Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
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 Garnet Hill Rehabilitation And Skilled Care during CMS and state inspections, most recent first.
A resident with anxiety disorder, paraplegia, and Alzheimer’s disease was receiving trazodone for insomnia, but the facility did not show that a GDR was considered or attempted after the medication was started. The care plan noted the need to review the antidepressant and consider tapering, yet progress notes did not document a GDR review, and a doctor recommendation asking for a trial dose reduction had no documented provider response. The NP said the review was denied because the resident did not want medication changes, while the DON stated GDRs were supposed to be considered every 90 days.
Failure to Provide Toenail Care: A resident with dementia, anxiety, and heart failure had severely overgrown toenails, including both great toenails extending about an inch past the toe and curving to the side. The resident said she had repeatedly asked staff to trim them or arrange podiatry, but no follow-up occurred. Interviews showed nursing and social services staff were aware of the issue and that the resident needed podiatry, while the facility policy stated routine foot and toenail care should be provided within staff scope of practice.
A resident admitted with a suprapubic catheter did not have physician orders in the chart for catheter care, and the April treatment record showed no catheter care orders or documented care. Staff interviews confirmed the resident sometimes performed his own catheter care and sometimes received help, but the LVN could not find any orders, and the DON and ADON stated the orders should have been entered after admission.
A resident with dementia, COPD, heart failure, and hypoxic respiratory failure received IV Invanz through a midline catheter, but the chart lacked physician orders for dressing changes, flushing, and monitoring for infection or infiltration. Staff observed the midline dressing dated several days earlier, and RN, ADON, DON, and NP interviews confirmed the absence of orders and that the dressing should have been changed on a routine schedule.
Failure to Document Review of Pharmacy Recommendations: A resident with anxiety disorder, paraplegia, Alzheimer’s disease, and mild cognitive impairment was receiving trazodone for insomnia and cyclobenzaprine for muscle spasm. The consultant pharmacist recommended a GDR trial for trazodone and review/switching of cyclobenzaprine due to geriatric contraindications, but the record did not show the attending physician documented review of the irregularities or any rationale for no change. Interviews with the ADON, NP, physician, and DON confirmed the recommendations were not clearly documented as acted upon in the chart.
A CNA transferred a resident with muscle weakness using a Hoyer lift without the required assistance of a second staff member, contrary to facility policy and recent training. Interviews and documentation confirmed that only one staff member was present during the transfer, and this practice had occurred on multiple occasions.
Two residents with COPD were not provided with safe respiratory care when their nasal cannulas were left unbagged and improperly stored after use, contrary to facility policy and professional standards. Staff interviews confirmed that the equipment should have been bagged for infection control, and one resident's care plan lacked an intervention for oxygen use despite a physician's order.
A resident with diabetes did not receive a scheduled dose of Farxiga because the medication was not in stock. Staff interviews revealed that the medication aide failed to re-order the medication in a timely manner, and the DON confirmed that the facility's procedures for medication ordering and receiving were not followed, resulting in the resident missing her prescribed medication.
A resident with moderate cognitive impairment and a documented sulfa allergy was given Bactrim, an antibiotic containing sulfa, without prior consent from her medical power of attorney. The allergy was not present in the facility's electronic records at the time, and staff did not notify the representative before administering the medication. The representative discovered the error after the fact, leading to the resident's transfer to the hospital and discontinuation of the medication.
A resident with a documented sulfa allergy was administered Bactrim after the allergy was omitted from the electronic medical record during a system transition. The allergy was not visible to staff or the NP when the medication was ordered and given. The error was discovered after the resident's representative raised concerns, leading to discontinuation of the medication and transfer to the hospital.
A resident's sulfa drug allergy was not transferred into the new electronic medical record system during a manual data migration, resulting in the resident being prescribed and administered Bactrim. The allergy was only discovered after administration, leading to discontinuation of the medication and hospital transfer. Staff interviews confirmed the omission and that the allergy was added to the system after the incident.
The facility failed to maintain privacy and confidentiality for residents during medical treatments and in handling personal health information. Instances included staff not closing doors during treatments and leaving sensitive information unattended, compromising residents' dignity and privacy.
