Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willow Rehab & Nursing during CMS and state inspections, most recent first.
Medication Storage Lapses: Multiple residents were found with OTC and prescribed meds left at the bedside or on nightstands, including hemorrhoid cream, ear drops, nystatin cream, and a Breyna inhaler. Records showed some residents had cognitive impairment or dementia, and several of the items had no current order. Staff interviews confirmed meds should not be accessible in resident rooms unless properly ordered and self-administered, and the DON stated there was no medication storage policy.
A resident with legal blindness, moderate cognitive impairment, and maximal ADL needs was observed in bed with the call light on the floor and out of reach on multiple occasions. The care plan directed staff to keep the call light within reach, and staff interviews confirmed that aides and other staff were responsible for ensuring call lights were accessible, consistent with the facility policy.
Unsecured Oxygen Cylinder Found in Resident Room: A resident with paraplegia and intact cognition was observed sitting in his motorized wheelchair while a freestanding oxygen tank in his room was not secured in a caddy. The same unsecured tank was still present later that day. The ADON, DON, and Administrator all stated the cylinder should have been secured, and the facility’s Oxygen Safety policy required cylinders to be chained or supported to prevent falling.
Unclean Oxygen Concentrator Filter: A resident with COPD, chronic respiratory failure, and continuous O2 orders was observed multiple times with a nasal cannula connected to a running O2 concentrator whose filter had a gray fuzzy substance on it. Staff stated the concentrator filters were supposed to be cleaned, but the DON said there was no Oxygen Administration policy, and the Administrator was unsure who was responsible for cleaning the filters.
A resident with MS, DM2, muscle weakness, and a suprapubic catheter received catheter care while a CNA failed to change gloves or sanitize hands after pulling down the resident’s pants and before touching the catheter. The CNA also touched disposable bags with dirty gloves and placed a dirty bag on the resident’s bedside table beside his water cup. Multiple staff members stated these actions were cross-contamination and infection control issues, and the facility’s policy required standard precautions and staff competence in infection control practices.
A resident with complex respiratory and cardiac conditions experienced acute respiratory distress after becoming disconnected from oxygen therapy. Despite repeated requests for a nurse, CNAs failed to recognize or report the change in condition to the RN, resulting in delayed emergency intervention. The RN discovered the resident in distress only during a routine task, leading to hospital transfer for acute hypercapnic respiratory failure.
The facility failed to prevent access to hazardous items and ensure fall prevention measures for three residents. A resident with severe cognitive impairment had rubbing alcohol in his room, another resident had five razors left in his bathroom, and a third resident's fall mat was not placed beside her bed as required. These oversights posed risks of poisoning, injury, and falls.
The facility failed to maintain food safety and hygiene standards in their kitchen, using unpasteurized eggs for resident meals and lacking an operable paper towel dispenser, leading to improper hand hygiene practices. These deficiencies posed a risk of infection to residents.
The facility failed to ensure safe and sanitary storage of food in personal refrigerators for three residents, leading to the presence of expired food items. Despite policies requiring weekly inspections, expired milk, yogurt, and other food items were found in the refrigerators of residents with varying cognitive abilities. Interviews with facility staff revealed an expectation for regular checks, which were not consistently performed.
The facility failed to maintain an effective infection prevention and control program, leading to deficiencies in resident care. A resident's room was found with used gloves and clothes on the floor, increasing infection risk. Another resident's gastrostomy tube syringe was improperly handled, left uncovered with visible sediment. Additionally, a nurse failed to follow Enhanced Barrier Precautions by not wearing a gown while caring for a resident with a feeding tube. These actions violated facility policies and posed infection risks.
A resident with moderate cognitive impairment gave her debit/credit card and PIN to a CNA for specific purchases, but the CNA misused the card for personal transactions, transferring $1,186.00 to her own Cash App account without the resident's consent. The facility discovered the unauthorized transactions during a review of the resident's bank statements, leading to the CNA's suspension and termination.
