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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at White Acres Wellness & Rehabilitation during CMS and state inspections, most recent first.
Care Plan Missing Wound Care: A resident with necrotizing fasciitis and a right forearm wound had physician-ordered wound care and was observed receiving wound treatment, but the revised care plan did not address wound care. An LVN, the DON, and the Administrator stated wound care should have been included in the care plan so staff would know the care to provide.
Failure to Resolve Resident Grievance Raised at Care Plan Conference: A resident with dementia, trisomy 21, intellectual disability, and total care needs had family and PASRR concerns raised about being left wet, not getting enough water, and recurrent UTIs. The concerns were documented in the care plan meeting, but no grievance form was completed and no follow-up call or resolution was provided, despite the facility policy requiring prompt review, investigation, and response to grievances.
Call lights were not kept within reach for three residents. One resident with CVA-related weakness was found asleep with the call light on the floor under the bed, another resident with multiple diagnoses including epilepsy, CHF, and hemiplegia had the call light placed out of reach on the wrong side of the bed and reported waiting 20 minutes for help, and a third resident with muscle wasting was found with the call string detached from the switch and did not know where the call light was. Staff, including an LVN, CNA, DON, and Administrator, acknowledged that call lights must be within reach and functional so residents can request assistance.
Survey Results Binder Not Readily Accessible: A resident council interview found residents were unaware of their right to review the annual survey results binder or where to find it. Staff interviews showed inconsistent knowledge of the binder’s location and contents, and multiple staff members, including the receptionist, CNA, activities staff, DON, and administrator, reported no training or in-service on the binder. The binder was observed near the entrance in a white unlabeled binder attached to a wall basket, but it was not clearly identified or readily accessible to residents, family members, or staff.
Failure to provide needed grooming and nail care for two residents. One resident with hemiplegia and moderate cognitive impairment was observed with long facial hair despite needing partial/moderate help with personal hygiene, and another resident with muscle wasting and intact cognition was observed with long fingernails and stated he wanted them trimmed. Staff stated that CNAs and nurses were responsible for ensuring residents were well groomed, including shaving and nail trimming.
Unqualified staff directed resident activities. Surveyors observed the Activities Staff facilitating multiple activities and organizing the resident council meeting, while her badge identified her as “Activities Director” under a covered label. The Activities Staff stated she was responsible for resident activities but had not completed certification, and the HR Manager and Administrator confirmed she was hired without a license or certification and was independently facilitating activities while the facility relied on the Regional Director of Activities’ license for compliance.
Respiratory Equipment Not Maintained Properly: A resident’s nasal cannula was found on the floor while oxygen was in use, another resident’s oxygen concentrator filter was observed dirty with dust and lint while in use, and a third resident’s suction equipment was left open to air at bedside. The residents had diagnoses including respiratory failure, chronic hypoxic respiratory failure, ALS, and acute respiratory failure with hypoxia, and staff interviews confirmed the equipment was not maintained or stored as expected.
Food Served at Unacceptable Temperatures: Two residents received meals in their rooms that were cold by the time they were delivered, including pureed and regular items that fell below the facility’s serving standards. One resident with dementia and diabetes reported occasional cold food and poor taste on a pureed diet, while another resident with mild cognitive impairment said room trays often arrived cold, especially eggs and sausage. Dietary leadership and the DON confirmed hot foods should be served at 140 F or higher and cold foods at 40 F or lower, and acknowledged the measured tray temperatures were not acceptable under facility policy.
Kitchen Food Storage and Sanitization Failures: Surveyors found expired tortillas, cheese, and sopapillas; opened or unsealed food items; dented cans stored on the floor; and improperly stored dry goods in the dry storage area. The plastic strip doors were draped over a shelf, the freezer contained trash and exposed food packaging, and a soy sauce container had dried drippings. Surveyors also observed that sink water temperatures for the 3-sink process were not recorded and cookware was not left in sanitizer for the required time, while the dietary aide reported limited recent training and uncertainty about the required water temperatures.
Dumpster Left Open and Area Not Kept Free of Debris: Surveyors observed Dumpster #2 with the lid open and the surrounding corral littered with pallets, a trash bin, a fish tank, and assorted waste. Staff from Dietary, Housekeeping, LVN, Maintenance, and the Administrator stated dumpsters were to be closed after use and kept free of debris to prevent odors, insects, and animals, and the facility policy required lids to remain closed when not in use and surrounding areas to be free of litter and debris.
Damaged and Stained Ceiling Tiles in Resident Areas: Surveyors observed cracked and bent ceiling tiles in the 100-, 200-, and 300-halls and the day-living area, along with stained ceiling tiles in the hall leading to the main dining area. The Maintenance Supervisor said there was no policy for the facility environment or ceiling tiles, and he was unaware of the damage until shown photos. The DON and Administrator stated staff and supervisors were responsible for reporting and monitoring environmental concerns, but no related grievance concerns were found and no maintenance work order documentation was provided.
A resident with ALS, dysphagia with PEG tube, anxiety, depression, and an indwelling catheter was observed sitting out of bed with the catheter drainage bag hanging on the side of the chair and yellow urine exposed. Staff interviews confirmed that nursing staff and CNAs were responsible for ensuring a privacy cover was placed over the drainage bag when the resident was out of bed, and the facility policy stated the cover was to protect privacy and dignity.
Unlabeled Enteral Feeding: A resident with ALS, dysphagia, and a PEG/G-tube had an enteral feeding hanging and actively pumping at the bedside, but the bag had no label, date, or name. Staff stated the assigned nurse was responsible for labeling enteral feedings with the resident information and formula details, and that feedings were to be replaced every 24 hours.
