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 Simpson Place during CMS and state inspections, most recent first.
A resident with intact cognition and multiple psychiatric and medical diagnoses required supervision or touching assistance with personal hygiene ADLs per the MDS, but surveyors found the comprehensive care plan lacked any measurable objectives, goals, interventions, or timeframes for ADLs. The DON reported that every resident should have a care plan reflecting preferences and routines and acknowledged that missing ADL information reduced staff communication and knowledge of preferences. The DON and Administrator both stated that the MDS Coordinator was responsible for updating care plans, charge nurses for triggering acute plans, and that the facility did not have an MDS Coordinator, resulting in the resident’s ADL needs not being incorporated into the care plan despite facility policy.
A cognitively intact male resident with multiple psychiatric and medical diagnoses, who required supervision or touching assistance for personal hygiene, was observed with an overgrown mustache and a long chin beard despite his admission photo showing a trimmed mustache and clean-shaven face. He reported receiving regular showers but stated he had been asking for weeks to have his mustache trimmed and beard shaved, and was told by staff he needed to schedule and pay for beauty salon services, which he could not afford. The CNA assigned to him had showered him but did not shave him, did not ask about his grooming preferences, and did not consult the charge nurse, despite stating CNAs are responsible for shaving on shower days if requested. The RN, DON, and Administrator each stated that CNAs are responsible for grooming, including shaving, and that nursing leadership is responsible for ensuring care is provided, but none were aware of the resident’s repeated requests. The resident’s care plan lacked ADL goals and interventions, and the facility’s policy required provision of hair care and shaving per standard practice guidelines.
Surveyors found that a resident with complex medical conditions, including COPD, chronic respiratory failure on O2, diabetes, CKD, and prior episodes of hypernatremia and hypoxia, experienced multiple hospitalizations and returned with changes in diet (thickened liquids), respiratory treatments, and IV therapy, but the facility did not complete a required Significant Change in Status Assessment (SCSA) MDS. Review of the admission and quarterly MDSs showed missing or inaccurate coding, including an empty BIMS summary score on one assessment and Section O indicating no special treatments despite documented use of oxygen and IV fluids. Interdisciplinary notes and MD orders confirmed ongoing O2 use, IV fluids, and aspiration precautions, while interviews with the CRN, DON, and ADM confirmed that no significant change MDS was present and that it was the responsibility of leadership and MDS staff to ensure timely and accurate assessments.
A resident with metabolic encephalopathy, DM, hypernatremia, and acute/chronic respiratory failure experienced multiple hospitalizations and returned with clinical changes including thickened liquids, respiratory treatments, and IV/enteral feeding, but these changes were not accurately captured on the MDS. One MDS had an undocumented assessment type and an empty BIMS summary score, and a subsequent quarterly MDS documented severe cognitive impairment and SOB but failed to include the need for thickened liquids in Section K and showed no special treatments such as oxygen or IV in Section O. The care plan and staff interviews confirmed oxygen therapy and diet changes, while leadership acknowledged that MDS assessments were not timely or accurate and that no change in condition MDS could be located, contrary to facility policy requiring comprehensive, accurate, and timely MDS completion.
Staff failed to follow infection control protocols during care of two residents, including not wearing required PPE such as gowns during high-contact procedures for a resident on Enhanced Barrier Precautions, not performing hand hygiene between glove changes, and placing soiled linen on the floor instead of in a designated bag. These actions were contrary to facility policies and were acknowledged by staff and leadership as lapses that could lead to cross-contamination.
A resident with multiple chronic conditions and significant ADL assistance needs did not have a comprehensive care plan addressing ADLs, including measurable objectives and timeframes, despite these needs being identified in assessments. Facility staff confirmed that the omission reduced communication and awareness of the resident's preferences and required care.
A resident with frequent incontinence and multiple chronic conditions did not receive timely incontinence care, as her brief was not changed throughout the morning. The CNA responsible had not provided care since the start of the shift, citing a heavy workload. Staff interviews and facility policy confirmed that care should be provided every two hours or as needed, but this expectation was not met.
A resident with an indwelling urinary catheter did not receive proper catheter care during a transfer, as a CNA placed the drainage bag above bladder level, resulting in observed urine backflow. Staff interviews confirmed knowledge of correct procedures, but the facility's policy did not address this issue.
