Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willowbend Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Maintain Privacy During Resident Treatment: An LVN checked a resident’s blood sugar and gave insulin with the door open and the resident visible from the hallway, an RN changed another resident’s G-tube dressing without pulling the privacy curtain while a roommate was present, and an LVN turned off a resident’s life vest while raising his clothing before the door was closed. The DON, ADONs, and Administrator stated that doors should be closed or privacy curtains pulled during care and treatment.
Unclean Resident Rooms and Bathrooms: Surveyors observed multiple resident rooms with dirt and dead gnats on windowsills, dust and dirt on AC units, stains and substances on shower and bathroom floors, and dust on a paper towel dispenser. Housekeeping staff said the entire room, including bathrooms and AC units, should be cleaned, and the Housekeeping Supervisor confirmed the areas should be mopped and dusted.
Missed Scheduled Showers and Inadequate ADL Hygiene Care: Four residents who required assistance with ADLs did not receive scheduled showers, with shower records showing little to no bathing documentation and resident interviews confirming repeated missed showers or only bed baths. One resident had matted hair, another had visible debris under his fingernails, and staff acknowledged missing shower documentation and that missed showers could lead to skin problems or skin breakdown.
A facility failed to keep resident areas free of hazardous items and to maintain a fall-risk resident’s bed in the lowest position. Aerosol sprays, Lysol products, hand sanitizer, and germicidal wipes were found in the rooms of several cognitively impaired residents, and three staff members left germicidal wipes on top of carts in hallways. A resident with severe cognitive impairment also had a bed that was not lowered as required by the care plan.
Improper Storage of Respiratory Equipment: A resident with BiPAP, two residents with nebulizer masks, and two residents using nasal cannulas were observed with respiratory equipment left unbagged or improperly stored when not in use. Staff interviews confirmed the masks and cannulas should have been bagged to keep them clean and prevent contamination, and the facility policy required oxygen equipment to be maintained in a clean and sanitary manner.
Surveyors found unsecured medications and biologicals in several resident areas and on a medication cart. An LPN left excess propranolol unattended on top of the cart while administering meds, and other staff observed peroxide, a saline nasal spray, an antifungal powder, and a topical roll-on analgesic in resident rooms in plain view rather than secured in the med cart. Staff stated these items should not have been left where residents could access them.
Dirty Coffee Station and Ice Equipment: The facility failed to maintain the dining area coffee station and a hallway ice machine in a clean and sanitary condition. Surveyors observed spilled coffee on the countertops, coffee machine, and floor, along with debris on the ice machine’s interior and exterior surfaces and a visibly soiled ice scoop used for resident service. Staff described routine cleaning schedules and said dirty equipment would be cleaned or removed from use if observed in that condition.
Staff failed to follow infection control and EBP requirements during resident care. A CNA did not perform hand hygiene when changing gloves during incontinent care for a resident with bowel and bladder incontinence, an RN changed a g-tube dressing without a gown for a resident with a feeding tube, an LVN performed treatment without a gown for a resident with an indwelling catheter, and a CNA changed linens without a gown for a resident receiving hemodialysis. Staff and leadership acknowledged the PPE and hand hygiene expectations.
Failure to Provide Dignified Mealtime Assistance: An RN was observed standing while assisting two residents during meals, including helping one resident drink and another resident eat. Both residents had severe cognitive impairment and required set-up assistance for eating; one had stroke-related deficits and the other had dysphagia. The RN stated she should have been sitting face to face with the residents, and the DON, ADON, and Administrator all stated staff should sit beside residents during mealtime assistance to promote dignity and respect.
Call Light Not Kept Within Reach: A resident with convulsions, muscle weakness, and moderate cognitive impairment was found in bed with his call light on the floor at the head of the bed. He said he used the call light but could not find it. The ADON retrieved it and placed it within reach, and the DON and Administrator stated that staff were responsible for ensuring call lights remained accessible.
Care plans for two residents did not reflect ordered respiratory treatments. One resident’s plan omitted oxygen therapy and nebulizer treatments despite MDS findings and physician orders for PRN oxygen and nebulized Ipratropium-Albuterol. Another resident’s plan omitted BiPAP use even though the MDS and physician orders reflected nighttime BiPAP for acute respiratory failure with hypoxia; staff interviews confirmed the respiratory items were not included in the care plans.
A facility failed to provide pharmaceutical services when an LVN left her personal coffee cup on top of a med cart during medication administration. The LVN stated the drink should not have been on the cart because it could cause cross contamination or be mixed with meds, and could also be taken by a resident and cause scalding. The DON, ADON, and Administrator stated personal beverages should not be on med carts.
Missing Smoking Assessment on Admission: A resident with acute respiratory failure with hypoxia, CHF, and tobacco use was admitted without a required smoking assessment in the chart. His MDS showed intact cognition, and his care plan included smoking interventions, but the clinical record contained no smoking assessment. The SW said it should have been completed on admission and was overlooked, and the DON confirmed the missing assessment after being informed by the SW.
