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 Hilltop Village Nursing And Rehabilitation during CMS and state inspections, most recent first.
A CNA removed towels and briefs from a resident's room without informing or seeking permission, despite the resident's cognitive intactness and care plan interventions for hoarding behavior. The resident became upset and expressed that the CNA did not communicate or explain the removal of her belongings. Nursing staff confirmed that there was no directive to remove these items and that such actions were not in line with resident rights or facility policy.
A resident's family reported to staff that an agency CNA provided rough care during toileting, leaving the resident visibly upset. The DON was informed but did not report the incident to the Administrator or state agency, interpreting it as rudeness rather than potential abuse. The incident was not documented or investigated as required by policy, and the Administrator only learned of the event after surveyor intervention.
A facility failed to investigate and document an allegation of rough care after a resident's family reported that an agency CNA was rough during toileting. The DON did not interview the resident or CNA, did not document the incident, and did not report it to the Administrator, contrary to facility policy. The Administrator only learned of the incident after surveyor intervention, and no investigation was initiated until that point.
A CNA failed to use a gait belt while transferring a resident who required maximum assistance, instead pulling the resident up by her pants during a transfer from the commode to a wheelchair. The resident, who had muscle weakness and urge incontinence, became upset, and family members reported the incident to staff. The facility did not have a policy for one-person or gait belt transfers, contributing to the deficiency.
Four residents with physician orders to self-administer medications were not properly assessed or care planned for this practice, and their ability to safely self-administer was not consistently evaluated by the interdisciplinary team. Medications were stored in unsecured locations, and some residents had medications not ordered for self-administration. Staff interviews revealed a lack of verification and documentation regarding whether self-administered medications were actually taken as ordered, and the DON was unaware of these lapses.
Four residents with physician orders for self-administration of medications were found storing their medications in unsecured locations such as unlocked drawers and on top of bedside tables. Interviews confirmed this was their usual practice, and the facility's policy did not address secure storage for these medications. The DON acknowledged the issue, and the deficiency was identified through observation, interviews, and record review.
A female resident with intact cognition and a history of anxiety and depression was subjected to unwanted sexual exposure by a male resident with severe dementia and chronic wandering. The incident was reported by the resident to multiple staff, but an LVN dismissed the allegations and failed to notify leadership or initiate an investigation. The event only came to the attention of facility leadership after a third-party review, revealing a breakdown in abuse reporting and protection protocols.
A resident with intact cognition reported to staff that another resident exposed himself and masturbated at her doorway on multiple occasions. Despite these allegations being communicated to a CNA and an LVN, the incidents were not promptly reported to facility leadership or the State Survey Agency as required. The LVN dismissed the reports, and the administrator only became aware of the situation through a third-party, leading to a delayed investigation and lack of timely documentation or external reporting.
A resident with respiratory and mobility issues who required partial assistance for showering was left unsupervised by a CNA, resulting in the resident independently exiting the bathroom after waiting for help that did not arrive. The CNA admitted to leaving residents alone during showers, contrary to facility policy, and the incident was confirmed by an LVN and the DON.
A resident with asthma, COPD, and sleep apnea regularly used both oxygen and CPAP therapy, but the facility did not have active physician's orders or care plan interventions for CPAP therapy, and lacked orders for oxygen use while in the facility. Nursing staff and the DON confirmed these omissions, and facility policy requires such orders and care planning for respiratory care.
A resident with cognitive communication deficit was not served her lunch meal while others at her table were eating, leading to feelings of being left out. Despite previous training, staff failed to serve meals table by table, as acknowledged by the Administrator and ADON.
Several residents in a long-term care facility did not receive their scheduled showers due to staffing shortages. These residents, who required assistance with bathing, were left without care, leading to discomfort and a loss of dignity. The facility was short-staffed, with some staff members not showing up for their shifts, which resulted in missed showers and inadequate documentation.
A resident with cognitive and physical impairments was unable to reach their call light during a meal because it was wedged between the wall and mattress. This deficiency was observed when the resident attempted to call for assistance and was confirmed by a CNA who had to retrieve the call light. Interviews with staff, including the DON, highlighted the expectation that call lights should be within reach at all times, as per the facility's policy on assistive devices.