The facility's kitchen failed to label opened food items, such as liquid eggs, with use-by dates, as required by professional standards and the facility's policy. This oversight was confirmed through observations and staff interviews, highlighting a risk of food-borne illness to residents. The facility's policy mandates that all foods be covered, labeled, and dated, in accordance with FDA guidelines.
The facility failed to complete and transmit discharge MDS assessments for two residents within the required 14-day period. A change in the electronic health record system contributed to the oversight, as staff were unable to access previous assessments. The MDS Nurse and Regional MDS RN acknowledged the lapse, which resulted in incomplete records for the residents.
A facility failed to include dialysis in a resident's care plan, despite the resident being admitted as a dialysis patient. The resident, who was cognitively intact, had multiple diagnoses including peripheral vascular disease and hypotension of hemodialysis. The omission was acknowledged by the DON and MDS Coordinator, who noted the importance of reflecting physician orders in the care plan.
The facility failed to provide necessary nail care for two residents, both of whom were unable to maintain personal hygiene independently. One resident, dependent on staff for personal hygiene, had dirty and jagged nails, while another resident, requiring moderate assistance, had long, discolored nails. Staff interviews revealed that nail care was the responsibility of CNAs and nurses, to be performed on shower days and as needed. Despite this, the residents did not receive adequate nail care, potentially increasing their risk of infections.
A resident with an indwelling urinary catheter was at risk for infection when a CNA placed the catheter drainage bag above bladder level during wound care, causing urine backflow. Despite training, the CNA failed to follow the care plan, which required the bag to be kept below the bladder. The facility's policy did not address this specific concern.
A facility failed to label an insulin pen with an open date, as observed on a nurses' cart. An LVN administered insulin without checking for an open date, acknowledging the importance of labeling for effectiveness. The DON confirmed the requirement for dating insulin pens and vials, with monthly checks by a pharmacy consultant and random checks by the DON and ADON.
The facility failed to maintain an effective pest control program, resulting in bed bug sightings on the 600 floor. Two residents reported bed bugs in their rooms, and the facility did not follow its bed bug policy, which required checking all rooms on the affected floor and training staff on prevention. Some staff were unaware of the issue, and there was a lack of documentation and communication regarding the sightings and treatments. The pest control treatments were not effective, contributing to the ongoing bed bug issue.
A resident with moderate cognitive impairment and complex medical conditions was verbally and mentally abused by a CNA. The incident was captured on video, showing the CNA removing the call light from the resident's hand, refusing to change her when wet, and speaking disrespectfully. The facility's investigation confirmed the inappropriate behavior, violating the resident's right to be free from abuse.
Two residents were found using wheelchairs with damaged armrests, exposing them to potential injury. Staff, including the ADON and Maintenance Director, were unaware of the issues, and there was no documentation in the maintenance log. The facility lacked a structured process for reporting and repairing equipment, placing residents at risk.
The facility failed to ensure proper hair restraint use by dietary staff, as observed with a dietary aide who did not fully cover her hair while preparing meals. Despite having sufficient hairnets available, the aide's hair was not completely restrained, posing a risk of food contamination. Interviews revealed that staff were aware of the importance of hairnets, but compliance was inconsistent.
A facility failed to implement a comprehensive care plan for a resident, missing a weekly skin assessment required by the care plan. The resident, with a history of dementia and hemiplegia, had a stage 3 pressure wound. Interviews revealed that the ADON and DON were responsible for the assessments but missed the audit, risking inadequate care. The facility's policy mandated weekly skin checks to prevent pressure ulcers.
A resident with multiple health conditions experienced a breach in infection control when an RN removed gloves and used hand sanitizer over an open wound. Despite being trained, the RN admitted to being nervous and unaware of the risk of contamination. Facility staff confirmed the RN's understanding of proper wound care protocols.