A facility failed to immediately report and investigate a family member's concerns about a resident's care, including multiple falls, a change in condition, and additional rib fractures found at the hospital. Despite internal communication of the complaint, the required external reporting to authorities and investigation were not completed, in violation of abuse and neglect reporting regulations.
A medication aide was observed speaking loudly on a personal cellphone near a medication cart and common area, making an inappropriate statement within earshot of multiple residents. This conduct violated facility policy prohibiting personal calls on the floor and disrupted the peace and dignity of residents, as confirmed by the DON and Assistant Administrator.
Three residents with or at risk for pressure ulcers did not receive care consistent with professional standards, including missed weekly wound measurements and failure to reposition as required by care plans and physician orders. Observations and interviews confirmed that residents were left lying flat for extended periods without appropriate offloading or turning, and staff did not consistently follow prescribed interventions.
A resident with moderate cognitive impairment and renal issues was transferred to the hospital for dehydration and acute renal failure, but only a voicemail was left for a friend listed as the second emergency contact, without specifying the hospital. The primary emergency contact (POA) was not notified, and both the POA and friend were unaware of the resident's location, leading to police involvement to locate the resident. Facility staff confirmed that notification procedures were not followed according to policy.
A CNA failed to provide adequate supervision and assistance to a dependent resident with severe cognitive impairment and physical disabilities during a shower, resulting in a fall. The CNA attempted to reposition the resident alone by pulling on a mechanical lift sling while the resident was soapy and unable to support herself, causing the resident to slide out of the shower chair. Facility staff confirmed that two staff members were required for such tasks and that the CNA was alone at the time.
A CNA was accused of being rough with a resident during a transfer, but the facility failed to suspend the CNA pending investigation, contrary to its abuse prevention policy. The resident, who was severely cognitively impaired, denied feeling abused. Despite the policy requiring immediate suspension, the CNA was only moved to a different hall, potentially placing other residents at risk.
A facility failed to report an alleged abuse incident involving a resident to the state agency within the required timeframe. The incident involved a resident reportedly transferred roughly by a CNA. Despite the family member's report, the ADM did not notify the state agency, believing it was unnecessary since the resident did not confirm the abuse. This was contrary to the facility's policy, which requires reporting all allegations of abuse.
The facility's kitchen failed to meet food safety standards, with issues such as unlabeled and undated food items, including sliced cheese, diced peppers, and dialysis meal bags. A container labeled as flour contained expired sugar. The Dietary Manager and Cook acknowledged the importance of proper labeling to prevent foodborne illness, but the facility lacked a specific food storage policy.
The facility failed to provide a clean and homelike environment for several residents, as evidenced by unsanitary conditions in their bathrooms and shower rooms. A resident with anxiety-related diagnoses reported her bathroom was dirty, with observations confirming various stains and substances. Another resident, at risk for falls, lacked a shower curtain, leading to water spreading during showers. Additional residents expressed dissatisfaction with cleanliness, and observations revealed unsanitary conditions in shared bathrooms and shower rooms. Staff interviews indicated daily cleaning was insufficient, and the Housekeeping Supervisor did not view the unclean environment as a risk.
A resident with moderate cognitive impairment and multiple medical conditions was found using a significantly rusted and deteriorated bedside commode, which had been in disrepair since her admission two years prior. Facility staff acknowledged the issue but had not received any prior complaints, and there was no proactive maintenance policy in place.
The facility failed to secure medications in one of its medication rooms, leaving it unlocked and unattended. LVN E admitted to forgetting to close the door, which did not lock automatically. The room contained various medications, including those for diabetes and high blood pressure. Staff interviews confirmed the expectation that medication rooms remain locked to prevent unauthorized access and potential harm.
Failure to Maintain Privacy During Resident Treatment
Penalty
Summary
The facility failed to ensure resident privacy during medical treatment for three residents. Resident #10 had type 2 diabetes mellitus, a BIMS score of 12, and orders for sliding-scale insulin. During an observation, LVN C checked the resident’s blood sugar and prepared to administer insulin while the resident was seated in his wheelchair in front of his door, visible from the hallway and TV room, and the door was not closed. LVN C later stated she forgot to close the door and acknowledged the door should be closed during treatment to provide privacy. Resident #29 had dysphagia, a BIMS score of 00, and a feeding tube with an order to cleanse the G-tube stoma and apply a dry dressing. During an observation, RN E changed the resident’s G-tube dressing while the resident was in her wheelchair in front of her bed and her roommate was in the room, but the privacy curtain was not pulled. RN E stated she should have pulled the privacy curtain for privacy and said the door should be closed every time care and treatment were being provided. Resident #36 had ventricular fibrillation, a BIMS score of 12, and an intervention to wear a life vest daily. During an observation, LVN C was at the bedside turning off the resident’s life vest and raised the resident’s upper clothing while the resident was visible from the hallway; the door was not closed until ADON B entered and closed it. LVN C stated the door should have been closed for privacy during treatment. The DON, ADONs, and Administrator all stated that doors should be closed or privacy curtains pulled during care and treatment to provide privacy and prevent improper exposure.