A CNA improperly handled an ice scooper by placing it on top of ice in a bowl, with the handle touching the ice, during drink preparation for residents. This action, observed during lunchtime, violated the facility's infection control policy, which requires the scooper to be placed on a plate beside the ice bowl. The CNA used bare hands, increasing the risk of cross-contamination. Interviews with facility staff confirmed the correct procedure and acknowledged the deficiency.
The facility failed to ensure accurate MDS assessments for two residents, one with an external catheter and oxygen therapy, and another receiving hospice care. The discrepancies between the MDS assessments and the residents' care plans and physician orders were confirmed through observations and interviews with staff. The Administrator acknowledged the importance of accurate assessments to avoid misunderstandings in care provision.
A resident with an overactive bladder using a PureWick external catheter system was at risk of urinary tract infections due to improper storage of the catheter's connecting tube, which was found on the floor. Facility staff, including an LVN, ADON, and DON, acknowledged the oversight and the potential for cross-contamination. The facility's policy on perineal care was reviewed, but the specific policy for external catheter care was not provided.
The facility failed to properly store respiratory equipment for two residents, leading to potential contamination risks. A resident's suction machine and Yankauer were found on the floor, while another resident's nasal cannula was improperly stored, with prongs nearly touching the floor. Staff confirmed the equipment should be bagged and stored correctly to prevent infection, as per facility policy.
A resident with Alzheimer's was sexually assaulted by a visitor at an LTC facility. The facility lacked a visitor tracking system, allowing the visitor to enter and access the resident's room without detection. Staff were not adequately informed or trained on visitor access procedures, contributing to the incident.
A CNA in a LTC facility failed to follow proper incontinent care procedures for a resident with chronic kidney disease and overactive bladder, using the same wipes for different areas, risking cross-contamination and infection. The facility's policy requires a new wipe for each stroke to prevent such risks.
The facility failed to store medications securely for two residents, with a bottle of fish oil found on a resident's recliner and eye drops and Allegra tablets on another resident's overbed table. Both residents had moderate cognitive impairments and no physician orders or assessments for self-administration. Staff interviews revealed a lack of oversight, contrary to the facility's policy requiring medications to be stored properly and accessible only to authorized personnel.
A CNA in a LTC facility failed to follow proper infection control protocols during incontinent care for a resident. The CNA did not perform hand hygiene before putting on gloves, failed to change gloves and sanitize hands appropriately, and hung a new brief on a dirty surface. These actions were contrary to the facility's policies and could lead to cross-contamination and infection.
Failure to Consider GDR for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication had a gradual dose reduction (GDR) considered and attempted, unless clinically contraindicated. Resident #2 had a BIMS score of 11 and diagnoses including anxiety disorder, paraplegia, and Alzheimer's disease. She was prescribed trazodone 100 mg at bedtime for insomnia starting 07/31/25, and record review showed she received the medication daily as ordered. Her care plan noted a potential for discomfort and side effects related to antidepressant use and stated that a physician should review the medication and that a GDR or tapering may be needed before discontinuation. Record review of progress notes for September 2025, October 2025, and January 2026 did not show that a GDR was attempted or that the medication was reviewed for a GDR. A recommendation for doctor dated 01/16/26 stated that the resident was prescribed trazodone for insomnia since 7/25 and asked the provider to consider a trial dose reduction or document why a GDR was not indicated, but there was no additional document showing a provider response. During interview, the NP stated the GDR review for trazodone was denied because the resident refused medication changes, and the Physician said there was likely not a concern because no changes were made. The DON stated GDRs were considered every 90 days and that failing to consider them timely could leave a resident on a medication long term that might not be good for them. The facility policy stated that within the first year after a psychotropic medication is initiated, GDR attempts are required in two separate quarters with at least one month between attempts unless clinically contraindicated.
