documentation on multiple occasions. Resident records revealed that individuals with complex medical needs, such as those with Alzheimer's disease, severe malnutrition, pressure ulcers, and significant cognitive and physical impairments, were not consistently provided with the necessary care and supervision. For example, one resident with a gastrostomy tube and severe ADL dependency was not properly positioned during tube feeding, leading to a hospital transfer for aspiration. Other residents with stage 3 and stage 4 pressure ulcers had multiple days where wound care treatments were not documented as administered, despite physician orders and care plan interventions requiring daily or scheduled treatments. Additionally, the facility did not ensure that the secured unit was adequately staffed to prevent accidents and provide supervision during critical times such as mealtimes. The lack of sufficient staff led to missed care interventions, incomplete documentation, and increased risk for resident safety. The survey identified an Immediate Jeopardy situation due to these failures, which was later removed, but the facility remained out of compliance due to ongoing gaps in staff education and policy adherence.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status, specifically when the resident experienced multiple episodes of low blood pressure, low heart rate, and low blood pressure with increased heart rate over several days. Despite repeated abnormal vital signs and the holding of blood pressure medications due to these readings, there was no documented evidence that the physician was consistently notified as required by facility policy. The resident's care plan and medication orders clearly indicated the need for monitoring and reporting such changes, but this was not followed. The resident involved had a complex medical history, including dementia, gastrointestinal hemorrhage, iron deficiency anemia secondary to blood loss, hypertension, and acute embolism and thrombosis of deep veins. The resident was on anticoagulant and antihypertensive therapies, with specific parameters for holding medications based on vital signs. Over a period of several days, the resident's vital signs were repeatedly outside of these parameters, and medications were held accordingly. However, the process for escalating these findings to the physician was inconsistent, with staff interviews revealing confusion about notification responsibilities and a lack of documentation of physician contact in the clinical record. On one occasion, the resident was found to have critically low hemoglobin and hematocrit levels and was subsequently sent to the emergency room, where a gastrointestinal hemorrhage was diagnosed and a blood transfusion was administered. Interviews with staff and review of records indicated that the physician was not adequately informed of the ongoing abnormal vital signs and medication holds prior to this acute event. The facility's own policies required immediate physician notification for significant changes in status and for any held doses of regularly scheduled medication, but these procedures were not followed, leading to a deficiency finding by surveyors.
Failure to Ensure Proper Positioning During Enteral Feeding Leads to Aspiration
Penalty
Summary
A facility failed to ensure that a resident receiving enteral nutrition was provided with appropriate treatment and services to prevent complications associated with tube feeding. The resident, an elderly male with Alzheimer's disease, severe protein-calorie malnutrition, gastrostomy status, anorexia, and dysphagia, was dependent on staff for all activities of daily living and had significant cognitive and physical impairments. According to the care plan and physician orders, the resident required the head of the bed to be elevated to at least 30 degrees during and after tube feedings to prevent aspiration. On the day of the incident, the resident was observed via video leaning over the left armrest of his Geri-chair for approximately 1 hour and 30 minutes during a tube feeding. Despite a CNA briefly attempting to reposition him, the resident quickly returned to the slumped position and remained there, moaning and grunting, until a nurse later intervened and repositioned him with pillows. The CNA did not check on the resident again due to being the only staff member assigned to the hallway and feeling overwhelmed by staffing shortages. The nurse who later found the resident did not receive any report from the CNA about the improper positioning. Following the incident, the resident's family member, after reviewing the video footage, requested a chest x-ray due to concerns about possible aspiration. The resident was subsequently transferred to the hospital, where aspiration into the airway was confirmed. Interviews with staff revealed that both the CNA and the nurse recognized that improper positioning during tube feeding could result in aspiration, and both cited staffing concerns as a contributing factor to the failure to provide adequate care and monitoring.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents who required such services, resulting in missed and delayed administration of scheduled pain medications, lack of pain assessments, and failure to offer alternative or non-pharmacological interventions as ordered. One resident, a female with diagnoses including fibromyalgia, chronic pain, and intact cognition, did not receive her scheduled doses of Oxycodone and Gabapentin on multiple occasions. Documentation showed that her pain assessments were not completed as required, and when doses were missed, the physician was not notified. Additionally, alternative PRN pain medications and non-pharmacological interventions, such as Tylenol and hot packs, were not offered per facility policy. The resident reported increased pain and agitation due to these lapses, and staff interviews confirmed confusion and lack of follow-through regarding medication administration and pain management responsibilities. Another resident, a male with severe cognitive impairment, dementia, and chronic pain, did not receive consistent pain assessments or PRN pain medications despite displaying nonverbal signs of pain such as grimacing, moaning, and pushing staff away during care. Although he was prescribed scheduled and PRN opioid medications, records indicated that PRN medications were not administered when he exhibited clear signs of discomfort during ADL care and wound treatments. Staff interviews revealed that pain assessments were not consistently documented, and PRN medications were not given prior to care activities known to cause pain, despite orders and care plan interventions specifying the need for such measures. The facility's failure to follow its own pain management policy, including timely administration of medications, documentation of pain assessments, and offering of alternative interventions, led to residents experiencing unmanaged pain and distress. Staff interviews and documentation review highlighted lapses in communication, inadequate handoff between shifts, and lack of adherence to professional standards of practice and individualized care plans. These deficiencies were identified by surveyors and resulted in an Immediate Jeopardy situation, though the report does not detail the corrective actions taken after the incident.
