Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brush Country Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow professional standards for food storage, labeling, dating, sealing, and sanitation in the main kitchen and nourishment room. In the walk-in refrigerator, opened yogurt and cottage cheese containers were past manufacturer best-by dates and had unclear handwritten dates, while bags of cooked bacon, deli ham, and thawed fajita meat were unlabeled, undated, and/or not properly sealed. A large bin of individual prune juice containers near the serving line contained damaged and leaking containers with visible green mold-like growth on the containers and in the bin. In the nourishment room, the refrigerator shelves were visibly soiled with stains and food particles, and an expired container of mayonnaise was present. Staff, including the DM, cook, DA, LVN, Maintenance Director, DON, and ADM, gave inconsistent accounts of who was responsible for monitoring expiration dates and cleaning the nourishment room refrigerator, despite existing facility policies requiring proper labeling, dating, and maintenance of a clean and sanitary food service area.
Surveyors observed a medication cart left unlocked and unattended near a nurses’ station while an LVN sat out of view and residents and staff walked by. The cart contained residents’ prescribed medications, OTC drugs, narcotics, and treatment supplies. Facility policy required all medication carts to be locked when not in use and never left unattended. In interviews, the LVN, DON, and ADM all confirmed their training and understanding of this policy and stated that the assigned nurse or med aide is responsible for locking the cart, with management monitoring through observation rounds, but none could explain why the cart was left unlocked.
Two residents did not receive their prescribed pain medications due to the facility's failure to order oxycodone and Percocet in a timely manner. One resident missed multiple doses and reported withdrawal symptoms and pain, while another was without pain medication for less than 24 hours. Staff interviews revealed there was no formal policy for medication ordering, and nurse management lacked a clear process for monitoring medication supplies.
Surveyors found that medications were not properly secured or stored at the correct temperature. The medication refrigerator was operating above the recommended range for several drugs, and a medication cart was left unlocked and unattended in a hallway. Staff interviews revealed confusion about monitoring responsibilities, and facility policy requiring locked storage and temperature checks was not followed.
A resident with chronic pain and multiple comorbidities did not receive prescribed Oxycodone for pain due to medication unavailability and lack of timely action by staff. Despite ongoing reports of severe pain, staff failed to complete pain assessments or ensure the medication was obtained, resulting in the resident seeking emergency care for pain relief.
Two residents sharing a room, both requiring assistance with incontinence care and other ADLs, did not have a privacy curtain in place, resulting in a lack of privacy during personal care. Staff and residents confirmed the absence of curtains, and facility leadership was unaware of the issue until it was identified during a survey. There was no documentation indicating that the residents or their families had requested no privacy curtains, despite facility policy requiring privacy to be maintained.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, or serve food according to professional standards, resulting in a deficiency.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
Surveyors found that a resident did not receive an accurate assessment, as required. The inaccuracy in the assessment process was documented during the survey, but no further details about the resident's condition or history were provided.
A resident's care plan was found to be incomplete, lacking measurable timetables and specific actions to address all assessed needs. Documentation and planning did not fully reflect the resident's requirements, resulting in a deficiency.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
Surveyors found that food served to residents was often unappealing, bland, and improperly prepared, with vegetables left sitting in water and served mushy and unseasoned. Meal trays were inconsistently arranged, portions were small, and food temperatures dropped due to open meal delivery carts. Staff interviews confirmed lapses in food preparation and delivery, especially with new cooks in training, and complaints about cold and unappetizing food were reported by the resident council.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Surveyors found that the facility did not have an effective training program in place for all new and existing staff members, resulting in staff not consistently receiving the required training.
A nurse left a computer screen displaying a resident's confidential medical information open and unattended in a hallway, allowing potential access by unauthorized individuals. Facility leadership confirmed that this action violated expectations and policy for safeguarding electronic protected health information.
A plan to meet a resident's most immediate needs was not created or implemented within 48 hours of admission. Surveyors found no documentation or evidence that this requirement was fulfilled for a newly admitted resident.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Several residents did not receive their scheduled 5:00 pm medications, including treatments for hypertension, diabetes, seizures, depression, and pain. MARs confirmed missed doses, and interviews revealed a lack of monitoring and communication regarding these omissions. The facility's policy required timely administration, but this was not consistently followed.
A resident with paraplegia and existing pressure ulcers did not receive consistent wound care or weekly skin assessments as ordered, resulting in missed treatments and worsening of wounds. Staff interviews and documentation revealed that wound care was not provided as required, and assessments were not completed, leading to significant deterioration of the resident's condition.