Failure to Provide Toenail Care
Penalty
Summary
The facility failed to ensure proper foot care and treatment for one resident, including trimming of toenails, in accordance with professional standards of practice. Resident #83 was a female with diagnoses including non-Alzheimer's dementia, anxiety disorder, and heart failure, and her BIMS score indicated severe cognitive impairment. Her MDS also showed she required substantial to maximal assistance from staff for personal hygiene, and she did not have diabetes. During observation, Resident #83 stated her only concern was her toenails. Both big toenails were observed to be approximately an inch past the tip of the toe and curved to the side, and the other toenails were approximately a quarter of an inch past the tip of the toe. Resident #83 stated she had been asking staff to trim them or to have podiatry come because she did not like seeing them that long. She stated nurses told her they were not able to cut them and that she needed to be seen by podiatry, but no one followed up with her regarding podiatry. Interviews showed CNA B, LVN A, the Social Worker, the ADON, and the DON were aware of the long toenails or the need for podiatry referral. CNA B stated nurses were responsible for trimming residents' fingernails and toenails. LVN A stated she had received report about the resident wanting her toenails trimmed and that the nails were too thick for staff to trim, and she said the resident needed a podiatry referral. The Social Worker stated the resident had last been seen by podiatry about 6 months earlier and that she was not sure why the resident was not being seen by the new podiatrist. The facility's 24 Hour Report/Changes of Condition Report noted the resident needed a podiatry consult/appointment, and the facility policy stated residents would be provided routine foot and toenail care within the professional scope of practice.
Missing catheter care orders for a resident with a suprapubic catheter
Penalty
Summary
The facility failed to ensure a resident with a suprapubic catheter had physician orders for catheter care after admission. Resident #6 was admitted with a suprapubic catheter, had a BIMS score of 15, and his diagnoses included renal insufficiency/renal failure/end-stage renal disease and diabetes mellitus. His care plan identified a urinary catheter problem and included interventions such as assessing for bladder distention, watching for irritation around the catheter, and providing catheter care/changing as ordered, but the April 2026 treatment record and physician orders did not reflect any catheter care orders or care for the catheter. Record review showed the resident arrived with the suprapubic catheter already in place and draining clear urine, with the site described as dry, clean, and intact. The resident stated he had the catheter placed at the hospital and mostly completed his own catheter care, though staff sometimes assisted him. CNA and LVN interviews confirmed he admitted with the catheter and that staff sometimes helped empty the bag or provided care, but the LVN could not find any catheter care orders in the chart. The DON and ADON both stated the resident should have had catheter care orders entered into the chart after admission, and the ADON said she did not review his chart because he was on her side of the building for only one night.
Midline Catheter Dressing and Order Management
Penalty
Summary
Facility staff failed to ensure safe administration of IV fluids for Resident #85, a male resident with diagnoses including non-Alzheimer's dementia, hypertension, acute respiratory failure with hypoxia, COPD, and heart failure. His BIMS score was 07, indicating severe cognitive impairment. He was receiving Invanz 1 GM for a UTI/ESBL, but the physician order did not include directions for changing the PICC/midline dressing, flushing the line, or monitoring for infection and infiltration. During observation, Resident #85 was lying in bed with a midline catheter in his upper left arm, and the dressing was dated 04/12. He stated he was doing well and denied pain or discomfort. RN C later reviewed the orders and confirmed the resident had completed antibiotic therapy, but there were no physician orders for midline dressing changes, flushing, or monitoring for infection. RN C also stated the dressing should be changed every 7 days, but she needed to obtain physician orders first. ADON F stated the expectation was for nurses to obtain physician orders for midline dressing changes, flushing before and after medication, and monitoring for infection, and that if the line was not removed after antibiotics were completed, nurses should still monitor the midline and change the dressing every 7 days. The DON also stated there should be orders for dressing change, flushing, and monitoring, but none were located in the chart. The facility policy for IV therapy required residents receiving infusion therapy to be monitored at established intervals and for staff to check the integrity of the system and dressing.