Failure to Develop Comprehensive ADL Care Plan for a Resident
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for activities of daily living (ADLs) for one resident. Record review showed this male resident, with diagnoses including UTI, anxiety disorder, bipolar disorder, schizophrenia, and depression, had an MDS assessment indicating intact cognition (BIMS score of 15) and a need for supervision or touching assistance with personal hygiene tasks such as combing hair, shaving, and washing/drying face and hands. However, review of the resident’s care plan, last reviewed on 02/11/26, revealed no plan of care addressing ADLs with measurable objectives, goals, interventions, and timeframes, despite the facility’s written policy requiring a comprehensive person-centered care plan to meet medical, nursing, mental, and psychosocial needs. During interviews, the DON stated that every resident should have a care plan reflecting their likes, dislikes, everyday routine, and anything that affected them, and acknowledged that the absence of ADLs in the care plan diminished staff communication and knowledge of resident preferences. The DON explained that the MDS Coordinator was responsible for updating residents’ care plans, but the facility did not have an MDS Coordinator nurse and instead used a corporate person for MDS assessments, while the DON handled acute and new resident care plans. The Administrator similarly stated that the care plan told a story about the resident’s care and preferences and confirmed that without ADLs listed, staff would not know what residents liked. The Administrator indicated that charge nurses were responsible for triggering acute care plans and the MDS Coordinator for updating care plans, but again noted the absence of an MDS Coordinator.
Failure to Provide Requested Shaving and Grooming Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required assistance with activities of daily living (ADLs) received necessary grooming and personal hygiene services, specifically shaving. The resident was an adult male with diagnoses including urinary tract infection, anxiety disorder, bipolar disorder, schizophrenia, and depression. His MDS showed intact cognition with a BIMS score of 15 and indicated he required supervision or touching assistance with personal hygiene tasks such as combing hair and shaving. His face sheet photo showed him with a trimmed mustache and clean-shaven face at admission. During observation, he was seen clean and groomed but with a full mustache growing over his lip and a chin beard approximately two inches long, which differed from his admission appearance. The resident reported he received showers three times a week but wanted his mustache trimmed and beard clean-shaven, and stated he had been asking to be shaved for weeks. He said staff told him he needed to make an appointment with the facility’s beauty salon, which he could not afford, and he confirmed he was not admitted with a beard. There was no care plan addressing ADLs with measurable objectives, goals, interventions, and timeframes. The CNA assigned to him on the day of observation stated she had showered him but had not shaved him or asked about his grooming preferences, and she had not consulted the charge nurse. She stated CNAs were responsible for shaving residents on shower days if requested. The RN, DON, and Administrator each stated that CNAs were responsible for grooming, including shaving, on shower days and that charge nurses, the DON, and the Administrator were responsible for ensuring residents received appropriate care. None of them were aware the resident had been requesting shaving. The facility’s policy stated that hair care, combing, and shaving would be provided in accordance with standard practice guidelines.
Failure to Complete Significant Change MDS After Multiple Hospitalizations and Treatment Changes
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive, accurate Significant Change in Status Assessment (SCSA) MDS within 14 days after a resident experienced significant changes in condition and multiple hospitalizations. The resident, an older male admitted with diagnoses including metabolic encephalopathy, diabetes mellitus with hyperosmolality, hypernatremia, and acute and chronic respiratory failure with hypoxia, had an MDS dated with the type left blank and key sections either incomplete or inaccurately coded. Section C (Cognitive Patterns) showed an empty BIMS summary score and staff assessment indicating memory problems and inattention. Section J documented shortness of breath with exertion, at rest, and when lying flat, and Section K noted parenteral/IV feeding while not a resident. Section O (Special Treatments) was left empty and did not address the resident’s oxygen and IV use. A subsequent quarterly MDS documented a BIMS score of 07, indicating severe cognitive impairment, and again noted shortness of breath in multiple positions and parenteral/IV feeding under Section K. However, Section O again indicated that the resident did not require any special treatments such as IV or oxygen, despite medical records showing orders and use of these treatments. The record showed MD orders for IV fluids, PRN albuterol nebulizer treatments, and PRN peripheral IV restarts for infiltration or extravasation. MD progress notes documented initiation of IV normal saline, completion of a BIMS with a score of 15/15 at one point, and the presence of a peripheral IV line. Interdisciplinary notes described a history of chronic respiratory failure on 2L nasal cannula O2, COPD, CKD, mood disorder, prior admissions for atypical chest pain, leukocytosis, hypernatremia, hypoxia with AMS, pulmonary