Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Heritage Gardens Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Surveyors found mechanical lifts on three resident halls parked unlocked and unsecured in corridor areas between or outside resident rooms, while lifts on another hall were properly locked, secured, and charging in empty rooms. An LVN and a CNA reported they were unaware the lifts on their halls were left unlocked, though both acknowledged prior in‑service training that lifts must be locked when not in use and stored on a designated hall, and noted that dialysis staff sometimes left lifts in the hallway for easy access. The DON stated she expected all lifts to be locked, secured, and not stored on hallways, but was unaware of the unlocked lifts and could not recall when staff last received in‑service training; review of facility policies showed no specific guidance on mechanical lift safety, storage, or related accident hazards.
An LVN left a laptop unlocked and unattended on a medication cart in a hallway between two occupied rooms, with the screen displaying residents’ medication information. Two staff and two residents walked past the exposed PHI while the device faced the hallway. The LVN, who believed she had locked the laptop, reported prior HIPAA/PHI training and usual practice of securing devices. A CNA on the same hall acknowledged that such a laptop would contain confidential medical records but did not notice it was unlocked when she passed by. The DON confirmed that computers should be locked when unattended and that staff are expected to maintain confidentiality, yet record review showed no recent in-services on privacy and no facility policy specifically addressing HIPAA, PHI, or safeguarding electronic records, and existing resident rights and medical record policies did not cover electronic privacy protections.
A cognitively impaired female resident with a history of cerebral infarction, bipolar disorder, memory deficit, and identified risk for psychosocial issues and re-traumatization was sexually touched over her clothing in the genital area by a cognitively impaired male resident with vascular dementia and other neurologic and mood disorders while they sat together in the dining room without staff present. Another resident witnessed the incident and reported it to the Administrator, and both the DON and Administrator later acknowledged being informed by an unidentified staff member of an allegation that the male resident touched the female resident’s private area. However, the female resident’s EMR contained no progress notes, incident reports, or witness statements about the allegation, demonstrating a failure to protect the resident from abuse and to document and address the reported incident.
The facility failed to report an allegation of sexual abuse between two cognitively impaired residents as required by regulation and its own abuse policy. A resident witness reported seeing one resident place a hand between another resident’s legs and touch the genital area in the dining room when no staff were present. The DON and Administrator acknowledged being informed of the allegation by staff but did not report it externally, citing both residents’ low BIMS scores, confusion, and their denials of the incident. No related progress notes, incident reports, or witness statements were found in the EMR, despite policy requiring immediate internal and external reporting of all abuse allegations.
The facility failed to investigate an allegation that a cognitively impaired male resident in the dining area touched a cognitively impaired female resident in her private area. Both residents had severe cognitive impairment and multiple neurologic and psychiatric diagnoses, and were care planned for significant ADL and cognitive deficits. The Administrator, acting as abuse coordinator, reported that the residents were separated and the male resident was placed on 1:1 and later discharged, but there was no documentation in either resident’s EMR of an abuse investigation or 1:1 monitoring. Interviews with leadership confirmed that no investigation had been completed, despite facility policy requiring immediate nursing examination, documentation, and prompt, thorough investigation of all abuse allegations.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A CNA did not change gloves or perform hand hygiene after providing incontinence care to a resident with dementia and mobility deficits. The CNA was aware of the required infection control procedures but did not follow them, as confirmed by both the Infection Preventionist and DON. This failure was observed and verified against the facility's handwashing policy.
Two nurse aides provided direct care to residents for several months without obtaining CNA certification, despite completing training and skills checkoffs. Facility staff were unclear about the 120-day certification requirement and responsibilities for tracking certification status, resulting in unqualified personnel performing resident care tasks beyond the permitted training period.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, on several occasions. The absence of an RN on these days, as confirmed by the DON, left residents at risk of inadequate medical care. The facility's procedure mandates daily RN services, which were not met.
