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 Lake Village Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities was left in bed wearing only a shirt and brief after an LVN provided incontinence care and removed the bed linens, leaving the room door open and failing to ensure visual privacy. Video showed the resident remained without sheets or a blanket and with the door open for several hours until a CNA, who had been instructed earlier but became busy and forgot, eventually entered the room and applied a fitted sheet, top sheet, and blanket. Staff interviews and written statements corroborated that the resident was visible from the hallway during this period, in violation of resident dignity and privacy expectations.
A resident with severe cognitive impairment, pancreatic cancer, and significant pain had a written order from hospice to change scheduled Hydromorphone 4 mg/mL from every 6 hours to every 4 hours, with an additional PRN order. Due to miscommunication between the DON, an LVN, and hospice staff, the new every-4-hour order was not entered into the system on the day it was received, and the MAR was not updated. The resident continued to receive Hydromorphone under a standing PRN order rather than according to the revised scheduled dosing, resulting in a failure to administer medications in accordance with the physician’s order during the cited period.
A resident with intellectual and developmental disabilities did not receive a recommended repositioning wedge as outlined in the PASRR evaluation, due to the facility's failure to update the care plan and submit a timely request for specialized services. Staff, including the MDS Coordinator, DON, and Administrator, were unaware of the recommendation, and the intervention was not reflected in the care plan or physician orders.
A nurse failed to perform required hand hygiene before and after glove use and between handling medications and resident care items while administering medications to a resident with cellulitis and impaired cognition. This occurred despite facility policy and staff expectations for hand hygiene to prevent infection transmission.
The facility failed to maintain effective infection control practices, as CNAs did not change gloves or sanitize hands during incontinent care, and an LVN did not sanitize medical equipment between residents. These actions risked cross-contamination and infection spread.
A CNA in a facility failed to maintain a resident's dignity by standing behind her while assisting with eating, rather than sitting beside her as required. The resident, who needed moderate assistance due to lack of coordination and muscle weakness, was not properly observed for swallowing difficulties. Facility staff confirmed that sitting beside residents during meals is essential for dignity and safety.
A resident's personal and medical information was exposed when a nurse left a laptop open and unattended in a hallway, displaying sensitive data. Staff interviews confirmed the expectation to secure such information, aligning with the facility's confidentiality policy.
A facility failed to include CPAP usage in a resident's care plan, despite the resident's diagnosis of obstructive sleep apnea and regular use of the device. The care plan lacked goals and interventions for the CPAP, which was confirmed through staff interviews and record reviews. This oversight could lead to confusion among staff regarding the necessary care for the resident.
A resident with obstructive sleep apnea was using a CPAP machine without a physician order, as required by facility policy. Despite the resident's regular use of the CPAP, the comprehensive care plan did not include it, and staff confirmed the absence of a necessary physician order. This oversight was acknowledged by the facility's LVN, ADON, Administrator, and DON, who all recognized the importance of having a physician order for the CPAP to ensure proper treatment and monitoring.
A facility failed to properly dispose of a controlled medication, Tramadol, for a resident. An LVN discarded the medication in a trash can instead of using the designated solution, despite the facility's policy and available resources for proper disposal. Interviews with staff confirmed the expectation for narcotics to be disposed of correctly to prevent unauthorized access.
A nurse's cart was left unlocked in a hallway, containing various medications, posing a risk of unauthorized access and potential harm. The LVN was unaware of the oversight, and the facility's policy requires carts to be locked when unattended.
The facility did not ensure a clean and homelike environment, as resident rooms and hallway handrails were found unclean. Observations showed dirt on handrails and a white substance in rooms. A resident reported infrequent cleaning, and the Housekeeping Supervisor cited staffing issues. The Administrator acknowledged the cleanliness as a dignity and infection control concern.
The facility failed to maintain food service safety standards, as observed with an ice scoop stored in a wet plastic bag and a stained ice machine. The Dietary Supervisor and Administrator acknowledged the risk of infection due to inadequate cleaning, contrary to the facility's policy and FDA guidelines.
The facility failed to maintain effective infection control during a flu outbreak, leading to the spread of the virus among residents. Observations revealed inconsistent use of PPE, lack of appropriate signage, and poor communication with families. Staff interviews highlighted confusion about infection control protocols, contributing to the rapid spread of the flu.
The facility failed to maintain the required RN coverage of at least 8 consecutive hours a day, 7 days a week, for 14 days between August and September 2023. This lapse was due to scheduling issues and the resignation of the ADON responsible for scheduling. The deficiency was identified through a review of time sheets and acknowledged by the DON and Administrator.