A resident with dementia and other health conditions was found without her call light within reach on multiple occasions, violating her right to reasonable accommodation of needs. Staff interviews confirmed the expectation for call lights to be accessible, as per facility policy, to ensure residents can call for assistance when needed.
A facility failed to ensure the accuracy of a PASRR Level I assessment for a resident with major depressive disorder and PTSD. The screening incorrectly indicated no mental illness, despite the resident receiving related medications. The MDS coordinator misunderstood the PASRR process, believing the resident would not qualify for services due to a lack of recent hospitalization. The facility's policy to correct inaccuracies was not followed.
A resident with hemiplegia and other medical conditions did not receive scheduled showers multiple times in January, despite being cognitively intact and expressing a desire for regular showers. Staff interviews revealed inconsistencies in the shower schedule and documentation, with the resident often missing night shift showers and requesting them during the day. The facility's policy on resident showers was not followed, leading to a deficiency in providing necessary hygiene care.
The facility failed to follow respiratory care protocols for two residents, leading to undated and unbagged oxygen tubing, CPAP masks, and nebulizers. This oversight was confirmed by staff and management, highlighting a lapse in infection control procedures.
A facility failed to maintain a medication error rate below 5%, resulting in errors involving two residents. One resident did not receive prescribed eye drops due to unavailability, while another received the wrong form of aspirin. The facility lacked a policy for ordering medications, contributing to these errors. Staff interviews revealed expectations for medication availability and correct administration were not met.
A resident was found with a white cream and green powder substance at her bedside, which were not securely stored as required by facility policy. The resident, who had intact cognition, reported that staff sometimes left the substances for her use. The facility's policy mandates that all medications be stored in locked compartments, but this was not followed, posing a risk of ingestion or adverse reactions.
A facility failed to coordinate hospice care and medication management for a resident, leading to discrepancies in the administration of Lorazepam. The resident, with multiple health issues, was at risk due to a lack of updated communication and documentation between the facility and hospice staff.
Two residents were discharged unsafely from a facility, leading to an Immediate Jeopardy situation. One resident, with a history of hemiplegia and diabetes, was left outside the facility and later hospitalized. Another resident, with a neck fracture and diabetes, was discharged to a motel without adequate support, resulting in multiple falls. The facility failed to ensure safe discharge plans, leading to significant deficiencies.
A resident with dementia eloped from a facility due to a failure in the alarm system and inadequate supervision. The resident, who was at risk for wandering, left through an alarmed door that was not responded to promptly. The malfunctioning alarm system and lack of communication regarding the resident's admission and elopement risk contributed to the incident.
Medication Storage Lapses
Penalty
Summary
Drugs and biologicals were not stored in locked compartments for 4 of 21 residents reviewed. During observation, a tube of hemorrhoid cream was found on Resident #24’s bedside dresser in plain view and accessible to anyone in the facility. Resident #24’s record showed diagnoses including cerebellar ataxia, peripheral vascular disease, and muscle weakness, and the MDS indicated a BIMS score of 15. The resident was also identified in the care plan as having an ADL self-care performance deficit and being at risk for not having needs met in a timely manner. Resident #27 was observed with ear relief ear drops on the bedside table and later at the bedside while asleep. Her record showed diagnoses including mild cognitive impairment and insomnia, with a BIMS score of 8 and highly impaired hearing. The order summary showed no order for Rexall ear relief ear drops. Resident #33 was observed with nystatin cream in a bucket on the nightstand while lying in bed watching television. Her record showed diagnoses including unspecified dementia, mild dementia, generalized anxiety disorder, and muscle weakness, and the order summary showed no order for Nystatin Cream 100,000 unit/gm. Resident #91 was observed with a Breyna inhaler on the nightstand during multiple observations while resting in bed, including one observation when oxygen was in place. His record showed diagnoses including cerebral infarction and generalized muscle weakness, and the order summary showed no order for Breyna inhalation aerosol 160 mcg/4.5 mcg. Interviews with the ADON, DON, LVN, and Administrator indicated that medications should not be accessible in residents’ rooms unless properly ordered and self-administered, and the DON stated the facility did not have a policy on medication storage.