The facility failed to ensure five residents could exercise their right to vote in the election cycle. Residents were not informed about voting options, and the Activity Director's efforts to obtain mail-in ballots were insufficient and undocumented. The Operations Manager also failed to document interactions and did not plan for in-person voting, leading to unmet mental and psychosocial needs.
The facility failed to prepare pureed meals to the required pudding consistency, resulting in pieces of pork and corn in the meals served to residents on pureed diets. The cook did not check the consistency before serving, and the Dietary Manager confirmed the error, which could pose a choking risk.
The facility failed to ensure five residents could exercise their voting rights in the current election cycle. Residents were not informed or assisted in voting, leading to dissatisfaction. The Activity Director and Operations Manager acknowledged inadequate efforts and lack of documentation. The facility's policy did not address voting rights, contributing to the oversight.
The facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents involving residents. An LVN did not adhere to enhanced barrier precautions when administering medication to a resident with a gastrostomy tube, failing to wear a gown as required. Another LVN did not follow proper infection control protocols during wound care for a resident with a pressure ulcer, neglecting to change gloves and perform hand hygiene. Both incidents highlight lapses in infection control practices, despite training being provided.
A facility failed to change a piston syringe daily for a resident with a feeding tube, as required by physician orders and facility policy. The resident, who was cognitively impaired and had a history of dysphagia, was at risk due to the staff's failure to adhere to the protocol, as confirmed by observations and staff interviews.
A facility failed to include dialysis in the baseline care plan for a newly admitted resident with end-stage renal disease, despite physician orders for hemodialysis five times a week. The DON confirmed that the care plan worksheet did not have an option for dialysis, leading to a lack of necessary instructions for effective and person-centered care.
A resident with end-stage renal disease missed a scheduled dialysis session due to miscommunication between the facility and the dialysis provider. The resident was admitted late in the evening, and the facility failed to ensure she was on the dialysis schedule for the following day, contrary to physician orders.
The facility failed to store food properly, as observed by surveyors who found withered and spotted produce, open and undated items in the freezer, and exposed dry goods. The Dietary Supervisor confirmed daily checks were conducted but acknowledged the risk of foodborne illness due to improper storage. The facility's policy and FDA guidelines emphasize preventing food contamination.
The facility failed to maintain an effective pest control program in Hall 300, where fruit flies were observed in several residents' rooms. Residents reported flies around their food, leading to refusal to eat at times. Staff acknowledged the issue, which persisted despite regular pest control services. Maintenance confirmed monthly pest control visits, but no specific treatment for flies was recorded recently.
The facility failed to provide necessary supervision and assistance for two residents, leading to deficiencies in their grooming and personal care. A resident with dementia and a history of stroke was left unsupervised with a razor, contrary to her care plan. Another resident with Parkinson's disease and moderate cognitive impairment was observed using the bathroom without required staff supervision, increasing her fall risk. These actions were against the facility's policy to maintain residents' well-being.
A resident with an indwelling urinary catheter was observed with the drainage bag touching the floor and overfilled, contrary to the facility's care plan and policy. Staff interviews revealed that CNAs were responsible for maintaining the catheter bag, supervised by nurses, but the bag was not properly managed, posing an infection risk. Despite training, the deficiency persisted, indicating a failure in implementing catheter care procedures.
The facility failed to maintain a safe environment in Shower Room A, where a resident reported experiencing cold showers. Maintenance checks revealed the water temperature did not exceed 77 degrees, below the required 100 to 110 degrees. Despite weekly checks showing compliant temperatures, no complaints were reported to the DON or Administrator. The maintenance director or designee is responsible for overseeing water temperature checks.