The facility failed to ensure that the call light system was accessible to three residents, preventing them from obtaining assistance when needed. Observations revealed that call lights were placed out of reach, causing frustration and potential safety risks for the residents.
The facility failed to maintain a clean and homelike environment for six residents, with observations revealing various cleanliness issues such as stains on bedside tables, bathroom floors, and sinks. Interviews with staff indicated that the leadership was aware of the issues but had not effectively addressed them due to vacant leadership positions, leading to potential infection risks.
A resident with severe cognitive impairment did not receive showers consistently as scheduled, and there was a lack of documentation and attempts to persuade the resident to take showers. Staff interviews confirmed the issue, and the DON acknowledged the challenge in maintaining resident care due to the absence of an ADON.
The facility failed to ensure proper food storage, labeling, and kitchen sanitation. Observations revealed unlabeled and undated food items, exposed food in the freezer, dirty ice machines and ice chests, and uncovered tea dispensers and trash cans. The Dietary Manager was also observed preparing food without a head covering.
A resident with acute kidney failure and neuromuscular dysfunction of the bladder was observed with an exposed catheter bag on multiple occasions, violating the facility's policy on dignity and respect. Interviews with staff confirmed the oversight and the importance of maintaining resident dignity by using privacy bags for catheter bags.
A resident with a history of falls and severe cognitive impairment was found using a scoop mattress without a physician's order or care plan. Interviews with facility staff revealed that the mattress was used at the family's request to prevent falls, but no assessment or documentation supported its use, violating the facility's policy on restraints.
The facility failed to develop comprehensive care plans for two residents, one requiring catheter care and another at high risk for falls. Despite physician orders and assessments indicating the need for specific interventions, these were not included in the residents' care plans, as confirmed by staff interviews and observations.
The facility failed to ensure that a fall mat was placed alongside the bed of an 82-year-old female resident with severe cognitive impairment and a history of repeated falls. The resident was found lying in bed with the fall mat leaning against a chest of drawers instead of being placed next to the bed. The LVN and DON confirmed that staff should ensure the resident's environment is free of hazards, including placing the fall mat correctly.
The facility failed to ensure that two residents who needed respiratory care were provided such care consistent with professional standards. The nasal cannulas were not properly stored when not in use, and the humidifier bottles did not have water in them, increasing the risk of respiratory infections and irritation.
A resident with a history of falls experienced a fall and hit her head, but the facility inaccurately documented that the family was notified immediately. Interviews revealed the family was contacted two hours later, and the nurse admitted to being unable to reach them initially and getting distracted by other incidents.
Resident Left Without Linens and Visual Privacy After Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure full visual privacy and dignity for a male resident with severe cognitive impairment. The resident, an older adult male with dementia, pancreatic cancer, anxiety, hypertension, hypothyroidism, depression, frequent falls, and pain, had a BIMS score of 3, indicating severe cognitive impairment. His care plan was in place, and he was admitted with multiple chronic conditions. On the night in question, video evidence showed that at 2:19 AM an LVN entered the resident’s room, which had an open door, to provide incontinence care. During this care, the LVN removed the resident’s sheet and blanket and left him in bed wearing only a shirt and brief, with no linens covering him, and did not close the door or draw curtains. The video further showed that from 2:19 AM until 4:43 AM, the resident remained in this state, with the door open and without bed linens, curtains, or a closed door to provide visual privacy. At 4:43 AM, the LVN returned to the room, with the door still open, and then left again after speaking with a CNA in the hallway. Audio from the video captured the LVN telling the CNA that she had previously instructed the CNA to take care of the resident, and the CNA responding that she had forgotten because she had gotten busy. The CNA then entered the room and provided appropriate clothing and linens, including a fitted sheet, blanket, and top sheet, to cover the resident and restore his privacy and dignity. Staff interviews and written statements confirmed the sequence of events. The LVN’s written statement indicated she found the resident wet, with his penis outside the brief, removed the wet linens and brief, provided perineal care, and expected the CNA to complete the linen replacement. The CNA’s statement confirmed that she was asked to assist but delayed going to the room because she was busy, and when she eventually entered around 4:00 AM, the resident was lying in bed with only underwear, socks, and a shirt, with no linens and the door open so he was visible from the hallway. The administrator, DON, and other staff acknowledged awareness of the incident and that the resident had been left in bed with only a brief and shirt and without linens for an extended period, during which he was visible from the hallway, contrary to the facility’s resident rights policy and posted resident rights materials regarding dignity and respect.