The facility failed to maintain the required RN coverage for at least 8 consecutive hours a day, 7 days a week, over an 8-day period. On several days, there were either no RNs on duty or less than the required hours of coverage. The DON was often the only RN scheduled, and the facility relied on telehealth services when he was unavailable. Concerns were raised about inadequate staffing, particularly on one day when only one nurse was available for all residents.
The facility failed to provide timely pharmaceutical services for two residents, resulting in missed and late medication doses. One resident did not receive several scheduled medications, including carvedilol and ciprofloxacin, while another missed doses of armodafinil and omeprazole. Both residents received multiple medications outside the professional standard window. Interviews revealed complaints about late medications and issues with internet connectivity affecting records.
A resident was discharged with incorrect medication intended for another resident, due to a failure in verifying medications against the resident's chart. The error was discovered by the family after leaving the facility, but before administration. The resident, with a history of serious health conditions, was prescribed Furosemide 20mg but received 40mg tablets. Facility staff acknowledged the error and attempted to rectify it by sending a prescription to the pharmacy.
The facility failed to document incidents and vital signs accurately for three residents, leading to potential errors in care. A resident's abuse allegation and another's injury were not recorded in progress notes, while vital signs for a third resident were marked as 'N/A' for two days. The facility's policy mandates documentation of all services, changes, and incidents.
The facility failed to ensure resident privacy as staff entered rooms without knocking, affecting five residents. Some residents felt uncomfortable and startled by this practice. Staff interviews confirmed the importance of knocking, but practical difficulties and lack of a formal policy contributed to lapses.
The facility failed to properly maintain oxygen equipment for three residents, leading to potential infection risks. Observations showed that oxygen tubing and humidifier bottles were not changed weekly as required, with some bottles being empty. Interviews revealed inconsistencies in policy implementation, and the facility's policy lacked specific guidelines for safe handling and maintenance of oxygen equipment.
The facility failed to follow food safety standards, with unlabeled and undated food items in storage and improperly thawed sausage at unsafe temperatures. Staff interviews revealed misunderstandings of food safety protocols, despite having food handler training. These deficiencies risked residents' health due to potential foodborne illness.
A resident with dysphagia and other medical conditions did not receive the prescribed mechanical soft diet, instead receiving a regular diet tray. Facility staff interviews revealed a failure to follow the protocol of checking meal trays against meal tickets, resulting in the resident not receiving the correct diet.
A resident was discharged without proper documentation and planning due to non-payment. Key sections of the discharge planning review were left blank, and there were no progress notes from the social worker. Staff interviews revealed a lack of communication and coordination regarding the discharge, and the facility's policy on preparing a resident for discharge was not followed.
A resident with multiple medical conditions and moderately impaired cognition was discharged a day earlier than the 30-day notice indicated, due to corporate pressure. The facility failed to follow its discharge policy, leading to improper discharge.
A resident and her legal representative did not receive the results of a care plan meeting within the required timeframe, despite multiple requests. The Social Worker cited various reasons for the delay, including a malfunctioning printer and being busy with other tasks.
Improper Food Storage, Labeling, and Sanitation in Kitchen and Nourishment Room
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, dating, sealing, and sanitation of food items in the main kitchen and nourishment room. During a tour of the kitchen walk-in refrigerator, surveyors observed multiple previously opened containers of yogurt and cottage cheese with handwritten dates that did not specify whether they were received, opened, or use-by dates, and whose manufacturer best-by/use-by dates had already passed. Additional items in the walk-in refrigerator, including an open plastic bag of cooked bacon, a plastic bag of sliced deli ham with two different handwritten dates and an internal package past its use/freeze-by date, and two bags of thawed fajita meat, were found unlabeled, undated, and/or not properly sealed. Staff interviews revealed that dietary personnel, including the new Dietary Manager (DM), a cook, and a dietary aide (DA), were trained in labeling, dating, and storing food but had not consistently applied these practices. The DM, on her first day, stated that facility policy required all food to be properly sealed, labeled, dated, and expired items discarded, and that items should include receive, open, and use-by dates. The cook acknowledged that all food should have received and opened dates and that freshly cooked food must be used or discarded within three days, but admitted expired yogurt and cottage cheese were missed because she did not cook with those items. The DA stated she had not checked for expired food due to the absence of a dietary manager. Staff consistently stated that expired or improperly stored food could cause contamination and illness. In the nourishment room, surveyors observed a dirty refrigerator with red and brown stains, food particles on the shelves, and an expired container of mayonnaise. A large bin near the serving line in the kitchen contained approximately 30 individual prune juice containers, several of which were damaged, leaking, or empty, with prune juice residue and visible patchy, fuzzy, velvety green growth on multiple containers and on the bottom of the bin; the DM and DON identified the growth as appearing to be green mold. An LVN reported not knowing who was responsible for checking or discarding expired food in the nourishment room refrigerator and confirmed that the refrigerator appeared dirty. The Maintenance Director stated that laundry staff cleaned the nourishment room refrigerator monthly but there was no checklist, schedule, or documentation, and that dietary staff were responsible for monitoring expired food. The Administrator stated dietary staff were responsible for labeling, dating, sealing, and discarding expired food, housekeeping staff were responsible for ensuring the nourishment room refrigerator was clean and free of expired food, and that there was no policy specific to sanitization of the nourishment room refrigerator. Facility policies on Food Receiving and Storage and Sanitization required proper labeling, dating, and maintenance of a clean and sanitary food service area.