Unclean Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to ensure resident rooms had a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 10 of 20 rooms observed. During observations of Rooms #1 through #10, surveyors noted dirt and dead gnats on a windowsill, black dirt and dust on air conditioning units and between vents, rust-like and black substances on shower floors, white substances under sinks and around toilets, grayish dirt stains and brownish stains on bathroom floors, dust and white substances on a paper towel dispenser, black stains on a windowsill, and a reddish spill stain on a windowsill and down the wall beneath it. In interviews, the Housekeeping staff member stated she cleaned the rooms on the Veteran's Way Hall and that the entire room, including bathrooms, air conditioning units, mini fridges, and floors, was to be cleaned. The Housekeeping Supervisor stated housekeeping was trained to clean from the back of the room to the front and to mop, dust, and clean bathrooms. The Administrator was informed of the concerns in Rooms #1 through #10 and stated he expected the rooms to be thoroughly cleaned. The facility policy on Safe/Comfortable/Homelike Environment stated residents are to be provided with a safe, clean, comfortable, and homelike environment and that cleanliness and order are included.
Missed Scheduled Showers and Inadequate ADL Hygiene Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the scheduled bathing and hygiene assistance needed to maintain good nutrition, grooming, and personal and oral hygiene. Four residents reviewed for ADL care—Residents #28, #87, #136, and #147—did not receive showers as scheduled during January 2026, despite care plans and MDS assessments showing they required assistance with bathing and showering. The facility’s ADL policy stated that appropriate care and services would be provided for residents unable to carry out ADLs independently, including assistance with hygiene such as bathing, dressing, grooming, and oral care. Resident #28 had diagnoses of muscle weakness and need for assistance with personal care, moderate cognitive impairment, and was totally dependent on staff for ADL care. Shower sheets showed no showers were provided until 01/21/26. During interview and observation, the resident stated he had only received maybe two bed baths since admission, wanted his scheduled showers, and had been given excuses by nursing staff; his hair was observed to be matted in the back. Resident #87 had muscle weakness and need for assistance with personal care, moderate cognitive impairment, and required substantial assistance for ADLs. Shower sheets showed only one shower in January 2026, and the resident stated he had only received one shower, was scheduled for showers three times weekly, and that a missed shower after physical therapy was not rescheduled. Resident #136 had muscle weakness and lack of coordination, intact cognition, and required substantial assistance for ADLs. Shower sheets for November 2025, December 2025, and January 2026 showed no showers, only bed baths. The resident stated he had only received bed baths during nearly a year at the facility and wanted showers, but staff told him there was no shower chair large enough for him; he was observed with a black substance under his fingernails. Resident #147 had muscle weakness and lack of coordination, intact cognition, and required substantial assistance for ADLs. Shower sheets showed only one shower in January 2026, and the resident stated he had been scheduled for three showers per week but had only received one since admission. Interviews with the ADON, CNA, LVN, and DON reflected that shower documentation was missing, some residents were said to have refused showers without supporting documentation, and staff acknowledged that missed showers could result in skin problems or skin breakdown.
Hazardous Items Left Accessible in Resident Rooms and on Staff Carts
Penalty
Summary
The facility failed to keep resident rooms free of hazardous items for several residents with cognitive impairment or limited ability to self-protect. Resident #22, a male with bladder cancer, heart failure, and chronic kidney disease, was observed asleep in bed with a can of air freshener spray on his nightstand and another can on a counter at the entrance of his room. Resident #27, diagnosed with neurocognitive disorder with Lewy bodies and requiring assistance with mobility and self-care, was observed asleep in bed while a family member sat at the table in his room; a bottle of Lysol spray and a bottle of multi-surface cleaner were on the table. The family member stated the resident was unable to get up and get the cleaning products and that she used the table for eating and projects. Resident #49, who had a cognitive communication deficit and a BIMS score of 04 indicating severe cognitive impairment, was not in his room when observed, but his room contained a 32-ounce pump bottle of alcohol hand sanitizer on the nightstand and a can of Lysol spray, a container of germicidal wipes, and a container of Lysol sanitizing wipes on the counter at the entrance. Resident #105, diagnosed with dementia and cognitive communication deficit, was sitting on the side of his bed when observed, and a can of air freshener spray was on the counter near his door. During interview, staff stated family members may have left the sprays and cleaning products in resident rooms and that the items should not have been left where residents could reach them. Resident #122, who had severe cognitive impairment, muscle weakness, and a history of falls, had a care plan intervention for the bed to be in the lowest position possible. During observation, her bed was not in the lowest position, and the LVN lowered it after the issue was identified. In addition, three staff members left containers of germicidal wipes on top of medication carts facing hallways where residents were passing by or sitting nearby. Staff and leadership stated the wipes should have been secured inside the carts because residents might access or misuse them, and the facility’s policy required a safe environment free from hazards as possible.