Failure to Implement and Maintain Infection Control Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program during a COVID-19 outbreak, as evidenced by multiple observations, interviews, and record reviews. Staff did not consistently follow infection control protocols, including the use of appropriate personal protective equipment (PPE) such as N-95 masks, face shields, or goggles when entering rooms of residents with confirmed COVID-19. PPE isolation carts were found to be missing required items, and staff were observed entering and exiting COVID-19 positive rooms without changing masks or performing hand hygiene due to lack of access to hand sanitizer. Additionally, signage indicating airborne isolation precautions was missing from the doors of several residents on isolation, and there was no signage at the facility entrance to alert staff and visitors to the outbreak status. Several residents with confirmed or suspected COVID-19, including those with severe cognitive impairment and complex medical histories, were not properly isolated or monitored according to facility protocols. For example, residents with active COVID-19 infections did not have appropriate isolation signage outside their rooms, and staff were observed providing care without the required PPE. In some cases, staff continued to wear the same masks after leaving COVID-19 positive rooms and provided care to other residents without changing masks or performing hand hygiene. Staff also reported not having access to necessary PPE, such as face shields or goggles, and hand sanitizer dispensers had been removed from the walls, further impeding proper infection control practices. The facility's leadership, including the Administrator, DON, and ADON, demonstrated a lack of awareness and oversight regarding the infection control protocols and the status of PPE and signage. Interviews revealed that the ADON was new and had not fully assumed responsibility for the infection control program, while the DON and Administrator were unaware of the deficiencies in PPE availability and signage. Additionally, residents who developed new signs and symptoms of COVID-19 were not promptly tested, contrary to facility policy. These failures were directly observed and confirmed through staff interviews, highlighting significant lapses in the facility's infection prevention and control measures during the outbreak.
Failure to Treat Resident with Dignity and Respect During Medication Dispute
Penalty
Summary
A deficiency occurred when a nurse failed to treat a resident with respect and dignity during an interaction regarding missed pain medications. The resident, who had diagnoses including fibromyalgia, low back pain, major depressive disorder, and anxiety, was cognitively intact and able to communicate her needs. On the day in question, the resident did not receive her scheduled pain medications at the expected time and reported being in pain. She made multiple calls to the front desk requesting her medications, but the nurse did not arrive until several hours later. When the nurse finally entered the resident's room, both the resident and the nurse raised their voices during the exchange. The resident reported that the nurse was condescending, clapped her hands at her, and acted in a superior manner. A CNA who witnessed the incident stated that the nurse spoke forcefully and with an attitude, describing the interaction as disrespectful and not conducive to resolving the situation. The CNA also noted that the nurse's tone was inappropriate and that she had never seen the resident so upset before. Interviews with facility leadership confirmed that staff are expected to communicate with residents in a polite and dignified manner. The DON and administrator acknowledged that speaking to a resident in a disrespectful way constitutes a violation of resident rights and dignity. The facility's policy also states that residents have the right to a dignified existence and must be treated with respect at all times.