The facility failed to maintain a clean and homelike environment for a resident who had food residue on her wall, and in a hallway where a large barrel was used to contain a ceiling leak. The resident, with moderate cognitive impairment, was observed in a room with a dirty wall, and the hallway setup obstructed residents' movement, causing dissatisfaction.
Two residents in a LTC facility were found to have inaccurate MDS assessments. One resident was incorrectly documented as receiving an anticoagulant instead of an antiplatelet, while another resident's range of motion limitations were not accurately reflected, despite having contractures. These inaccuracies were confirmed by staff and could lead to inadequate care.
The facility failed to coordinate assessments with the PASRR program for two residents. One resident's PASRR Level 1 Screening did not reflect a developmental disability related to Multiple Sclerosis, and another resident's screening did not accurately reflect their mental illness. These discrepancies were confirmed by the MDS nurse, indicating a lack of adherence to the facility's policy requiring prompt referral for Level II resident reviews.
A resident with dysphagia was served a regular diet instead of a mechanically soft diet, and her preference against gravy was not accommodated, leading to decreased food intake. The CDM was unaware of the preference, and the dietary department was not informed of updated diet orders following the resident's hospital stay. This oversight in communication resulted in the resident receiving an incorrect diet.
A resident was prescribed a regular diet but was served a mechanical soft diet with gravy, which she disliked. Despite voicing her preference, the meal ticket was not updated, and the dietary department was not informed of the correct diet order. The DON confirmed the oversight in communication between nursing and dietary staff.
The facility failed to provide necessary special eating equipment for two residents during meal service, affecting their dignity and feeding independence. One resident, with severe cognitive impairment, was observed eating without a plate guard, resulting in food spillage. Another resident, with moderate cognitive impairment, struggled to eat without a divided plate. Staff interviews revealed that the required equipment was on back order, and the facility did not have enough available to meet residents' needs.
A LTC facility failed to maintain an effective infection control program, as evidenced by two incidents. A Medication Aide did not sanitize a blood pressure cuff between two residents, and a CNA failed to change gloves or wash hands while providing incontinent care. Both staff members acknowledged their oversights, despite having received infection control training. The DON confirmed the lapses in adherence to the facility's infection control policies.
The facility failed to meet the required square footage per resident in 15 rooms, with each room measuring between 72.4 and 76.4 square feet instead of the required 80 square feet for multiple resident rooms. The deficiency was confirmed during a survey, and the DON noted that some rooms were intended for single occupancy despite being certified for two residents.
The facility failed to protect residents from verbal abuse by staff, involving an RN and an OT. The RN was reported to have verbally abused two residents, making inappropriate comments about medication and personal hygiene. An OT called a resident a liar and contacted their previous employer, upsetting the resident. These incidents were witnessed by other staff members, and the facility's administrator stated that abuse is not tolerated.
A resident in an LTC facility missed 25 doses of Doxycycline due to a transcription error by an LVN, who entered the medication order incorrectly. The MAR confirmed the absence of administration, and a doctor's note suggested the resident's symptoms were likely neurological. The DON verified the error after a change in facility ownership.
Failure to Respect Resident's Personal Space and Belongings
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident's room, supplies, and personal space with respect, contrary to the resident's rights to dignity and self-determination. The resident, a cognitively intact female with chronic obstructive pulmonary disease, major depressive disorder, and generalized anxiety disorder, was known to require supervision for showering and set-up assistance for dressing. The care plan also noted a history of hoarding towels and linens, with interventions focused on positive interaction and calm communication. The incident began when the CNA removed approximately ten towels from the resident's room without informing or seeking permission from the resident, who was outside on a smoke break at the time. The CNA stated that towels were removed due to facility shortages and that this was a routine practice when supplies were low. The CNA also admitted to previously removing briefs from the resident's room, leaving only a small supply, and did not notify or seek direction from nursing staff before doing so. The CNA acknowledged being trained on resident rights and the importance of seeking permission before entering a resident's room or taking belongings but did not follow this protocol in this instance. The resident expressed distress and frustration over the removal of her towels and briefs, stating that the CNA did not ask before taking the items and that it made her feel upset and unsure of the CNA's intentions. Interviews with nursing staff confirmed that there was no directive to remove towels or briefs from resident rooms and that such actions were not appropriate. The facility's policy emphasized treating residents with kindness, respect, and dignity, and staff interviews reiterated that residents have the right to their belongings and to be asked before items are removed from their rooms.