Unlocked and Improperly Stored Mechanical Lifts on Multiple Halls
Penalty
Summary
The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible by not ensuring mechanical lifts were locked, secured, and properly stored when not in use on three of four resident halls (200, 300, and 400). During observations on multiple halls, surveyors found one unlocked and unsecured mechanical lift parked between two resident rooms on the 200 Hall, another unlocked and unsecured lift parked outside a resident room on the 400 Hall, and a third unlocked and unsecured lift parked outside a resident room on the 300 Hall. At the same time, the 500 Hall, which contained only empty rooms, had several mechanical lifts that were locked, secured, plugged in, and recharging. Interviews with staff revealed that licensed and unlicensed personnel were unaware that the mechanical lifts on the 200, 300, and 400 Halls were parked unlocked and unsecured. An LVN assigned to the 100 Hall stated she did not know the lifts on the other halls were left in that condition, although she acknowledged having received in‑service training on mechanical lift safety and storage and stated that lifts were supposed to be locked when not in use and stored on the 500 Hall. She reported that staff from the dialysis center located in the facility sometimes left mechanical lifts outside the dialysis center for easy access. A CNA assigned to the 200 Hall similarly reported she was unaware of the unlocked lift on her hall, acknowledged prior in‑service training on lift usage, safety, and storage, and stated she had previously seen lifts on the 300 and 400 Halls without checking whether they were locked. The DON, who had been employed at the facility for several years, stated she was unaware that the lifts on the 200, 300, and 400 Halls were parked unlocked and unsecured. She confirmed her expectation that all mechanical lifts in the building be locked and secured when not in use and not stored on resident hallways, but instead stored on the 500 Hall. The DON stated that staff had been educated and trained on proper usage, safety, and storage of mechanical lifts, including the requirement to keep them locked and secured, but she could not recall when the last in‑service training occurred. Record review showed the facility had an undated mechanical lift policy and an incident reporting policy revised in 05/2025, neither of which contained information regarding accidents and hazards related to mechanical lift safety and storage.
Unattended Unlocked Laptop Exposes Resident PHI in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ personal privacy and the confidentiality of their medical records when an LVN left a laptop unlocked and unattended on a medication cart in a resident care hallway. On the specified date and time, a state surveyor observed a laptop on top of the medication cart between two occupied resident rooms on the 100 Hall. The laptop screen was on, unlocked, and displaying residents’ medication information that needed to be passed. The cart and laptop were unattended, and the laptop was positioned facing the hallway, making the information potentially visible to anyone walking by. During the observation period, two staff members and two residents walked past the unattended, unlocked laptop on the 100 Hall. The LVN later identified the laptop as hers and stated she had been using a hallway outlet to charge it while assisting a resident in their room. She believed she had locked the laptop before leaving it but acknowledged that, at the time of the surveyor’s observation, it was unlocked on the medication cart. The LVN reported she had been employed at the facility for 29 years and had received multiple in-service trainings on HIPAA, PHI, and protecting patient information, and that she normally locked laptops, computers, and medication carts when not in use. She also stated she was unaware that the surveyor had previously observed the same laptop unlocked and unattended earlier that morning. A CNA assigned to the same hall and shift reported she walked past the laptop on the medication cart but did not notice it was unlocked and did not know which staff member had last used it. She stated that such a laptop would contain patient records, including confidential medical information that should not be seen by unauthorized individuals, and that if she noticed an unlocked device she would notify the charge nurse. The DON, when interviewed, stated she was unaware of the incident but affirmed that computers and laptops should always be locked when unattended and that all employees were expected to maintain privacy and confidentiality of patient information. Record review showed that, for the period reviewed, there were no in-service trainings on residents’ privacy, and the facility lacked a specific policy on HIPAA, PHI, or safeguarding electronic records. Existing written policies on resident rights and medical record content did not address HIPAA, PHI, or electronic record safeguards, despite the facility’s practice of following HIPAA guidelines.