Failure to Document Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented in Resident #2’s medical record that identified drug irregularities had been reviewed and what action, if any, had been taken. Resident #2’s record showed diagnoses including anxiety disorder, paraplegia, and Alzheimer’s disease, with a BIMS score of 11 indicating mild cognitive impairment. She was receiving trazodone 100 mg daily for insomnia since 07/31/25 and cyclobenzaprine 10 mg daily since 09/25/25, and her quarterly MDS noted she had not completed any GDRs for her medications. The consultant pharmacist issued recommendations regarding both medications. On 09/17/25 and again on 10/21/25, the pharmacist documented that cyclobenzaprine was contraindicated in geriatric patients because of its strong anticholinergic effects and risk for cognitive impairment, weakness, and urinary retention, and recommended considering a different antispasmodic. On 01/16/26, the pharmacist recommended a trial dose reduction for trazodone and asked the provider to indicate if a GDR was not appropriate. The record review found no additional document showing the provider responded to or reviewed these recommendations, and progress notes for September 2025, October 2025, and January 2026 did not reflect that the pharmacy recommendations were acted upon. During interviews, the ADON stated she was responsible for ensuring the pharmacy recommendations were completed and reviewed, but she could not recall or provide proof that Resident #2’s recommendations had been reviewed in the earlier months. The NP and physician stated they received and reviewed the recommendations monthly, but the NP could not recall whether the specific recommendations for Resident #2 had been reviewed and said she reviewed them on the day of interview without making changes because the resident did not want her medications changed. The DON stated the ADONs were responsible for ensuring the recommendations were provided to the providers and followed up on, and that no one else ensured the recommendations were followed up on.
Single-Staff Hoyer Lift Transfer Performed Against Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a Hoyer lift without the required assistance of a second staff member. The resident, an elderly female with muscle weakness and incontinence, required extensive assistance with activities of daily living and was cognitively intact. According to the resident's care plan and the facility's policy, two staff members were required to operate the Hoyer lift to ensure safety during transfers. On the day of the incident, the resident was observed in bed with the Hoyer lift still positioned over her, and only one CNA was present in the room. Interviews with the resident and staff confirmed that the transfer was performed by a single CNA, despite the facility's policy and recent in-service training mandating two-person operation of the lift. The CNA involved acknowledged she was unable to find another staff member to assist and proceeded with the transfer alone. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both confirmed the two-person requirement for Hoyer lift use, and the facility's policy reflected this standard. Documentation and interviews indicated that this practice of single-staff transfers with the Hoyer lift had occurred on multiple occasions.
Failure to Properly Store Oxygen Delivery Equipment for Residents Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents with chronic obstructive pulmonary disease (COPD) by not ensuring that their oxygen delivery equipment was properly stored when not in use. For one resident, the nasal cannula was observed hanging unbagged on the bedrail after use, despite the resident only requiring oxygen at night and not having used it since early morning. The responsible LVN confirmed that the nasal cannula should have been stored in a bag for infection control, as per facility practice and policy. For the second resident, the nasal cannula was found unbagged on top of the bed while the resident was not present in the room. The ADON acknowledged that the nasal cannula should have been bagged when not in use to prevent infection, and that nursing staff were responsible for ensuring this practice. Additionally, the care plan for this resident did not include an intervention for oxygen use, despite a physician's order for oxygen therapy. The facility's policy required that cannulas be placed in a plastic bag and labeled if oxygen was to be administered on a PRN basis.
Failure to Ensure Timely Re-Ordering and Availability of Diabetes Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with diabetes by not ensuring the availability of a prescribed medication, Farxiga. The resident, who was cognitively intact and required daily Farxiga for diabetes management, did not receive her scheduled dose because the medication was not in stock. Interviews with staff revealed that the medication aide was responsible for re-ordering medications but did not do so in a timely manner, resulting in the medication being unavailable when needed. The LVN and DON confirmed that the medication should have been re-ordered when only a few doses remained, but this process was not followed. Record reviews indicated that the resident's care plan included administering medications as ordered to manage her diabetes and prevent hyperglycemic or hypoglycemic episodes. The facility's policies required staff to order and receive medications according to standard practice guidelines, but these procedures were not adhered to in this instance. The DON acknowledged that the resident's insurance only allowed a 14-day supply of the medication, which required more frequent re-ordering, but staff failed to ensure the medication was ordered and received in time.
