Sundance Inn Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Braunfels, Texas.
- Location
- 2034 Sundance Parkway, New Braunfels, Texas 78130
- CMS Provider Number
- 676472
- Inspections on file
- 36
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 20 (2 serious)
Citation history
Health deficiencies cited at Sundance Inn Health Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide required written transfer/discharge notices, including appeal rights and Ombudsman notification, for three residents with dementia and elopement or wandering concerns. One resident with moderate cognitive impairment was moved to another city’s secure unit while a family member was out of the country, after only a handwritten notice was given the day before transfer and after the Ombudsman had advised the facility to provide proper notice. Another resident with vascular dementia was labeled as having eloped after going outside to see fireworks, then was discharged to another town without any 30‑day or prior written notice. A third resident with severe cognitive impairment and documented elopement risk was transferred to a secure unit at another facility based only on verbal agreement with the responsible party, with no written notice in the record. The ADM acknowledged that written notices were not provided because families were involved in discussions, and the SW reported uncertainty about the discharge process, despite a facility policy requiring 30‑day written notice (or as soon as practicable in exceptions) with specific content and evidence of notice to the LTC Ombudsman.
A resident admitted with bipolar disorder and other medical conditions was receiving Seroquel 100 mg twice daily, but the facility failed to maintain a complete and properly documented consent for this antipsychotic medication in the medical record. Nursing staff were responsible for medication consents, yet the DON reported being unfamiliar with the required state psychotropic consent form and unaware it was needed for the resident’s Seroquel. Two different consent documents dated the same day were found: one digitally signed by an LVN with only the resident’s initials, and another antipsychotic consent form that lacked diagnostic criteria and assessment findings, contained an altered provider name, and did not include the resident’s printed name, despite a requirement that the original form be in the clinical record. These practices did not comply with the facility’s policy requiring complete, accurate electronic clinical records with proper signatures and identifiers.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report does not provide further details about the specific events or residents involved.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found that necessary safeguards were missing or not consistently followed, resulting in inadequate protection for residents.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment presented risks that were not properly mitigated, and supervision was not sufficient to ensure resident safety.
A treatment cart containing drugs and biologicals was left unlocked and unattended by a nurse while wound care was provided to a resident with multiple medical conditions, contrary to facility policy and accepted practice. The nurse believed the cart was locked, but observations showed it remained accessible until after the treatment was completed.
CNAs failed to fully close a privacy curtain while providing incontinent care to a resident with multiple medical conditions and moderate cognitive impairment, resulting in exposure of the resident's genital area. The curtain was too short to provide adequate coverage, and a housekeeper nearly entered the room during care before being stopped. Both CNAs and the administrator confirmed that privacy should have been maintained and that staff had received resident rights training.
A housekeeper accepted a $350 check from a resident, who was cognitively intact and had multiple medical conditions, after the resident offered financial help. The incident was discovered by the resident's family member, reported to facility administration, and investigated internally. The housekeeper admitted to accepting the money despite knowing it was against policy, and the incident was not reported to law enforcement as required by facility protocol.
A facility failed to report an allegation of exploitation to law enforcement after a cognitively intact male resident gave a $350 check to a housekeeper, despite the family member's request for escalation and the facility's own protocols requiring such reporting. The administrator handled the matter internally, believing it was a voluntary gift rather than misappropriation, and did not notify law enforcement as mandated.
A container of Clorox disinfecting wipes, labeled as causing eye irritation, was found unsecured on a bedside table in a resident's room. The resident was severely cognitively impaired and required assistance with ADLs. Staff confirmed the wipes should not have been present and that a family member had brought them in, despite prior education on prohibited items.
A resident's urinary collection bag was found uncovered, violating the facility's policy to maintain resident dignity. The resident, who was cognitively intact, was unaware of the issue and expressed a preference for the bag to be covered. Facility staff, including an LVN, DON, and ADM, confirmed that covering the bag is necessary to uphold dignity, as per the facility's policy.
A resident with legal blindness and limited shoulder mobility was unable to reach their call light, leading to unmet needs and frustration. Despite facility policy and staff acknowledgment of the importance of call light accessibility, the call light was placed out of reach, contrary to standard practice.