Call Light Not Within Reach for a Blind Resident
Penalty
Summary
The facility failed to ensure Resident #73 had a call light within reach. Resident #73 was a male with diagnoses including type II diabetes mellitus, lack of coordination, unsteadiness on feet, muscle weakness, epilepsy, fatigue, age-related physical debility, legal blindness, angina pectoris, dysphagia, muscle wasting and atrophy, gait and mobility abnormalities, and major depressive disorder. The quarterly MDS indicated the resident understood and was understood by others, had a BIMS score of 9, and required maximal assistance with ADLs. The care plan identified impaired visual function and fall risk, with an intervention to keep the call light in reach when in the room or bathroom. During observations, Resident #73 was lying in bed while the call light was found on the floor under the bed and not within reach at 10:21 AM, 12:05 PM, and 2:14 PM. Staff interviews stated that aides and other staff were responsible for ensuring call lights were within reach, and the facility’s call light response policy stated that with each interaction in the resident’s room or bathroom, staff would ensure the call light was within reach and secured as needed. The DON, ADON, LVN, CNAs, and Administrator all stated they expected residents’ call lights to be within reach.
Unsecured Oxygen Cylinder Found in Resident Room
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible when an oxygen cylinder was found in Resident #31’s room without a caddy. Resident #31 was a male resident admitted to the facility with diagnoses including paraplegia and anxiety disorder. His quarterly MDS assessment reflected a BIMS score of 15, indicating intact cognition. During observation, he was sitting in his motorized wheelchair while a freestanding oxygen tank was present in his room without being secured in a caddy, and the same condition was observed again later that day. During interviews, the ADON stated the oxygen container should have been in a caddy and could have caused a hazard and potentially hurt a resident. The DON also stated the tank should have been in a caddy because it could have fallen over and caused a hazard to residents, and identified nursing staff and housekeeping staff as responsible for ensuring oxygen containers were secured. The Administrator stated there should not have been any unsecured tanks in the resident’s room. The facility policy on Oxygen Safety stated that cylinders must be properly chained or supported in racks or other fastenings to secure all cylinders from falling.
Unclean Oxygen Concentrator Filter
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident #37. The resident was a cognitively intact female with diagnoses including COPD, chronic respiratory failure, and morbid obesity. Her physician orders included oxygen at 2 liters via nasal cannula continuously every shift and changing oxygen tubing every Sunday night. Her care plan identified that she used oxygen therapy routinely or as needed and was at risk for ineffective gas exchange. During multiple observations, Resident #37 was sitting in her room or in a wheelchair with a nasal cannula connected to a running oxygen concentrator, and the concentrator filter had a gray fuzzy substance on it each time. Staff interviews indicated that nursing staff were responsible for checking, cleaning, and replacing concentrator air filters, but the DON stated the facility did not have an Oxygen Administration policy. The DON and Administrator both stated they expected the filters to be clean, and the Administrator was unsure who was responsible for cleaning them.