Failure to Timely Enter and Implement New Hydromorphone Order
Penalty
Summary
The deficiency involves the facility’s failure to timely enter and implement a new physician order for scheduled pain medication for Resident #1. The resident was an elderly male with diagnoses including dementia, pancreatic cancer, anxiety, hypertension, hypothyroidism, depression, frequent falls, and pain, and had a BIMS score of 3 indicating severe cognitive impairment. On 11/04/2025, a written order was issued to change his Hydromorphone 4 mg/mL from every 6 hours to every 4 hours, with an additional PRN Hydromorphone order. The facility did not input this new every-4-hour order into the system on the day it was received, so the MAR did not reflect the updated dosing schedule. According to progress notes and interviews, Hospice Nurse D delivered the written order on 11/04/2025 and documented that the existing every-6-hour Hydromorphone order was discontinued and replaced with an every-4-hour schedule plus a PRN order. Hospice Nurse D reported that the facility had been administering the PRN Hydromorphone routinely and that the change to every 4 hours was intended to keep the resident more comfortable. She stated that the facility should have implemented the order the same day to avoid any risk of the resident missing the newly scheduled regimen. Review of the MAR showed that the new every-4-hour order was not entered, and the resident continued under the previous standing PRN order, with pain medication still being administered. Interviews with facility staff revealed miscommunication and assumptions regarding responsibility for entering the order. The DON stated that Hospice Nurse D arrived near the end of her shift, attempted to give her the written order, and was directed to speak with LVN A. The DON reported that Hospice Nurse D placed the orders in a box and informed LVN A that the DON was aware of them. LVN A stated that it was her first day working with the resident, that she initially declined to take the order by phone and requested a written order, and that when Hospice Nurse D later attempted to speak with her in person, she directed her to the DON because she was on the phone. LVN A observed the DON and Hospice Nurse D discussing the orders and assumed the DON would handle them. As a result, the new Hydromorphone every-4-hour order was not entered into the system on 11/04/2025, constituting a failure to administer medications according to the physician’s orders during the identified period of non-compliance.
Failure to Implement PASRR Recommendations for Specialized Services
Penalty
Summary
The facility failed to incorporate recommendations from the Pre-Admission Screening and Resident Review (PASRR) evaluation into the assessment, care planning, and transitions of care for a resident with intellectual and developmental disabilities. Specifically, the facility did not submit a complete and accurate request for specialized services in the required online portal within 20 business days after the annual interdisciplinary team meeting. The PASRR Comprehensive Service Plan recommended a repositioning wedge for the resident, but this intervention was not included in the resident's care plan or physician orders. The resident in question was an adult male with a history of frontal lobe executive function deficit following a cerebral infarction, bipolar disorder, schizophrenia, and other speech disorders. He was PASRR positive for intellectual and developmental disabilities and had functional quadriplegia, morbid obesity, and activity limitations. Despite these complex needs and the explicit recommendation for a repositioning wedge to address his tendency to lean to one side, the care plan and order summary did not reflect this intervention, and staff were unaware of the recommendation. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed a lack of awareness and follow-through regarding the PASRR recommendation. The MDS Coordinator was not informed of the need for a repositioning wedge, and the DON and Administrator were also unaware of the recommendation until it was brought to their attention during the survey. The facility's policy required proper screening and implementation of specialized services as determined by the interdisciplinary team, but this was not followed in this instance.