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to recognize, document, and respond appropriately to an allegation of sexual abuse between residents. On 01/25/2026, video evidence showed a male resident (Resident #2), who had severe cognitive impairment and diagnoses including vascular dementia with mood disturbance, depression, cerebral infarction, and cognitive communication deficit, placing his hand between a female resident’s (Resident #1) legs and touching her private area over her pants while they were in the dining room. Resident #1 also had severe cognitive impairment with diagnoses including cerebral infarction, bipolar disorder, and memory deficit, and her care plan identified risks related to impaired cognitive function, psychosocial well-being, and re-traumatization due to a history of trauma from other resident violence. At the time of the incident, no staff were present in the dining room, as confirmed by another resident (Resident #3) who witnessed the event. Despite the allegation being reported to the Administrator by a resident witness and to the DON and Administrator by an unidentified staff member around the end of January 2026, the facility’s records for Resident #1 contained no progress notes, incident reports, or witness statements regarding the abuse allegation. The Administrator, who served as the abuse coordinator, and the DON both acknowledged being informed of an incident in which Resident #2 attempted or was alleged to have touched Resident #1 in her private area, but neither could recall which staff member reported it. When interviewed, Resident #1, who was alert and willing to speak but severely cognitively impaired, denied remembering anyone touching her inappropriately. The lack of documentation and investigation in the EMR, combined with the absence of staff supervision at the time of the incident, formed the basis of the cited failure to ensure the resident’s right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of sexual abuse between residents to the State Agency and other required authorities, as mandated by regulation and facility policy. Resident #1 was a cognitively severely impaired female with a history of cerebral infarction, bipolar disorder, memory deficit, left-sided paralysis, TIA, depression, fall risk, social isolation, and a documented care plan entry indicating risk for re‑traumatization related to prior trauma from other resident violence. Resident #2 was a cognitively severely impaired male with vascular dementia with mood disturbance, depression, cerebral infarction, and cognitive communication deficit. Both residents had care plans reflecting significant cognitive and functional impairments. A third resident (Resident #3) reported witnessing Resident #2 place his hand between Resident #1’s legs and touch her private area while they were seated together in the dining room, with no staff present at the time. The DON stated she was informed toward the end of January that Resident #2 attempted to touch Resident #1 while they were in the dining room. She reported that the incident was reported by a staff member, though she could not recall who, and that she did not consider the allegation valid because both involved residents denied the incident when questioned. Based on this, she did not report the allegation to the State. The Administrator, who served as the abuse coordinator, stated he was informed by a staff member (whom he could not identify) that Resident #2 touched Resident #1 in her private area while they were in the dining room. He confirmed that the residents were separated and that Resident #2 was placed on 1:1 and later transferred, but he did not report the allegation to the State Agency, citing both residents’ low BIMS scores, confusion, and the fact that Resident #2 was in the process of being transferred. When interviewed, Resident #1 denied being touched or hurt and was unable to recall any inappropriate touching. Review of Resident #1’s EMR revealed no progress notes, incident reports, or witness statements regarding the allegation, despite the facility’s written abuse policy requiring that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate State or Federal agencies within applicable timeframes.