Unlocked Medication Cart Left Unattended With Medications Accessible
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications on one of four medication carts (MC #1) were properly secured and accessible only to authorized personnel. During an observation at the nurses’ station, surveyors found MC #1 unlocked and unattended while a nurse sat inside the nurses’ station out of view of the cart, with residents and staff walking by. The unlocked cart contained residents’ prescribed creams, prescribed drugs, over-the-counter medications, narcotics, catheters, and breathing treatment medications. The facility’s written policy on storage of medications, dated 4/2019, stated that drugs and biologicals must be stored in locked compartments and that unlocked medication carts are not to be left unattended. In interviews, LVN A stated he had been trained on medication storage and acknowledged that the policy required staff to lock the medication cart anytime they walked away, even briefly, and that the nurse assigned to the cart was responsible for locking it, although any staff member who noticed an unlocked cart could lock it. He acknowledged that a resident might get into an unlocked cart and did not know why he had left MC #1 unlocked. The DON and the ADM both confirmed they had been trained on medication storage and described the same policy expectations that medication carts must always be locked when not in use, with the assigned nurse or medication aide responsible for securing the cart. They each reported that nursing management, including the DON and ADM, monitored compliance by walking the halls and observing carts, and neither could explain why LVN A did not lock the cart at the time of the observation.
Failure to Ensure Timely Ordering and Administration of Pain Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the timely ordering and administration of pain medications for two residents. For one resident, who had a history of congenital malformation of the nervous system, somatization disorder, and spinal fusion, the facility did not order her prescribed Percocet (oxycodone with acetaminophen) in a timely manner, resulting in her missing 18 doses over several days. Documentation showed that the resident experienced significant discomfort, including headaches, sore throat, burning sensations, and reported withdrawal symptoms. The resident refused alternative pain medications offered, such as tramadol and ibuprofen, citing adverse effects, and only agreed to take Tylenol at one point. Progress notes indicated ongoing somatic complaints and repeated requests for her prescribed medication, with delays attributed to issues in obtaining the necessary triplicate prescription forms for controlled substances. A second resident, with diagnoses including hip fracture and above-the-knee amputation, also experienced a lapse in receiving his prescribed oxycodone for pain management. The medication was not ordered in advance, resulting in the resident being without his pain medication for less than 24 hours. The resident reported a moderate pain level and was unaware that the facility had run out of his medication until informed by staff. Interviews with nursing staff revealed a lack of a formal policy for timely medication ordering, and staff typically ordered medications only a few days before they were due to run out. Administrative interviews confirmed the absence of a policy or systematic process for monitoring medication supplies and ensuring timely reordering. Nurse management was identified as responsible for overseeing medication ordering, but there was no clear method in place for monitoring this process. The administrator acknowledged that running out of pain medication could result in residents experiencing severe pain, and was only aware of one resident's medication lapse at the time of the survey.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and security of medications in two key areas: the medication refrigerator and a medication cart (MC #1). During observation, the medication refrigerator was found to be operating at 52°F, which is above the recommended storage temperature range of 36°F to 46°F for several medications stored inside, including Lantus, NovoLog, Trulicity, and Repatha. Staff interviews revealed that while there was a policy requiring daily temperature checks by the night shift, there was confusion among staff regarding who was responsible for monitoring and ensuring the refrigerator maintained the correct temperature. The Director of Nursing (DON) confirmed the required temperature range and acknowledged that the facility had not established clear monitoring responsibilities following a recent change in refrigerator equipment. Additionally, MC #1 was observed unattended and unlocked in a hallway, containing both prescription and over-the-counter medications. No staff were present in the vicinity at the time of observation. Interviews with medication aides and nursing staff confirmed that facility policy requires medication carts to be locked whenever unattended and that both nurses and medication aides are responsible for ensuring this. Staff acknowledged that leaving the cart unlocked could allow unauthorized access to medications. Review of the facility's medication storage policy confirmed that all drugs and biologicals must be stored in locked compartments and under proper temperature controls. Despite this, both the medication refrigerator and MC #1 were not secured according to policy at the time of the survey, and staff were unable to provide a clear explanation for these lapses. The findings were based on direct observation, staff interviews, and review of facility policies and medication storage guidelines.