A resident with multiple active wounds did not have an updated comprehensive care plan reflecting current treatments, despite physician orders and interventions being in place. The care plan only addressed a bruise and lacked updates for wounds on the right foot, left foot, and contracted right hand. Facility staff were unaware of the oversight, which could lead to inadequate care.
A resident with a gastrostomy tube was incorrectly administered hydralazine, prescribed orally, through the tube due to a transcription error. The RN and DON acknowledged the mistake, highlighting a failure to verify medication orders as per facility policy.
A facility failed to maintain proper infection control practices during incontinent care for a resident with multiple health conditions. CNAs did not follow hand hygiene protocols, such as sanitizing hands after touching a trash can and between glove changes, despite having received training and passing competency checks. The DON confirmed the need for proper hand hygiene as per facility policy.
Failure to Provide Required Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer and discharge notices, including appeal rights and Ombudsman notification, for three residents who were discharged or transferred due to wandering and elopement concerns. For the first resident, an older male with NSTEMI, malnutrition, acute respiratory failure with hypoxia, BPH, and moderate dementia, the record showed moderate cognitive impairment with a BIMS score of 8 and a SLUMS score of 8/30. His care plan documented resistance to care and a wish to be discharged to another facility for elopement risk and wandering. Family members reported concerns about possible urinary infection, anxiety, and wandering behavior, and the facility informed them that the resident had tried going to exit doors. While the family was out of the country, the facility decided to move the resident to another facility with a secure unit. The family and the Ombudsman objected to the move and requested that he not be transferred until the family could be present, but the resident was still sent to another facility in another city. The Ombudsman reported that the facility only provided a handwritten notice the day before the move, which did not meet the 30‑day requirement and did not provide a reason for immediate discharge. The second resident, an older female with major depressive disorder, generalized anxiety disorder, cognitive communication deficit, peripheral vascular disease, and vascular dementia, had a BIMS score of 11 indicating moderate cognitive impairment. Her care plan addressed impaired cognition but did not address wandering. According to her representative, the resident became upset about a roommate’s frequent male visitor and was moved to a room near exit doors. On New Year’s Eve, she went outside to see fireworks and was locked out, after which the facility considered this an elopement. The representative had placed a camera in the room and reported that staff failed to check on the resident for 14 hours, which was reported as a complaint. The facility told the representative that the resident needed a secured unit due to confusion and wandering and insisted on discharge. The resident was discharged to another town without any 30‑day or prior written notice of transfer or discharge being provided to the resident or representative. The third resident, an older male admitted with metabolic encephalopathy, altered mental status, and moderate dementia, had a BIMS score of 7 indicating severe cognitive impairment. His care plan identified him as at risk for elopement, with interventions including elopement risk assessment and distraction from wandering. The social worker stated that this resident was wandering from the day of admission, was more combative, and refused care, and that the facility contacted the family and sent clinical information to a local facility with a secure unit. However, record review showed no discharge notice provided to the resident or responsible party; the record only documented that the responsible party agreed to move the resident. In interviews, the social worker acknowledged she was not sure about the discharge process and that only the administrator or business office manager issued notices. The administrator stated that because the families of all three residents were involved in decision‑making about alternate placement, the facility did not feel written notices were needed, and confirmed that only a late, non‑compliant notice was given for the first resident after Ombudsman involvement, with no notices given for the second and third residents. The facility’s own transfer and discharge policy, however, required written notice with specific content, 30‑day timing (or as soon as practicable in exceptions), and evidence of notice to the Ombudsman, which was not followed in these cases. The facility also failed to send copies of the transfer/discharge notices to the State Long‑Term Care Ombudsman as required. The Ombudsman reported that she generally received a monthly list of discharged residents but, in the case of the first resident, only received a handwritten notice the day before the move, after she had already advised the facility to provide proper notice and not to move the resident without it. The facility’s policy required that notices be provided to the resident and representative in a language and manner they understand, include specific reasons for transfer or discharge, the effective date, the receiving location, appeal rights and how to obtain assistance, and the Ombudsman’s contact information, and that the facility maintain evidence that the notice was sent to the Ombudsman. The survey findings showed that these policy elements and regulatory requirements were not met for any of the three residents reviewed for discharge rights.