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored properly when not in use for five residents who had orders or care plan interventions related to respiratory care. On 01/20/2026, Resident #12, a male with acute respiratory failure with hypoxia and an order to use BiPAP at bedtime, was observed lying in bed with a BiPAP nasal mask on the nightstand and not stored in a bag. Resident #87, a male with a diagnosis of iron deficiency anemia and an order for Ipratropium-Albuterol nebulizer treatment as needed for shortness of breath, was observed asleep with a nebulizer on the nightstand and the face mask and tubing connected to it, not stored in a bag. Resident #32, a female with chronic obstructive pulmonary disease and an order for continuous oxygen at 3 L/min via nasal cannula, was observed in bed with a nasal cannula attached to an oxygen tank at the back of her wheelchair. The nasal cannula was on the floor and was not bagged, and there was no bag at the back of the wheelchair. Resident #91, a male with fatigue and anemia and an order for Ipratropium-Albuterol inhalation solution for wheezing, was observed in bed with a nebulization machine on the side table and a breathing mask inside the drawer, not bagged. Resident #102, a male with acute respiratory failure with hypoxia and an order for continuous oxygen at 3 L/min via nasal cannula, was observed with the nasal cannula sitting on top of the bed and unbagged after returning from a smoke break. Staff interviews confirmed that the respiratory equipment should have been stored in bags when not in use. An LVN stated the breathing mask and BiPAP mask should have been bagged to prevent contamination and infection. An RN stated the nasal cannula should have been bagged when not in use. The DON, ADON, and Administrator also stated that nasal cannulas and breathing masks should be bagged when not in use, and the facility policy reflected that oxygen equipment should be maintained in a clean and sanitary manner, with masks or cannulas temporarily not being used covered loosely to prevent contamination from airborne microorganisms.
Unsecured medications found on carts and in resident rooms
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and were not left unsecured or unattended. Surveyors observed multiple medication storage issues involving four residents: one nurse left excess propranolol on top of a medication cart unattended while administering medications to a resident with hypertension and a BIMS of 14; a bottle of peroxide was found in the room of a resident with dementia and cognitive communication deficit; a saline nasal spray was observed on the side table in the room of a resident with COPD and dementia; and an antifungal powder plus a topical roll-on analgesic were observed on the side table in the room of a resident with dementia and osteoarthritis. For Resident #35, the nurse prepared propranolol, dropped two pills, placed the extra pill in a small cup, and left it on top of the cart while he went into the resident’s room to administer the medication. During observation and interview, the nurse stated he should not have left the medication unattended and should have disposed of it before leaving the cart. The DON, ADON, and Administrator each stated medications should not be left unattended on top of carts because residents could access them. For Resident #105, a bottle of peroxide was observed on the counter near the room door, and the resident stated he did not know how long it had been there. Staff stated it should not have been in the room and removed it. For Resident #102, a saline nasal spray was observed on the side table in plain view, and the ADON stated it should have been inside the cart and administered by staff. For Resident #150, an antifungal powder and a topical analgesic were observed on the side table in plain view, and staff stated these medications should not have been inside the room because they should be secured in the cart and administered by staff.
Dirty Coffee Station and Ice Equipment
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the only kitchen reviewed for food and nutrition services. During observation on January 20, 2026, the dining area coffee station was visibly filthy, with spilled coffee on the countertops, on the exterior surfaces of the coffee machine, and on the floor directly in front of the coffee station. The coffee residue was dry, indicating it had been present for an extended period of time and had not been recently cleaned. During the same observation, one ice machine in the main hallway was visibly dirty, with debris on both the interior and exterior surfaces. The ice scoop used for resident service was also visibly soiled, with brown spots and residue present. In interviews, the Dietary Manager, a Dietary Aide, a [NAME], ADMIN, and the Maintenance Supervisor described routine cleaning schedules for the coffee station and ice machines, and stated that visibly dirty equipment would be cleaned, sanitized, replaced, unplugged, or taken out of service if needed. The Maintenance Supervisor stated that maintenance cleans the ice machine monthly and that a contracted professional service performs deep cleaning every three months, and he agreed to provide documentation of the cleaning log.