Failure to Timely Report Allegation of Rough Care and Potential Abuse
Penalty
Summary
The facility failed to report an allegation of rough care and possible abuse involving a resident, as required by federal and state regulations. The incident involved a cognitively intact female resident who required maximum assistance with transfers and was being assisted by an agency CNA. The resident's family reported to staff that the CNA had provided rough care during toileting, specifically stating that the CNA pushed the resident down onto the toilet and wiped her roughly, which left the resident visibly upset. The family initially reported the incident to another CNA (who was also the facility scheduler), who then informed the DON. The DON did not speak directly to the resident and did not report the incident to the Administrator or the state survey agency, as required by policy and regulation. The DON interpreted the family's complaint as an issue of rudeness and improper use of a gait belt, rather than as a potential abuse allegation. The DON removed the CNA from caring for the resident but did not initiate a formal report or investigation as required. The CNA involved was allowed to continue working in the facility for at least one additional day before being sent home. The incident was not documented in the facility's self-reported incidents system, and there was no evidence that the Administrator was informed until surveyors intervened and began asking questions. Interviews with staff and the Administrator revealed confusion and inconsistency regarding what was reported and how it was handled. The Administrator only became aware of the incident after surveyor intervention and stated that she would have expected the DON to report the incident if it had been described as abuse. The facility's abuse policy requires immediate reporting of all allegations of abuse, neglect, exploitation, or misappropriation of resident property, but this policy was not followed in this case. The failure to report the allegation in a timely manner constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate and Document Allegation of Rough Care
Penalty
Summary
The facility failed to thoroughly investigate and document an allegation of rough care and treatment for one resident. The incident involved a cognitively intact female resident who required maximum assistance with transfers and had a care plan indicating the need for one staff member to assist with toileting and transfers. The resident's family reported concerns that an agency CNA provided rough care during toileting, specifically stating the CNA pushed the resident down onto the toilet and was rough when wiping. The family reported the incident to a staff member, who then informed the DON. However, there was no documentation of a formal investigation, and the facility's grievance records did not reflect the complaint. Interviews revealed inconsistencies in staff responses and actions. The CNA scheduler, who was informed of the incident by the family, reported the matter to the DON but did not directly notify the Administrator. The DON stated she did not consider the incident to be abuse, did not interview the resident or the CNA involved, and was unable to produce any documentation or notes regarding the incident, stating that any notes had been shredded. The DON also did not report the incident to the Administrator, as required by facility policy. The Administrator only became aware of the incident after being questioned by a surveyor and confirmed that no investigation had been initiated prior to surveyor intervention. The facility's policy requires all reports of abuse, neglect, or mistreatment to be thoroughly investigated and documented, with findings reported to appropriate agencies. In this case, the facility did not follow its own policy, as there was no evidence of a thorough investigation or documentation of the incident involving the resident. The lack of investigation and documentation could place residents at risk by failing to address and resolve allegations of abuse or neglect.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA), identified as agency staff, failed to use a gait belt while transferring a resident who required maximum assistance with transfers. The resident, a cognitively intact female with diagnoses including generalized muscle weakness and urge incontinence, was care planned to require one-person assistance and the use of a gait belt for transfers and toileting. Despite this, the CNA assisted the resident from the commode to a wheelchair without a gait belt, instead pulling the resident up by her pants, which caused distress to the resident and concern from her family members. Family members reported that the CNA was rough during the transfer and did not use the gait belt that was available in the room. The resident was visibly upset after the incident, and family members relayed their concerns to facility staff. The facility scheduler and the Director of Nursing (DON) were both informed of the incident, with the DON confirming that a gait belt should have been used for safety during transfers. The CNA admitted to not using a gait belt and described assisting the resident by pulling her up by her pants due to the resident's foot getting stuck and her knee locking during the transfer. Further review revealed that the facility did not have a policy in place for one-person or gait belt transfers. The DON acknowledged that agency staff were not provided with additional training and that the facility relied on removing agency staff who did not meet expectations. The lack of a clear policy and failure to ensure the use of appropriate transfer techniques led to the deficiency in providing adequate supervision and assistance devices to prevent accidents.