Failure to Follow Hand Hygiene Protocol During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the actions of an LVN during medication administration to a resident with a history of hypertension and cellulitis. The LVN was observed not performing hand hygiene before donning gloves, after removing gloves, or between handling medications and resident care items. Specifically, the LVN prepared and administered oral medications, including antibiotics and pain medication, without using hand sanitizer or washing hands at critical points, such as before entering the resident's room, after glove removal, and after exiting the room. The LVN also handled medication cups, pudding containers, and the resident's bed controls without appropriate hand hygiene. The resident involved had moderately impaired cognition and was being treated for cellulitis of the lower right leg, requiring antibiotics and pain management. The facility's own hand hygiene policy, which requires hand washing or use of alcohol-based hand rub before and after direct resident contact, before preparing or handling medications, after contact with objects in the resident's vicinity, and after glove removal, was not followed. Interviews with the LVN, DON, and Administrator confirmed the expectation for proper hand hygiene practices, which were not met during the observed medication administration.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs and an LVN during resident care. Specifically, two CNAs did not adhere to proper hand hygiene protocols while providing incontinent care to a resident. They failed to change gloves and sanitize their hands after handling soiled materials and before touching clean items, which is a critical step in preventing cross-contamination and infection. Additionally, an LVN did not sanitize medical equipment, such as a blood pressure cuff and pulse oximeter, between uses on different residents. This oversight occurred while the LVN was administering medications and checking vital signs for multiple residents. The lack of sanitization of these devices between residents poses a risk of transferring infections from one resident to another. The facility's policies on hand hygiene and infection control were not followed, as staff did not perform hand hygiene before and after resident care or after removing gloves. The facility's infection control plan emphasizes the importance of hand hygiene as the primary means to prevent the spread of infections, yet these protocols were not adhered to during the observed incidents.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident during mealtime. A CNA was observed assisting a resident with eating while standing behind her, rather than sitting beside her, which is the expected practice to ensure dignity and proper observation of the resident's needs. The resident, an elderly female with a diagnosis of lack of coordination and muscle weakness, required moderate assistance with eating. The CNA acknowledged that standing behind the resident was inappropriate and attributed it to a lack of space at the table, although she admitted she should have moved the resident to a more suitable location. Interviews with facility staff, including the ADON, Administrator, and DON, confirmed that the standard practice is for staff to sit beside residents during mealtime to promote dignity, respect, and safety. The staff recognized that standing behind a resident could convey a sense of haste and disrespect, potentially compromising the resident's dignity and ability to communicate any distress. The facility's policy on dignity and respect emphasizes treating residents with kindness and respect, which was not adhered to in this instance.
Breach of Resident Confidentiality Due to Unsecured Laptop
Penalty
Summary
The facility failed to secure confidential and personal medical records for a resident, leading to a breach of privacy and confidentiality. During an observation, a nurse's cart was found unattended in the hallway with a laptop displaying the resident's personal and medical information, including their name, status, location, gender, date of birth, age, physician's name, latest vital signs, allergies, code status, emergency instructions, and physician orders. This information was visible to anyone passing by, as the laptop screen was facing the hallway. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), confirmed that the laptop should have been closed, locked, or minimized to protect the resident's information. The staff acknowledged the importance of maintaining confidentiality and recognized that the failure to do so could lead to unauthorized exposure of sensitive information. The facility's policy on confidentiality emphasizes the responsibility of all individuals handling resident information to protect its confidentiality.
Failure to Include CPAP in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with obstructive sleep apnea, who required the use of a CPAP machine. The resident's care plan, dated February 23, 2025, did not include any mention of CPAP usage, despite the resident's condition and the necessity of the device for her care. This oversight was identified during a review of the resident's records, which showed no physician order for the CPAP, and was confirmed through interviews with the resident and staff. The resident, who was unable to complete an interview for the BIMS score, was observed using the CPAP machine regularly, both at night and during naps. However, the care plan lacked any goals or interventions related to the CPAP, which was acknowledged by the LVN and the MDS Nurse. The MDS Nurse admitted that the absence of a care plan for the CPAP was due to the lack of a physician order, despite documentation indicating the resident's use of the device. This gap in the care plan could lead to confusion among staff regarding the necessary care and interventions for the resident. Interviews with facility staff, including the ADON, Administrator, and DON, highlighted the importance of having a comprehensive care plan to ensure consistent and appropriate care for residents. The facility's policy mandates that the interdisciplinary team develop a care plan within seven days of completing the Resident MDS, which should include all identified needs. The failure to include the CPAP in the care plan represents a significant deficiency in meeting the resident's medical needs as identified in the comprehensive assessment.
Lack of Physician Order for CPAP in Resident with Sleep Apnea
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident diagnosed with obstructive sleep apnea, as there was no physician order for the resident's CPAP machine. The resident, who was unable to complete an interview for the BIMS score, had been using the CPAP every night and during naps for months. However, the comprehensive care plan did not include CPAP usage, and there was no physician order documented for the CPAP in the resident's records. This oversight was confirmed by both the LVN and the ADON, who acknowledged the necessity of a physician order for the CPAP to ensure proper treatment and monitoring. Interviews with facility staff, including the Administrator and the DON, revealed a consensus that a physician order was essential for the CPAP, as it is a medical device requiring supervision to ensure safe and effective treatment. The absence of a physician order meant that staff might not be aware of the resident's use of the CPAP, potentially impacting the assessment of its effectiveness. The facility's policy on physician orders and oxygen delivery emphasized the need for orders to guide the administration of treatments, highlighting the deficiency in the resident's care plan and physician orders.