Three residents were discharged without complete discharge summaries, as required information such as diagnoses, course of treatment, lab results, and final status were missing or left blank. The summaries also lacked physician signatures, and staff interviews revealed inconsistent practices in completing and documenting these records. The residents involved had complex medical needs, and while discharge planning was initiated, the official documentation did not meet regulatory requirements.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
Staff failed to apply the brakes on a mechanical lift while transferring a resident with dementia and complete trisomy 21 syndrome, who was fully dependent for mobility. Two CNAs conducted the transfer without securing the lift, contrary to facility training and procedures, placing the resident at risk during the process.
The facility failed to ensure accurate MDS assessments for three residents, omitting their fall histories despite documented incidents and care plans indicating fall risks. This oversight was attributed to incomplete information following a change in facility ownership, as acknowledged by the MDS Coordinator.
A resident experienced a delay in resolving a cable service outage grievance due to the facility's failure to follow its grievance process. The resident, recovering from knee surgery and diagnosed with major depressive disorder, was not informed of the grievance policy and the issue was not resolved for nearly two weeks. Staff interviews revealed a lack of communication and documentation, contributing to the delay.
The facility failed to maintain proper sanitation and food safety standards in its kitchen, with issues such as unsealed food containers, grease build-up, and improper food storage. Perishable items were not discarded, and food preparation areas were not kept clean. Additionally, food was not served at appropriate temperatures, and thermometers were not cleaned between uses, leading to potential food contamination.
The facility failed to administer medications correctly for two residents, including not providing Lactobacillus as ordered and improperly administering Trelegy Ellipta without following rinsing instructions. Additionally, staff did not sign off on controlled substance counts during shift changes, risking drug diversion.
The facility did not provide mandatory training on effective communication for key staff members, including the Administrator, Receptionist, LVN, and Dietary Manager. This deficiency was identified through interviews and record reviews, revealing that these employees had not completed the required training, which is essential for resident safety. The facility's policy requires documentation of competency achievements and mandatory education, but the Administrator admitted that training records were not available on-site.
The facility failed to provide required training on dementia management and abuse prevention for four staff members, including the Administrator and LVN C. The absence of training records at the facility, which are kept at the corporate office, highlights a gap in compliance with the facility's policy on mandatory education documentation.
A facility failed to document a medication order change for a resident, leading to inaccurate medical records. An LVN did not record in the Nurse's Notes when he contacted the Nurse Practitioner to change the order for Lactobacillus. The resident, with a history of constipation and irritable bowel syndrome, had discrepancies in their medication administration record. The facility's policy requires documentation of such communications, which was not followed.
A resident receiving continuous enteral feeding was found lying flat on his back, contrary to the care plan and facility policy requiring the head of the bed to be elevated at 30-45 degrees to prevent aspiration. Despite staff training and awareness, the proper positioning was not maintained, as confirmed by interviews with an LVN, a CNA, and the DON.
A facility failed to maintain accurate medical records for a resident regarding the use of a wander guard device. Despite the resident's care plan indicating the need for a wander guard due to elopement risk, there was no physician's order documented before a specified date. Interviews with the DON and the resident's physician confirmed the requirement for such an order. The resident, who had a history of falls and dementia, was observed without a wander guard and could not recall any recent attempts to leave the facility.
The facility failed to provide a privacy cover for a resident's catheter bag, compromising his dignity and potentially exposing him to infection risks. Despite the facility's policy, staff did not ensure the catheter bag was covered, leaving it visible from the hallway.
A facility failed to honor a resident's preference for having her room light on at all times, despite her diagnosis of glaucoma and repeated requests. The preference was not documented in her care plan, leading to staff, including the DON, turning off the light, which violated the resident's rights to dignity and respect.
The facility failed to conduct a PASRR Evaluation for a resident identified as positive for intellectual and developmental disabilities during pre-admission screening. Despite a meeting with the local mental health authority, the necessary request for PASRR services was not submitted to the state agency, resulting in the resident not receiving required specialized services.
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in meeting their medical and nursing needs. One resident's preference for having her room light on at all times was not documented, and another resident's PASRR services were not incorporated into her care plan. This oversight could potentially violate their rights and compromise their well-being.
The facility failed to provide appropriate respiratory and catheter care for two residents. One resident's nasal cannula was not bagged when not in use, and another resident's catheter bag was left uncovered, exposing it to potential infection risks. These deficiencies were confirmed by staff and did not align with the facility's infection control policies.
Care Plan Missing Wound Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1 that included wound care, measurable objectives, and timeframes. Resident #1 was admitted on 04/26/2026 with diagnoses including necrotizing fasciitis and another specified soft tissue disorder. The quarterly MDS dated [DATE] showed a BIMS score of 14 and indicated that the resident was receiving surgical wound care and nonsurgical dressings. Physician orders dated 04/26/2026 directed wound care to the right forearm, including cleansing with NSS, applying xeroform and an ABD pad, wrapping with kerlix, and securing with tape every other day and as needed. Record review showed the care plan revised on 04/10/2026 did not address wound care. During observation on 06/16/2026 at 9:50 AM, wound care was performed to the resident’s right forearm and the wound was described as clean with no signs of infection. In interviews, an LVN stated that if the facility was providing wound care, it should have been included in the care plan, and the DON and Administrator stated wound care needed to be addressed in the care plan so staff would know what care was to be provided. The facility policy titled Care Planning stated that a comprehensive person-centered care plan is to be developed for each resident based on individual assessed needs.