embolism, aspiration pneumonia, GI bleed, AKI, and the need for thickened liquids with aspiration precautions. The resident experienced multiple hospitalizations for atypical chest pain, hypoxia, altered mental status, leukocytosis, and later for severe hypernatremia, with documented changes in diet (thickened liquids), respiratory treatments, and IV therapy upon return to the facility. The facility’s own change of condition policy defined acute changes of condition and circumstances requiring communication and evaluation, including transfer to another healthcare community and unexpected deterioration in condition or status. Despite these significant clinical events and changes in treatment approaches, there was no significant change in condition MDS assessment in the resident’s file. Interviews with the CRN and DON confirmed that the resident had several hospitalizations and returned with clinical changes to diet, respiratory treatments, and IV therapy, and that the MDS should accurately reflect current care status and needs. The DON and ADM acknowledged that it was the responsibility of the ADON, MDSC, and DON to ensure timely and accurate completion of MDS assessments, and that the facility had not completed a change in condition assessment for this resident. The care plan documented cognitive loss, dietician referral, prescribed diet, altered nutrition status related to weight loss, shortness of breath, risk of dehydration, oxygen therapy related to COPD, and extensive assistance needs with ADLs, but there remained no corresponding significant change MDS to capture the resident’s updated status following the hospitalizations and treatment changes. During surveyor interviews, the resident provided minimal information about recent hospitalization, oxygen treatments, and thickened water, responding only "whatever they said." The CRN initially stated that updated MDS assessments were in the EMR but was unable to produce a significant change MDS. The ADM reported that the facility had recently terminated the MDSC after observing a pattern of failing to complete timely and accurate assessments and confirmed that the DON was responsible for monitoring and ensuring that the MDS was updated. Overall, the survey findings showed that despite clear evidence of significant changes in the resident’s physical and clinical status, the facility did not complete the required significant change MDS assessment and did not accurately code existing MDSs to reflect oxygen and IV treatments and diet changes. The facility’s written policy on change of condition emphasized the importance of recognizing and managing acute changes of condition and defined an acute change as a sudden, clinically important deviation from baseline that, without intervention, may result in complications or death. The resident’s multiple hospitalizations for serious conditions, including hypernatremia, hypoxia, and aspiration pneumonia, along with changes in diet consistency, respiratory support, and IV therapy, met the criteria for significant change. Nonetheless, the record review and staff interviews confirmed that no significant change MDS was completed, and existing MDS assessments were incomplete or inaccurate in key sections, particularly Section O for special treatments. This failure to conduct and accurately complete a significant change assessment within the required timeframe formed the basis of the cited deficiency.
Inaccurate MDS Assessments for Diet and Respiratory Treatments After Change in Condition
Penalty
Summary
Surveyors identified a failure to ensure that a resident’s Minimum Data Set (MDS) assessments accurately reflected the resident’s current clinical status, specifically related to diet and respiratory treatments. Record review showed that the resident, an older male with diagnoses including metabolic encephalopathy, diabetes mellitus with hyperosmolality, hypernatremia, and acute and chronic respiratory failure with hypoxia, had an MDS dated 09/09/2025 with an undocumented assessment type and an empty BIMS summary score field. This MDS documented shortness of breath with exertion, at rest, and when lying flat, and noted parenteral/IV feeding while not a resident, but did not clearly capture subsequent clinical changes. The resident was hospitalized multiple times and returned with changes in diet approaches, including thickened liquids, and with respiratory treatments and IV for enteral feeding. The quarterly MDS completed later by an LVN/MDS nurse documented a BIMS score of 07, indicating severe cognitive impairment, and again noted shortness of breath with exertion, at rest, and when lying flat. In Section K, the quarterly MDS continued to list parenteral/IV feeding as a nutritional approach but did not address the resident’s need for thickened liquids. In Section O, the assessment indicated that the resident did not require any special treatments, such as IV or oxygen, despite other information indicating oxygen therapy and respiratory treatments. Section Z of this quarterly MDS was signed by an RN on 12/23/2025, certifying completion of the assessment. Additional documentation and interviews confirmed that the resident’s care needs had changed and were not reflected in a corresponding change in condition MDS. The care plan dated 01/14/2026 included problems and interventions such as cognitive loss, dietician referral, prescribed diet, altered nutritional status, shortness of breath, risk of dehydration, and oxygen therapy related to COPD, and noted that the resident recently received thin liquids and was progressing in speech. The CRN stated the resident had been hospitalized several times and returned with