Failure to Prevent Misappropriation of Resident's Controlled Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of property, specifically regarding the administration and documentation of the resident's prescribed Oxycodone. The resident, who had diagnoses including fibromyalgia and low back pain, was on a scheduled opioid regimen and was cognitively intact, independently managing aspects of her care and regularly counting her medications. On the date in question, records showed that six doses of Oxycodone were documented as administered, despite only five being scheduled. Discrepancies were noted between the individual control drug record and the electronic medication administration record (eMAR), with the control record reflecting an extra administration that was not corroborated by the eMAR or the resident's own account. Multiple staff members, including medication aides and nurses, identified and reported the irregularity in the narcotic count and documentation. The nurse responsible for the extra entry could not provide a clear explanation, alternately stating she may have given an extra dose or simply documented the wrong time. The resident denied receiving an extra dose and consistently counted her pills before taking them. The incident was reported up the chain of command, and interviews with staff indicated concerns about the nurse's behavior and the possibility of drug diversion, though the nurse was not immediately suspended for this incident. The facility's own policies defined misappropriation of resident property as the wrongful use of a resident's belongings, including medications. The documentation and interviews confirmed that a dose of the resident's Oxycodone was unaccounted for and could not be reconciled through resident or staff accounts, nor through medication records. The failure to ensure accurate administration and documentation of controlled substances resulted in the misappropriation of the resident's medication.
Failure to Investigate Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and misappropriation of property were thoroughly investigated and that residents were protected from further potential harm. In one instance, a nurse was reported to have documented an extra administration of a resident's oxycodone, raising concerns of possible drug diversion. Despite the resident denying receipt of an extra dose and staff reporting the incident to facility leadership, there was no evidence of a comprehensive investigation into the alleged misappropriation. The nurse in question continued to work with the resident after the incident until being suspended several days later, and there was no documentation of a thorough inquiry or protective measures taken immediately following the allegation. Another resident experienced an alleged incident of neglect when the same nurse failed to administer requested pain medication. The resident and her family reported that the nurse refused to provide the medication, acted in a verbally aggressive manner, and displayed erratic behavior. Documentation revealed that the pain medication was not signed out as administered, and there was no evidence that a pain assessment was completed or that the medication administration record was reviewed to verify the omission. The investigation into this incident was incomplete, lacking attempts to determine the reason for the alleged omission or to fully assess the resident's condition at the time. Interviews with facility staff, including the DON and Administrator, revealed confusion and lack of clarity regarding responsibility for conducting thorough investigations into these allegations. The facility's own policy required comprehensive investigations of all abuse, neglect, and misappropriation allegations, but this was not followed in these cases. The lack of thorough investigation and immediate protective actions left residents at risk for continued abuse, neglect, and misappropriation.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents, and that supervision measures were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Allow Use of Motorized Wheelchair for Resident with Mobility Needs
Penalty
Summary
The facility failed to ensure that a resident was allowed to use his personal motorized wheelchair during his stay, despite his prior use of such a device and his medical need for independent mobility. The resident, who had spastic quadriplegic cerebral palsy and chronic kidney disease, was admitted to the facility and had a BIMS score indicating intact cognition. Upon admission, he informed staff that his motorized wheelchair would be arriving, but the facility did not permit him to use it, instead providing a manual wheelchair that he was unable to propel independently due to his physical limitations. Interviews with facility staff revealed that there was a longstanding practice of not allowing motorized wheelchairs, originating from a previous administrator's decision after an incident involving another resident. However, current staff, including the ADON and the Administrator, indicated that the expectation was to allow motorized wheelchairs if the resident was assessed by therapy and found to be safe. Despite this, the resident was not given the opportunity for such an assessment and was denied the use of his motorized wheelchair throughout his stay. Facility policy stated that residents have the right to retain and use personal possessions, including motorized wheelchairs, unless doing so would endanger the health or safety of others. The policy also required an assessment for safe use of electric wheelchairs. In this case, the facility did not follow its own policy or provide reasonable accommodation for the resident's needs and preferences, resulting in the resident's loss of independence and reliance on staff for mobility.