Failure to Assess, Monitor, and Care Plan for Medication Self-Administration
Penalty
Summary
The facility failed to ensure that residents with physician orders for self-administration of medications were properly assessed, monitored, and care planned for this practice. Four residents with orders to self-administer medications were not consistently evaluated by the interdisciplinary team for their ability to safely self-administer, and their care plans did not include interventions or focus areas related to medication self-administration. In several cases, documentation of assessments was missing, outdated, or not present in the residents' electronic medical records, and care plan meetings did not reflect discussion or planning for self-administration. Observations revealed that residents were storing medications in unsecured locations, such as unlocked dresser drawers or on top of bedside tables, and in some cases, residents possessed medications that were not ordered for self-administration. For example, one resident had two medications in his possession without physician orders for self-administration and reported difficulty applying a topical medication to an area not specified in the physician's order. Another resident was found with over-the-counter eye drops not prescribed by the facility physician and was unable to articulate the appropriate use of the medication. Interviews with staff, including the DON and nursing staff, indicated a lack of consistent verification and documentation regarding whether self-administered medications were actually being taken as ordered. Staff reported that there was no process for documenting self-administration on the MAR, and verification of administration was not routinely performed. The DON was unaware of these gaps in practice and acknowledged that care plans should include planning for self-administration of medications. The facility's policy required that the interdisciplinary team and physician determine a resident's capacity for self-administration, but this was not consistently implemented.
Failure to Secure Self-Administered Medications in Locked Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals used by residents with physician orders for self-administration were stored in locked compartments, as required by regulation. Four residents with intact cognition and various medical conditions, including neuralgia, neuropathy, asthma, glaucoma, and chronic pain, were observed storing their self-administered medications in unsecured locations within their rooms. Specifically, medications were found in unlocked dresser drawers, unlocked nightstand drawers, and on top of bedside tables and nightstands, making them accessible to others. Interviews with the residents confirmed that these unsecured storage methods were their usual practice. The Director of Nursing (DON) acknowledged that four residents had physician orders to self-administer medications and stated that staff believed medications were safely stored by keeping them out of reach. However, the DON also indicated that residents were instructed not to keep medications in visible or easily accessible places, which was inconsistent with the observed practices. A review of the facility's policy on self-administration of medications revealed that it did not address the storage of medications in residents' rooms. The lack of secure storage for self-administered medications was identified through direct observation, resident interviews, and record review, demonstrating a failure to prevent unintended access to medications by other residents.