Infection Control Lapses During Catheter Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 1 of 20 residents reviewed, Resident #9. Resident #9 was a male with Multiple Sclerosis, type 2 diabetes, muscle weakness, and a suprapubic catheter. His record also showed he was dependent with personal hygiene and had an indwelling catheter. During an observation, CNA A and CNA B were providing catheter care while using EBP precautions. During the care, CNA A pulled Resident #9’s pants down and then began suprapubic catheter care without changing her gloves or sanitizing her hands. She cleaned the part of the catheter closest to the resident using both hands, then used the same gloves to touch multiple disposable bags while looking for the dirty bag to discard her used wipe. She later removed her gloves, sanitized her hands, donned clean gloves, and continued catheter care. Clear disposable bags were on the resident’s bedside table with his water cup while the care was being provided. During interviews, CNA A said she should have changed her gloves and sanitized her hands after pulling down the resident’s pants and before touching the catheter, and that touching the bags with dirty gloves and placing the dirty bag on the bedside table were cross-contamination and infection control issues. CNA B, LVN E, CNA C, ADON D, the DON, and the ADM all stated that gloves should have been changed and hands sanitized before moving from the resident’s clothing to catheter care, and that dirty bags should not have been placed on the bedside table, especially beside the resident’s drinking cup. Record review showed both CNAs were competent in perineal and catheter care, and the facility’s infection prevention and control policy required standard precautions and staff competence in infection control practices.
Failure to Provide Timely Respiratory Care and Communication of Change in Condition
Penalty
Summary
A deficiency occurred when a resident with significant respiratory and cardiac conditions, including acute on chronic respiratory failure, atrial fibrillation, and heart failure, was not provided timely and appropriate respiratory care. The resident was dependent on staff for most activities of daily living and had active orders for oxygen therapy. On the night of the incident, the resident became disconnected from her oxygen concentrator, resulting in severe hypoxia and acute respiratory distress. Despite the resident and her roommate activating the call light and requesting a nurse, the certified nursing assistant (CNA) who responded did not effectively communicate the resident's request or recognize the change in condition that required immediate nursing intervention. Multiple failures in communication and recognition of the resident's deteriorating condition were documented. The CNA did not notify the registered nurse (RN) that the resident needed a nurse, and another CNA who later assisted also did not report the change in condition, relying on the first CNA's assurance that the nurse had been informed. The RN only discovered the resident's distress by chance when entering the room to change the oxygen tubing as per routine orders. Upon assessment, the RN found the resident with blue fingertips, shallow breathing, and a pulse oximeter reading in the 50s. Emergency services were called, and the resident was transferred to the hospital, where she was diagnosed with acute hypercapnic respiratory failure and treated for severe hypoxia and heart failure exacerbation. Interviews with staff and residents confirmed that the CNAs did not recognize or report the resident's acute change in condition, and the nurse was not made aware of the urgent need for assessment until she entered the room for unrelated reasons. Facility records and disciplinary documentation indicated that the CNA involved was suspended pending investigation for failing to notify the charge nurse of the change in condition, and that there was a lack of adherence to facility policy regarding notification of significant changes in resident status.
Failure to Prevent Access to Hazardous Items and Ensure Fall Prevention Measures
Penalty
Summary
The facility failed to maintain a safe environment for three residents by not preventing access to potentially hazardous items. Resident #20, who had severe cognitive impairment, was found with a bottle of 91% isopropyl alcohol in his room, which he used for personal hygiene. Despite the facility's policy against residents having such items due to the risk of poisoning, the alcohol remained in his room until it was discovered and removed by staff. Resident #76, who was cognitively intact but had impaired visual function, was found with five razors in his bathroom. The facility's expectation was for staff to provide razors only when needed and to remove them immediately after use to prevent potential injury to other residents who might wander into the room. However, the razors were left in the resident's bathroom, posing a risk to other residents. Resident #5, who had severe cognitive impairment and a history of falls, was supposed to have a fall mat beside her bed as part of her care plan. On two separate occasions, the fall mat was found beside the wall instead of the bed, contrary to the care plan designed to prevent further falls. This oversight by the staff left the resident at risk of injury from potential falls.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed in their kitchen operations. During an inspection, it was found that the facility used unpasteurized eggs for preparing fried eggs, despite the requirement to use pasteurized eggs to prevent foodborne illnesses. The Dietary Manager admitted to not realizing that unpasteurized eggs were received and used, which was against the facility's policy and posed a risk of infection to residents. The grocery delivery records confirmed that a substitution was made due to the unavailability of pasteurized eggs, but this was not caught by the staff responsible for food safety. Additionally, the facility's kitchen staff did not have access to an operable paper towel dispenser, leading them to place paper towels on a clean dish rack, which compromised hygiene standards. This issue had persisted for months, and despite requests for a replacement, the previous administrator did not address it due to budget constraints. The improper placement of paper towels resulted in water splashing onto clean dishes, further increasing the risk of contamination and infection among residents. The facility also failed to ensure proper hand hygiene practices among kitchen staff. Observations revealed that staff members, including the Dietary Manager in training and a kitchen helper, did not wash their hands for the required duration and turned off the faucet before drying their hands, which is against proper handwashing procedures. These lapses in hand hygiene were acknowledged by the staff, who admitted to being unaware of the correct procedures or simply forgetting them. This negligence in hand hygiene practices posed a significant risk of spreading germs and infections to the residents.