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A deficiency occurred when a resident with chronic pain syndrome, migraines with aura, and other medical conditions did not receive appropriate pain management services as ordered. The resident had a physician's order for Oxycodone 5 mg every 6 hours as needed for pain, but the medication was not available in the facility for an extended period. Documentation showed that the resident was only administered a limited number of Oxycodone tablets shortly after admission, and there was no evidence of the medication being provided during the month of September, despite ongoing reports of pain rated as high as 7 out of 10. The pharmacy records confirmed that the Oxycodone prescription was not filled or delivered until much later, and the facility's medication administration records and narcotic count sheets corroborated the lack of availability. On one occasion, the resident complained of severe abdominal pain and requested her prescribed pain medication, but staff were unable to provide it due to its unavailability. The nurse offered Tylenol, which the resident refused, and the resident subsequently requested to be transferred to the emergency room for pain management. Progress notes indicated that staff did not complete a pain assessment at the time of the complaint, nor did they contact the nurse practitioner or physician in a timely manner to resolve the medication issue. Interviews with staff revealed confusion and lack of clarity regarding the process for obtaining triplicate prescriptions for controlled substances, and there was no evidence that the necessary steps were taken to ensure the resident's pain medication was available as ordered. The facility's own policies required comprehensive pain assessments and prompt interventions consistent with professional standards of practice and the resident's care plan. However, these procedures were not followed, as evidenced by the lack of pain assessments, failure to monitor the effectiveness of interventions, and inadequate communication with providers and pharmacy. The deficiency resulted in the resident experiencing unmanaged pain and requiring emergency transfer for pain relief.
Failure to Provide Privacy Curtains for Residents Receiving Personal Care
Penalty
Summary
The facility failed to ensure that resident rooms were equipped to provide adequate privacy for two residents who shared a room. Both residents, a female with severe cognitive impairment and mobility limitations, and a male with paraplegia and an indwelling catheter, required assistance with incontinence care and other activities of daily living. Despite their need for personal care, there was no privacy curtain in their shared room, which was observed during multiple staff and resident interviews. Interviews with the residents revealed that the female resident was uncomfortable and embarrassed by the lack of privacy during personal care, especially as she shared the room with her male family member. The male resident stated he was not bothered by the absence of privacy curtains but acknowledged it might affect his roommate. Staff members, including CNAs and an LVN, confirmed that there were no privacy curtains in the room and that they sometimes attempted to use sheets to provide some privacy. However, none of the staff had reported the missing curtains to facility management prior to the survey. Facility leadership, including the Assistant Maintenance Director, Administrator, and DON, were unaware of the missing privacy curtains until it was brought to their attention during the survey. There was no documentation or care plan indicating that the residents or their families had requested the removal or absence of privacy curtains. The facility's policy required the promotion and maintenance of resident privacy, but this was not followed in the case of these two residents.
Failure to Follow Approved Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which could impact the care planning and services provided to residents. Specific details about the residents involved, their medical history, or their condition at the time of the deficiency are not provided in the report. The deficiency centers on the inaccuracy of resident assessments, as observed and documented by surveyors during their review.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover the resident's assessed needs.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on all shifts.
Failure to Serve Palatable, Attractive, and Properly Prepared Food
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and prepared in a manner that conserved nutritive value, flavor, and appearance. Observations revealed that lunch meal trays delivered to residents in one hallway were unappealing, with poor arrangement and small side portions. Test trays showed inconsistencies, with one tray being well-presented and another containing overcooked, mushy, and unseasoned broccoli. Additionally, vegetables were observed sitting in water for extended periods before serving, resulting in a watery and mushy texture. The meal delivery cart doors were left open during meal delivery, exposing trays and reducing food temperatures. Staff interviews confirmed that vegetables should not be left in water, and that proper portioning and seasoning were not consistently followed, especially by new cooks in training. Further interviews indicated that complaints had been received from the resident council regarding cold food, and staff acknowledged that delays in meal delivery and improper handling of food carts contributed to this issue. The Certified Dietary Manager (CDM) admitted to being distracted during training, which led to oversight in food preparation practices. The facility's policy requires that meals be nourishing, palatable, well-balanced, and served at safe and appetizing temperatures, but these standards were not consistently met during the survey period.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and/or maintain an effective training program for all new and existing staff members. This deficiency was identified based on observations and review of facility practices, which showed that staff did not consistently receive adequate training as required. The lack of a comprehensive and ongoing training program for staff members was directly observed and documented by surveyors during the review.
Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to maintain the confidentiality of a resident's personal and medical records. During an observation, the RN left the medication cart unattended with the computer screen open and facing the hallway, displaying confidential medical information including the resident's name and medications. The RN acknowledged that the screen was left open and that anyone passing by, including visitors or other residents, could have accessed the information. The RN also admitted to having received in-service training on HIPAA protocols but did not recall the date and did not follow the required procedures to lock the computer screen when not in use. Interviews with facility leadership, including the Administrator and Director of Nursing (DON), confirmed that the expectation was for all resident information to be kept confidential and for computer screens to be locked when not in use. The facility's policy on safeguarding electronic protected health information requires that workstations be protected from unauthorized access, including placing terminals away from high-traffic areas and automatically locking screens. The failure to follow these protocols resulted in the exposure of a resident's confidential medical information.
Failure to Develop and Implement Immediate Needs Plan Within 48 Hours of Admission
Penalty
Summary
A plan to address a resident's most immediate needs within 48 hours of admission was not created or implemented. This deficiency was identified based on the absence of documentation or evidence that such a plan was developed and put into place for newly admitted residents. The lack of timely planning for immediate needs upon admission was observed during the survey.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Administer Scheduled Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of seven residents, as evidenced by the omission of scheduled medication doses. Multiple residents did not receive their prescribed medications at the scheduled 5:00 pm administration time on various dates. Medication Administration Records (MARs) confirmed that medications such as antihypertensives, antiepileptics, antibiotics, antidepressants, and pain management drugs were not administered as ordered. Residents and their family members reported missed doses, and staff interviews revealed a lack of awareness or documentation regarding these omissions. Residents affected had a range of medical conditions, including gastroesophageal reflux disease, hypertension, diabetes, seizure disorders, depression, and chronic pain. Care plans for these residents included specific interventions requiring timely administration of medications to manage their conditions. Despite these documented needs, the MARs showed repeated failures to administer medications as scheduled, and in some cases, associated assessments such as blood pressure or pain level checks were also omitted. Interviews with medication aides (MAs) and the nurse practitioner (NP) indicated that there was no consistent system in place to monitor or report missed medication doses. The NP stated that missed doses were not communicated to her, and the DON acknowledged ongoing issues with medication administration, noting that a staff member responsible for one of the affected halls had been terminated for poor performance. The facility's own policy required medications to be administered within one hour of the prescribed time, but this standard was not met for the residents reviewed.
Failure to Provide Consistent Pressure Ulcer Care and Assessments
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers for a resident with significant risk factors, including complete paraplegia, muscle weakness, and a history of sepsis related to a sacral wound. The resident was admitted with a stage IV pressure ulcer to the sacrum and an unstageable pressure area on the left heel. Despite physician orders for specific wound care treatments and the need for weekly skin assessments, the facility did not complete weekly skin assessments or consistently provide ordered treatments to the resident's wounds over a period of several weeks. Documentation revealed that the resident did not receive wound care treatments as ordered on multiple occasions for both the sacral wound and the left heel. The treatment administration records showed missed treatments, and there was a lack of weekly skin assessments following the initial admission assessment. The wound care doctor was not made aware of the pressure area on the left heel, and the wound care nurse had left the facility, leaving gaps in wound care oversight. The resident's wounds worsened during this period, with the sacral wound increasing in size and the left heel developing into a full-thickness open wound with necrotic tissue. Interviews with staff confirmed that weekly skin assessments were not performed, and treatments were not administered as ordered. The resident reported not receiving care to the left heel and was unaware of the wound due to paralysis. The nurse responsible for documenting treatments admitted to mistakenly signing off on treatments that were not performed. Observations confirmed the presence of an old, dated dressing on the left heel and significant deterioration of the wound. Facility policies required regular skin assessments and documentation, which were not followed, leading to the identification of an Immediate Jeopardy situation.
Removal Plan
- Resident #1 received a head-to-toe assessment including skin by the DON, findings of a worsening left heel were relayed to Medical Director and new orders received to clean wound with normal saline, pat dry, apply alginate with silver and cover with non-adherent dressing daily.
- Findings were relayed to the Medical Director.
- Emotional Distress Assessment completed for Resident #1 by the Social Worker with no emotional distress observed.
- Resident #1's Care Plan was updated by Corporate MDS Nurse regarding wound care and observations to be performed by staff. All nursing staff were in-serviced including PRN, agency staff and all newly hired staff prior to their shift.