Failure to Obtain Consent from Resident's Representative Prior to Administering Contraindicated Medication
Penalty
Summary
The facility failed to ensure that a resident's representative, who held both medical and financial power of attorney, was given the opportunity to exercise the resident's rights regarding consent for new medications. The resident, an elderly female with moderate cognitive impairment and a history of multiple allergies including sulfa, was admitted with diagnoses such as hypertension, UTI, and altered mental status. Despite the resident's cognitive limitations and the presence of a designated representative, the facility administered Bactrim, an antibiotic containing sulfa, without obtaining prior consent from the representative. Documentation showed that the resident's allergy to sulfa drugs was not present in the facility's electronic medical record at the time the medication was ordered and administered. The nurse practitioner prescribed Bactrim for a UTI, and the first dose was given by nursing staff after confirming with the resident, who verbally agreed. However, the representative was not contacted for consent, despite being listed as the medical power of attorney and having a history of being involved in medication decisions. The representative discovered the administration of the medication after the fact and expressed agitation, stating that consent should have been obtained. Interviews with facility staff revealed that the omission of the sulfa allergy in the electronic system was due to a transition in documentation platforms. Staff also indicated that it was standard practice to notify the representative for medication changes, especially given the resident's cognitive status. The nurse practitioner and nursing staff acknowledged that the representative was not contacted prior to administration, and the allergy was only identified after the pharmacy flagged it. The resident was subsequently transferred to the hospital at the representative's request, and the medication was discontinued.
Failure to Update Allergy List Leads to Administration of Contraindicated Medication
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident by not ensuring the resident's allergy list was accurately updated during a transition to a new electronic medical record system. Specifically, the resident had a documented allergy to sulfa drugs, among 37 other allergies, which was omitted when staff manually transcribed information into the new system. As a result, the allergy was not visible to staff or the nurse practitioner (NP) when new medications were ordered. Due to the incomplete allergy documentation, the NP prescribed Bactrim, a sulfa-containing antibiotic, for the resident's urinary tract infection. The medication was administered by nursing staff without knowledge of the sulfa allergy, as the system did not flag the allergy. The resident's responsible representative (RR) became agitated upon learning of the medication administration and expressed concerns about not being consulted prior to the medication being given. The medication was discontinued after the allergy was discovered, and the resident was subsequently transferred to the hospital at the RR's request. Interviews with facility staff, including the administrator, DON, nurses, and the NP, confirmed that the omission of the sulfa allergy was a result of human error during the manual data entry process. The NP stated she would not have ordered Bactrim had the allergy been visible. The incident was documented in the facility's incident log, and hospital records noted the resident's sulfa allergy and subsequent confusion following the administration of Bactrim. The failure to maintain an accurate allergy list directly led to the administration of a contraindicated medication.
Failure to Accurately Transfer Allergy Information During System Change
Penalty
Summary
The facility failed to maintain accurate medical records for a resident during the transition to a new electronic documentation system. Specifically, the resident's allergy to sulfa drugs was not transferred into the new system, despite being listed among 37 allergies on the resident's face sheet. This omission resulted in the allergy not being visible to staff and providers when new medications were ordered. As a result of the missing allergy information, a nurse practitioner prescribed Bactrim, a sulfa-containing antibiotic, for the resident to treat a urinary tract infection. The medication was administered before the error was discovered. The allergy was only identified after the resident's representative notified staff, prompting the discontinuation of the medication and subsequent transfer of the resident to the hospital for evaluation and treatment. Interviews with facility staff, including the administrator, DON, and nursing staff, confirmed that the sulfa allergy was not present in the new system at the time the medication was ordered and administered. The administrator acknowledged the error occurred during the manual transfer of records to the new system and stated that the allergy was added after the incident. No other residents were found to have similar errors during the transition.
Privacy and Confidentiality Breaches in Resident Care
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records, as observed in several instances involving four residents. In the first instance, two RNs did not close the door while administering a breathing treatment to a resident with chronic obstructive pulmonary disease. This oversight allowed the treatment to be visible from the hallway, compromising the resident's privacy. The RN acknowledged the mistake, stating that the door should have been closed to ensure the resident's dignity, especially since the resident was non-verbal and unable to express discomfort. In another case, an RN failed to close the door or fully pull the privacy curtain while administering medication through a g-tube to a resident with severe cognitive impairment. This lapse in privacy allowed the procedure to be visible from the hallway. The RN admitted forgetting to close the door or pull the curtain, recognizing the importance of these actions in maintaining the resident's dignity and privacy during medical treatment. Additionally, a medication aide left documents containing personal health information of two residents on top of a medication cart unattended. This occurred in a public area, making the information accessible to unauthorized individuals. The aide acknowledged the error, understanding that the information should have been kept confidential. Interviews with facility staff, including the ADON and DON, confirmed that these actions violated HIPAA regulations and the residents' rights to privacy and confidentiality.