Improper Storage of Oxygen Cylinder in Resident Room
Penalty
Summary
A deficiency was identified when an oxygen cylinder was found stored upright on the floor in a resident's room, rather than in a caddy or secured storage area as required by facility policy. The resident, a male with diagnoses including pleural effusion, heart failure, and end stage renal disease, was observed lying in bed while the unsecured oxygen tank remained on the floor. The resident was unsure how long the tank had been present in this manner. Multiple observations confirmed the tank's improper storage, and staff interviews revealed that the tank should have been stored in a caddy or secure area to prevent it from being knocked over. Staff members, including an LVN, the Maintenance Supervisor, the ADON, and the Administrator, all acknowledged during interviews that oxygen tanks should not be left free-standing and must be properly secured to prevent accidents. The facility's policy on the safe handling of compressed gases specifically states that tanks must be stored in a cylinder cart or securely chained in a storage area, and never left free-standing. The failure to follow this policy resulted in the cited deficiency.
Non-Functional Call Light Leaves Dependent Resident Unable to Summon Assistance
Penalty
Summary
A deficiency was identified when a resident's call light was found to be non-functional, preventing the resident from being able to summon staff assistance. The issue was discovered during an observation and interview, where the resident requested help and the call light did not activate when pressed. The resident's roommate confirmed that the call light had not been working for approximately two weeks, and she had been using her own call light to request help on behalf of the affected resident. Staff members, including a CNA, verified that the call light was not working and acknowledged the risk to the resident, noting that maintenance had not been notified of the issue prior to the surveyor's discovery. The resident affected by the deficiency had significant medical needs, including diagnoses of dementia, heart failure, and major depressive disorder. She was severely cognitively impaired, completely dependent on staff for all activities of daily living, and always incontinent of bowel and bladder. Her care plan required that adaptive equipment, such as a functional call light, be provided and maintained. Despite these needs, the call light remained non-functional for an extended period, and there was no documentation or maintenance request indicating that the issue had been previously reported or addressed. Interviews with facility staff, including the Maintenance Supervisor, ADON, and Administrator, revealed that routine checks of call lights were conducted, but the specific non-functioning call light in the resident's room had not been identified or reported through the facility's maintenance request system. The facility's records showed that the call lights in the affected room were only checked on the day of the survey, with no prior checks documented for the preceding period.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who resided on a secured unit. The resident, who had a history of wandering and severe cognitive impairment, was able to leave the facility unsupervised. The resident was found at a local hospital emergency room after being taken there by local police. The facility was unaware of the resident's absence for approximately four hours until staff went to retrieve him for his evening meal. The resident had a care plan indicating a risk for wandering and elopement, requiring a secured unit and close supervision. Despite these measures, the resident managed to elope from a window in an empty room on the secure unit. The resident had previously demonstrated behaviors such as pacing, rummaging through other residents' belongings, and attempting to leave the facility. Staff had noted these behaviors in progress notes, but the interventions in place were insufficient to prevent the elopement. Interviews with staff revealed that the resident had been seen after lunch but was not accounted for until supper time. The resident had used a toilet tank lid to break a window and exit the facility. Staff were not aware of the resident's ability to disable window alarms and remove thumb locks, which contributed to the elopement. The facility's lack of a specific policy on making rounds and the failure to monitor the resident closely enough allowed the incident to occur.