- Charge nurses on staff conducted a 100% skin audit on 78 residents overseen by the DON. Charge nurses were in-serviced on proper skin assessment by the DON prior to the conduction of assessments. No other residents were identified as having unidentified skin issues.
- Administrator/DON initiated Staff in-service for ALL NURSING STAFF on Prevention of Pressure Ulcers, Pressure Ulcers/Skin Breakdown - Clinical Protocol & Abuse and Neglect. DON trained by VP of Clinical Services prior to start of in-service. If staff are unable to attend any of the in-services, they will be required to complete them before starting their assigned shift to include PRN staff, agency staff and any new hires.
- The Medical Director has been involved in developing the Plan of Removal. These conversations are considered a part of the QA process.
- A QAPI meeting was held with attendance of the Company President, Director of Nursing & VP of Clinical Services.
- This plan will be monitored through completion by corporate staff.
- Plan of Removal completion with continuation of oncoming staff and follow up.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was observed over a period of 8 days from January 1, 2025, to January 8, 2025. During this time, there were days when no RN was on duty, and on other days, the RN coverage was less than the required 8 hours. Specifically, on January 2, 6, and 7, 2025, there were zero hours worked by an RN charge nurse, and on January 1, 3, 4, 5, and 8, 2025, the RN coverage was less than 8 hours. Observations on January 7 and 8, 2025, confirmed the absence of RNs on the staffing sign-in sheet for certain shifts, with only one nurse working a 6-hour shift on January 8, 2025. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the DON was often the only RN scheduled to work, and there was no dedicated RN charge nurse on certain days. The DON mentioned that when he was not present, the facility relied on an outside telehealth service for triage. The ADM stated that they strive to have an RN in the building for the required hours but acknowledged the challenges in maintaining this coverage. A confidential interview also highlighted concerns about inadequate nursing staff on January 1, 2025, with only one nurse providing care to all residents during the morning shift.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services, including the timely administration of medications, for two residents. Resident #1 did not receive several scheduled medications, including carvedilol, hydralazine, isosorbide dinitrate, and ciprofloxacin, on multiple occasions. Additionally, several medications were administered outside the professional standard window of one hour before or after the scheduled time. These medications included sodium bicarbonate, Abilify, sertraline, amlodipine besylate, lisinopril, hydralazine, isosorbide dinitrate, ciprofloxacin, Acidophilus, Vitamin D3, Mirtazapine, and Med pass. Resident #1 had a history of metabolic encephalopathy, breast cancer, dementia, aphasia, dysphagia, acute kidney failure, depression, gastro-esophageal reflux disease, and hypertensive heart disease. Resident #2 also experienced issues with medication administration. He did not receive his armodafinil and omeprazole as scheduled and received several other medications outside the professional standard window. These included Jardiance, Toprol XL, Cholecalciferol, Vitamin C, senna-docusate, torsemide, citalopram, lactulose, ferrous sulfate, potassium chloride ER, Rivaroxaban, metformin, and diltiazem. Resident #2 had a history of encephalopathy, atrial fibrillation, dysphagia, heart failure, depression, diabetes mellitus, edema, and hyperlipidemia. Interviews with the nurse practitioner and the Director of Nursing revealed that there were complaints from residents about late medications, and the facility had issues with internet connectivity, which affected the accuracy of medication administration records. The facility's policy on administering oral medications did not provide specific guidance on medication timing, contributing to the deficiencies in pharmaceutical services.
Medication Error During Resident Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, resulting in the resident receiving incorrect medication. The resident, an elderly female with a history of metabolic encephalopathy, breast cancer, dementia, and other significant health issues, was discharged with a blister card of Furosemide 40mg tablets intended for another resident. This error was discovered by the resident's family after leaving the facility, but before any medication was administered. The resident was prescribed Furosemide 20mg tablets upon discharge, but instead received a higher dosage of 40mg tablets, which were meant for a male resident with different medical conditions. The facility's records showed that the resident's discharge medication list included the incorrect dosage, and the error was confirmed through interviews with the family and facility staff. The family provided photographic evidence of the blister card, which had the other resident's name and medication instructions. Interviews with facility staff, including the interim DON and ADM, revealed a lack of proper medication verification processes during discharge. The DON stated that medications should be checked against the resident's chart before dispensing, but this was not done in this case. The ADM acknowledged the error and mentioned that a prescription was sent to the pharmacy to correct the mistake. However, the family did not return the incorrect medication card to the facility. The incident raised concerns about potential adverse effects and a possible HIPAA violation due to the mix-up of resident information.