Incomplete and Improperly Documented Antipsychotic Medication Consent in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident receiving an antipsychotic medication. The resident, a female admitted with metabolic encephalopathy, acute respiratory failure with hypoxia, bipolar disorder, and insomnia, had a discharge MDS showing a BIMS score of 13, indicating fully intact cognition. Her care plan, initiated on 3/8/26, identified the use of psychotropic medications with interventions to administer them as ordered and monitor for side effects and effectiveness every shift. The order summary dated 4/17/26 showed an active order for Seroquel 100 mg by mouth twice daily for bipolar disorder, starting 3/8/26 with no end date. A document titled Psychoactive Medication Consent dated 3/8/26 indicated the resident consented to Seroquel 100 mg twice daily, was digitally signed by LVN A, and contained the resident’s initials at the bottom. During interviews, the SW stated that nursing staff handled medication consents, and the DON stated that charge nurses usually completed medication consents on admission. The DON reported being unfamiliar with the required 3713 form for psychotropic medication consent and stated the facility was not aware that such a form was needed for the resident’s Seroquel. Later, the DON produced a different consent form, dated 3/8/26, titled “Consent for Antipsychotic or Neuroleptic Medication Treatment” (version September 2021-E). This form documented the resident’s bipolar disorder, Seroquel 100 mg twice daily as a home regimen, listed side effects, and described the need for treatment, but it did not list diagnostic criteria and assessment findings exhibited by the resident, had alterations to the provider’s last name, and lacked the printed name of the resident in Section II, although it contained the resident’s initials and date. The bottom of the form required that the original copy be included in the clinical record. The facility’s policy on Maintenance of Electronic Clinical Records required complete and accurate electronic clinical records, including pre-admission screening assessments with required signatures and individualized identifiers for staff attestations with date and time recorded, which was not fully met in this case.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through surveyor observations and review of facility documentation, which revealed that the required safeguards and protocols were either not in place or not consistently followed. As a result, the facility did not ensure adequate protection of residents from potential harm related to abuse, neglect, or theft. Surveyors noted the absence of comprehensive preventive measures and a lack of staff adherence to existing procedures, contributing to the facility's inability to safeguard residents as required by regulations.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for their daily personal care and routine activities.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not properly addressed, and supervision measures were insufficient to prevent potential incidents. No further details about the specific hazards, the individuals involved, or the circumstances at the time of the deficiency are provided in the report.
Unattended and Unlocked Treatment Cart with Medications
Penalty
Summary
A deficiency occurred when a nursing treatment cart containing drugs and biologicals was left unlocked and unattended by the Treatment Nurse. During the provision of wound care to a resident with heart failure, high blood pressure, and an open wound on the right toes, the nurse entered the resident's room to wash her hands, leaving the cart in the hallway, out of her line of sight, and in an unlocked state as indicated by the visible red portion of the lock handle. The nurse subsequently removed betadine from the cart to apply to the resident's toes and continued to leave the cart unlocked while providing wound care, only locking it after completing the treatment and retrieving another item from the cart. Interviews confirmed that the Treatment Nurse believed she had locked the cart, as was her usual practice, but observations showed otherwise. The Director of Nursing (DON) stated that the cart should be locked when unattended to prevent unauthorized access to medications. Review of facility policy confirmed that all compartments containing drugs and biologicals must be locked when not in use and not left unattended if open or accessible.
Failure to Ensure Resident Privacy During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) C and D failed to ensure complete privacy for a resident during incontinent care. On the observed date, the privacy curtain in the resident's room was not fully closed, leaving the end of the bed uncovered and exposing the resident's genital area. The curtain was noted to be too short to provide full coverage, and a housekeeper began to enter the room during care before being stopped by the surveyor and the CNAs. Both CNAs acknowledged that the curtain was not completely closed and stated that the curtain had recently been changed, resulting in inadequate coverage. The resident involved had multiple medical conditions, including a non-traumatic acute subdural hemorrhage, dysphagia, prostate cancer, type 2 diabetes mellitus, hypertension, and depression. The resident was moderately cognitively impaired, required extensive assistance with activities of daily living, and was always incontinent of bowel and bladder. The care plan required incontinent care every two hours and as needed, with privacy to be maintained during care. Both the CNAs and the facility administrator confirmed that staff had received training on resident rights, including the right to privacy.