Infection Control and PPE Noncompliance During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for four residents reviewed for infection control. During observation, interview, and record review, staff did not consistently use required hand hygiene and enhanced barrier precautions while providing care to residents with devices or conditions requiring PPE. For Resident #73, who had Parkinson's disease, hypertension, atherosclerotic heart disease, and was incontinent of bowel and bladder, CNA K provided incontinent care on 01/21/2026. CNA K cleaned the resident, removed soiled gloves, did not use hand sanitizer, and then put on a pair of gloves taken from the pocket of her scrub top before continuing care. CNA K stated she should have used hand sanitizer when she changed gloves and should not have carried gloves in her pocket for resident care. ADON L and the DON stated staff should sanitize hands with every glove change and should not use gloves carried in a pocket. For Resident #29, who had dysphagia, severe cognitive impairment, and a feeding tube, RN E was observed checking the g-tube site and changing the dressing on 01/20/2026. She washed her hands and wore gloves, but did not wear a gown while removing the old dressing and applying the new dressing. A sign outside the room indicated the resident was on EBP and PPE was required because of the g-tube. RN E stated she should have worn a gown because the resident had a g-tube and that the gown was required to help prevent spread of infection. For Resident #36, who had acute kidney failure, moderate cognitive impairment, and an indwelling catheter, LVN C was observed doing a treatment while leaning on the resident's bed and not wearing a gown. LVN C stated that if she was doing a treatment requiring contact, she should wear a gown to prevent transfer of microorganisms and spread of probable infection. For Resident #117, who had renal failure and was undergoing hemodialysis, CNA F entered the room with linens, wore gloves, and changed the resident's bedding without wearing a gown. A sign outside the room indicated the resident was on EBP and PPE was required. CNA F stated she should have worn a gown when changing the linens because the signage clearly indicated PPE was required. The DON, ADON B, and the Administrator stated that staff should wear gowns when residents are on EBP and that the expectation was for staff to adhere to infection control policy.
Failure to Provide Dignified Mealtime Assistance
Penalty
Summary
The facility failed to treat two residents with respect and dignity during mealtime assistance. Resident #81 was a male with left-sided hemiplegia, hemiparesis, and speech deficits following a cerebral infarction, and his MDS assessment showed severe cognitive impairment with a BIMS score of 00 and set-up assistance needed for eating. Resident #93 was a female with muscle weakness, dysphagia, and pneumonia, and her MDS assessment also showed severe cognitive impairment with a BIMS score of 00 and set-up assistance needed when eating. On 01/20/2026, RN E was observed walking around the dining area and, when she reached Resident #81's table, she picked up his glass and assisted him to drink while standing. She then continued walking around the dining area. Later that same observation period, RN E reached Resident #93's table, picked up her fork, took a piece of food with the fork, and gave it to the resident while standing. She then walked around the dining area again. During interview, RN E stated she should have been sitting down when assisting somebody in the dining area and said standing was not a way of showing respect and dignity. The DON, ADON B, and the Administrator each stated staff should sit beside residents when assisting during mealtimes to provide dignity and respect. The facility policy on Resident Rights Services stated residents have the right to a dignified existence and to be treated with respect and dignity.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure Resident #102’s call light was positioned within reach. Resident #102 was an [AGE]-year-old male admitted with diagnoses of convulsions and muscle weakness. His quarterly MDS assessment reflected moderate cognitive impairment with a BIMS score of 10, and he was documented as independent for transfer, toileting hygiene, showering, dressing, and bed mobility. His care plan identified him as at risk for falls related to convulsions and weakness and included an intervention to keep his call light within reach. During observation, Resident #102 was found in bed awake, and his call light was observed on the floor at the head of the bed. The resident stated he used his call light but could not find it. The ADON later entered the room, saw the call light on the floor, and placed it where the resident could reach it, stating that call lights should always be within reach and that staff were responsible for ensuring this. The DON and Administrator also stated that call lights should be within reach at all times, and the facility policy directed staff to place the call device within the resident’s reach before leaving the room.
Care plans did not include ordered respiratory treatments
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents whose assessments and physician orders reflected respiratory interventions. Resident #87, a male with diagnoses including iron deficiency anemia and diabetes, had a quarterly MDS that indicated oxygen therapy, but his comprehensive care plan dated 12/10/2025 did not reflect oxygen therapy or breathing treatments via nebulizer. His physician orders included PRN oxygen at 2-3 liters per minute via nasal cannula to keep oxygen saturation above 92% and an order for Ipratropium-Albuterol inhalation solution to be administered via nebulizer every 6 hours as needed for shortness of breath. Resident #12, a male with diagnoses including acute respiratory failure with hypoxia, diabetes, and chronic kidney disease, had a quarterly MDS that indicated respiratory therapy with mechanical ventilation, but his comprehensive care plan dated 12/10/2025 did not reflect a BiPAP machine. His physician order dated 11/24/2025 directed BiPAP use at bedtime related to acute respiratory failure with hypoxia. During observation, the resident was lying in bed with a BiPAP and attached nasal mask on the nightstand, and he stated he used the nasal mask at night because a face mask had been too tight. Interviews with the MDS Coordinator, DON, and ADON B confirmed the respiratory items were not included in the care plans and should have been.
Personal Beverage Left on Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for one LVN who was reviewed for pharmaceutical services. During an observation on 01/20/2026 at 9:35 AM, a cup from a coffee shop was seen on top of a medication cart parked in a hallway and left unattended beside applesauce that was being used during medication administration. During the observation and interview, the LVN stated the cup was her coffee and acknowledged that it should not have been left on top of the cart because it could cause cross contamination and could be mixed with medications she was preparing. She also stated a resident might drink it and could be scalded if it was hot. The DON, ADON, and Administrator later stated that personal beverages should not be on medication carts and should be kept in the break room, but the report did not include the facility policy when requested.