Improper Disposal of Controlled Medication
Penalty
Summary
The facility failed to provide proper pharmaceutical services for a resident, specifically in the disposal of a controlled medication, Tramadol. During an observation, an LVN was seen preparing the resident's pain medication when the tablet fell onto the nurse's cart. The LVN decided to waste the medication due to contamination, placing it in a pill crusher pouch and crushing it. However, instead of using the designated solution for disposing of narcotics, the LVN discarded the pouch with residual medication into a trash can, citing a lack of access to the solution. Interviews with staff, including a medication aide, the DON, ADON, and the Administrator, revealed that the facility had a solution available for the proper disposal of narcotics, which was not utilized in this instance. The DON and ADON confirmed that narcotics should not be disposed of in the trash, as this could lead to unauthorized access by residents, staff, or visitors. The facility's policy on controlled medications emphasized safeguarding access and proper disposal, which was not adhered to in this case.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as observed with one of the seven nurse's carts. During a medication pass on hall 300, a nurse's cart was left unlocked, containing various medications such as blister packs, eyedrops, insulin, and insulin paraphernalia. This oversight was noted by several staff members who passed by without noticing the unlocked cart. The Assistant Director of Nursing (ADON) later observed the unlocked cart and acknowledged the risk of residents accessing the medications, which could lead to accidental ingestion or allergic reactions. Interviews with the involved Licensed Vocational Nurse (LVN), the Administrator, and the Director of Nursing (DON) confirmed the expectation that medication carts should always be locked when unattended. The LVN admitted to being unaware that the cart was left unlocked and recognized the potential dangers. The Administrator and DON reiterated the importance of securing medication carts to prevent unauthorized access by residents, staff, or visitors, which could result in accidental ingestion or overdose. The facility's policy on medication storage emphasizes the need for medications to be stored in locked compartments, aligning with the professional principles that were not adhered to in this instance.
Facility Fails to Maintain Cleanliness in Resident Rooms and Hallways
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by observations and interviews. Specifically, the facility did not ensure that resident rooms 303b and 307b were thoroughly cleaned and sanitized. Observations revealed a large circular white patch of powdery substance on the top of a 5-drawer chest in one of the rooms, and a white substance circling the floor around the toilet. A resident in one of the rooms reported that her room was only cleaned once a week, contrary to the facility's policy of daily cleaning, and noted that her trash can was not emptied and the floors were not cleaned. Additionally, the facility failed to clean the hallway handrails, which were observed to have dark and light dirt along the brown wooden rails. The Housekeeping Supervisor acknowledged the oversight, attributing it to having only one housekeeper responsible for cleaning two halls. The Administrator recognized the cleanliness issues as a dignity and infection control concern, indicating a lapse in maintaining the facility's policy of providing a safe and clean environment.
Deficiency in Food Service Safety and Sanitation
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an observation in the facility's dining area, it was noted that the ice scoop was placed in a clear plastic bag with water at the bottom, and the ice scoop itself had black marks on it. Additionally, the ice machine had light brownish stains on its inside front opening. These conditions were not in compliance with the facility's policy on dietary services and infection control, which mandates that all work surfaces, utensils, and equipment should be cleaned and sanitized after each use. Interviews with the Dietary Supervisor and the Administrator revealed that the ice machine was cleaned at least three times a month, and the ice scoop and holder were run through the washing machine daily. However, the presence of water in the plastic bag and the stains on the equipment indicated a lapse in maintaining sanitary conditions. The Administrator acknowledged the risk of not addressing these concerns, which could result in residents becoming ill. The facility's policy and the FDA Food Code emphasize the importance of preventing contamination to avoid foodborne illnesses.