Staff Accepted Money from Resident in Violation of Facility Policy
Penalty
Summary
A deficiency occurred when a housekeeper accepted a $350 check from a resident over a two-day period. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including rhabdomyolysis, alcohol abuse, hypertension, anxiety disorder, and depression, was under the care of the facility. The resident's family member, who managed his checkbook, discovered a missing check after leaving it at the facility for bill payments. Upon questioning, the resident admitted to giving the check to the housekeeper, stating she needed help for a trip. The family member reported the incident to the facility's receptionist, who then notified the Administrator. The Administrator investigated and found that the housekeeper had accepted the check, despite knowing it was against facility policy. The housekeeper later admitted to taking the money after the resident offered it, and did not report the incident to her supervisor or management. The facility's policy clearly prohibits staff from accepting gifts or money from residents, and defines such actions as misappropriation of resident property. The Administrator did not report the incident to law enforcement, reasoning that the resident had voluntarily given the check and was cognitively intact. However, the facility's own protocol requires reporting any reasonable suspicion of misappropriation or exploitation to the state agency and law enforcement. The failure to prevent the housekeeper from accepting money from the resident and the lack of immediate reporting to authorities constituted the deficiency.
Failure to Report Alleged Exploitation to Law Enforcement
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act. Specifically, the facility did not report an allegation of exploitation to law enforcement after a housekeeper received a $350 check from a resident. The incident was brought to the attention of the facility by the resident's family member, who noticed a missing check and confronted both the resident and facility staff. The family member expressed concern and requested immediate action, including escalation to law enforcement, but the facility administrator assured her that he would handle the matter internally. The resident involved was a male with a history of rhabdomyolysis, alcohol abuse, hypertension, anxiety disorder, and depression. He was assessed as cognitively intact with a BIMS score of 15 and was able to perform activities of daily living independently or with some assistance. The resident's care plan included monitoring for involuntary behaviors and protecting him from self-harm or harm to others. Despite these measures, the resident gave a check to the housekeeper, who initially refused but ultimately accepted the money. The housekeeper did not report the gift to her supervisor, and the incident was only discovered after the family member raised concerns. Interviews with facility staff revealed that the administrator did not report the incident to law enforcement, believing that the resident's cognitive status and voluntary action did not constitute misappropriation but rather the acceptance of a gift. The facility's own protocol required reporting any reasonable suspicion of a crime, including misappropriation or exploitation, to both the state agency and law enforcement within specified timeframes. However, the administrator failed to follow this protocol, and the incident was not reported to law enforcement as required.
Hazardous Cleaning Product Left Unsecured in Resident Room
Penalty
Summary
A deficiency was identified when a container of Clorox disinfecting wipes, which carries a hazard statement indicating it causes eye irritation, was found on top of a bedside table in a resident's room. The resident had a history of hydrocephalus, dementia, hypertension, type 2 diabetes mellitus, and anxiety disorder, and was assessed as severely cognitively impaired with a BIMS score of 00. The resident also had a self-care deficit and required assistance with activities of daily living (ADLs), as documented in the care plan. During the survey, staff confirmed that the disinfecting wipes should not have been left in the resident's room. It was further revealed that the wipes had been brought in by the resident's wife, despite previous education provided to her about not bringing certain items into the facility. The presence of the hazardous cleaning product in the resident's room was observed and acknowledged by both nursing and administrative staff as a failure to maintain an environment free from accident hazards.