Failure to Investigate Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving one cognitively impaired female resident and one cognitively impaired male resident. The female resident had severe cognitive impairment and diagnoses including cerebral infarction, bipolar disorder, memory deficit, TIA, depression, left-sided paralysis, and a history of falls and psychosocial well-being problems. The male resident also had severe cognitive impairment and diagnoses including vascular dementia with mood disturbance, depression, cerebral infarction, and cognitive communication deficit, and was care planned for risks related to altered neurological status, depression, and impaired cognitive function. The Administrator, who served as the abuse coordinator, reported being informed by an unidentified staff member that the male resident touched the female resident in her private area while they were in the dining area. He stated that the residents were separated, the male resident was placed on 1:1 monitoring, and then discharged and transferred to another facility the following day. Despite the Administrator’s statement that he completed an investigation, there was no documentation of any abuse investigation or 1:1 monitoring in either resident’s EMR. The DON indicated that the Administrator should have a copy of the investigation, but none was available in the records reviewed. The corporate Administrator later confirmed that an investigation had not been completed and that work on an investigation would begin at that time. Review of the facility’s abuse policy showed that all allegations of abuse were to be promptly and thoroughly investigated by the Administrator or designee, that a licensed nurse was to immediately examine the resident and document findings in the medical record, and that all identified events were to be reported to the Administrator immediately. Record review and interviews showed that these required investigative steps and documentation were not carried out for the alleged sexual abuse incident involving these two residents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Infection Control Procedures During Incontinence Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident. The CNA did not change gloves or perform hand hygiene after cleaning the resident's perineal area and before applying a clean brief. This action was observed while the resident, who was in bed, awake, alert, and confused, received care. The CNA acknowledged awareness of the required procedures but chose not to follow them due to concerns about the resident playing with water in the sink. The resident involved had a history of stroke, non-Alzheimer's dementia, and was occasionally incontinent of bowel and bladder. The resident was severely cognitively impaired and had a self-care performance deficit related to dementia and decreased mobility. Both the Infection Preventionist and the Director of Nursing confirmed that staff are required to change gloves and perform hand hygiene after cleaning a resident, as outlined in the facility's handwashing policy. The failure to adhere to these procedures was identified through observation, interviews, and record review.
Failure to Ensure Nurse Aide Certification and Competency
Penalty
Summary
The facility failed to ensure that nurse aides (NAs) demonstrated competency in the skills and techniques necessary to care for residents, as required by resident assessments and care plans. Specifically, two nurse aides, NA A and NA B, were employed and provided resident care for more than four months without obtaining certification as Certified Nurse Assistants (CNAs). Both NAs completed their training and skills checkoffs, but there was no documentation of CNA certification, and their status remained 'Prospective' on the state portal. Timesheet reviews confirmed that both NAs worked regular shifts and provided direct care to residents beyond the allowed 120-day period for certification. Interviews with staff revealed a lack of clarity and oversight regarding the certification process and the 120-day requirement. NA A reported technical difficulties in registering for the CNA test and was unaware of the exact timeframe for certification. The DON and Operations Manager both indicated they had only recently become aware of the 120-day requirement, and there was confusion about who was responsible for tracking certification deadlines. The staffing coordinator and HR Director also expressed uncertainty about their roles in ensuring timely certification, and the corporate CNA trainer stated that while she tracked training start dates, the facility was responsible for monitoring certification deadlines. Facility documentation, including the employee handbook and job descriptions, outlined the responsibility of maintaining current credentials and described the NA position as a training role leading to CNA certification. Despite this, both NA A and NA B worked independently and performed resident care tasks similar to those of certified CNAs, with the only noted restriction being documentation. The lack of proper certification and oversight resulted in unqualified staff providing care to residents, as identified through interviews and record reviews.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified for 7 specific days within a 61-day review period. The facility was unable to provide evidence of RN coverage on these dates, which included several Sundays and a Saturday. The absence of an RN on these days placed all residents at risk of not receiving adequate medical care and supervision. Interviews and record reviews revealed that the Director of Nursing (DON) acknowledged the lack of RN coverage on the specified dates. The DON indicated that typically an RN is scheduled for at least 8 hours each day, but on these occasions, only Licensed Vocational Nurses (LVNs) were working. The DON was uncertain about the oversight that led to the absence of RNs on these days, suggesting a lapse in communication or scheduling with the staffing coordinator. The facility's procedure and guidance require RN services to be provided daily, which was not adhered to during the identified dates.
Failure to Facilitate Resident Voting Rights
Penalty
Summary
The facility failed to provide medically related social services to ensure that five residents could exercise their right to vote in the current election cycle. During a confidential group interview, the residents revealed that they were not asked if they wanted to vote or informed about how they could vote while living in the facility. They expressed their desire to vote and their disappointment at not being able to participate in the election. The Activity Director attempted to obtain mail-in ballots and communicated with residents about voting during a bingo activity, but lacked documentation of these efforts and did not follow up adequately. The Operations Manager acknowledged that the responsibility for ensuring residents could vote was assigned to the Activity Director. However, the Operations Manager also failed to document interactions with residents regarding voting and did not make plans for in-person voting. The Operations Manager admitted that only initial attempts were made to facilitate voting and recognized the need for better follow-up. The facility's Resident Rights and Responsibilities policy did not address residents' voting rights, contributing to the deficiency in meeting the residents' mental and psychosocial needs.