Missing Smoking Assessment on Admission
Penalty
Summary
The facility failed to follow its smoking policy for Resident #102 by not completing a smoking assessment upon admission. Resident #102 was a [AGE]-year-old male admitted on [DATE] with acute respiratory failure with hypoxia and a need for assistance with personal care. His Quarterly MDS Assessment dated 11/08/25 reflected intact cognitive response and active diagnoses of respiratory failure, congestive heart failure, and tobacco use. His Comprehensive Care Plan dated 11/08/25 included a smoking care plan with an intervention to complete a smoking assessment as needed, but the resident’s clinical record did not contain a smoking assessment. During an interview on 01/21/26 at 10:00 AM, the Social Worker stated there was no smoking assessment in the resident’s record and said it should have been completed when he was admitted by the admitting nurse, but it was overlooked. She also stated the resident needed a smoking assessment to ensure there were no dangers for him. During an interview on 01/22/26 at 8:51 AM, the DON stated the SW had informed her of the missing assessment and said the SW should have assessed the resident as soon as she found out he was a smoker. The facility’s undated Smoking Policy stated that any resident who wishes to smoke is to have a smoking assessment on admission by the SW or licensed nurse.
Failure to Timely Report Alleged Neglect and Injuries
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown source were reported immediately, but not later than two hours after the allegation was made, as required by regulation. Specifically, the facility did not report a family member's (FM) concern regarding the care of a resident who had experienced multiple falls and a change in condition. The FM expressed concerns to facility staff about the resident's care, including the timeliness of response to a possible stroke and the presence of additional rib fractures identified at the hospital. Despite these concerns being communicated to the social worker, assistant director of nursing (ADON), and later to the director of nursing (DON) and administrator, the facility did not report the allegations to the State Survey Agency or initiate an investigation as required by their own policy and federal regulations. The resident in question was an elderly male with severe cognitive impairment, a history of falls, and multiple comorbidities including atrial fibrillation, renal insufficiency, urinary tract infection, diabetes, cerebrovascular accident, malnutrition, and muscle weakness. He was dependent on staff for most activities of daily living and had experienced two falls with injury (not major) since admission. On the day of the incident, the resident exhibited right-sided weakness and difficulty feeding himself, prompting the nurse to notify the physician and arrange for hospital transfer for possible stroke evaluation. The FM later reported to staff that the hospital had found additional rib fractures, raising concerns about the adequacy of care and fall prevention in the facility. Interviews with facility staff revealed that the FM's complaints were communicated internally but not reported externally as required. The DON and administrator both stated that they did not believe the situation constituted neglect or required reporting, and no investigation was initiated. The facility's abuse and neglect policy mandates immediate reporting of all allegations to the administrator and appropriate agencies, but this protocol was not followed in this case. The failure to report and investigate the FM's concerns about the resident's care and injuries constituted a deficiency in the facility's compliance with abuse and neglect reporting requirements.
Staff Loud Personal Call Disrupts Resident Environment and Dignity
Penalty
Summary
Medication Aide A was observed speaking loudly on her personal cellphone near a medication cart, in proximity to a nurse's station and a common area where two residents were nearby and seven additional residents were watching television. During the call, Medication Aide A made an inappropriate statement, saying, 'I am so livid I could punch them in the face.' This behavior was audible down the hallway and continued for approximately two minutes before the aide exited the building through a side door. The aide later confirmed in an interview that she was on a personal call regarding a family member and acknowledged that her manner of speaking could have led residents to believe she was referring to them. Facility leadership, including the DON and Assistant Administrator, confirmed that staff are not permitted to take personal calls on the floor and that all staff are aware of this policy. The DON noted that Medication Aide A typically speaks loudly, and both the DON and Assistant Administrator recognized that such conduct could disrupt the peace and dignity of residents, potentially affecting those with PTSD. The facility's policy emphasizes residents' rights to dignity, respect, and a peaceful environment, which were not upheld in this instance.
Failure to Provide Consistent Pressure Ulcer Care and Repositioning
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards of practice for pressure ulcer management and prevention for three residents. Specifically, two residents with existing pressure ulcers did not have their wounds measured during weekly skin assessments as required by facility policy. This omission was confirmed through record reviews and interviews, with the Director of Nursing (DON) acknowledging that wound measurements were not consistently obtained, making it difficult to determine wound progression. Additionally, three residents were not consistently repositioned or turned according to their care plans, physician orders, and facility policy. Multiple observations showed that residents remained lying flat in bed for extended periods without repositioning or the use of pillows to offload pressure, despite care plans and orders specifying repositioning every two hours. Staff interviews revealed inconsistent adherence to turning schedules, with some staff relying solely on air mattresses or reporting that residents did not like to be turned, rather than following prescribed interventions. The residents involved had significant risk factors for pressure ulcers, including immobility, cognitive impairment, and comorbidities such as diabetes, malnutrition, and obesity. One resident was dependent on staff for all mobility, another was in a persistent vegetative state, and another had multiple wounds develop during their stay. The facility's own policy required weekly wound measurements and regular repositioning to prevent and manage pressure injuries, but these standards were not met, as evidenced by the lack of documentation and direct observations.