Failure to Maintain Resident Dignity by Not Covering Urinary Collection Bag
Penalty
Summary
The facility failed to ensure that a resident's urinary collection bag was covered with a privacy bag, which is a requirement to maintain the resident's dignity. This deficiency was observed during an interview and observation of a male resident who was admitted with several diagnoses, including hypertension, gastroesophageal reflux disease, acute kidney failure, muscle weakness, and a cognitive communication deficit. The resident, who was cognitively intact with a BIMS score of 15, was found with an uncovered urinary collection bag in his room. The resident expressed that he was unaware of the lack of coverage and expressed a preference for the bag to be covered at all times. Interviews with facility staff, including an LVN, the DON, and the ADM, confirmed that it is the facility's policy and expectation that all residents' catheter drainage bags should be covered to prevent dignity issues. The facility's policy on resident rights, dated December 2016, emphasizes treating all residents with kindness, respect, and dignity. The staff acknowledged that the responsibility for ensuring the catheter bags are covered lies with the nursing staff, and failure to do so constitutes a dignity issue.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was placed within their reach, which is a necessary accommodation for their needs. The resident, a legally blind male with a history of congestive heart failure, urinary tract infection, generalized anxiety, unspecified falls, and a risk for falling, was observed sitting in a wheelchair with the call light placed on the opposite side of the bed, out of reach. The resident expressed frustration at being unable to reach the call light due to limited range of motion in his right shoulder and his legal blindness, resulting in long periods of waiting for assistance. Interviews with facility staff, including a CNA, RN, and the DON, revealed that it was standard practice to attach the call light to the resident's shirt to ensure accessibility. However, this practice was not followed in this instance, leading to the deficiency. The staff acknowledged the importance of having the call light within reach to prevent falls and ensure residents' needs are met. The facility's policy also emphasized the necessity of keeping call lights within easy reach for residents confined to a bed or chair.
Failure to Update Comprehensive Care Plan for Resident's Wounds
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with multiple active wounds, including those on the right heel, left foot second toe, and a contracted right hand. Despite having physician orders for wound treatments and interventions, the care plan did not reflect these current skin issues. The resident, who had a history of hemiplegia, dysphagia, type 2 diabetes, peripheral vascular disease, and hypertension, was at moderate risk for skin breakdown according to the Braden Scale. The resident's care plan focused on the risk of pressure development and impaired skin integrity but did not include specific treatments for the existing wounds. The care plan only addressed a bruise on the left side of the neck and lacked updates for the wounds on the right foot, left foot, and contracted right hand. Observations confirmed the presence of these wounds, and the resident indicated that staff changed his wound dressings as ordered. Interviews with the DON and MDS Coordinator revealed that they were unaware of any wounds not being care planned. They stated that care plans should be updated when new concerns arise, and they discussed resident issues in daily meetings. However, the care plan for this resident was not updated to reflect the current wound treatments, which could lead to a failure in providing appropriate care.
Medication Administration Error via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of medications through a gastrostomy tube. A resident, who was dependent on a gastrostomy tube for nutrition and medication due to conditions such as hemiplegia, essential hypertension, and dysphagia, was prescribed hydralazine to be administered orally. However, the medication was transcribed incorrectly, and the resident received it through the gastrostomy tube. This error was observed during a medication administration session, where the RN noted that the medication order on the computer screen indicated oral administration, yet it was given via the gastrostomy tube. The RN, who was also the Assistant Director of Nursing (ADON), acknowledged the discrepancy and stated that the order should have been clarified with the physician to prevent the risk of aspiration. The Director of Nursing (DON) confirmed that nurses were expected to double-check medication orders before administration and that there was a skills check-off in the training packet for nursing, although the frequency of its completion was uncertain. The facility's policy on administering medications through an enteral tube emphasized verifying physician orders and confirming medication details with the Medication Administration Record, which was not adhered to in this instance.
Inadequate Hand Hygiene Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices observed during the provision of incontinent care for a resident. The resident, who was admitted with multiple diagnoses including chronic respiratory failure, type 2 diabetes mellitus, and severe obesity, required extensive assistance and was always incontinent of bladder and bowel. During the care, CNA A touched a trash can with bare hands and did not wash or sanitize her hands before putting on gloves and assisting with care. Similarly, CNA B did not sanitize or wash her hands between changing gloves while providing care. Interviews with the CNAs confirmed their failure to follow proper hand hygiene protocols, despite having received infection control training within the year. The Director of Nursing (DON) acknowledged that CNAs should sanitize or wash their hands after touching the trash can and between glove changes. The facility's policy on hand hygiene, dated August 2014, requires the use of an alcohol-based hand rub after contact with objects in the resident's vicinity and after removing gloves. Despite passing annual competency checks for incontinent care and infection control, the CNAs did not adhere to these protocols during the observed incident.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