Failure to Resolve Resident Grievance Raised at Care Plan Conference
Penalty
Summary
The facility failed to ensure efforts were made to resolve a resident grievance for one resident whose family member and PASRR caseworker voiced concerns during a care plan conference. The concerns documented in the conference note included the resident being soaked and not changed, lack of water, drinking water not being left within reach, needing more help on the floor, not enough staff, and questions about IV fluids given the prior month for dehydration and UTIs. The resident had dementia, trisomy 21 syndrome, intellectual disability, developmental disability, seizure disorder, was not oriented, had no speech or rarely understood others, and required total care with bowel and bladder incontinence. During interviews, the PASRR caseworker stated she and the family member attended the care plan conference and reported that the resident was frequently found soaking wet with urine, was not offered water, and was not checked for incontinence on a regular basis. She stated no one called them back to follow up on what was going to be done about the concerns voiced at the meeting. The family member also stated she had voiced concerns during the care plan conference and did not know what the facility was doing to make sure the resident was not left wet for long periods of time. The social worker stated she attended the conference but did not complete a grievance form when the concerns were raised. The Administrator and DON stated a grievance form should have been completed after the care plan conference when the concerns were voiced, and that grievances were assigned to the department head for follow-up with the person who filed the grievance. The DON stated she was never given a grievance form regarding these concerns and therefore did not follow up on them. The facility policy required grievances and complaints to be promptly reviewed, investigated, and responded to, with the disposition recorded in the grievance log and the resident or representative informed of the findings and any corrective actions in a timely manner.
Call Lights Not Kept Within Reach for Three Residents
Penalty
Summary
The facility failed to ensure resident call lights were within reach for 3 of 12 residents reviewed for call lights. On 01/27/2026 at 10:15 a.m., Resident #24 was observed asleep in bed with the call light on the floor under the bed. Resident #24 had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, a BIMS score of 11 indicating moderate cognitive impairment, and care plan interventions that included ensuring the call light was within reach. Resident #25 was observed and interviewed on 01/27/2026 at 11:20 a.m. and stated the call light was out of reach when he requested assistance to use the restroom. The call light was laid across the nightstand on the resident’s left side even though the resident was right side dominant due to his medical condition. Resident #25’s record showed dependence for multiple activities of daily living, frequent urinary and bowel incontinence, and diagnoses including epilepsy, chronic respiratory failure with hypoxia, cognitive communication deficit, heart failure, myotonic dystrophy type 2, pure motor hemiplegia, and end stage renal disease. The resident later stated he had waited 20 minutes before the surveyor arrived. Resident #68 was observed on 01/27/2026 at 9:55 a.m. with the call string detached from the switch, and the resident stated he did not know where his call light was. Resident #68 had a history of muscle wasting and atrophy, a BIMS score of 13 indicating intact cognition, and was dependent for personal hygiene and toileting hygiene. Interviews with LVN C, CNA B, the DON, and the Administrator confirmed that call lights were to be within reach, that staff were responsible for repositioning them if out of reach, and that if the call light was not within reach or the string was not attached, the resident would not be able to call for assistance.
Survey Results Binder Not Readily Accessible
Penalty
Summary
The facility failed to ensure residents had the right to examine the results of the most recent survey of the facility and failed to post the survey results binder in a place that was readily accessible to the entire facility. On 01/29/2026, the annual survey results binder was observed in a white unlabeled binder placed in a basket mounted to the wall to the right of the facility entrance near a glass case and posterboard for employee rights. The binder was attached to the basket by a chain and was approximately 4 feet from the ground. The binder contained past annual survey results and previous investigations. During a Resident Council interview on 01/29/2026, 10 alert and oriented residents were unaware of their right to review the annual state inspection binder and did not know where to locate it. Staff interviews showed inconsistent and limited knowledge of the binder’s location and contents. LVN C stated the binder could be located with the receptionist in the front but was not aware of the exact location. CNA B stated the results could be located on the facility software called Kardex and that supervisors of the nursing department would have the binder, but she did not know what information was in it. The Receptionist stated she did not know what the binder was and would refer requests to the DON or Administrator. Additional interviews showed other staff also lacked knowledge of the binder and had not received training or in-service education on it. The Activities Staff stated she was not aware residents had the right to review the annual survey results and did not know where the binder was located. The DON stated no resident or family member had requested the binder, did not know its current location, and identified the Administrator as responsible for updating and placing it in an accessible area. The Administrator stated the binder was near the entrance and online at care.gov, but also denied providing training to staff or department heads and declined to have a policy in place for mandatory postings or for the annual survey results binder. Record review of Resident Council minutes from multiple prior meetings showed resident rights topics were discussed, but the annual survey results binder was not identified as a topic.
Failure to Provide Needed Grooming and Nail Care
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received needed assistance with grooming and personal hygiene. During observations and record review, Resident #24, a female with a history of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and a BIMS score of 11, was identified as needing partial/moderate assistance with personal hygiene, including shaving. Her care plan also documented an ADL self-care performance deficit related to limited mobility and the need for partial/moderate assistance with personal hygiene. On observation, Resident #24 was seen with long white hair on her chin, and she declined to answer questions about grooming. Resident #68, a male with a history of muscle wasting and atrophy and a BIMS score of 13, was documented as dependent for personal hygiene. His care plan identified an ADL self-care performance deficit related to limited weakness and stated that he was dependent with personal hygiene. On observation, Resident #68 was seen with long fingernails on both hands, and he stated that his nails had not been cut and that he wanted them trimmed. Interviews with CNA, LVN, DON, and the Administrator indicated that nail trimming and facial grooming were responsibilities shared by nursing staff and CNAs, with nail trimming offered at least weekly and facial grooming provided upon request or preference. The facility policy titled Grooming Care of the Fingernails and Toe nails stated that CNAs trim fingernails except for residents with certain conditions, when a licensed nurse trims them.