Failure to Protect Resident from Sexual Abuse and Inadequate Reporting
Penalty
Summary
A deficiency occurred when the facility failed to protect a female resident with a history of anxiety disorder, depression, and recent joint replacement from abuse, specifically unwanted sexual exposure by another male resident with severe cognitive impairment and a history of wandering. The female resident reported that the male resident entered her room in a wheelchair and masturbated in front of her. She disclosed the incident to multiple staff members, expressing distress and fear. Documentation in her progress notes confirmed her reports of the male resident's behavior on two consecutive nights. Despite the resident's reports, the staff response was inadequate. A CNA who received the allegations reported them to an LVN on at least two occasions, but the LVN dismissed the concerns, attributing them to confusion and did not escalate the report to facility leadership as required. The LVN did not speak to the resident about the allegations or initiate any investigation, and there was no immediate notification to the administrator or abuse coordinator. The incident only came to the attention of facility leadership after a third-party professional discovered documentation of the event during a chart review, significantly delaying the facility's awareness and response. The male resident involved had a documented history of chronic wandering and was previously observed engaging in sexually inappropriate behavior in a communal area. However, there was no evidence that the facility implemented additional behavioral interventions or supervision in response to these behaviors prior to the incident. The facility's policies required prompt investigation and reporting of abuse allegations, but these procedures were not followed, resulting in a failure to ensure the resident was free from abuse and to report the incident in accordance with federal guidelines.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported within the required two-hour timeframe to the administrator and State Survey Agency (SSA), as mandated by federal and state regulations. Specifically, a female resident with a history of anxiety disorder, depression, and recent joint replacement surgery reported to staff that a neighboring male resident had exposed himself and masturbated at her doorway on multiple occasions. The resident was cognitively intact at the time, as indicated by a recent BIMS score of 15. Despite the resident reporting these incidents to multiple staff members, including a CNA and an LVN, the allegations were not promptly reported to facility leadership or the SSA. The CNA who received the initial reports from the resident stated that she informed the LVN on at least two separate occasions, but the LVN was dismissive and attributed the allegations to resident confusion. The LVN did not report the allegations to the administrator or initiate an investigation, believing the matter was already known or not credible. The social worker only became aware of the incident through a third-party professional and subsequently notified the administrator and initiated an assessment. The administrator confirmed that she was not notified by staff and only began an investigation after being informed by the social worker, well after the initial allegations were made. The facility's internal investigation confirmed the identity of the alleged perpetrator, a male resident with severe cognitive impairment and a history of wandering and inappropriate behavior. However, the incident was not documented in the facility's incident report log for the relevant month, and there was no evidence that the incident was reported to the SSA as required. Interviews with facility leadership revealed uncertainty about reporting requirements and a lack of immediate notification procedures, despite existing policies mandating prompt reporting of abuse allegations.
Resident Left Unsupervised During Shower
Penalty
Summary
A deficiency occurred when a resident with diagnoses including asthma, COPD, lack of coordination, muscle weakness, and unsteadiness on feet, who required partial assistance for showering, was left unsupervised in the shower by a CNA. The resident reported being assisted into the shower and then left alone, after which he used the call light for help but did not receive a response. The resident experienced difficulty breathing due to the heat and humidity and, after waiting approximately 20 minutes, independently ambulated to his wheelchair and exited the restroom without assistance. Interviews confirmed that the CNA left the resident unsupervised to assist another resident or obtain supplies, despite facility policy requiring supervision during showers. The resident reported the incident to an LVN, who confirmed the resident's account. The CNA acknowledged leaving residents unsupervised at times and recognized the potential for harm, such as slipping. The DON confirmed awareness of the incident and facility policy against leaving residents unsupervised during bathing.
Failure to Ensure Physician Orders and Care Planning for Respiratory Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with multiple respiratory diagnoses, including asthma, COPD, and obstructive sleep apnea. The resident was observed to use both an oxygen concentrator and a CPAP device, and confirmed using the CPAP every night and oxygen as needed. However, a review of the resident's medical record revealed there were no active physician's orders for CPAP therapy or for oxygen use while at the facility, despite evidence of regular use. The care plan only addressed PRN oxygen use and did not mention CPAP therapy or its maintenance. Interviews with nursing staff and the DON confirmed that the resident should have had signed physician's orders and care planning for CPAP therapy, and that staff should be monitoring the application of respiratory devices. Facility policy also requires verification of physician's orders and review of the care plan prior to oxygen administration. The lack of appropriate orders and care planning for the resident's respiratory therapies constituted a failure to provide care consistent with professional standards and the resident's comprehensive care plan.