Inadequate Infection Control Measures During Flu Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to the spread of the flu among residents. Observations revealed that residents with the flu did not have appropriate signage on their doors, and personal protective equipment (PPE) was not consistently available or used by staff. For instance, a CNA entered a flu-positive resident's room wearing only a mask, and another resident's room lacked the necessary PPE and signage, despite the resident being in isolation for the flu. Additionally, flu-negative roommates were not cohorted separately from flu-positive residents, and families of flu-negative roommates were not notified about the risk of infection or offered prophylactic treatment for the flu. Interviews with staff and family members further highlighted the deficiencies. A family member of a flu-negative resident was unaware that their relative was sharing a room with a flu-positive resident and had not been informed about the option for prophylactic treatment. Staff interviews revealed a lack of clarity and consistency in following infection control protocols, such as wearing appropriate PPE and ensuring proper isolation measures. The Director of Nursing (DON) admitted to seeing staff not wearing PPE correctly and acknowledged that some residents were not tested for the flu unless they showed symptoms. The facility's failure to adhere to CDC guidelines and its own infection control policies contributed to the rapid spread of the flu. The DON noted that the outbreak began when residents first showed symptoms, but there was a delay in receiving lab results, which delayed the implementation of isolation measures. Additionally, some staff mistakenly believed that isolation ended after five days, leading to premature removal of PPE bins. The facility's inadequate response to the flu outbreak, including poor communication with families and inconsistent use of PPE, placed residents at risk of cross-contamination and further illness.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 14 days between August and September 2023. This deficiency was identified through a review of the facility's time sheets, which showed that on specific dates, the facility only had RN coverage for 4 hours each day. The dates with insufficient RN coverage included multiple weekends in August and September 2023. This lapse in coverage was not initially recognized by the Director of Nursing (DON) until the report was run for the survey. The DON attributed the issue to difficulties in maintaining a scheduler and the resignation of the Assistant Director of Nursing (ADON) who was responsible for scheduling RN coverage during that period. In interviews, the DON and the Administrator acknowledged the lapse in RN coverage and the associated risks. The DON mentioned that the ADON had failed to complete her responsibilities, leading to her resignation after disciplinary discussions. The Administrator confirmed that he was aware of the weekend RN staffing concerns and stated that they had since hired an RN dedicated to weekends. The facility's policy on RN coverage, which requires an RN to provide services for at least 8 consecutive hours a day, 7 days a week, was not adhered to during the specified period, placing residents at risk of not receiving necessary care that only an RN could provide.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system in the rooms of three residents was accessible, which could prevent them from obtaining assistance when needed. Resident #228, a male with a fractured right arm and moderate cognitive impairment, was observed with his call light placed on a drawer out of his reach. He expressed that while he did not need assistance at the moment, it would be beneficial to have the call light within reach for future needs. His care plan specifically indicated that the call light should be within reach due to his fall risk and weakness, but this was not adhered to during the observation. Resident #7, a female with a high risk for falls and cognitive intactness, was found with her call light on the floor near her feet while she was seated in a recliner. She expressed frustration as she had difficulty bending over to retrieve the call light due to back pain. Her care plan also required the call light to be within reach, but this was not followed, leading to her struggle to access it. The resident's frustration and difficulty in accessing the call light were evident during the observation. Resident #39, a female with coordination issues and extensive assistance needs, was observed in her wheelchair with the call light placed on a drawer behind her. She was unaware of the call light's location. Both the LVN and ADON confirmed the importance of call lights being within reach for resident safety and communication. The facility's policies also mandated that call lights be accessible to residents, but these were not followed, as evidenced by the observations and interviews conducted with the staff and residents.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for six residents. Observations revealed various cleanliness issues in the residents' rooms, including white fluid stains on bedside tables, brownish stains on bathroom floors, black dirt stains along the walls, and light brown stains around bathroom sinks and faucets. These deficiencies were noted in the rooms of six residents, indicating a lack of proper sanitation and maintenance, which could lead to infection risks and decreased quality of life for the residents. Interviews with the Housekeeping Manager, DON, and Administrator revealed that the facility's leadership was aware of the cleanliness issues but had not effectively addressed them due to vacant leadership positions. The Housekeeping Manager admitted that her staff should have cleaned the areas in question and acknowledged the risk of infection due to inadequate cleaning. The DON and Administrator also recognized the infection control concerns and attributed the inconsistency in cleanliness checks to the vacant leadership roles, which hindered the effectiveness of their Angel rounds designed to ensure room cleanliness.