Resident Restraint Violation in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which is a violation of resident rights. A certified nursing assistant (CNA) admitted to restraining a resident on multiple occasions, including swaddling the resident with a blanket and tying the resident's legs to the bed with leggings. This restraint was applied from early morning until later that morning, during which time the resident was unable to move freely. The resident involved had a complex medical history, including Huntington's Disease, schizoaffective disorder, and anxiety disorder, which contributed to her involuntary movements and agitation. The resident was known to have a history of falls and required supervision for all activities of daily living. Despite these needs, the CNA took it upon herself to restrain the resident without proper authorization or medical necessity, citing concerns for the resident's safety as justification. The incident was discovered when another CNA attempted to assist the resident and found her tied to the bed. The facility's administration was notified, and an investigation was initiated. Interviews with staff revealed that the CNA responsible for the restraint had previously received training on abuse, neglect, and the facility's restraint-free policy, yet chose to disregard these protocols. The facility's failure to prevent this incident placed the resident at risk of harm and demonstrated a lack of adherence to established resident rights and safety procedures.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by two separate incidents involving residents. In the first incident, a resident with severe cognitive impairment and a history of wandering was found with an unattended spray bottle of cleaner in the dining room. The resident had the nozzle in one hand and the bottle in the other, and there was a lemon scent detected on her breath, suggesting possible ingestion. The cleaner was not an approved facility product and was left unattended by a staff member, contrary to facility policy requiring chemicals to be stored in a locked area. In the second incident, a resident who required dialysis and used a wheelchair was not properly secured during transportation in the facility's van. The resident's wheelchair was not adequately strapped, leading to the wheelchair tipping backward during transit, resulting in two abrasions to the resident's scalp. The transport CNA responsible for securing the resident had not been trained on how to properly secure and transport residents, which contributed to the incident. The CNA moved the resident after the fall without conducting a proper assessment, which was against protocol. Both incidents highlight significant lapses in supervision and adherence to safety protocols, placing residents at risk of harm. The facility's failure to ensure proper training and adherence to safety procedures for handling chemicals and securing residents during transport were key factors leading to these deficiencies.
Failure in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications underwent gradual dose reductions and behavioral interventions, as required by regulations. Specifically, the facility did not adequately assess the necessity of these medications for treating specific conditions, nor did it limit PRN orders for psychotropic drugs to 14 days without proper documentation from the prescribing practitioner. This deficiency was observed in four residents, including a resident who experienced lethargy, increased falls, incontinence, unusual behavioral symptoms, and weight loss due to the side effects of Lorazepam and Risperidone. The facility did not notify the physician of a significant weight loss in one resident, nor did it accurately report the resident's behaviors to the physician, leading to inappropriate medication adjustments. The resident was reported to be aggressive, which was not consistent with the observed behaviors of wandering. Additionally, the facility failed to ensure that the resident had appropriate diagnoses for the use of Trazodone and Lorazepam, contributing to the misuse of these medications. Furthermore, the facility did not limit the use of PRN Lorazepam for other residents to 14 days, nor did it provide the necessary rationale for extended use. This lack of monitoring and evaluation of psychotropic medication use placed residents at risk for adverse side effects and decreased quality of life. The facility's failure to implement proper medication management and monitoring protocols resulted in potential harm to the residents.
Inaccurate PASRR Screenings for Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessments for four residents, which resulted in the omission of mental illness diagnoses. Resident #49, who was re-admitted with a diagnosis of Post Traumatic Stress Disorder (PTSD), had a PASRR Level I screening that incorrectly indicated no mental illness. Similarly, Resident #15, admitted with schizoaffective disorder and major depressive disorder, also had a PASRR Level I screening that failed to reflect these mental health conditions. Resident #52, who was readmitted with a diagnosis of major depressive disorder, had a PASRR Level I screening that did not acknowledge her mental illness. Additionally, Resident #16, who had a history of major depressive disorder and was readmitted with a diagnosis of depression, had a PASRR Level I screening that inaccurately marked no mental illness. These inaccuracies in the PASRR screenings could potentially prevent residents from receiving necessary assessments, individualized care, or specialized services. Interviews with facility staff, including MDS nurses and social workers, revealed a lack of awareness and understanding regarding the need to update PASRR screenings when residents are admitted or re-admitted with mental health diagnoses. The facility's policy requires that PASRR evaluations be completed within specific timeframes and that any positive findings be communicated to the interdisciplinary team. However, the failure to accurately complete these screenings suggests a breakdown in the facility's processes for ensuring compliance with PASRR requirements.
Lack of Meaningful Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs of residents in the memory care unit, as observed during a survey conducted from September 30 to October 1, 2024. Observations revealed that the dining and sitting areas, as well as the hallways, lacked dementia-focused activities, with a television playing in the background that did not engage the residents. The activity schedule for October 2024 listed various activities, but these were not observed being implemented in the memory care unit. Interviews with staff, including CNAs and an LVN, indicated that the activity director was responsible for conducting activities but was not consistently present in the memory care unit. Staff reported that the activity director visited the unit infrequently, primarily to deliver snacks, and that the aides were left to occupy the residents. The staff expressed uncertainty about the specific interests of some residents and suggested that the lack of activities might contribute to falls and incidents among the residents. The Director of Nursing and the Administrator acknowledged the importance of activities for dementia residents and noted that the activity director had been absent due to personal reasons. The Administrator mentioned that there was an activity closet available for use by the aides, but it was not being utilized effectively. The absence of a specific activity calendar for the memory care unit and the lack of meaningful activities were identified as contributing factors to the deficiency.