Failure to Maintain Safe Food Storage in Resident Refrigerators
Penalty
Summary
The facility failed to maintain safe and sanitary storage of food items in the personal refrigerators of three residents. Resident #62's refrigerator contained expired whole milk, which was observed on multiple occasions without being removed. Resident #62, an elderly female with severe cognitive impairment due to dementia and other health conditions, was found resting in her room during these observations. Resident #61's refrigerator, which was actually his hospitalized roommate's, contained expired strawberry yogurt. Despite Resident #61 having intact cognition and being independent in most activities, the expired yogurt remained in the refrigerator over several days. Resident #61 was aware that the refrigerator had not been checked in a while, indicating a lapse in routine checks by the facility staff. Resident #56's refrigerator contained expired baked beans and macaroni and cheese, observed over several days without removal. Resident #56, who had intact cognition and was independent in her activities, was found in her room during these observations. Interviews with the facility's ADONs, DON, and Administrator revealed an expectation for staff to check and clean the refrigerators, but this was not consistently done. The facility's policy required weekly inspections and disposal of expired food, which was not adhered to, leading to the deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In the case of Resident #47, the room was found to have latex gloves, folded clothes, a clean disposable adult brief, and wet clothes left on the floor. Interviews with staff, including a CNA, LVN, the Director of Nursing, and the Administrator, confirmed that such practices were against facility policy and posed a risk of infection to residents. The staff acknowledged that used personal protective equipment should be disposed of in trashcans or biohazard bags, and clean items should be stored appropriately to prevent contamination. Resident #54's care was compromised by the improper handling of his gastrostomy tube piston syringe. Observations revealed that the syringe was left uncovered on the bedside table with visible white sediment, contrary to the order for it to be changed, dated, and bagged nightly. Interviews with the ADON, DON, and the Administrator highlighted the expectation for the syringe to be properly maintained to prevent infection. LVN U admitted to possibly misplacing the syringe, which increased the risk of bacterial buildup and infection for the resident. For Resident #5, the facility failed to adhere to Enhanced Barrier Precautions (EBP) during care. RN S was observed flushing and disconnecting the resident's gastrostomy tube without wearing a gown, despite the requirement for both gown and gloves under EBP due to the resident's feeding tube. The DON and Administrator confirmed that staff were expected to follow EBP protocols to minimize infection risks. The facility's policy on infection control emphasized the importance of using personal protective equipment and maintaining cleanliness to prevent the spread of infections.