clinical changes including thickened liquids, respiratory treatments, and IV for enteral feeding, and acknowledged the need to check updated MDSs. The DON stated that MDS clinical assessments and plans should be updated to reflect the resident’s current status and that failing to complete or update MDS assessments placed the resident at risk of missing individualized clinical care, treatment, and tasks. The ADM reported that the facility had observed a pattern of failing to complete timely and accurate assessments and that the MDS coordinator had been terminated, and staff were unable to produce a change in condition MDS for this resident. The facility’s policy required comprehensive, accurate MDS assessments, coordinated and certified by an RN, and completed on admission, annually, quarterly, and within 14 days of a significant change, but this process was not followed for this resident’s change in condition.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple staff not adhering to required infection control practices during care of two residents. For one resident with a suprapubic catheter and wounds, who was under Enhanced Barrier Precautions (EBP) isolation, several staff members, including an LVN and three CNAs, provided care without wearing gowns as required for high-contact procedures. Observations showed that while gloves were used, gowns were not donned, and staff were unaware or forgot the necessity of this PPE despite the presence of a PPE supply cart outside the room. There was also no EBP isolation signage present. Interviews revealed that some staff did not know the purpose of the PPE cart or the need for gowns, and one staff member admitted to rushing and forgetting proper PPE due to time constraints. In another instance, during incontinent care for a different resident, a CNA failed to perform hand hygiene between glove changes, and an LVN placed dirty linen on the floor instead of in a designated plastic bag. The CNA acknowledged knowing the correct procedure but did not follow it due to nervousness, while the LVN stated that placing dirty linen on the floor was not an issue, despite facility policy requiring dirty linen to be bagged. The administrator and DON confirmed that staff were expected to perform hand hygiene before and after care, between glove changes, and to properly handle soiled linen, but these protocols were not followed during the observed care. Record reviews and staff interviews confirmed that the facility had policies in place for hand hygiene and EBP, requiring gowns and gloves for high-contact care and proper handling of soiled linen. However, the observed failures in PPE use, hand hygiene, and linen handling during resident care directly contradicted these policies and placed residents at risk for cross-contamination and infection, as acknowledged by staff and leadership during interviews.
Failure to Develop Comprehensive Care Plan for ADLs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for activities of daily living (ADLs) for a resident. Record review showed that the resident, a 90-year-old individual with multiple diagnoses including idiopathic peripheral autonomic neuropathy, depression, secondary hypertension, atrial fibrillation, and chronic diastolic congestive heart failure, required varying levels of assistance with ADLs such as toileting hygiene, bathing, dressing, eating, and oral hygiene. Despite these needs being identified in the most recent MDS assessment, the resident's care plan did not include a plan of care for ADLs, nor did it specify measurable goals, interventions, or timeframes related to these needs. Interviews with facility staff, including the Administrator, DON, and MDS Nurse, confirmed that the absence of ADLs in the care plan diminished staff communication and knowledge of the resident's preferences and routines. The staff acknowledged that the care plan should reflect the resident's functioning, preferences, and required assistance, and that the MDS Coordinator was responsible for updating the care plan. Review of the facility's care plan policy indicated that the interdisciplinary team is required to coordinate and review care plans based on assessments within specified timeframes, but this process was not followed for the resident in question.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was frequently incontinent of bladder and bowel did not receive timely incontinence care. The resident, a cognitively intact female with multiple diagnoses including autonomic neuropathy, depression, hypertension, atrial fibrillation, and chronic heart failure, reported not having her incontinence brief changed all morning. She also stated her call light had not worked for two months, and she relied on a bell to alert staff. Record review confirmed her incontinence status, and interviews with staff revealed that the certified nursing assistant (CNA) assigned to her had not changed her since the start of the shift at 6:00am, despite facility policy and staff expectations that incontinence care be provided every two hours or as needed. The CNA reported being responsible for 16 residents and having multiple competing duties, which contributed to the delay in providing care. Both the licensed vocational nurse (LVN) and the director of nursing (DON) confirmed that the facility's expectation was for incontinence care to be provided every two hours or when requested, and that delays could result in skin breakdown, depression, or infection. Facility policy required perineal/incontinent care after each episode of incontinence. The failure to provide timely care was directly observed and confirmed through interviews and record review.