Failure to Prepare Pureed Meals Correctly
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of residents requiring pureed diets. During the lunch service, pureed rosemary roast pork and pureed corn were not prepared to a pudding consistency as required. Observations revealed that the pureed roasted pork contained pieces of pork, and the pureed corn contained pieces of corn and corn skin, indicating that the food was not fully blended to the necessary smooth consistency. Interviews with the staff involved revealed that the cook responsible for preparing the pureed meals did not check the consistency of the food before serving. The cook admitted to using a hand blender and sometimes a robot blender, but on this occasion, she did not ensure the food was fully pureed before serving. The Dietary Manager confirmed that the expectation was for pureed food to have a smooth, pudding-like consistency and acknowledged that the cook had mistakenly used gravy from the regular texture menu, which contributed to the presence of chunks in the pureed meal.
Failure to Facilitate Resident Voting Rights
Penalty
Summary
The facility failed to ensure that five residents were able to exercise their right to vote in the current election cycle. During a confidential group interview, the residents expressed that they were not asked if they wanted to vote or informed about how they could vote while living in the facility. They emphasized the importance of voting and expressed dissatisfaction with not being able to participate. The Activity Director attempted to facilitate mail-in voting but lacked documentation and follow-up, and the Operations Manager acknowledged the lack of adequate efforts to assist residents in voting. The Activity Director mentioned voting during a bingo activity but did not document the details or follow up with residents. The Operations Manager also failed to document interactions with residents regarding voting and did not make arrangements for in-person voting. The facility's Resident Rights and Responsibilities policy did not address voting rights, contributing to the oversight. Both the Activity Director and Operations Manager recognized their shortcomings in ensuring residents could exercise their voting rights.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Licensed Vocational Nurse (LVN) did not adhere to enhanced barrier precautions when administering medication to a resident with a gastrostomy tube. Despite a sign indicating the need for gown and gloves, the LVN only donned gloves and not a gown, which was required for high-contact care activities. The LVN admitted to being unaware of the need for such precautions for residents with a gastrostomy tube, despite having received training on enhanced barrier precautions. In the second incident, another LVN did not follow proper infection control protocols during wound care for a resident with a pressure ulcer. The LVN failed to change gloves and perform hand hygiene after removing the old dressing and before cleansing the wound. This oversight was acknowledged by the LVN, who attributed it to nervousness and a lack of specific training on wound care, despite having attended infection control training. The Assistant Director of Nursing (ADON) confirmed that the expected procedure was not followed, which could lead to cross-contamination and infection. Both incidents highlight lapses in the facility's infection control practices, particularly in the use of personal protective equipment and adherence to hand hygiene protocols. The Director of Nursing (DON) and ADON both expressed expectations for staff to follow these protocols to prevent the spread of infection, indicating that training had been provided, but the practices were not consistently implemented by the staff involved.
Failure to Change Piston Syringe Daily for Tube Feeding
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. Specifically, the facility did not ensure that the piston syringe used for flushing the resident's G-tube was changed daily as required. Observations revealed that the piston syringe on the resident's bedside table was dated two days prior, indicating it had not been changed as per the physician's orders and facility policy. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Licensed Vocational Nurse (LVN) confirmed that the piston syringe should be changed every shift to prevent infections, but this protocol was not followed in this instance. The resident in question was a cognitively impaired male with a history of dysphagia following a cerebral infarction, necessitating the use of a feeding tube. The resident's care plan and physician orders explicitly stated that the piston syringe should be changed every shift and rinsed after each use. Despite these directives, the facility staff failed to adhere to the protocol, as evidenced by the undated syringe observed during the survey. Interviews with the nursing staff revealed a lack of consistent monitoring and adherence to the policy, which could lead to unsanitized treatment and potential infections for the resident.