Unqualified staff directed resident activities
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional. Surveyors observed that the Activities Staff facilitated multiple activities during the survey period, including organizing the resident council meeting for the surveyor. On 01/29/2026 at 3:05 PM, the Activities Staff’s badge had the title “Activities Director” covered with a printed label that read “Staff.” During an interview on 01/29/2026 at 3:30 PM, the Activities Staff stated she was responsible for organizing and hosting resident activities and said she had worked on Saturday and Sunday because there was no one else to facilitate weekend activities. She stated she was not the Activities Director because she had not completed her certification, and that she had started working on her certification in December 2025 with an expected completion in March 2026. She also stated she had previously worked as a CNA for 5 years and this was her first full-time job in activities. The DON stated it was not okay for staff to work without a professional license or certification when the position required it, and the HR Manager stated the Activities Staff was hired on 10/29/2025 without a license or certification in place. The HR Manager identified the Regional Director of Activities as the Director of Activities for the facility, but said that person was a traveling employee and had not been in the building to her knowledge during the year she had worked there. The Administrator stated the Activities Staff and the Regional Director of Activities oversaw the activities department, that the Activities Staff independently facilitated activities, and that the facility was using the Regional Director of Activities’ license for compliance.
Respiratory Equipment Not Maintained Properly
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for three residents who were receiving oxygen therapy or respiratory support. Resident #12 had chronic hypoxic respiratory failure and was ordered oxygen via nasal cannula. During observation, the resident’s nasal cannula was found on the floor while the oxygen concentrator was in use. Resident #12’s care plan directed staff to provide oxygen as ordered, including 2 liters per minute via nasal cannula with titration up to 4 liters per minute as needed. Resident #46 had diagnoses including respiratory failure and acute respiratory failure with hypoxia and was also on oxygen therapy. During observation, the resident’s oxygen concentrator filter was seen dirty with dust and lint while the equipment was in use. The resident was unable to recall when the filter had last been cleaned. Staff interviews stated that oxygen concentrator filters were to be clean and that dirty filters could pose infection or illness concerns. Resident #62 had amyotrophic lateral sclerosis and acute respiratory failure with hypoxia and was on oxygen therapy and respiratory care. During observation, suction equipment was found at the bedside on the nightstand, open to air. Staff interviews stated suction equipment should not be left open to air, should be stored properly after use, and that the equipment observed was considered dirty and needed to be replaced. The facility’s policy stated oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen were for single use only and were to be changed weekly and when visibly soiled.
Food Served at Unacceptable Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents in their rooms was palatable and at an acceptable temperature for 2 of 2 residents reviewed for food and nutrition services. Resident #3 was an older female with dementia and type II diabetes, a BIMS score of 13, and a care plan identifying her as at risk for malnutrition and nutritional problems because she required a mechanical and therapeutic modified diet. Resident #7 was a female resident with a BIMS score of 10, no swallowing-related dietary restrictions, and a care plan noting potential for nutritional problems and malnourishment related to cognitive impairment and poor appetite. During observation of the steam table, hot foods were recorded at temperatures including 172 F, 170 F, 180 F, 167 F, 155 F, and 141 F. Later, when sample trays were delivered for room service, the trays were delayed because they were initially not on the cart due to storage limitations and arrived after space was made available. When the trays were rechecked, temperatures had dropped to 139.4 F for pozole, 132.6 F for rice, 113.7 F for puree pozole, 123.6 F for puree rice, 121.2 F for puree pinto beans with tortilla, and 60.6 F for puree tres leches cake; the survey team noted the food was cold but still had appetizing flavors. Resident #3 stated she was on a pureed diet and did not like how the food tasted and that the food temperature was occasionally cold, so she would buy meals from outside the facility or have family bring food she enjoyed. Resident #7 stated she preferred to eat in her room and that her meals arrived cold, especially eggs and sausage, though staff would honor substitute meal requests. Interviews with dietary leadership and the administrator confirmed that hot foods should be served at 140 F or higher and cold foods at 40 F or lower, and the facility policy required hot foods above 140 F and cold foods below 40 F. The Dietary Manager stated the temperatures measured on the sample trays were not acceptable in accordance with facility policy.
Kitchen Food Storage and Sanitization Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observations in the kitchen, expired tortillas were found in the fridge, an opened carton of liquid eggs was observed in a second fridge, and a cardboard box of frozen sugar cookie dough was left open in the freezer. Expired cheese was found on the floor behind a metal shelf in the walk-in fridge, the plastic strip doors to the walk-in fridge were draped on a metal shelf holding sealed packages of hot dogs, an empty cardboard box was left in the freezer, frozen biscuits were exposed through a large opening in the packaging, and an expired package of sopapillas was found between the wall and cardboard boxes in the walk-in freezer. In the dry storage room, 1 dented can of tomato sauce and 1 dented can of tapioca were located on the floor behind a rolling table. A 5-gallon container of cooking oil without a cap was on a metal shelf, and a gallon of soy sauce with dry drippings from the spout and down the body of the container was also stored on a shelf. The facility’s dietician stated the observed conditions were not acceptable and identified expectations that food be labeled, not stored on the floor, and properly sealed. The dietary manager also stated the observed conditions were not acceptable and identified dietary staff as responsible for properly sealing food, keeping the plastic strip doors down, and discarding expired food during their shift. The facility also failed to ensure staff were trained to capture temperatures of waters for the 3-sink compartment and failed to ensure cookware was properly rinsed and sanitized. During observation of the 3-sink compartment, the sink water temperatures were not captured, and the wash, rinse, and sanitize cycle was completed in 11.58 seconds, which did not allow cookware to sit in the rinse and sanitization solution for a minimum of 1 minute per facility policy. The sanitization solution tested at 150-400 parts per million quaternary ammonium. The dietician stated cookware needed to remain in sanitizer for a minute or more, while the dietary aide stated he had not received dishwashing training for approximately 2 years and did not know the required water temperatures. The dietary manager stated staff should check water temperatures before beginning dishwashing and recognized the 3-sink process observed was not conducted as required.