Misappropriation of Resident's Funds by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her property by a Certified Nursing Assistant (CNA). The resident, who was moderately cognitively impaired, had given her debit/credit card and PIN to the CNA to purchase items for her. However, the CNA used the card for personal transactions, transferring money to her own Cash App account without the resident's consent. The resident was unaware of these unauthorized transactions until a meeting with facility staff revealed the misuse of her funds. The investigation into the incident showed that the CNA had made multiple unauthorized withdrawals and transfers from the resident's account, totaling $1,186.00. The resident had initially given the CNA permission to use her card for specific purchases, but the CNA exceeded this authorization by transferring additional funds to her personal account. The facility's Business Office Manager, along with other staff, discovered the unauthorized transactions during a review of the resident's bank statements. Interviews with the resident and facility staff confirmed that the CNA had misused the resident's financial information. The resident expressed her distress over the situation, acknowledging that while she had given the CNA her card for specific purchases, she did not authorize the additional transactions. The facility's Director of Nursing and other staff members were involved in the investigation, which led to the CNA's suspension and eventual termination. The facility reported the incident to the state agency and law enforcement for further action.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call button was within reach while she was in her bed, which is a violation of the resident's right to reasonable accommodation of needs and preferences. The resident, a female with dementia, high blood pressure, and GERD, was observed on multiple occasions without her call light within reach. During an observation, the call light was found hanging on the wall behind a room divider curtain, out of the resident's reach. The resident expressed that she did not know where her call light was and would walk to the door to alert staff if she needed anything. Interviews with staff, including a Treatment Nurse, ADON, DON, and the Administrator, confirmed that the call light should have been within the resident's reach to ensure she could call for assistance when needed. The facility's policy on call light response requires that call lights be within reach of residents during each interaction in their room or bathroom. The failure to adhere to this policy could result in residents not receiving timely assistance, potentially leading to falls or other adverse outcomes.
Inaccurate PASRR Level I Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessment for one resident, who was admitted with diagnoses of major depressive disorder and post-traumatic stress disorder. Despite these diagnoses, the PASRR Level I screening incorrectly indicated that the resident did not have a mental illness. This discrepancy was identified during a review of the resident's records, which showed that the resident had been receiving antianxiety and antidepressant medications, and had a BIMS score indicating intact cognition. Interviews with the MDS coordinator revealed a misunderstanding of the PASRR process, as the coordinator believed the resident would not qualify for PASRR services due to a lack of recent hospitalization related to mental illness. The coordinator also indicated that the form was not corrected because it was completed due to a change of ownership, and there was an assumption that the resident would not be deemed PASRR positive. The facility's policy requires coordination with the referring entity to correct any inaccuracies in the PASRR Level I screening, but this was not followed in this case.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain grooming and personal hygiene. Specifically, the resident did not receive scheduled showers on multiple occasions throughout January 2025, despite being cognitively intact and expressing a desire for regular showers. The resident, who had a history of stroke, depression, diabetes, and high blood pressure, required assistance with bathing due to hemiplegia affecting his right side. The care plan indicated that staff should assist with bathing, but the resident reported receiving showers only once a week instead of the scheduled three times per week. Interviews with staff revealed inconsistencies in the shower schedule and documentation. A CNA mentioned that the resident was scheduled for night shift showers but often requested showers during the day shift due to missed showers. An LVN and the state surveyor could not find any shower documentation for the resident in January 2025, and the LVN was unaware of the missed showers. The ADON and DON both stated that showers should be given according to the schedule and documented, with refusals noted in the resident's chart. The Administrator, who started at the facility recently, also emphasized the importance of adhering to the shower schedule for hygiene and infection prevention. The facility's policy on resident showers highlighted the need for proper hygiene and prevention of skin issues, but this was not followed in the case of the resident.