Inadequate Hydration for Residents
Penalty
Summary
The facility failed to ensure adequate hydration for three residents, leading to potential health risks. Resident #36, a male with multiple sclerosis, depression, and hypertension, reported having a dry mouth due to insufficient fluid intake. His care plan indicated a potential for nutritional problems, yet during an observation, it was noted that his water was from the previous evening, and he expressed a preference for ice in his water. Resident #42, a male with cerebral infarction, peripheral vascular disease, diabetes, depression, and vascular dementia, also experienced inadequate hydration. Despite being able to communicate, he had to request ice and water, and his cup was observed to be out of reach and without ice on multiple occasions. His quarterly MDS assessment indicated severe cognitive impairment, which may have contributed to his inability to ensure his hydration needs were met independently. Resident #61, diagnosed with Alzheimer's disease, atrial fibrillation, subdural hemorrhage, diabetes, and depression, was similarly affected. His care plan included interventions to encourage fluid intake and ensure fluids were within reach. However, observations revealed that his cup was often empty or out of reach, and his lab results showed elevated BUN levels, suggesting possible dehydration. Interviews with staff highlighted inconsistencies in the facility's hydration practices, with some staff expressing dissatisfaction with the current system and acknowledging the potential health risks of inadequate fluid intake.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of several residents, resulting in missed medication doses and improper medication administration. Specifically, Resident #18 did not receive Niacin, Ativan, and Nicotine Patch on multiple occasions due to unavailability. The records indicated that the medications were either on order or awaiting delivery, and the emergency kit did not have the necessary doses. This lack of availability was acknowledged by the medication aides and nurses, who reported the issues to the nursing staff. Resident #23's Aspirin EC, which was not supposed to be crushed, was administered in a crushed form, potentially altering its effectiveness. The medication aide responsible for administering the medication was unaware of the order's instruction not to crush the medication. This oversight was observed during a medication pass, where the medication was given with a custard substance. Resident #34 and Resident #68 also experienced issues with medication availability. Resident #34's Lorazepam was not available for several days, and the emergency kit was empty. Similarly, Resident #68's Lomotil was not delivered in a timely manner, resulting in missed doses. Interviews with staff revealed that there were communication issues with the pharmacy regarding medication delivery, and the facility's emergency kit was not adequately stocked to address these shortages.
High Medication Error Rate in Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 61.76% involving four residents. The errors included late administration of medications, incorrect infusion rates, and failure to administer prescribed medications. These errors were observed during medication administration for residents with complex medical conditions, including Alzheimer's disease, anxiety, depression, epilepsy, and chronic pain. One resident received multiple medications, including Buspirone, Lorazepam, and Tramadol, significantly later than the prescribed time. Another resident's medications, such as Divalproex and Sertraline, were also administered outside the facility's liberalized policy time. Additionally, a resident's IV antibiotic was administered at an incorrect rate, potentially leading to adverse effects. These discrepancies were attributed to staff being behind schedule and a lack of assistance from other nursing staff. Interviews with staff revealed a misunderstanding of medication administration times and a lack of adherence to physician orders. The Director of Nursing and other staff acknowledged the importance of timely medication administration and the potential risks of late or incorrect dosing. The facility's liberalized medication policy was not consistently followed, contributing to the high error rate.
Failure to Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors related to the administration of losartan, a blood pressure medication. Resident #23 received losartan on multiple occasions when her blood pressure and heart rate were outside the ordered parameters. Specifically, the medication was administered on dates when her heart rate was below the threshold set by the physician's order. Similarly, Resident #34 was given losartan when her blood pressure readings were below the specified parameters on several occasions. Interviews with facility staff revealed a lack of understanding and adherence to medication administration protocols. Medication Aide (MA) O admitted to administering the medication despite the residents' vital signs being outside the prescribed limits, based on instructions from the nurse. The Licensed Vocational Nurse (LVN) E confirmed that the facility had not instructed nurses to monitor MAs to ensure compliance with medication hold parameters. The Director of Nursing (DON) and the Administrator acknowledged the expectation that medications should be held when vital signs are not within the prescribed range. The facility's Medication Administration Procedures policy outlines the importance of adhering to the ten rights of medication administration, including the right assessment and evaluation. However, the failure to follow these procedures resulted in the administration of losartan to residents when their vital signs indicated that the medication should have been withheld, potentially placing them at risk for adverse effects.