Improper Catheter Bag Positioning During Resident Transfer
Penalty
Summary
A deficiency occurred when a resident with an indwelling suprapubic urinary catheter did not receive appropriate catheter care during a transfer from bed to Geri-chair. During the transfer, CNA C placed the catheter drainage bag flat on the foot of the bed, which was above the resident's bladder level, and later hung the bag on the shaft of the mechanical lift. This positioning allowed urine to flow back toward the resident's bladder. The resident required extensive assistance with mobility and had a history of obstructive uropathy and cancer, with moderately impaired cognition. Interviews with CNA C, the Administrator, and the DON confirmed that staff were trained and expected to keep the catheter drainage bag below the bladder to prevent backflow and potential infection. However, the facility's policy on catheter care did not address this specific concern. The failure to maintain the drainage bag below bladder level during the transfer was observed directly and acknowledged by staff as contrary to proper procedure.
Failure to Date Opened Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their only kitchen, as observed during a survey. Specifically, the facility did not ensure that food items, such as liquid eggs, were labeled with use-by dates after being opened. During an observation, it was noted that two packets of liquid eggs in the walk-in refrigerator were opened but lacked a use-by date. Interviews with the Dietary Manager and kitchen staff confirmed that all open food items should have an 'open date' and a 'use-by date,' and that the liquid eggs should have been labeled with a use-by date of three days after opening. The Dietary Manager and staff acknowledged the risk of not dating food items, which could lead to food-borne illnesses among residents. The facility's policy on food storage, revised in February 2024, mandates that all foods be covered, labeled, and dated, aligning with the FDA Food Code requirements. The failure to date opened food items, as per the facility's policy and FDA guidelines, posed a risk of food contamination and illness to residents consuming meals from the facility's kitchen.
Failure to Transmit Discharge MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that discharge Minimum Data Set (MDS) assessments for two residents were electronically completed and transmitted to the CMS System within 14 days after completion. Resident #23, a female who was admitted to the facility and later passed away, did not have a discharge MDS assessment completed, which was identified as being over 120 days late. Similarly, Resident #43, a male who was discharged against medical advice, also lacked a completed discharge MDS assessment, which was also over 120 days late. This oversight was discovered during a review of the residents' records and interviews with facility staff. Interviews with the MDS Nurse and the Regional MDS RN revealed that a change in the electronic health record system in November 2024 contributed to the inability to access previous assessments. The MDS Nurse was responsible for completing all MDS assessments, while the Regional MDS coordinator handled the transmission to CMS. Both staff members acknowledged the requirement to complete and transmit discharge assessments within 14 days of discharge or death. The facility's policy mandates that MDS assessments be conducted and transmitted in a timely manner, but this was not adhered to, leading to incomplete records for the residents involved.
Failure to Include Dialysis in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not address the resident's need for dialysis, despite the resident being admitted as a dialysis patient. The omission was identified during a survey, and the care plan had not been updated to include dialysis prior to the survey date. The resident, a cognitively intact male with a BIMS score of 15, had been admitted with diagnoses including peripheral vascular disease, hypotension of hemodialysis, muscle wasting and atrophy, and enterocolitis due to clostridium difficile. The Director of Nursing (DON) and the MDS Coordinator acknowledged the oversight, with the MDS Coordinator noting that the care plan should reflect physician orders and the facility's actions for the patient. The facility's policy required the interdisciplinary team to coordinate an appropriate care plan based on assessments within required timeframes.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for two residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #30, a male with a history of stroke, hypertension, hyperlipidemia, and anxiety, was totally dependent on staff for personal hygiene. On observation, his fingernails were found to be dirty and jagged, extending 0.4 cm from the tip of his fingers. Resident #30 expressed a desire for his nails to be clipped and cleaned, indicating his dependence on staff for nail care. Similarly, Resident #19, a male with fractures, hypertension, peripheral vascular disease, hyperlipidemia, and schizophrenia, required moderate assistance for personal hygiene. His nails were observed to be long, jagged, and discolored, extending 0.3 cm from the tip of his fingers. Resident #19 also expressed a need for assistance with nail care, noting that his nails had not been clipped for several days. Interviews with facility staff, including a CNA and RN, revealed that both CNAs and nurses were responsible for nail care, which was to be performed on shower days and as needed. The CNA mentioned that Resident #30 sometimes refused nail care, and refusals were reported to the Charge Nurse. The RN acknowledged that dirty, jagged nails could increase the risk of infections. The DON confirmed that nail care was the responsibility of all CNAs and nurses, and nails should be observed daily. The facility's policy on bathing indicated that nail care should be performed to keep nails clean and trimmed. Despite these protocols, the facility failed to ensure that the residents received the necessary nail care, potentially placing them at risk for infections and decreased quality of life.