Failure to Notify Responsible Party and Emergency Contacts of Resident Hospital Transfer
Penalty
Summary
The facility failed to properly notify the responsible party and emergency contacts regarding a resident's transfer to the hospital for dehydration and acute renal failure. The resident, who had moderate cognitive impairment and a history of dehydration, malnutrition, and renal insufficiency, was transferred to the hospital following a physician's order. Documentation showed that only the resident's friend, listed as the second emergency contact, was notified via voicemail, which did not include the name of the hospital to which the resident was sent. The resident's Power of Attorney (POA), who was listed as the primary emergency contact on the face sheet, was not notified of the transfer or the resident's location. The friend who received the voicemail was also not informed of the hospital's name and had to visit the facility and subsequently contact the police to locate the resident. The facility staff eventually determined the resident had been transferred from one hospital to another, but this information was not communicated to the responsible parties in a timely manner. Interviews with facility staff, including the RN involved and the DON, confirmed that the POA should have been notified first, and that the lack of notification could prevent the responsible party from making necessary decisions for the resident. The facility's policy required notification of family or responsible party in the event of a change in condition, but this was not followed in this instance, as evidenced by the lack of timely and complete communication to the resident's POA and emergency contacts.
Failure to Provide Adequate Supervision During Resident Shower Results in Fall
Penalty
Summary
A certified nursing assistant (CNA) failed to provide adequate supervision and assistance to a resident with severe cognitive impairment and physical disabilities during a shower, resulting in a fall. The resident, who had dementia, a cognitive communication deficit, and an absence of the right foot, was totally dependent on staff for bathing and required two staff members for repositioning in the shower, as documented in her care plan. During the incident, the CNA attempted to reposition the resident alone by tugging on the mechanical lift sling while the resident was soapy and unable to support herself, causing the resident to slide out of the shower chair and onto the floor. No other staff were present in the shower room at the time, and the CNA called for assistance only after the fall occurred. Interviews with facility staff confirmed that the expectation was for two staff members to assist with repositioning residents in the shower when using a mechanical lift, and that staff should not pull on the sling to reposition residents due to the risk of falls. The CNA acknowledged being alone during the incident and attempting to reposition the resident without assistance. The incident was documented in the resident's progress notes, and the facility's policy emphasized the need for adequate supervision and assistance to prevent accidents.
Failure to Suspend CNA Following Abuse Allegation
Penalty
Summary
The facility failed to implement its own written abuse and neglect prevention policy and procedure for a resident reviewed for abuse and neglect. The incident involved a certified nursing assistant (CNA) who was accused by a family member of being rough with a resident during a transfer from a chair to a bed. Despite the allegation, the CNA was not immediately suspended pending investigation, as required by the facility's policy. Instead, the CNA was moved to a different hall and continued to work with other residents. The resident involved was an elderly male with a history of cerebrovascular disease, muscle weakness, and other medical conditions. At the time of the incident, the resident was severely cognitively impaired but able to express himself and understand others. The family member reported that the CNA was rough during the transfer, and the resident almost fell off the bed. However, when interviewed, the resident denied feeling abused or experiencing any pain. The facility's policy required the immediate suspension of any employee involved in an allegation of abuse, neglect, or exploitation pending investigation. However, the Director of Nursing (DON) and the Administrator (ADM) did not suspend the CNA because the resident did not confirm the alleged abuse. The Clinical Resource Nurse later confirmed that the facility's policy was to suspend the staff member involved immediately, highlighting a failure to follow established procedures, which could place other residents at risk of abuse.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the state agency within the required two-hour timeframe. The incident involved a resident who was reportedly transferred in a rough manner by a CNA, with allegations of being kicked and thrown onto the bed. The resident, a male with severe cognitive impairment and multiple medical conditions, was dependent on staff for transfers. Despite the family member's report of the incident, the facility's administration did not notify the state agency as required by their policy. The Assistant Director of Nursing (ADON) was informed of the alleged abuse by the resident's family member and conducted an assessment of the resident, finding no visible injuries or distress. The ADON reported the incident to the Administrator (ADM) and the Director of Nursing (DON), who then interviewed the resident. The resident did not confirm feeling abused or neglected, and the CNA involved was reassigned to a different hall. However, the ADM did not report the incident to the state agency, believing it was unnecessary since the resident did not confirm the abuse. The facility's policy on abuse prevention requires that all allegations of abuse, neglect, or exploitation be reported to the appropriate state or federal agencies within specified timeframes. The ADM's decision not to report the incident was based on the resident's response, which was contrary to the facility's policy. This failure to report placed residents at risk of continued abuse, trauma, and psychosocial harm, as the alleged abuse was not properly investigated or addressed by external authorities.