Failure to Follow Respiratory Care Protocols
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as observed during a survey. Resident #27, who has a history of respiratory failure, dementia, and diabetes, required oxygen therapy and CPAP use at night. However, the staff did not follow the facility's policy for dating the oxygen tubing and bagging the CPAP mask when not in use. Observations on two separate days revealed that the oxygen tubing was not dated, and the CPAP mask was left unbagged on the bedside table. Resident #290, diagnosed with dementia, anxiety, and a sleep disorder, was prescribed handheld nebulizer treatments. The facility's staff failed to bag and date the nebulizer when not in use, as required by the facility's policy. During observations, the nebulizer was found on the nightstand without being bagged or dated. Interviews with the LVN and DON confirmed that the nebulizer should have been bagged and dated to prevent infection control issues. The facility's policy on oxygen administration requires that oxygen tubing and masks be stored in a plastic bag and dated when not in use. The DON and Administrator both acknowledged the importance of these procedures to prevent infection. However, the staff's failure to adhere to these policies for both residents indicates a lapse in following established protocols, potentially compromising the residents' respiratory care.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a rate of 5.56% due to two errors out of 36 opportunities. The errors involved two residents who did not receive their medications as prescribed. Resident #37 did not receive his prescribed eye drops, Tetrahydrozoline HCL, due to the medication not being available in the facility. The medication aide noted that the eye drops had been ordered but not yet delivered, and the nurse was informed of the situation. Resident #80 was administered the incorrect form of aspirin. Instead of the prescribed chewable 81mg aspirin, the resident received an enteric-coated form. The medication aide acknowledged the mistake during an interview, stating she did not realize the error at the time of administration. The facility's Assistant Directors of Nursing (ADONs) and Director of Nursing (DON) expressed expectations that medications should be available and administered in the correct form as ordered. The facility lacked a policy for ordering medications, which contributed to the medication errors. The facility's existing policy on medication administration and documentation emphasized verifying labels and orders, checking medications against the MAR three times, and administering medications according to physician orders. However, these procedures were not adequately followed, leading to the identified deficiencies.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required by state and federal laws. This deficiency was observed in the case of a resident who had a white cream and a green powder substance found at her bedside inside medicine cups. The resident, who had intact cognition and did not exhibit behaviors of rejection of care or wandering, reported that the substances were for a wound on her bottom and that staff sometimes left them at her bedside or in the bathroom for her use. The physician's orders for the resident included apple zinc oxide barrier cream and nystatin external cream, but there was no order for a medication matching the green powder. During interviews, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both stated that medications should not be left at the bedside, as this poses a risk of ingestion or adverse reactions. The facility's policy on medication storage requires that all drugs and biologicals be stored in locked compartments and only accessible to authorized personnel. Despite this policy, the medications were left unsecured at the resident's bedside, indicating a failure to adhere to the facility's guidelines and potentially placing residents at risk.
Failure to Coordinate Hospice Care and Medication Management
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified through interviews and record reviews, which revealed that the facility did not obtain the most recent updated hospice medication profile for a resident. Specifically, there was a discrepancy between the hospice medication record and the facility's physician order regarding the administration of Lorazepam, an antianxiety medication. The facility's order indicated a scheduled administration every 12 hours, while the hospice medication record indicated administration every 4 hours as needed. The resident involved was an elderly male with multiple diagnoses, including dementia, cerebral infarction, high blood pressure, and malnutrition, who required total assistance for all activities of daily living and received more than half of his calories through a feeding tube. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, highlighted a lack of communication and coordination between the facility and hospice staff, which placed the resident at risk of receiving inadequate end-of-life care. The facility's policy on the coordination of hospice services emphasized the need for updated communication and documentation, which was not adhered to in this case.
Unsafe Discharge Practices Lead to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for two residents, leading to significant deficiencies. The first resident, a male with a history of hemiplegia, diabetes, and other health issues, was discharged without a proper plan or destination. Despite his cognitive awareness, he was left outside the facility after expressing a desire to leave against medical advice. The staff did not secure a safe environment for him, resulting in him being found hours later on the ground behind the facility, requiring hospitalization for atrial fibrillation and high blood pressure. The second resident, a male with a history of neck fracture and diabetes, was discharged to a motel without adequate support, despite needing supervision for some activities of daily living and being a moderate fall risk. The facility issued a discharge notice due to non-payment, but failed to ensure a safe discharge plan. The resident experienced multiple falls after being discharged, highlighting the lack of preparation and support provided by the facility. Interviews with staff and documentation revealed a lack of coordination and communication regarding the discharge plans for both residents. The facility did not adequately involve the residents in their discharge planning, nor did they ensure that the residents had a safe place to go. The failures in discharge planning and execution resulted in an Immediate Jeopardy situation, indicating a severe risk to resident safety and well-being.