Resident Not Served Lunch Promptly
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not serving her lunch meal while other residents at her table were eating. On the specified date, Resident #94, who had a cognitive communication deficit and required setup assistance for eating, was observed without her lunch meal while two other residents at her table were already eating. A fellow resident had to signal the nursing staff to indicate that Resident #94 had not been served. Resident #94 expressed that this situation occurred frequently, although she could not specify how often, and stated that she felt left out when it happened. The facility's Administrator and Assistant Director of Nursing (ADON) acknowledged during an interview that serving residents table by table was important for quality of care. They admitted that this issue had been a problem in the past, and staff had been trained to serve all residents at a table before moving to the next. However, they speculated that the nursing staff might have been nervous due to the presence of the state agency, despite knowing the correct procedure. The facility's policy on dignity, revised in February 2021, emphasized that residents should be treated with dignity and respect at all times.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary services to maintain good personal hygiene. Specifically, five residents did not receive their scheduled showers on a particular day due to staffing issues. These residents were dependent on staff for assistance with bathing, and the failure to provide this care could lead to a loss of dignity and diminished quality of life. Resident #9, a male with intact cognition but incontinent of bowel and urine, did not receive a shower on the scheduled day. His care plan required extensive assistance with bathing three times a week. Similarly, Resident #36, a female with quadriplegia and intact cognition, was scheduled for showers three times a week but missed her scheduled shower due to short staffing. She expressed discomfort and sadness due to the lack of care. Other residents, including Resident #19, who had osteoarthritis and diabetes, and Resident #13, with multiple sclerosis and dementia, also missed their scheduled showers. The facility was short-staffed on the day in question, with several staff members not showing up for their shifts. This led to a situation where the available staff could not meet the residents' needs, resulting in missed showers and inadequate documentation of care provided.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is necessary for the resident to communicate their needs to the staff. During an observation, the resident was found sitting up in bed with their lunch meal, and when asked by the surveyor how they would normally get staff's attention, the resident attempted to reach for the call light. However, the call light was wedged between the wall and the mattress, making it inaccessible to the resident. This situation was confirmed when a CNA entered the room and had to pull the call light out from its wedged position. The resident in question had been admitted with diagnoses including Hemiplegia and Hemiparesis following a cerebral infarction affecting the right dominant side, and vascular dementia. The resident's care plan indicated a communication problem, requiring staff to anticipate their needs. Interviews with facility staff, including a CNA and the DON, confirmed that the call light should always be within the resident's reach, and it was the nursing staff's responsibility to ensure this. The facility's policy on assistive devices and equipment also supports the need for such devices to be accessible to residents to aid in their mobility, safety, and independence.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident #17, who was observed with food residue on the wall next to her bed. Despite the resident's habit of wiping her hands on the wall, the housekeeping staff did not adequately clean the area, as confirmed by observations and interviews with staff members. The resident, who has moderate cognitive impairment and requires assistance with personal hygiene, was found in a room with a dirty wall on multiple occasions. The housekeeping supervisor was informed of the issue, but improvements were minimal. Additionally, the facility did not ensure a homelike environment in the D-wing hallway, where a large industrial barrel was placed to contain a ceiling water leak. This setup obstructed the hallway and affected residents' ability to move freely, as noted by residents and staff. The barrel, positioned under a dripping ceiling, was a temporary solution that had been in place for about two weeks, causing inconvenience and dissatisfaction among residents. The maintenance director acknowledged the issue and considered using a smaller container to minimize obstruction.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential risks for inadequate care. Resident #7's quarterly Minimum Data Set (MDS) inaccurately documented the resident as receiving an anticoagulant medication, when in fact, the resident was receiving Clopidogrel, an antiplatelet medication. This error was confirmed by the MDS nurse, who acknowledged that Clopidogrel should not have been coded as an anticoagulant. The MDS nurse had access to the Resident Assessment Instrument (RAI) for reference but did not utilize it correctly in this instance. Resident #51's quarterly MDS inaccurately reflected that the resident did not have upper or lower range of motion limitations, despite having contractures in both upper and lower extremities. This inaccuracy was confirmed through observation and interviews, where the resident expressed limited mobility in his limbs. The MDS Coordinator acknowledged the inaccuracy and emphasized the importance of accurate MDS assessments to ensure residents receive the necessary assistance, as the MDS drives the care plan. The Director of Nursing stated that a review of the MDS and care plans would be conducted.