Failure to Include Dialysis in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident that included necessary instructions for dialysis, which is crucial for effective and person-centered care. The resident, a [AGE] year-old female with multiple diagnoses including end-stage renal disease, was admitted to the facility and required hemodialysis five times a week. However, the baseline care plan and the initial care plan did not include any focus area for dialysis, despite physician orders indicating the need for this treatment. The Director of Nursing (DON) confirmed that the care plan worksheet used by the facility did not have an option for dialysis and did not allow for additional information to be added. The DON acknowledged the importance of including specialized services like dialysis in the baseline care plan to ensure a true reflection of the care and services required by the resident. The facility's policy on Comprehensive Person-Centered Care Planning mandates that a baseline care plan be developed within 48 hours of admission, including minimum healthcare information necessary to properly care for each resident. The omission of dialysis from the baseline care plan indicates a failure to meet these professional standards of quality care, potentially affecting the continuity of care and communication among nursing home staff.
Failure to Provide Scheduled Dialysis Treatment
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received the treatment as ordered by the physician. The resident, a female with multiple diagnoses including end-stage renal disease, was admitted to the facility late in the evening. Despite the physician's order for dialysis five times a week from Monday to Friday, the resident missed her scheduled dialysis on Friday due to miscommunication between the facility and the dialysis provider. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the resident was not on the dialysis schedule for Friday, and the hospital paperwork did not specify when the last dialysis session was conducted. The resident's admission was delayed, and the night shift nurse reported that the resident had received dialysis on the day of admission, leading to the missed treatment the following day. Interviews with the DON, ADON, and the dialysis provider's RN revealed that the resident's late admission and the lack of clear communication about her last dialysis session contributed to the oversight. The Administrator acknowledged the miscommunication and confirmed that the resident missed her dialysis session on Friday, which was against the physician's orders. The facility's policy on dialysis care emphasized the importance of maintaining homeostasis and ongoing communication with the dialysis provider, which was not adhered to in this case.
Improper Food Storage in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage of food items in the kitchen. During an inspection, surveyors observed several issues in the facility's refrigerator, freezer, prep table, and dry storage areas. Specifically, the refrigerator contained withered tomatoes and tomatoes with white spots, as well as heads of cabbage with black spots. In the freezer, a box of country fried beef steak was found open and exposed to air, along with undated bags of chicken and fries. Additionally, the prep table had a white onion with black spots, and the dry storage area contained an open container of corn flakes exposed to air. The Dietary Supervisor, during an interview, stated that both he and the dietary staff were responsible for daily checks to ensure proper food storage, using a first in, first out system. He acknowledged that improper food storage could lead to residents being exposed to foodborne illnesses. The facility's policy on infection control in dietary services, dated October 2022, emphasized the prevention of food contamination to avoid foodborne illnesses. The Food and Drug Administration Food Code of 2017 was also referenced, highlighting the requirement for food to be stored in a clean, dry location, protected from contamination.
Ineffective Pest Control in Hall 300
Penalty
Summary
The facility failed to maintain an effective pest control program, specifically in Hall 300, where fruit flies were observed in multiple residents' rooms. During observations and interviews, residents reported the presence of fruit flies, which were seen around their food and personal items. One resident mentioned that the flies were so pervasive that they would sometimes refuse to eat. Staff members, including an LVN and a housekeeper, acknowledged the issue, noting that the flies had been present for several weeks. The facility's pest control service agreement indicated regular pest control services, but there was no record of treatment specifically targeting flies in the past month. Despite a recent inspection report stating no pest activity in common areas, the issue persisted in Hall 300. Maintenance staff confirmed that a pest control company visited monthly, but residents continued to report problems with flies in their living areas.