Dumpster Left Open and Surrounding Area Contained Debris
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 1 of 3 dumpsters reviewed for food and nutrition services. On 01/27/2026 at 9:08 AM, surveyors observed Dumpster #2 left open by the overhead plastic lid. The surrounding dumpster corral contained approximately 15 wooden pallets, 1 plastic rolling trash bin, 1 fish tank, and various waste items on the ground, including food, gloves, plastic, an over-the-counter medicine bottle, briefs, bed liners, cans, and leaves. During interviews, Dietary A described the process for disposing of waste and stated staff were expected to close the dumpster after use and keep debris off the floor because it was cross contamination and could attract cockroaches, flies, mice, and cats. [NAME] A stated the dumpster had been dirty two days earlier and that it needed to be closed at all times to prevent odors and to keep animals and insects away. The Dietary Manager stated the condition of the dumpster on 01/27/2026 was not acceptable because it was left open and debris was on the ground around the dumpsters. Additional interviews with LVN C, Housekeeping, the Maintenance Supervisor, and the Administrator confirmed that staff from multiple departments used the dumpsters and were expected to close them after use. They also stated the area around the dumpsters needed to be free of debris. The facility policy titled Garbage Cans, Dumpsters and Grease Trap Use and Cleaning stated that outside trash dumpsters, doors and/or lids will be kept closed when not in use and surrounding areas will be free of litter and debris.
Damaged and Stained Ceiling Tiles in Resident Areas
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in the 100-hall, 200-hall, 300-hall, the day-living area next to the resident halls, and the hall leading to the main dining area. On observation, ceiling tiles in the 100-, 200-, and 300-halls and the day-living area were cracked and bent, and ceiling tiles in the hall leading to the main resident dining area were stained. The deficiencies were identified during survey observations of the facility environment. During interviews, the Maintenance Supervisor stated there was no policy regarding the environment of the facility, including ceiling tiles, and that he was responsible for making building corrections and monitored the environment daily. He stated he was not aware of the damaged and stained ceiling tiles until they were shown to him and said they needed to be replaced because they were cracked or damaged. The DON stated staff were responsible for notifying maintenance of environmental concerns and that supervisors assessed the environment during daily Ambassador rounds. The Administrator also stated there was no policy regarding the environment or the facility's ceiling tiles. The facility's grievance record for the last 6 months did not include concerns about the ceiling tiles, and requested maintenance work order documentation related to the ceiling tiles was not provided by time of exit.
Uncovered Foley Catheter Exposed Resident's Urine
Penalty
Summary
The facility failed to treat one resident with respect and dignity when Resident #62 was observed sitting in a specialized recliner in his room with a foley catheter hanging on the side of the chair and yellow urine exposed while he was out of bed. Resident #62 was a [AGE]-year-old male with an admission history including ALS, dysphagia with PEG tube, suprapubic catheter, anxiety, and depression. He was unable to answer the surveyor’s questions, and the MDS noted that BIMS was not conducted because he was never or rarely understood. Record review and interviews showed that staff expected the resident’s catheter drainage bag to be covered with a privacy bag when he was out of bed or out of his room. CNA, LVN, DON, and the Administrator each stated that nursing staff and CNAs were responsible for ensuring the privacy covering was in place to protect the resident’s privacy and dignity. The facility’s catheter-care policy also stated that the resident’s privacy and dignity would be protected by placing the cover over the drainage bag when the resident was out of bed.
Unlabeled Enteral Feeding
Penalty
Summary
The facility failed to ensure an enteral feeding was labeled in accordance with currently accepted professional principles for Resident #62. During observation, the resident was found in his room sitting in a specialized recliner next to his bed, with an enteral feeding hanging at the bedside and actively pumping. The bag was half full with pale brown fluid, and there was no label on the enteral feeding, including no date or name of the feeding. Resident #62 was a [AGE]-year-old male with an admission record showing an initial admission date of 09/11/23 and a re-admission date of 08/04/25. His medical history included amyotrophic lateral sclerosis, dysphagia, post status PEG tube, anxiety, and depression. His MDS noted he was not able to participate in the BIMS and had a feeding tube on admission and while a resident in the facility. His care plan identified dysphagia and the need for a G-tube, with a goal of maintaining adequate nutritional and hydration status. Interviews confirmed nursing staff were responsible for labeling enteral feedings and that the assigned nurse administering the feeding was responsible for completing the label. CNA F stated the purpose of labeling was to show the date the feeding was being provided and noted spoilage could cause illness. LVN G stated labeling included the resident name, room number, rate, goal, and formula type, and that feedings were to be replaced every 24 hours to prevent bacteria from growing. The ADON, who was also the Infection Control nurse, stated the nurse administering the feeding was responsible for labeling it and that she monitored and confirmed labeling daily. The DON stated the assigned nurse was responsible for labeling the enteral feeding and the saline used to flush the feeding.