Failure to Coordinate PASRR Assessments
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program under Medicaid, specifically for two residents reviewed for PASRR. Resident #29's PASRR Level 1 Screening did not accurately reflect a diagnosis of developmental disability related to Multiple Sclerosis, despite the resident having been diagnosed with Multiple Sclerosis on 01/29/2022. The care plan for Resident #29 indicated a physical functioning deficit related to Multiple Sclerosis, but the PASRR Level 1 Screening showed no evidence of mental illness, intellectual disability, or developmental disability. This discrepancy was confirmed during an interview with the MDS nurse, who was unaware if the PASRR 1 had been updated after the resident's admission. Similarly, Resident #13's PASRR Level 1 Screening did not accurately reflect the resident's mental illness, despite a diagnosis of schizoaffective disorder, bipolar type, and Multiple Sclerosis. The PASRR Level 1 Screening for Resident #13 was positive for mental illness but did not include evidence of intellectual or developmental disability. The MDS nurse confirmed that Resident #13 had a Mental Illness/Dementia Review, despite the diagnosis of mental illness and Multiple Sclerosis. The facility's policy requires prompt referral for a Level II resident review for any resident with a newly evident or possible intellectual disability or related condition, which was not adhered to in these cases.
Failure to Provide Correct Diet and Accommodate Food Preferences
Penalty
Summary
The facility failed to provide a mechanically soft diet to a resident who required it due to oropharyngeal phase dysphagia, instead serving a regular diet during a lunch meal. Additionally, the resident had expressed a preference against gravy, which was not accommodated, leading to decreased food intake. The resident, who was cognitively intact, had previously communicated this preference to staff, but it was not reflected in her meal ticket. The Certified Dietary Manager (CDM) was unaware of the resident's preference and stated that gravy was part of the mechanical soft diet recipe, which was believed to prevent choking hazards. The Director of Nursing (DON) and the CDM acknowledged that the resident should have been on a regular diet following a hospital stay, but the dietary department had not been informed of the updated diet orders. The facility's policy on therapeutic diets emphasizes that diets should align with residents' informed choices and preferences, but this was not adhered to in this case. The oversight in communication between nursing staff and the dietary department resulted in the resident being served an incorrect diet, which could potentially affect other residents with specific diet orders.
Failure to Provide Prescribed Diet
Penalty
Summary
The facility failed to ensure that a therapeutic diet was prescribed and provided to a resident as ordered by the attending physician. Specifically, a resident who was prescribed a regular diet was instead provided with a mechanical soft diet during lunch on 07/09/24. This discrepancy was observed when the resident expressed dissatisfaction with the meal, particularly due to the presence of gravy, which was not to her preference. The resident had previously communicated her dislike for gravy to the staff, but no action was taken to adjust her meal preferences accordingly. The resident's meal ticket incorrectly reflected a mechanical soft diet, which included gravy, contrary to the doctor's order for a regular diet. The issue was further compounded by a lack of communication between the nursing staff and the dietary department. The Director of Nursing (DON) confirmed that the nursing staff failed to provide the necessary communication form to update the dietary department about the resident's prescribed regular diet. The Certified Dietary Manager (CDM) was unaware of the resident's diet change until after the incident, indicating a breakdown in communication and adherence to the facility's policy on therapeutic diets. The facility's policy requires that diets be determined in accordance with the resident's informed choices and physician's orders, which was not followed in this case.