Improper Ice Handling by CNA Leads to Contamination Risk
Penalty
Summary
The facility failed to ensure proper handling of ice to prevent contamination and potential waterborne illness. During lunchtime, a CNA was observed using an ice scooper to prepare drinks for residents. The CNA placed the scooper on top of the ice in the bowl, with the handle touching the ice, instead of placing it on a small plate beside the bowl. This action was repeated multiple times as the CNA prepared drinks for the residents. The CNA used bare hands to handle the scooper, which could lead to cross-contamination from the handle to the ice. Interviews with the ADON, DON, and the Administrator confirmed that the ice scooper should be placed on a plate beside the ice bowl to prevent contamination. The facility's policy on ice storage and sanitary care, revised in August 2018, specifies that ice scoops should be held by the handle and kept in a covered tray when not in use. The CNA acknowledged the mistake and admitted uncertainty about the cleanliness of the tray used to serve drinks. The improper handling of the ice scooper was identified as a deficiency in infection control practices at the facility.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the assessments for two residents accurately reflected their current medical conditions and care requirements. Resident #20's Quarterly MDS assessment did not indicate the use of an external catheter and oxygen therapy, despite the resident having a diagnosis of overactive bladder and respiratory failure. The resident's care plan and physician orders confirmed the use of a PureWick system and oxygen therapy, which were also observed during an interview with the resident and a Licensed Vocational Nurse (LVN). The LVN confirmed that the resident had been using the PureWick system since admission and was on oxygen therapy for respiratory failure. Similarly, Resident #49's Quarterly MDS assessment failed to reflect that the resident was receiving hospice care, despite the resident's care plan indicating admission to hospice due to cerebrovascular disease. During an observation and interview, it was noted that a suction machine provided by hospice was present in the resident's room. An LVN confirmed that the resident was in hospice care. Interviews with MDS Nurses revealed that the MDS assessments should have included these care details to ensure proper care and interventions were provided. The Administrator acknowledged the importance of accurate MDS assessments in reflecting the residents' current conditions to avoid misunderstandings about the care needed. The facility's policy on resident assessment emphasizes the need for accurate assessments to develop a comprehensive care plan that supports the residents' highest practical level of functioning and well-being. However, the discrepancies in the MDS assessments for Residents #20 and #49 indicate a failure to adhere to this policy, potentially impacting the residents' care and services.
Improper Storage of External Catheter Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. The resident, diagnosed with an overactive bladder, used a PureWick external catheter system every night. However, the facility did not properly store the external catheter, as observed on a specific date when the connecting tube was found on the floor. This improper storage could lead to cross-contamination and increase the risk of urinary tract infections. Interviews with facility staff, including an LVN, ADON, and DON, confirmed that the connecting tube should not be on the floor and should be cleaned and stored properly when not in use. The staff acknowledged the oversight and the potential for germs from the floor to transfer to the catheter, which would have direct contact with the resident's perineal area. The facility's policy on perineal care and incontinence care was reviewed, but the specific policy for external catheter care was not provided during the survey exit.
Improper Storage of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the storage and cleanliness of respiratory equipment. Resident #49, a female with severe cognitive impairment and chronic obstructive pulmonary disease, had a suction machine and Yankauer suction tip improperly stored on the floor under her bed. The Yankauer was not bagged, which could lead to contamination. LVN B confirmed that the equipment should not be on the floor and should be kept clean, regardless of its usage status. Similarly, Resident #64, who was diagnosed with shortness of breath and chronic obstructive pulmonary disease, had an oxygen concentrator with a nasal cannula improperly stored. The nasal cannula was hanging on the oxygen concentrator with its prongs nearly touching the floor, posing a risk of contamination. LVN C acknowledged that the nasal cannula should be properly stored even if the resident used it as needed. The nasal cannula was discarded due to potential contamination. Interviews with the ADON, DON, and Hospice Nurse I confirmed that the facility was responsible for maintaining the cleanliness and proper storage of respiratory equipment to prevent cross-contamination and infection. The facility's policy on infection prevention for respiratory therapy tasks emphasized the importance of storing equipment in a plastic bag marked with the date and resident's name, which was not adhered to in these cases.