Improper Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a risk of urinary tract infections. During a wound care procedure, a CNA placed the resident's catheter drainage bag on the bed, above the bladder level, which caused urine to flow back toward the bladder. This action was contrary to the resident's care plan, which specified that the catheter tubing should be kept below the bladder level to prevent complications. Both the CNA and the LVN involved acknowledged the mistake, with the CNA stating she placed the bag on the bed to prevent it from pulling, despite being trained to keep it below the bladder. The resident involved was an elderly male with a history of prostate cancer and a pressure ulcer, requiring extensive assistance with mobility and transfer. His care plan included specific instructions for catheter management to avoid complications. The facility's Director of Nursing confirmed that the improper placement of the catheter bag could lead to urinary tract infections and cross-contamination. Despite the CNA's previous competency check indicating proficiency in catheter care, the facility's policy on catheter care did not address the specific concern of maintaining the drainage bag below bladder level.
Failure to Label Insulin Pen with Open Date
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles, specifically regarding the labeling of an insulin pen for a resident. During an observation of the nurses' cart on Hall 600, it was noted that an insulin pen for a resident did not have an open date. The pen was not full and had been used, indicating it was in active use without proper labeling. This oversight was confirmed by LVN A, who admitted to administering insulin from the pen without checking for an open date. LVN A acknowledged the importance of labeling the pen with an open date to ensure the insulin's effectiveness, as it is only viable for 28 days after opening. Further interviews revealed that the Director of Nursing (DON) was aware of the requirement for insulin pens and vials to be dated upon opening, as they have a specific shelf life. The DON stated that the pharmacy consultant conducts monthly checks of the medication carts, and both the DON and Assistant Director of Nursing (ADON) are responsible for performing random checks to monitor compliance. A review of the facility's policy on medication labeling confirmed the necessity of documenting the open date on multi-dose vials to maintain product integrity, aligning with the manufacturer's specifications.
Ineffective Pest Control Program Leads to Bed Bug Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in bed bug sightings on the 600 floor. Two residents reported bed bugs in their rooms, with one resident seeing a bed bug on his bed sheet and another resident's room being treated for bed bugs after a report. The facility's pest control program was not effectively implemented, as evidenced by the lack of comprehensive inspections and staff training on bed bug prevention. Interviews with staff and residents revealed that the facility did not follow its bed bug policy, which required checking all rooms on the affected floor and training staff on bed bug prevention. Some staff members were unaware of the bed bug issue, and there was a lack of documentation and communication regarding the sightings and treatments. The facility's pest control provider was reportedly not thorough, and there were inconsistencies in the pest control treatments and inspections. The facility's pest control policy required immediate notification of the Administrator and Director of Nursing upon realization of a bed bug infestation, but this was not consistently followed. The facility had a history of bed bug issues, and the pest control treatments were not effective in eliminating the problem. The lack of a coordinated response and proper training contributed to the ongoing bed bug issue, which posed a risk to residents' well-being.
Verbal and Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with moderate cognitive impairment and multiple complex medical conditions, including dementia and anxiety. The resident required substantial assistance with daily activities and was observed to have no history of recurrent outbursts or excessive use of the call light until the day of the incident. On the day of the incident, the resident was reportedly on the call light all day and was observed to be anxious. A family member reported witnessing the CNA verbally abusing the resident and forcing her to get out of bed against her will via a video camera in the resident's room. The video footage showed the CNA removing the call light from the resident's hand, refusing to change her when she was wet, and speaking to her in a threatening and disrespectful manner. The CNA was heard making statements that were verbally abusive and dismissive of the resident's needs. The facility's investigation into the incident included reviewing video footage and interviewing staff and the resident. The CNA involved denied the allegations, claiming she was speaking to someone else via earbuds during the incident. However, the video evidence and interviews with the resident and staff indicated that the CNA's behavior was inappropriate and abusive. The facility's policy on abuse and neglect emphasizes the right of residents to be free from abuse and the facility's duty to protect these rights, which was not upheld in this case.