Deficient Documentation in Resident Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records of three residents, which could lead to errors in care and treatment. For Resident #1, an incident involving an allegation of abuse by two individuals was reported to the Administrator by a hospice social worker. However, there was no entry in the progress notes for the date of the incident, indicating a lack of documentation regarding the allegation and any subsequent plan of action. Resident #2, who has a diagnosis of dementia and moderate cognitive impairment, was involved in an incident where she pointed to a staff member and accused them of causing an injury. The resident had a tender and swollen finger, but the progress notes did not reflect any documentation of this self-reported injury of unknown origin. The Corporate RN acknowledged that the incident should have been documented to ensure follow-up care. For Resident #3, who has a history of coronary artery disease and other conditions, the treatment administration record for two consecutive days showed 'N/A' for vital signs, indicating that blood pressure, temperature, pulse, and respiratory rate were not recorded. The LVN confirmed this omission and noted the potential implications of not accurately recording vital signs. The facility's Charting and Documentation Policy requires that all services, changes in condition, and incidents be documented in the resident's medical chart to facilitate communication among the interdisciplinary team.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to uphold resident rights to personal privacy for five residents, as observed during a survey. Staff members, specifically CNAs, were noted entering residents' rooms without knocking, which is a breach of privacy. This practice was observed during meal tray deliveries, where CNAs entered the rooms of several residents without knocking, despite being trained on the importance of this protocol. Interviews with the residents revealed mixed feelings about the lack of knocking. Some residents expressed discomfort and a desire for staff to knock before entering, citing feelings of nervousness and being startled when staff entered unannounced. Others were less concerned but acknowledged that knocking would be preferable, especially in situations where they might be undressed or asleep. Staff interviews, including those with CNAs and the Director of Nursing, confirmed that the facility's policy requires staff to knock before entering a resident's room to respect their privacy and dignity. However, it was noted that there was no formal policy document regarding this practice. The staff acknowledged the importance of knocking and admitted to lapses in following this protocol, attributing it to practical difficulties such as carrying trays.
Oxygen Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to ensure the safe handling, humidification, cleaning, storage, and dispensing of oxygen for respiratory care services provided to three residents. Observations revealed that the oxygen tubing and humidifier bottles for Residents 9, 16, and 25 were not dated or changed weekly as required. Specifically, Resident 9's tubing and humidifier bottle were dated 7/14/24, Resident 16's were dated 7/3/24, and Resident 25's were dated 6/30/24 with the humidifier bottle being empty. These observations indicate a lack of adherence to the facility's policy of changing the tubing and humidifier bottles every seven days. Resident 9, a female with chronic obstructive pulmonary disease, congestive heart failure, and other conditions, had an order to apply oxygen as needed and to replace humidified water and tubing weekly. However, the tubing and humidifier bottle were not changed as per the order. Resident 16, a male with shortness of breath and other diagnoses, did not have an order for changing the tubing, which was not updated after his return to the facility. Resident 25, a female with limited physical mobility and other conditions, also had an order to change the humidifier water and tubing weekly, but this was not followed. Interviews with the Infection Control Practitioner (ICP), Director of Nursing (DON), Assistant Director of Nursing (ADON), and an LVN revealed inconsistencies in the understanding and implementation of the policy for changing oxygen tubing and humidifier bottles. The facility's policy, labeled Dynasty Health Care Group-Oxygen Administration, was found to be lacking in specific guidelines for the safe handling and maintenance of oxygen equipment. This deficiency placed residents at risk of developing respiratory infections due to potential contamination of the tubing and humidifier water.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation, as observed in their kitchen operations. During an inspection, it was noted that various food items in the walk-in refrigerator and freezer were not labeled or dated, including fruit cups, cooked ground meat, boiled eggs, drinks, chicken strips, hamburger patties, and English muffins. Additionally, breakfast sausage was found improperly thawed at a temperature of 63 degrees, which is above the safe temperature of 41 degrees or below. This improper handling and storage of food items placed residents at risk of foodborne illness. Interviews with kitchen staff revealed a lack of adherence to food safety protocols, despite having completed food handler training. One cook acknowledged the incorrect temperature of the sausage and disposed of it to prevent potential illness. Another staff member incorrectly stated the safe thawing temperature for meat, indicating a misunderstanding of food safety standards. The facility's Food Storage Policy and the FDA's Food Code were not followed, as evidenced by the lack of labeling, dating, and proper temperature control of food items, which could lead to bacterial growth and potential health risks for residents.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a physician-prescribed therapeutic diet to a resident who required a mechanical soft diet due to multiple medical conditions, including dysphagia, which poses a risk for choking. The resident was observed receiving a regular diet tray that did not match the prescribed mechanical soft diet, as evidenced by the meal consisting of a whole breaded chicken patty, spaghetti noodles, mixed vegetables, and a roll. This discrepancy was noted during dining services, and the resident confirmed receiving a regular diet for all meals. Interviews with facility staff, including an LVN, the DON, and the ADM, revealed that there was a protocol in place for nurses to check meal trays against meal tickets before serving them to residents. However, the staff did not know why the resident did not receive the correct diet. The facility's Tray Identification Policy required nursing staff to verify each food tray for the correct diet before serving, but this procedure was not followed, leading to the resident not receiving the appropriate mechanical soft diet as ordered.