Failure to Provide Baseline Care Plan to Resident's Responsible Party
Penalty
Summary
The facility failed to ensure that a baseline care plan, which included instructions for effective and person-centered care, was completed and provided to the responsible party (RP) of a resident within 48 hours of admission. The resident, a female with severe cognitive impairment and multiple diagnoses including dementia with psychotic disturbance and paranoid schizophrenia, was admitted to the facility. Although the resident received a copy of the baseline care plan, her RP did not, which could lead to a lack of understanding of the care being provided. Interviews with facility staff, including an LVN, MDS Nurse, DON, and ADM, revealed that the responsibility for providing the baseline care plan to the RP was not consistently executed. Staff acknowledged the importance of providing the RP with a copy to ensure they were informed about the resident's care and to gather additional information that could aid in the resident's care. Despite the facility's policy to provide a summary of the baseline care plan to the resident and their representative, this was not done for the RP of the resident in question.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #62's care plan did not include her prescribed psychotropic medication, Lorazepam, which was ordered by the physician but inconsistently administered. Interviews with the ADON, DON, and Administrator revealed that they expected a care plan for psychotropic medications to be in place to prevent unfamiliar staff from missing necessary interventions. Resident #34's care plan did not address her behavioral symptoms, including urinating on her and other residents' property, despite these behaviors being documented in progress notes. The care plan also failed to reflect other behavioral symptoms coded on the MDS. Interviews with staff, including LVN E, CNA D, and MDS Nurse M, indicated that these behaviors should have been care planned to ensure proper interventions and goals were established. Resident #53's care plan lacked documentation of her limited range of motion and her activity preference for listening to music. Observations noted her lower extremities appeared bent without voluntary movement, and she had a radio playing music in her room. Interviews with staff, including LVN E, CNA D, and the DON, highlighted the importance of care planning these aspects to ensure the resident's needs and preferences were met. The facility's policy stated that comprehensive care plans should include measurable objectives and timeframes to meet residents' needs, which was not adhered to in these cases.
Failure to Provide Scheduled Baths for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for three residents, resulting in missed scheduled baths. Resident #25, a male with cerebral palsy and heart failure, required substantial assistance with bathing. His care plan indicated he was totally dependent on staff for bathing, scheduled for Tuesdays, Thursdays, and Saturdays. However, documentation showed he only received a bed bath on a few occasions in August and September, with many scheduled days lacking any documentation. Interviews with the resident and staff confirmed the baths were likely missed due to staff turnover and lack of documentation. Resident #42, a male with severe cognitive impairment and multiple health conditions, required supervision or touching assistance with bathing. His care plan indicated he was scheduled for baths on the evening shift, but documentation showed he had not received a bath for several weeks. Interviews revealed that the resident was unsure of when he last received a shower, and staff acknowledged that documentation was missing, indicating the baths were not performed as scheduled. Resident #61, a male with Alzheimer's disease and severe cognitive impairment, required set-up or clean-up assistance with bathing. His care plan indicated he was scheduled for baths three times a week, but documentation showed he received only a few baths in August and September. Interviews with the resident's representative and staff revealed concerns about the resident's hygiene and lack of documentation, suggesting the baths were not provided as required. Staff turnover and inadequate documentation were cited as contributing factors to the missed baths.
Failure to Replace Damaged Oxygen Filter
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not replacing a damaged oxygen filter on the resident's oxygen concentrator. The resident, a female with a history of Chronic Obstructive Pulmonary Disease (COPD), Chronic Systolic Heart Failure, and Hyperlipidemia, was observed to have an oxygen concentrator with a filter that was 90% missing. This observation was made during a survey, and it was noted that the absence of a proper filter could lead to respiratory infections. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility had policies in place requiring nurses to ensure that oxygen concentrators have clean and functioning filters. The ADM mentioned that the maintenance supervisor was responsible for daily checks of the oxygen concentrators. However, the failure to replace the damaged filter indicated a lapse in following these procedures, potentially exposing the resident to dust and bacteria.