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Several deficiencies were noted, including improper labeling and dating of food items. Specifically, a storage bag containing sliced cheese was found without a use-by date or content description. Additionally, a package of diced peppers and five supplemental meal bags intended for dialysis patients were not labeled with dates or contents. Furthermore, a container labeled as flour was found to contain sugar, which was past its use-by date. During an interview, the Dietary Manager (DM) acknowledged the oversight, stating that she usually ensures items are labeled with received and use-by dates. She admitted that the cheese was repackaged without her knowledge and that the sugar should have been discarded. The DM also identified the unlabeled vegetables as peppers and committed to labeling them. She expressed concern about the potential for foodborne illness and contamination, acknowledging the importance of proper labeling to prevent negative effects on residents. The Cook, when interviewed, confirmed his understanding of the need for correct labeling and proper storage of food. He emphasized the importance of providing high-quality food to residents to prevent illness. The facility administrator later revealed that there was no specific food storage policy in place, and they followed the Texas Food Establishment Rules, which do not specify requirements for labeling and dating food items. The U.S. FDA Food Code, however, outlines the necessity for labeling and dating food to ensure safety and compliance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, as observed in the conditions of their bathrooms and shower rooms. Resident #80, a female with moderately impaired cognition and anxiety-related diagnoses, reported her bathroom was dirty. Observations confirmed brown splatters and smudges on the grab bar and wall, a white chalky substance on the floor, and dark dried substances near the toilet. Resident #75, a male with intact cognition and a risk for falls, stated his shower curtain was removed a year ago and never replaced, leading to water spreading during showers. His bathroom also had dried liquid on the walls, a large wet spot on the floor, and a black substance around the shower edges. Resident #41, with moderately impaired cognition and a history of stroke, expressed dissatisfaction with the cleanliness of his room and bathroom, which had urine in the toilet and stains on the wall. Resident #84, also with moderately impaired cognition and at risk for falls, shared similar concerns about cleanliness. Observations of their shared bathroom revealed stains and substances on the walls and trim. Additionally, two shower rooms on Redwood Hall were found to have black and orange residues, with one room having a large brown splatter on a cabinet. Interviews with staff, including a CNA and the Housekeeping Supervisor, indicated that bathrooms were supposed to be cleaned daily, but sometimes required more frequent cleaning due to multiple users. The Housekeeping Supervisor acknowledged the need for deep cleaning but did not consider the unclean environment a risk to residents. The ADM confirmed the responsibility of the Housekeeping Supervisor for monitoring cleanliness and emphasized the importance of a clean environment for residents' comfort.
Failure to Maintain Safe Assistive Devices
Penalty
Summary
The facility failed to ensure that all assistive devices were maintained and free of hazards, specifically concerning the bedside commode used by a resident. The resident, who has moderate cognitive impairment and several medical conditions including dementia and peripheral vascular disease, was observed using a bedside commode that was in significant disrepair, with extensive rusting and paint loss on all metal bars. The resident reported that the commode had been in this condition since her admission to the facility approximately two years ago, but she had not reported it as she was unaware she could do so. Despite the commode's poor condition, the resident did not report any injuries from its use. Interviews with facility staff revealed a lack of proactive maintenance checks on equipment such as bedside commodes, with the maintenance department relying on nursing staff to report issues. The maintenance supervisor and other staff acknowledged the commode's poor condition and the potential risk it posed, but no prior complaints had been recorded. The facility did not have a specific policy for maintenance and equipment repair, relying instead on staff to submit maintenance requests when issues arose.
Medication Room Security Breach
Penalty
Summary
The facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents in one of the four medication rooms reviewed. Specifically, the medication room for Whispering Way was found unlocked and unattended on multiple occasions. During an observation, it was noted that the room contained various medications, including those for diabetes, high blood pressure, and high cholesterol, as well as a pneumonia vaccine. LVN E admitted to leaving the medication room unlocked, stating that she forgot to pull the door closed, and acknowledged that the door did not close automatically. Interviews with staff, including LVN E, RN F, and the DON, confirmed that the medication room should always remain locked to prevent unauthorized access and potential harm. The facility's policy, revised in July 2023, mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel. The failure to adhere to this policy could result in unauthorized access to medications, posing a risk of harm or drug diversion.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,053 citations issued within 25 miles in the last 12 months — including the 41 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 Mesquite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewood Rehabilitation And Care Center | 1 mi | ★★★★★ | 2 | 0 |
| Palomino Place | 1.3 mi | ★★★★★ | 13 | 1 |
| Mesquite Village Wellness & Rehabilitation | 1.6 mi | ★★★★★ | 6 | 0 |
| Town East Rehabilitation And Healthcare Center | 1.7 mi | ★★★★★ | 18 | 2 |
| Christian Care Communities And Services Mesquite | 3 mi | ★★★★★ | 4 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.