Incomplete Discharge Summaries and Missing Physician Signatures
Penalty
Summary
The facility failed to provide complete and compliant discharge summaries for three residents who were reviewed for discharge documentation. Each resident's discharge summary lacked essential information, such as a recapitulation of the resident's stay, including diagnoses, course of illness or treatment, pertinent laboratory and radiology results, and a final summary of the resident's status at the time of discharge. In several cases, sections of the discharge summary were left blank, including prognosis, special treatments or procedures, medical information, cognitive and psychosocial status, sensory and physical impairments, dental condition, and status upon discharge. Additionally, the discharge summaries were not signed by the attending physician as required. For the residents involved, the records showed that they had complex medical histories, including conditions such as upper respiratory infection, ureteral stones, obstructive uropathy, pyelonephritis, Alzheimer's dementia, chronic urinary tract infection, hydronephrosis, and post-surgical rehabilitation needs. Discharge planning was initiated upon admission, and arrangements for home health services, therapy, and follow-up with primary care providers were documented in progress notes and care plans. However, the official discharge summaries did not reflect a comprehensive account of the residents' medical status or the care provided during their stay, nor did they consistently document vaccine administration or declination. Interviews with facility staff, including nurses, the DON, and medical records personnel, revealed inconsistent practices regarding the completion and physician signature of discharge summaries. Staff reported that discharge summaries were completed by nurses at the time of discharge and were supposed to be signed by the physician, but in practice, this was not consistently done. The medical records staff also indicated that some discharge documents had not yet been scanned into the electronic medical record. Facility policies required that discharge summaries be provided to residents and included in the medical record, with specific content requirements that were not met in these cases.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. This failure was observed and documented by surveyors during their review of facility practices.
Failure to Secure Mechanical Lift Brakes During Resident Transfer
Penalty
Summary
Staff failed to provide adequate supervision and safe transfer assistance for a resident with significant physical and cognitive impairments. During a transfer from a wheelchair to a bed using a mechanical lift, two CNAs did not secure the brakes on the lift before elevating the resident. One CNA positioned the lift and began lifting the resident without locking the brakes, while the other CNA moved the wheelchair and assisted with the transfer. Both CNAs acknowledged after the transfer that the brakes had not been applied, and recognized that this was not in accordance with safe transfer procedures. The resident involved had a history of dementia, degenerative disease of the central nervous system, and complete trisomy 21 syndrome, and was dependent on staff for all mobility and transfers. The care plan indicated the resident was normally bedfast and required two staff for transfers using a mechanical lift. Interviews with the ADON and DON confirmed that staff are trained to apply the mechanical lift brakes before lifting a resident, and that failure to do so could result in injury. The facility was unable to provide a copy of its transfer and ADL policy when requested.
Inaccurate MDS Assessments for Fall History
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the fall history of three residents, leading to a deficiency in the accuracy of resident assessments. Resident #7, a female with dementia and unsteadiness on feet, had a documented fall on January 27, 2025, which was not captured in her MDS assessment. Her care plan indicated a risk for falls due to various factors, including dementia and poor safety awareness, yet the MDS inaccurately reported no falls since admission. Similarly, Resident #8, also diagnosed with dementia and unsteadiness, had a fall on January 12, 2025, which was not reflected in her quarterly MDS. Her care plan noted a history of falls and risk factors such as confusion and poor safety awareness. Despite these documented incidents and risks, the MDS inaccurately stated that she had not experienced any falls since admission. Resident #9, a male with moderate cognitive impairment and unsteadiness, experienced a fall on January 1, 2025, resulting in a minor injury. This incident was not captured in his MDS assessment, which incorrectly indicated no falls since admission. The MDS Coordinator acknowledged the oversight, attributing it to a lack of complete information following a change in facility ownership. The Director of Nursing emphasized the importance of accurate MDS assessments for effective care planning, noting that inaccuracies could impact the interventions in place for residents.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances, specifically for a resident who experienced a cable service outage. The resident, who was admitted for recovery from knee surgery and had a diagnosis of major depressive disorder, reported that the cable television channels went out the day before Christmas, leaving only one channel available. Despite voicing her complaint immediately to the staff, the issue was not resolved until nearly two weeks later. The resident was not informed of the facility's grievance policy upon admission and was not provided with any policy regarding the grievance process. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) did not complete a written grievance form, assuming the Maintenance Director was already addressing the issue. The Maintenance Director confirmed the cable outage was due to a transition of new ownership affecting payment of services. He attempted to resolve the issue but did not file a grievance, and the administration was not immediately informed. The Facility Administrator learned of the issue during a morning meeting and acknowledged that no formal grievance was filed, which contributed to the delay in resolving the issue. The facility's grievance records from November 2024 through January 2025 showed no grievance filed for the resident's concern. The Facility Administrator admitted that the grievance process was not followed, which may have delayed the resolution. The facility's grievance policy allows residents to file verbal or written grievances without fear of reprisal, but this process was not effectively communicated or executed in this instance.
Facility Fails to Maintain Kitchen Sanitation and Food Safety Standards
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen, as observed during a survey. The tile floors in the dry storage room were not kept free of black grease build-up, and foods were not stored in sealed containers. Additionally, food containers were found with grease build-up and food particles, and the sheet pan rack in the dry storage room was stained and dusty. Food cans were improperly stored alongside chemicals, and a 5-gallon water bottle was placed directly on the floor. In the walk-in refrigerator, food was not stored in sealed containers, and perishable items like cucumbers were found to be soft, mushy, and covered in fuzzy white surfaces. The facility also failed to keep food preparation tables and equipment free of rust, stains, and food particles. Foods in the refrigerator were not labeled or dated, and the metal shelving in the food preparation area was dusty. Spice bottles and food containers were not sealed properly and had grease build-up, and a scoop was improperly stored in a food container. The facility also failed to serve food at appropriate temperatures and did not clean the food thermometer between uses, which could lead to food contamination. The kitchen walls and equipment, such as the deep fryer and juice machine, were not kept clean, with evidence of rust, grease, and black substances. The facility's policies and procedures on food storage, sanitation, and temperature monitoring were not adhered to, as evidenced by the numerous deficiencies observed during the survey.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by the failure to administer medications according to physician's orders and manufacturer's specifications. For Resident #22, the facility did not administer Lactobacillus as prescribed on a specific date. The medication was not available in the required capsule form, and the staff held the dose without proper documentation of the physician's order change. This oversight was confirmed through interviews with the staff involved, who acknowledged the lack of documentation and the failure to administer the medication as ordered. For Resident #35, the facility did not follow the manufacturer's instructions for administering Trelegy Ellipta Inhalation Aerosol Powder. The nurse administered the medication but failed to instruct the resident to rinse and spit the water after use, as required to prevent thrush. The nurse incorrectly assumed the resident had followed the instructions without verifying the action, leading to improper administration of the medication. Additionally, the facility did not ensure proper documentation and verification of controlled substances during shift changes. Several staff members, including LVNs and a Med Aide, failed to sign the Controlled Drugs - Audit Record after counting controlled substances, which is a critical step in preventing drug diversion. This lapse in procedure was acknowledged by the staff and confirmed by the Director of Nursing, who stated that staff were trained to complete these tasks accurately and promptly.