Failure to Protect Resident from Sexual Abuse by Visitor
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a visitor. The resident, who was cognitively impaired with a diagnosis of Alzheimer's, was sexually assaulted by a visitor she did not know. The incident occurred when the visitor, who was there to see another resident, engaged in inappropriate and non-consensual sexual activities with the resident in her room. The facility did not have a procedure for tracking visitors, which allowed the visitor to enter and move around the facility without detection. The resident's care plan indicated she had severe cognitive impairment and required assistance with daily activities. Despite these needs, the facility did not have adequate measures in place to prevent unauthorized access to residents' rooms or to monitor interactions between residents and visitors. The lack of a visitor log and the posting of the door code outside the facility contributed to the visitor's ability to enter the building and access the resident's room without staff intervention. Interviews with staff revealed that they were not informed of the details of the incident and had not received training on changes to visitor access procedures. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to prevent the incident and the lack of timely reporting and investigation. The facility's inaction and inadequate monitoring placed residents at risk for abuse and emotional distress.
Improper Incontinent Care Leading to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, which could lead to urinary tract infections. During an observation, a CNA was seen using the same wipes to clean both the resident's lower abdomen and perineal area, instead of discarding the wipe after each use. This practice was contrary to the facility's policy, which requires using a different wipe for each stroke to prevent cross-contamination and infection. The resident involved was an elderly female with chronic kidney disease and an overactive bladder, who was frequently incontinent of both bowel and bladder. The CNA acknowledged the mistake during an interview, admitting that the improper technique could cause a urinary tract infection. The facility's policy clearly outlines the correct procedure for perineal care, emphasizing the importance of using a new wipe for each stroke to prevent infection.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications for two residents were stored in locked compartments, as required by regulations. Specifically, a bottle of Nature Made Fish Oil was found on Resident #6's recliner, and Equate Lubricant eye drops and Allegra tablets were found on Resident #7's overbed table. These medications were not stored securely, and there were no physician orders or assessments for self-administration of these medications for either resident. Resident #6, a male with dementia and depressive disorder, was observed with a bottle of fish oil on his recliner. His records showed no physician order for fish oil and no assessment for self-administration of medications. Similarly, Resident #7, a female with anxiety disorder, had eye drops and Allegra tablets on her overbed table without any physician orders or self-administration assessments. Both residents had moderate cognitive impairments, as indicated by their BIMS scores, and neither had care plans for self-medication. Interviews with facility staff, including LVNs, the ADON, the DON, and the Administrator, revealed a lack of awareness and oversight regarding the presence of medications in residents' rooms. Staff acknowledged that medications should not be in residents' rooms to prevent risks such as overdose, accidental ingestion, and choking. The facility's policy mandates that medications be stored properly and accessible only to authorized personnel, which was not adhered to in these instances.
Infection Control Lapses During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during incontinent care for a resident. The CNA did not perform hand hygiene before putting on gloves and failed to change gloves and sanitize hands appropriately during the care process. Specifically, after cleaning the resident's perineal area, the CNA changed gloves without sanitizing hands and did not change gloves after cleaning the resident's bottom before handling a new brief. Additionally, the CNA improperly hung a new brief on the wooden frame of the bed, which was considered a dirty surface, potentially leading to cross-contamination. The CNA acknowledged the failure to follow proper hand hygiene and glove-changing protocols, which could result in cross-contamination and infection. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed the importance of hand hygiene and the need to change gloves when transitioning from dirty to clean tasks. The facility's policies on perineal care and hand hygiene were not adhered to, as staff are expected to perform hand hygiene before and after care, change gloves appropriately, and avoid placing clean items on potentially contaminated surfaces. The failure to follow these protocols was recognized by the facility's administration, who acknowledged the risk of cross-contamination and infection due to these lapses in procedure.
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Illustrative
What surveyors actually found near you
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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
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Illustrative
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Nursing homes near Wylie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wylie Oaks Healthcare And Rehabilitation | 4.1 mi | — | 2 | 0 |
| Collinwood Nursing And Rehabilitation | 4.8 mi | — | 1 | 0 |
| San Remo | 4.8 mi | — | 3 | 0 |
| Victoria Gardens Of Allen | 5.7 mi | — | 13 | 0 |
| The Parks At Garland Healthcare And Rehab | 6.6 mi | — | 3 | 0 |
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