Failure to Maintain Wheelchair Safety
Penalty
Summary
The facility failed to ensure that assistive devices, specifically wheelchairs, were maintained and free of hazards for two residents. Resident #2, a male with a history of stroke and high fall risk, was observed in a wheelchair with damaged armrests, exposing jagged edges and metal parts. Multiple staff members, including a medication aide, MDS coordinator, CNA, ADON, and Central Supply Director, were unaware of the condition of the wheelchair, indicating a lack of communication and oversight in maintaining equipment. Resident #3, a female with cognitive deficits and high fall risk, was also found using a wheelchair with torn armrests, exposing the cotton padding. Despite her attempts to address the issue by taping the armrests and speaking to the Maintenance Director, the problem persisted for over a year. Interviews with staff, including the ADON and Maintenance Director, revealed a lack of awareness and a failure to document repair requests in the maintenance log, further highlighting the facility's inadequate system for reporting and addressing equipment maintenance issues. The facility's failure to maintain the wheelchairs in good repair was compounded by the absence of a documented maintenance policy and incident/accident prevention policy, as requested during the survey. The lack of a structured process for identifying and repairing damaged equipment placed residents at risk of injury, as acknowledged by various staff members during interviews. The Administrator and former Administrator were also unaware of any issues with the wheelchairs, indicating a systemic oversight problem within the facility.
Improper Hair Restraint Use by Dietary Staff
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed with Dietary Aide G, who did not properly wear a hair restraint while preparing meals for residents. During an observation, it was noted that Dietary Aide G's hair, approximately 3 inches in length, was not fully covered by the hairnets she wore. She had two small hairnets on either side of her head, leaving the front, sides, and back of her hair exposed. Dietary Aide G admitted to forgetting to put on an additional hairnet due to rushing back from outside to prepare the meal trays. Interviews with other dietary staff and the Dietary Director (DD) revealed that there was an expectation for all hair to be restrained using hairnets to prevent contamination of food. Despite having sufficient hairnets available, the staff did not consistently ensure proper usage. The DD acknowledged the importance of hairnets in maintaining food safety and stated that she would address the issue with Dietary Aide G. The facility's policy and federal food code require effective hair restraints to prevent contamination, but the deficiency in compliance was evident in this instance.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the facility did not complete a weekly skin assessment for a resident from April 14 through April 20, despite the care plan requiring a head-to-toe skin inspection every week. This lapse in care was identified during a record review and interviews with facility staff. The resident involved was an elderly female with a history of urinary tract infection, dementia, absence of the left leg above the knee, and hemiplegia and hemiparesis following a cerebral infarction. The resident had a stage 3 pressure wound on the left ischium, and the lack of a weekly skin assessment could have placed her at risk of receiving inadequate care. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that they were responsible for ensuring the completion of weekly skin assessments, but they missed the audit for the week in question. The facility's policy required weekly skin assessments to prevent pressure ulcers and ensure proper wound care.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of RN D during wound care for a resident. RN D was observed removing gloves and performing hand hygiene with hand sanitizer directly over the resident's open wound on the left ischium. This practice was contrary to infection control protocols, as it posed a risk of micro-organisms or sanitizer contaminating the wound. RN D acknowledged being nervous during the procedure and admitted to not realizing the potential risk of his actions. The resident involved was an elderly female with a history of urinary tract infection, dementia, absence of the left leg above the knee, and hemiplegia and hemiparesis following a cerebral infarction. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that RN D was trained in proper wound care techniques and understood the risks associated with his actions. The facility's infection prevention and control policy emphasized the importance of preventing contamination during wound care, yet the observed practices did not align with these guidelines.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 876 citations issued within 25 miles in the last 12 months — including the 43 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Dallas | 0.6 mi | — | 1 | 0 |
| Ventana By Buckner | 1 mi | — | 0 | 0 |
| Fair Park Health & Rehabilitation Center | 1.4 mi | — | 6 | 0 |
| Autumn Leaves | 4.7 mi | — | 0 | 0 |
| Southern Oaks Therapy And Living Center | 4.9 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.