Resident Elopement Due to Alarm System Failure and Inadequate Supervision
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that each resident received adequate supervision to prevent accidents. This deficiency was highlighted by the elopement of a resident with dementia, who left the facility through an alarmed door. The resident wandered approximately 200 yards down the road from the facility before being intercepted by a staff member and returned to the facility. The incident occurred because the door alarm was not responded to in a timely manner, and the resident was able to leave the premises unnoticed. The resident involved in the incident was admitted for respite care and had a diagnosis of dementia with other behavioral disturbances. The resident's care plan indicated a risk for wandering due to cognitive impairment, and interventions were in place to manage this risk. However, the facility's failure to respond to the door alarm and the malfunctioning of the wander guard system contributed to the resident's elopement. The maintenance director noted issues with the door alarm system, including a magnet that needed to be manually repositioned for the alarm to function properly. Interviews with staff revealed that there was a lack of communication and proper handover of admission paperwork, which contributed to the oversight of the resident's elopement risk. The nurse responsible for the resident's care was not informed of the admission or provided with the necessary documentation in a timely manner. This lack of communication and the malfunctioning alarm system were significant factors leading to the resident's unsupervised departure from the facility.
Removal Plan
- Resident #3 is no longer in the facility.
- The Maintenance Director/Designee completed environmental assessments to include checks on all doors.
- The ADON and/or designee completed elopement assessments on all facility residents with no changes noted.
- The ADON and/or designee completed in-service education with facility direct care nursing staff on the missing resident policy which ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.
- The facility RNC completed in-service education with the facility Admin and ADONs. Facility direct care nursing staff were trained prior to their next shift.
- The Missing Resident Policy Inservice Education included Residents will be assessed for risk of elopement and unsafe wandering upon admission, quarterly, and as needed throughout their stay at the facility.
- The ADON and/or designee completed a Missing Resident Drill with facility direct care staff to ensure staff know the proper procedure for locating missing residents to include when a staff member hears the alarm sound they will initiate the code silver alert to notify all other staff members of the missing resident.
- Facility direct care staff completed a missing resident drill prior to their next shift.
- The facility RNC completed in-service education with the facility Administrator regarding do not take a resident to their room without notifying the admitting nurse and providing the admission paperwork to them.
- Any staff member hired for direct nursing staff will complete during orientation by the facility DON and/or designee: In-service education with facility direct care nursing staff on the missing resident policy which ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.
- The DON and/or designee will complete a Missing Resident Drill with facility direct care staff during orientation to ensure staff know the proper procedure for locating missing residents to include when a staff member hears the alarm sound they will initiate the code silver alert to notify all other staff members of the missing resident.
- The ADON/Designee will conduct weekly random missing resident drills two times a week for six weeks to ensure facility staff know the proper procedure for locating missing residents to include when a staff member hears the alarm sound they will initiate the code silver alert to notify all other staff members of the missing resident.
- Results of weekly observations will be reviewed in the morning meeting by the Administrator or designee.
- The facility's Administrator notified the Medical Director to conduct an AdHOC QAPI meeting regarding the Immediate Jeopardy the facility received related to Free of Accidents/ Hazards/ Supervision and reviewed plan to sustain compliance.
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 199 citations issued within 25 miles in the last 12 months — including the 11 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 Kilgore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Grace Guest Care Center | 0.7 mi | ★★★★★ | 13 | 1 |
| Avir At Overton | 8.9 mi | ★★★★★ | 19 | 1 |
| Pine Tree Lodge Nursing Center | 11.8 mi | ★★★★★ | 20 | 2 |
| Highland Pines Nursing Home | 12.2 mi | ★★★★★ | 10 | 0 |
| Heritage At Longview Healthcare Center | 12.9 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 August 2026) and official state health department websites.