Failure to Ensure Consistent Showering for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, Resident #51, a male with severe cognitive impairment and a history of falls, did not receive showers consistently as scheduled. The resident was supposed to receive showers on Tuesdays, Thursdays, and Saturdays, but records showed only four instances where showers were documented, all of which indicated the resident refused. There was no documentation in the facility's system regarding attempts to persuade the resident to take a shower or notifications to family members or the resident's physician about the refusals. Interviews with staff revealed that CNAs were aware of the requirement to document whether a resident received or refused a shower, but this was not consistently done. The CNA and LVN/Charge nurse both acknowledged the lack of documentation and attempts to persuade the resident. The Director of Nursing (DON) confirmed the issue and noted that the absence of an Assistant Director of Nursing (ADON) made it challenging to stay on top of all resident care. The facility's policy on baths and showers emphasized the importance of promoting cleanliness and documenting all appropriate information, which was not adhered to in this case.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed multiple deficiencies in the facility's only kitchen, including unlabeled and undated food items in the refrigerator and freezer, such as a large bag of bread sticks, a package of pie crust, a gallon container of Dill Pickle Relish, and a gallon container of Italian dressing. Additionally, a large bag of French toast sticks in the walk-in freezer was not sealed and exposed to air-borne contaminants. The ice machine had dark reddish stains on the inside door hinges, and the ice chest in the dining area was dirty. The tea dispenser and trash can in the kitchen were uncovered, exposing them to air-borne contaminants. The Dietary Manager was observed preparing food without a head covering, which she acknowledged could result in hair contaminating the food. Interviews with the Dietary Manager and the Administrator confirmed awareness of these issues. The Dietary Manager admitted to forgetting to wear a hair net and acknowledged the risks associated with the observed deficiencies. She also stated that she had trained staff to date items correctly but needed to remind them to include the month, date, and year. The Administrator expected the Dietary Manager to ensure compliance with all guidelines, including wearing a hair net. The facility's policy on food storage and supplies emphasized maintaining storage areas in an orderly manner to prevent foodborne illnesses, which was not adhered to in this instance.
Failure to Provide Privacy Bag for Catheter
Penalty
Summary
The facility failed to treat Resident #228 with dignity and promote enhancement of his quality of life by not providing a privacy bag for his catheter bag. Resident #228, a [AGE] year-old male with acute kidney failure and neuromuscular dysfunction of the bladder, was observed on multiple occasions with his catheter bag exposed. On 01/24/2024, the catheter bag was visible hanging on the side frame of the bed, and on 01/25/2024, it was observed hanging below the wheelchair seat without a privacy bag. The resident confirmed that he had never seen his catheter bag with a privacy bag since having the catheter for six days. The facility's policy and physician orders required the use of a privacy bag for catheter bags to maintain resident dignity, which was not followed in this case. Interviews with the ADON, CNA, DON, and Administrator revealed a consensus that the catheter bag should have been covered to avoid embarrassment and maintain the resident's dignity. The ADON acknowledged the oversight and provided an improvised cover for the catheter bag during the observation. The CNA admitted responsibility for not ensuring the privacy bag was in place, and the DON emphasized the importance of catheter care and dignity for residents. The Administrator reiterated that all staff were responsible for ensuring residents' dignified existence and committed to monitoring the situation. The facility's policy on dignity and respect, revised in 2007, mandates that all residents be treated with kindness, dignity, and respect, which was not upheld in this instance.
Failure to Ensure Resident was Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that Resident #13 was free from physical restraints not required to treat medical symptoms. Resident #13, a [AGE] year-old female with a history of right hip fracture and multiple falls, was observed using a scoop mattress without a physician's order or a comprehensive care plan. The resident's cognitive status was severely impaired, and the scoop mattress was used to limit her ability to get out of bed due to her history of falls. However, there was no documented assessment, order, or care plan for the use of the scoop mattress, which is considered a form of restraint. Interviews with the ADON and DON revealed that the scoop mattress was implemented at the family's request to prevent falls, but neither staff member confirmed the existence of a physician's order or assessment for its use. The DON acknowledged that the resident should have had an assessment, order, and care plan for the scoop mattress but noted that the resident could still get off the mattress. The facility's policy on Freedom From Abuse, Neglect, Exploitation, revised in October 2022, mandates that residents be free from physical restraints not required to treat medical symptoms, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, Resident #288 and Resident #7, as required by regulations. Resident #288, a male with acute kidney failure and neuromuscular dysfunction of the bladder, had an indwelling catheter but did not have a care plan addressing catheter care. Despite physician orders specifying catheter care every shift and monitoring for signs of complications, the care plan lacked any mention of these necessary interventions. This oversight was confirmed through observation and interviews with the RN and MDS Nurse, who acknowledged the absence of a care plan for catheter care for Resident #288. Similarly, Resident #7, a female with a high risk for falls due to muscle wasting and abnormalities of gait, did not have any interventions for fall prevention in her care plan. Despite being assessed as high risk for falls and requiring supervision for various activities, her care plan did not include any specific measures to mitigate this risk. This deficiency was also confirmed through interviews with the RN and MDS Nurse, who recognized the importance of having a fall prevention plan for high-risk residents. Interviews with the Director of Nursing (DON) and the Administrator further highlighted the importance of comprehensive care plans in addressing the specific needs of residents. Both acknowledged that without a care plan, residents' health issues would not be adequately managed. The DON stated that care plans are a team approach and should be updated upon admission, quarterly, and when there is a change in the resident's condition. The facility's policy on comprehensive person-centered care planning was reviewed, which mandates the development of a care plan for each resident, but this was not adhered to in the cases of Resident #288 and Resident #7.