Failure to Provide Special Eating Equipment for Residents
Penalty
Summary
The facility failed to provide necessary special eating equipment and utensils for two residents during meal service, which could affect their dignity and feeding independence. Resident #21, who has severe cognitive impairment and dysphagia, was observed eating without a plate guard, resulting in food spilling onto her clothes. Despite her care plan and meal ticket indicating the need for a plate guard, staff did not provide one, and it was noted that the dietary manager mentioned they were on back order. Similarly, Resident #63, with moderate cognitive impairment and a history of stroke, was observed struggling to eat without a divided plate, which was part of her dietary requirements. Staff interviews revealed that the facility did not have enough divided plates available, and they were also on back order. The deficiency was further highlighted by staff interviews, where it was revealed that the dietary manager had ordered the necessary equipment weeks prior, but they were still awaiting delivery. The facility's policy on assistive devices and equipment, which mandates the provision and supervision of such devices for resident independence and safety, was not adhered to. The lack of available equipment and the failure to ensure residents had the necessary tools for eating compromised the residents' ability to eat independently and maintain their dignity.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving improper care practices. In the first incident, a Medication Aide did not sanitize a blood pressure cuff between using it on two residents. This oversight was confirmed by the Medication Aide, who acknowledged forgetting to disinfect the cuff, despite having received infection control training within the year. The Director of Nursing (DON) also confirmed that the cuff should have been sanitized between uses to prevent cross-contamination. In the second incident, a Certified Nursing Assistant (CNA) failed to change gloves or wash hands while providing incontinent care to a resident. The CNA touched a bed remote with gloved hands and then proceeded to provide care without changing gloves or sanitizing hands. Additionally, the CNA handled both soiled and clean incontinent pads with the same gloves. The CNA admitted to realizing the mistake after the fact and confirmed having received infection control training within the year. The DON confirmed that the CNA should have changed gloves and sanitized hands after touching contaminated surfaces. Both incidents highlight lapses in adherence to the facility's infection control policies, which require cleaning and disinfecting reusable items between residents and proper hand hygiene practices. The facility's policies, dated 2001 and 2019, respectively, emphasize the importance of these practices to prevent the transmission of infections.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide bedrooms that met the required square footage per resident, as specified by regulations. Specifically, 15 out of 99 rooms were found to be deficient in size, with each room measuring between 72.4 and 76.4 square feet per resident, instead of the required 80 square feet for multiple resident rooms. This deficiency was identified during a survey conducted on July 20, 2024, where measurements were taken and confirmed by the Maintenance Director. The rooms in question were certified for two beds each, yet they did not meet the necessary space requirements. During an interview, the Director of Nursing (DON) mentioned that certain rooms were designated as small and were intended for single occupancy, although they were certified for two residents. The DON was unable to clarify the meaning of the acronym SCU, which was used to label these rooms. A review of the facility's documentation, including Form 3740 and an undated list of rooms with insufficient square footage, confirmed the deficiency. This failure could potentially impact the quality of life for residents by limiting space for personal effects and movement within their rooms.
Verbal Abuse Incidents Involving Staff and Residents
Penalty
Summary
The facility failed to ensure residents' right to be free from verbal abuse, affecting three of the seven residents reviewed for abuse. Specifically, RN A was reported to have verbally abused two residents. In one incident, RN A was witnessed telling a resident that they wanted to spray them with Ativan spray because they were getting on their nerves. In another instance, RN A told a different resident that they couldn't get clean because the staff were busy feeding others. These incidents were corroborated by a CNA who witnessed RN A's behavior. Additionally, the facility failed to protect another resident from verbal abuse by an occupational therapist (OT). The OT was reported to have called the resident a liar and proceeded to verify the resident's past employment by contacting their previous employer, which upset the resident. This incident was witnessed by a physical therapy assistant (PTA) staff member. The facility's administrator, who was not familiar with these incidents due to a recent change in ownership, stated that abuse is not tolerated. The facility's abuse and neglect policy prohibits any form of abuse, including verbal abuse.
Medication Transcription Error Leads to Missed Doses
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the error involved the transcription of a medication order for Doxycycline, an anti-infective prescribed for epididymitis. The Licensed Vocational Nurse (LVN) responsible for transcribing the order incorrectly entered it to be administered every 21 days instead of for 21 days. As a result, the resident missed 25 doses of the medication over a period from early to mid-April. A review of the Medication Administration Record (MAR) confirmed the absence of Doxycycline administration during this time frame. Additionally, a doctor's note from mid-April indicated a trial of Doxycycline for possible epididymitis, although the physician noted that the resident's symptoms were likely neurological and not related to any physical abnormalities. The Director of Nursing (DON), who was not in the position at the time of the incident, verified the missing medication doses upon review.
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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.
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Nursing homes near Kerrville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor View Nursing & Rehabilitation | 2.7 mi | — | 3 | 1 |
| Avir At Kerrville | 3.6 mi | — | 21 | 0 |
| River Hills Health And Rehabilitation Center | 4.6 mi | — | 4 | 0 |
| Avir At Comfort | 16.6 mi | — | 0 | 0 |
| Knopp Nursing & Rehab Center Inc | 20.5 mi | — | 0 | 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.