Failure to Maintain Sanitary Conditions in Residents' Personal Refrigerators
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food items in the personal refrigerators of two residents. For one resident, expired protein drinks were found in their personal refrigerator. This resident, who had severe cognitive impairment and required substantial assistance with activities of daily living (ADLs), was unaware of the expiration dates on the items in their refrigerator. Interviews with the Director of Nursing (DON) and the Administrator revealed that housekeeping and Certified Nursing Assistants (CNAs) were responsible for ensuring that residents' personal refrigerators were clean and free of expired food. However, this responsibility was not adequately fulfilled, placing the resident at risk of harm from consuming expired products. In the case of the second resident, their personal refrigerator was observed to be unclean, containing a brown and black substance with dead gnats. This resident, who had intact cognition and required supervision with ADLs, was aware of the unsanitary condition of their refrigerator but continued to consume food from it. Interviews with various staff members, including CNAs, housekeeping, and nursing staff, indicated confusion and lack of clarity regarding who was responsible for cleaning the residents' refrigerators. The DON and Administrator acknowledged that the facility's policy required family members to ensure cleanliness, but in their absence, facility staff were responsible. The facility's policy on personal refrigerators, dated 2012, stated that residents or their responsible parties were accountable for the care and maintenance of personal refrigerators. However, the policy also allowed for housekeeping to assist by inspecting refrigerators weekly and removing outdated food items. Despite this policy, the facility failed to implement it effectively, resulting in unsanitary conditions and expired food in residents' personal refrigerators, which could pose a risk to their health.
Improper PPE Use in COVID-19 Positive Resident's Room
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) by a medical assistant (MA S) when entering and exiting the room of a COVID-19 positive resident. The resident, an elderly female with multiple diagnoses including dementia, paroxysmal atrial fibrillation, type II diabetes, and COVID-19, was placed on isolation precautions. Despite the presence of signage indicating the need for full PPE, MA S entered the resident's room wearing only a surgical mask, contrary to the requirement for an N95 mask, gown, gloves, and face shield. The deficiency was further highlighted by the failure of MA S to change her mask after leaving the COVID-19 positive resident's room, which is a critical step in preventing cross-contamination and the spread of infection. Interviews with other staff members, including a CNA, RN, MDS nurse, ADON, and DON, revealed a general understanding of the PPE requirements for entering 'warm' and 'hot' zones, yet MA S did not adhere to these protocols. The staff acknowledged that full PPE should be worn in such zones and that PPE should be disposed of in the resident's room, followed by hand hygiene. The facility's policies and signage provided clear instructions on the sequence for donning and removing PPE, emphasizing the importance of using N95 masks or higher-level respirators in the care of COVID-19 positive patients. Despite these guidelines, the incident with MA S demonstrated a lapse in adherence to infection control practices, which could potentially lead to the spread of communicable diseases within the facility.
Failure to Timely Report Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of an investigation into an alleged abuse incident between two residents to the state survey agency within the required 5 working days. The incident involved a resident reporting being slapped by another resident. Both residents were assessed, and no marks or injuries were found. The facility's investigation concluded that the allegation was unfounded. However, the administrator did not submit the investigation report to the state survey agency as required by state law. The administrator acknowledged during interviews that she did not send the provider investigation report to the state within the required timeframe. She admitted to being solely responsible for the submission and mentioned that she had forgotten to send it. The facility's policy on abuse and neglect requires that a written report be sent to the state no later than the fifth working day after the initial report, but this was not adhered to in this case.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 213 citations issued within 25 miles in the last 12 months — including the 9 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Longview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Pines Nursing Home | 1.5 mi | ★★★★★ | 10 | 0 |
| Longview Hill Nursing And Rehabilitation Center | 2 mi | ★★★★★ | 13 | 0 |
| Treviso Transitional Care | 2 mi | ★★★★★ | 19 | 0 |
| Avir At Longview | 2.1 mi | ★★★★★ | 8 | 0 |
| Heritage At Longview Healthcare Center | 2.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.