Failure to Place Fall Mat for Resident with Repeated Falls
Penalty
Summary
The facility failed to ensure that a fall mat was placed alongside the bed of an 82-year-old female resident with severe cognitive impairment and a history of repeated falls. During an observation, the resident was found lying in bed with the bed in a low position, but the fall mat was leaning against a chest of drawers instead of being placed next to the bed. This oversight was confirmed by an LVN, who acknowledged that the absence of the fall mat could result in the resident falling and injuring herself. The LVN also stated that staff are expected to check the resident's environment every two hours to ensure it is free of hazards. The Director of Nursing (DON) was informed of the incident and confirmed that staff should ensure the resident's bed is in the lowest position, the call light is within reach, and the fall mat is placed alongside the bed. The DON mentioned that staff might have forgotten to place the fall mat back after the resident had eaten lunch. The facility's policy on Fall Management, dated June 2018, states that the environment should be as free of accident hazards as possible and that appropriate assessments and interventions should be provided to prevent falls and minimize complications if falls occur.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that two residents who needed respiratory care were provided such care consistent with professional standards of practice. Resident #58 and Resident #10's nasal cannulas were not properly stored when not in use, and their humidifier bottles did not have water in them. These deficiencies were observed during a survey, where it was noted that the nasal cannulas were either loosely coiled on the oxygen tank or wrapped around the backrest of a wheelchair, and the humidifier bottles were empty. Both residents had relevant diagnoses that required continuous oxygen therapy, and the lack of proper humidification and storage of nasal cannulas could lead to respiratory infections and irritation of the nasal and throat passages. Resident #58, a [AGE] year-old male with diagnoses including respiratory failure with hypoxia and pneumonia, was observed resting in bed with an oxygen supplement via nasal cannula connected to an empty humidifier bottle. The resident was unaware of the lack of water in the humidifier. Similarly, Resident #10, a [AGE] year-old male with respiratory failure and interstitial lung disease, was also observed with an oxygen supplement via nasal cannula connected to an empty humidifier bottle. Both residents' nasal cannulas were not stored in a sanitary manner when not in use, increasing the risk of respiratory infections. Interviews with the facility's staff, including an LVN, RN, ADON, DON, and the Administrator, confirmed that the humidifiers should always have water to prevent nasal and throat irritation and that nasal cannulas should be bagged when not in use to maintain cleanliness. The staff acknowledged the deficiencies and the potential health risks posed by these lapses in care. The facility's policy on oxygen delivery and maintenance was reviewed, which indicated that delivery device components should be placed in a bag when not in use, highlighting the failure to adhere to established protocols.
Inaccurate Documentation of Family Notification After Resident Fall
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident who experienced a fall. Specifically, the facility inaccurately documented that the family of the resident was notified immediately following the fall. The resident, a [AGE] year-old female with a history of repeated falls and muscle wasting, fell out of her wheelchair and hit her head, resulting in a hematoma. The nurse on duty documented that the family was notified immediately, but interviews revealed that the family was not contacted until at least two hours after the incident. The nurse admitted to making several attempts to contact the family but was unable to reach them due to a busy tone and subsequently got distracted by other falls occurring in the facility. The Director of Nursing confirmed that the documentation was incorrect and should have reflected the attempts made rather than stating the family was notified. This discrepancy in documentation could lead to inaccurate medical records and delayed family notification in critical situations.
What surveyors are citing around you — mapped
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lewisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rambling Oaks Courtyard Extensive Care Community | 3.5 mi | — | 0 | 0 |
| Hollymead | 3.8 mi | — | 2 | 0 |
| Cross Timbers Rehabilitation And Healthcare Center | 4.4 mi | — | 17 | 1 |
| Vista Ridge Nursing & Rehabilitation Center | 5.6 mi | — | 13 | 0 |
| Corinth Rehabilitation Suites On The Parkway | 6.2 mi | — | 18 | 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.