Failure to Provide Mandatory Communication Training
Penalty
Summary
The facility failed to include effective communication as mandatory training for direct care staff, affecting four out of nine staff members reviewed, including the Administrator, Receptionist, LVN C, and Dietary Manager. This deficiency was identified through interviews and record reviews conducted on 10/16/2024. The Business Office Manager confirmed that these employees had not completed the required training on effective communication, which is crucial for ensuring resident safety. The facility's policy on Competency and Mandatory Education Requirements, dated 09/17/2024, mandates that competency achievements and mandatory education requirements be documented and reviewed as part of the performance appraisal process. However, the Administrator acknowledged that the facility did not have copies of the training records and employee files on-site, as they were kept at the corporate office.
Deficiency in Staff Training on Dementia and Abuse Prevention
Penalty
Summary
The facility failed to provide necessary training on dementia management and resident abuse prevention for four employees, including the Administrator, Receptionist, LVN C, and Dietary Manager. This deficiency was identified during an interview and record review conducted on 10/16/2024. The Business Office Manager confirmed that these employees had not completed the required training, which is crucial for ensuring the safety and proper care of residents with dementia. The lack of training could lead to improper management of dementia-related issues among residents. The Administrator acknowledged the absence of training records and employee files at the facility, stating that these documents were maintained at the corporate office. Despite the facility's policy requiring documentation of competency achievements and mandatory education as part of the performance appraisal process, the necessary training records were not available for review. This oversight in maintaining and documenting training compliance highlights a significant gap in the facility's adherence to its own policies and procedures.
Failure to Document Medication Order Change
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of a medication order change. A Licensed Vocational Nurse (LVN) did not document in the Nurse's Notes when he contacted the Nurse Practitioner to change the order for Lactobacillus for a resident. This lack of documentation was identified during a review of the resident's medical records, which showed discrepancies in the medication administration record and the physician's orders. The resident, a 62-year-old male, was admitted with diagnoses including constipation and irritable bowel syndrome with diarrhea. The resident's care plan noted constipation related to decreased mobility. The LVN documented a code indicating to see the Nurse's Notes on the Medication Administration Record but failed to record the communication with the Nurse Practitioner in the electronic record. This oversight was contrary to the facility's policy, which requires licensed staff to document such communications. The Director of Nursing confirmed that staff were trained to document changes in physician's orders in a timely manner.
Failure to Maintain Proper Positioning for Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was properly positioned to prevent complications such as aspiration. Resident #7, a male with severe cognitive impairment and multiple medical conditions including anoxic brain damage and Parkinson's disease, was observed lying flat on his back while receiving continuous enteral feeding. This was contrary to the care plan and facility policy, which required the head of the bed to be elevated at 30-45 degrees during feeding to prevent aspiration. Interviews with staff, including an LVN and a CNA, revealed that they were aware of the requirement to maintain the head of the bed at 30 degrees for residents on continuous enteral feeding. Despite receiving monthly training on proper positioning, the staff failed to ensure Resident #7 was positioned correctly. The Director of Nursing confirmed that all CNAs and nurses were responsible for maintaining proper positioning during their rounds, which were conducted at least every two hours. The facility's policy also reflected the need for the head of the bed to be elevated during feeding, yet this protocol was not followed in the case of Resident #7.
Inaccurate Documentation of Wander Guard Use
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the documentation of a wander guard device. The resident, who had a history of falls, dementia, and was at risk of elopement, was admitted and re-admitted to the facility. Despite the resident's care plan indicating the use of a wander guard to manage elopement risk, there was no physician's order documented for the device before a specified date. This lack of documentation was confirmed during interviews with the Director of Nursing (DON) and the resident's physician, who stated that a physician's order is required for the use of a wander guard. The deficiency was identified through a review of the resident's medical records and interviews with facility staff. The facility's policies on nursing documentation and physician orders did not address the accuracy of documentation, and no additional policies were provided during the survey. The resident was observed without a wander guard, and during an interview, the resident could not recall any recent attempts to leave the facility. The failure to document the physician's order for the wander guard could lead to inaccurate medical records, potentially affecting the monitoring and medical services provided to the resident.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to treat Resident #7 with respect and dignity by not providing a privacy cover for his catheter bag. Resident #7, a male diagnosed with Neurogenic Bladder and requiring a long-term Foley catheter, was observed with his catheter bag exposed and filled with dark yellow urine. The catheter bag was visible from the hallway as the resident's room door was open. This observation was confirmed by LVN A, who acknowledged the lack of privacy and the potential risks of embarrassment and infection for the resident. Interviews with the Nurse Manager, DON, and CNA B confirmed that it is the facility's policy to cover catheter bags with a privacy bag to protect residents' dignity and prevent infection. The facility's policy on catheter care also mandates that catheter bags should be covered when visible from the door or hallway. Despite this policy, the staff failed to ensure that Resident #7's catheter bag was covered, compromising his dignity and potentially exposing him to infection risks.