Failure to Properly Document and Plan Resident Discharge
Penalty
Summary
The facility failed to ensure all residents were discharged per facility requirements, specifically for one resident who was discharged without proper documentation and planning. The resident, a female with multiple medical conditions including chronic kidney disease, diabetes, and depression, was discharged due to non-payment. The facility did not complete or document the discharge planning and summary in the resident's chart upon her discharge. Key sections of the discharge planning review were left blank, including the reason for discharge, recap of the resident's stay, and post-discharge medication list discussion with the resident or family. Additionally, there were no progress notes from the social worker on discharge planning and preparation. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's discharge. The social worker stated she was not in the building when the resident was discharged, and the Assistant Director of Nursing (ADON) mentioned that none of the staff knew where the resident was going. The Nurse Practitioner, who signed off on the discharge, was not involved in the discharge planning and only became aware of the discharge on the day it occurred. The Director of Nursing (DON) and the Administrator acknowledged that the discharge planning review and summary were supposed to be completed but were not. The facility's policy on preparing a resident for transfer or discharge was not followed. The policy required a post-discharge plan to be reviewed with the resident or their representative and for nursing services to provide discharge information and inform appropriate departments of the discharge. The failure to adhere to these policies and procedures placed residents at risk of improper discharges and inadequate post-discharge care.
Failure to Provide Timely Discharge Notice
Penalty
Summary
The facility failed to provide appropriate timing of notice before transferring a resident. Specifically, the facility did not provide the required 30-day notice before discharging a resident with multiple medical conditions, including benign neoplasm of the pituitary gland, gout, muscle weakness, hyperlipidemia, depression, edema, chronic kidney disease, unspecified convulsions, type 2 diabetes, spinal stenosis, hypothyroidism, morbid obesity, and chronic pain syndrome. The resident, who had moderately impaired cognition, was given a 30-day discharge notice due to non-payment, but was discharged a day earlier than the notice indicated. The discharge occurred without proper coordination and communication among the facility staff, the resident, and the resident's family member. Interviews with facility staff revealed that the discharge was expedited due to pressure from the corporate office, which demanded the resident be discharged within 24 hours. The Nurse Practitioner was unaware of the discharge until the day it occurred and was instructed to write the discharge order on short notice. The Administrator acknowledged that the discharge process had been ongoing for 90 days but did not provide a clear explanation for the premature discharge. The facility's policy on preparing residents for discharge was not followed, leading to the improper discharge of the resident.
Failure to Provide Care Plan Meeting Results
Penalty
Summary
The facility failed to provide a copy of the care plan meeting results to a resident and her legal representative within the required timeframe. Resident #1, a cognitively intact female with multiple medical conditions, including Gastro-esophageal Reflux Disease, Irritable Bowel Syndrome, and Chronic Pain Syndrome, requested the results of a care plan meeting held on 01/25/24. Despite multiple requests from the resident's family member (FM), who is also the responsible party, the facility did not provide the requested documents. The initial request was made on 02/04/24, followed by a reminder on 02/16/24, but as of 03/05/24, the documents had not been furnished. Interviews with the Director of Nursing (DON) and the Social Worker (SW) revealed that the SW was responsible for communicating care plan details to residents and their families. The SW cited various reasons for the delay, including a malfunctioning printer, a vacation, and being busy with other tasks. Additionally, the SW expressed uncertainty about disclosing the care plan details due to HIPAA concerns, despite the FM being listed as the responsible party on the resident's face sheet. This failure to provide the requested care plan results could impact the resident's involvement in their care planning and overall well-being.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 248 citations issued within 25 miles in the last 12 months — including the 14 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 Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Barton Valley Rehabilitation And Healthcare Center | 2.2 mi | — | 18 | 0 |
| West Oaks Nursing And Rehabilitation Center | 3.1 mi | — | 13 | 0 |
| Brookdale Westlake Hills | 4.2 mi | — | 9 | 0 |
| Querencia At Barton Creek | 4.7 mi | — | 3 | 0 |
| Southpark Meadows Nursing And Rehabilitation Cente | 4.9 mi | — | 5 | 0 |
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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.