Deficiencies in Resident Supervision and Assistance
Penalty
Summary
The facility failed to provide necessary supervision and assistance for two residents, leading to deficiencies in their grooming and personal care. Resident #34, a female with dementia, depression, schizophrenia, and a history of stroke, required supervision for activities of daily living (ADLs) due to her cognitive and physical impairments. Despite this, she was observed handling a razor unsupervised, which she was not supposed to have due to safety concerns. The Activity Director, unaware of the risk, provided her with a razor, and she was left alone in the bathroom, contrary to her care plan that required supervision to prevent self-harm. Resident #54, a female with hypertension, Parkinson's disease, and moderate cognitive impairment, required extensive assistance with toileting. However, she was observed using the bathroom without staff supervision, which was against her care plan that mandated one-person assistance due to her fall risk. Interviews revealed inconsistencies in the staff's understanding of her supervision needs, with some staff leaving her unattended based on her perceived condition at different times of the day. This lack of consistent supervision led to her toileting herself when staff did not respond to her call light, increasing her risk of falls. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain their well-being. However, the failure to adhere to care plans and provide adequate supervision for Residents #34 and #54 demonstrated a lapse in following this policy. The Director of Nursing acknowledged the need for supervision and assistance for both residents, highlighting the risk of injury due to inadequate care.
Inadequate Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a deficiency in preventing urinary tract infections. The resident, an elderly male with multiple diagnoses including a stage 4 pressure ulcer, mild cognitive impairment, and urinary retention, was observed with his Foley catheter drainage bag touching the floor and filled beyond capacity. This was noted on multiple occasions, indicating a lack of adherence to the care plan and facility policy, which required the catheter bag to be kept off the floor and emptied regularly. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN), revealed that the responsibility for ensuring the catheter bag was not overfilled and off the floor was assigned to Certified Nursing Assistants (CNAs) and supervised by nurses. However, the staff acknowledged that the catheter bag was not maintained properly, which was not acceptable and posed an infection control issue. The ADON and LVN admitted to having received training on catheter care, but the LVN was unsure about attending recent in-service training sessions. The Director of Nursing (DON), who had recently assumed the position, confirmed the observations and acknowledged the deficiency. The DON stated that the expectation was for staff to monitor catheter bags throughout their shifts to prevent them from touching the floor or becoming too full. Despite monthly in-service training on catheter care, the deficiency persisted, highlighting a gap in the implementation of the facility's policies and procedures regarding catheter management.
Facility Fails to Maintain Safe Water Temperature in Shower Room
Penalty
Summary
The facility failed to maintain a safe environment for residents using Shower Room A, as the water temperature was not at a comfortable level. During a confidential resident council meeting, a resident reported experiencing cold showers and had informed staff, although they could not recall the specific staff members. The resident mentioned having three cold showers in the month and expressed unwillingness to continue with cold showers. On inspection, Maintenance L checked the water temperature in Shower Room A and found it did not exceed 77 degrees, which is below the required range of 100 to 110 degrees for resident areas. Maintenance L stated that water temperatures were checked weekly and could be adjusted, although no complaints had been received since the summer. The facility's policy requires weekly water temperature checks, and records showed temperatures ranging from 103 to 110 degrees. Interviews with the DON and Administrator revealed no resident complaints had been reported to them, and the Administrator confirmed that the maintenance director or designee was responsible for overseeing water temperature checks.
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Nursing homes near Carrollton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carrollton Health And Rehabilitation Center | 1.9 mi | — | 10 | 0 |
| Sandy Lake Rehabilitation And Care Center | 2.6 mi | — | 0 | 0 |
| The Madison On Marsh | 3 mi | — | 2 | 0 |
| Vista Ridge Nursing & Rehabilitation Center | 3.9 mi | — | 13 | 0 |
| Brookhaven Nursing And Rehabilitation Center | 4 mi | — | 3 | 1 |
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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.