Failure to Honor Resident's Preference for Room Lighting
Penalty
Summary
The facility failed to ensure that a resident's preference for having her room light on at all times was honored. The resident, who has a diagnosis of glaucoma among other medical conditions, had expressed her need for the room light to remain on due to her vision impairment. Despite this, the facility did not include this preference in her care plan, and the Director of Nursing (DON) was reported to have turned off the light on multiple occasions, contrary to the resident's wishes and her family's requests. Interviews with various staff members, including a family member, a medical assistant (MA), licensed vocational nurses (LVNs), and the MDS Coordinator, confirmed that the resident's preference for having the room light on was well-known among the staff. However, it was not documented in her care plan, which could lead to staff inadvertently turning off the light, thereby not honoring her preference. The staff acknowledged that this oversight could be a risk to the resident's rights and preferences. The facility's failure to document and honor the resident's preference for having the room light on at all times is a violation of her rights to dignity and respect. The facility's own policies on resident rights emphasize the importance of treating residents with dignity and respecting their preferences. The lack of a care plan addressing this specific need highlights a significant gap in the facility's adherence to these policies.
Failure to Conduct PASRR Evaluation
Penalty
Summary
The facility failed to coordinate assessments and conduct a PASRR Evaluation for a resident who was identified as positive for intellectual disability and developmental disability during the pre-admission screening. The resident was admitted to the facility without a follow-up PASRR Level 2 Evaluation, which is required to determine the need for specialized services. Despite the initial screening indicating the need for further evaluation, the facility did not complete the necessary steps to ensure the resident received appropriate care and services as mandated by the PASRR program under Medicaid. Interviews with facility staff, including the MDS Coordinator, Social Worker, and Director of Rehab, revealed a lack of clarity and responsibility regarding the PASRR process. The MDS Coordinator was unaware of the PASRR services and deferred to the Director of Rehab and Social Worker, who both acknowledged that a meeting was held with the local mental health authority. However, they did not submit the request for PASRR services to the state agency, mistakenly believing the resident was already receiving these services in the community. This misunderstanding led to the failure to conduct the required PASRR Evaluation. Further interviews with representatives from the local mental health authority confirmed that the resident was not receiving PASRR services in the community and required these services. The facility's failure to conduct the PASRR Evaluation and submit the request for services to the state agency resulted in the resident not receiving the necessary specialized services. This oversight was contrary to the facility's policy and the requirements of the PASRR process, which aims to ensure that individuals with intellectual disabilities receive appropriate care in the most suitable setting.
Failure to Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in meeting their medical and nursing needs. Resident #4, who has a history of glaucoma and other medical conditions, preferred to have her room light on at all times. Despite this preference being communicated to the staff, it was not included in her care plan. Multiple staff members, including the family member, MA, LVN, and MDS Coordinator, confirmed that Resident #4's preference for having the room light on was known but not documented in her care plan. This oversight could potentially violate her rights and preferences, as well as pose a risk to her well-being. Resident #6, who has a diagnosis of mental retardation and other medical conditions, was identified as PASRR positive, indicating the need for specialized services. However, the facility failed to incorporate these PASRR services into her care plan. The MDS Coordinator acknowledged that the PASRR services were discussed in a care conference but were not documented in the care plan. This failure could result in Resident #6 not receiving the necessary PASRR services, which are crucial for her care and well-being. The facility's policies on comprehensive care and PASRR services emphasize the importance of developing person-centered care plans that include measurable objectives and timetables. However, the facility did not adhere to these policies for Residents #4 and #6. The lack of proper documentation and implementation of care plans for these residents highlights a significant deficiency in the facility's ability to meet the individualized needs of its residents, potentially compromising their highest practicable physical, mental, and psychosocial well-being.
Failure to Ensure Proper Respiratory and Catheter Care
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care received appropriate and safe care, consistent with professional standards of practice. Resident #2, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and a history of COVID-19, was observed multiple times with her nasal cannula not placed in a plastic bag when not in use. This was confirmed by the Nurse Manager and the Director of Nursing (DON), who both acknowledged that the nasal cannula should be bagged to prevent infection. Despite the resident not showing signs of respiratory distress, the improper handling of the nasal cannula posed a risk of infection. Resident #7, diagnosed with Neurogenic Bladder and using a long-term Foley catheter, was observed with his catheter bag exposed and not covered with a privacy bag. The catheter bag, filled with dark yellow urine, was visible from the hallway, compromising the resident's privacy and potentially increasing the risk of infection. This observation was confirmed by LVN A, the Nurse Manager, and the DON, all of whom stated that the catheter bag should be covered with a privacy bag to ensure sanitation and prevent bacterial contamination. The facility's policies on catheter care and infection prevention were not followed, as evidenced by the observations and interviews. The failure to properly bag the nasal cannula and cover the catheter bag exposed the residents to potential health risks and did not align with the facility's established protocols for infection control and resident privacy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 292 citations issued within 25 miles in the last 12 months — including the 8 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 El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Bartlett Skilled Nursing And Assisted Living | 0.6 mi | ★★★★★ | 5 | 0 |
| Franklin Heights Nursing & Rehabilitation | 1.1 mi | ★★★★★ | 10 | 0 |
| The Montevista At Coronado | 2.5 mi | — | 0 | 0 |
| Avir At El Paso | 2.9 mi | ★★★★★ | 16 | 0 |
| Mountain View Health & Rehabilitation | 5.2 mi | ★★★★★ | 29 | 2 |
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 October 2026) and official state health department websites.