Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Vintage Health Care Center during CMS and state inspections, most recent first.
The facility failed to keep call lights within reach for four residents, including individuals with severe cognitive impairment, vascular dementia with a history of falls, legal blindness with anxiety, and lack of coordination with difficulty walking. Observations found each resident in bed with their call light on the floor or behind the headboard and not accessible, despite care plans specifying that call lights must be within reach as part of fall-risk and safety interventions. Staff, including CNAs, an LVN, the ADON, and the DON, acknowledged that all staff are responsible for ensuring call bells are within reach and that facility policy requires placing the call device within the resident’s reach before leaving the room.
Surveyors found that three residents with respiratory conditions did not receive respiratory care consistent with professional standards and facility policy. One resident with acute respiratory failure had a nebulizer mask left unbagged on a nightstand and no physician order for nebulizer use. Another resident with CHF, COPD, and acute respiratory failure had an oxygen nasal cannula lying unbagged on the floor, reported discomfort and fluid on the cannula, stated she had been unable to get it replaced, and had no physician order for oxygen use until the survey date. A third resident with COPD and severe cognitive impairment had a care plan calling for oxygen therapy but no corresponding physician order, and her nasal cannula was also observed unbagged on the floor. Multiple staff, including an LVN, CNAs, the DON, and ADONs, acknowledged that oxygen devices must be bagged when not in use and that oxygen requires physician orders.
Two residents' rights to dignity and privacy were not upheld when one resident with severe cognitive impairment and swallowing difficulty was fed by a med aide who stood over him rather than sitting at eye level, and when another resident with an indwelling Foley catheter had a physician-ordered privacy bag omitted, leaving the drainage bag visible from the hallway. In both cases, staff acknowledged that facility expectations and resident rights required eye-level feeding and continuous use of catheter privacy covers to maintain dignity and privacy, yet the care plans and observed practices did not reflect these standards.
A dependent, cognitively intact resident with morbid obesity, care planned as totally dependent for ADLs, did not receive scheduled showers over approximately one month, with no shower sheets on file and no documentation of refusals. The resident reported receiving only one shower and one bed bath and stated she never refused showers, while staff cited issues with a Hoyer lift and an undersized shower chair and acknowledged incomplete documentation of a bed bath. Facility leadership stated the resident was scheduled for thrice-weekly evening showers and that CNAs were required to complete shower sheets signed by the charge nurse, consistent with a bathing policy emphasizing hygiene and cleanliness.
A resident with severe cognitive impairment, multiple fractures, and identified as a fall risk had a care plan intervention for a fall mat to be placed alongside the bed to cushion any potential fall. During observation, the resident was found in bed with the fall mat propped against the wall instead of positioned next to the bed as ordered. A CNA, an LVN, the DON, and the ADON all acknowledged that the resident was a fall risk, that the bed should be in a low position with the fall mat in place, and that staff were responsible for ensuring the environment was set up for fall prevention, but this was not done.
Multiple lists containing sensitive medical information, such as oxygen use, Foley catheters, dialysis, g-tubes, and pacemakers, were left unattended and visible on a nurse's cart, exposing residents' last names and medical details. Additionally, a medication blister pack with a resident's full name and prescription information was left on a medication cart. Staff interviews confirmed that these actions failed to maintain confidentiality of residents' medical records as required by facility policy.
Staff failed to properly store medications and biologicals, leaving medicated creams, a nebulizer solution, and a topical pain reliever unsecured in the rooms of four residents with various medical conditions. These items were found on drawers and side tables, accessible to residents, in violation of facility policy and regulatory requirements. Staff interviews confirmed that medications should not have been left in resident rooms and that proper storage procedures were not followed.
A resident with COPD was found with a nebulizer breathing mask left unbagged on a shelf when not in use, contrary to infection control expectations. Nursing staff confirmed the mask should have been stored in a clean plastic bag, and the facility's policy emphasized infection prevention, but a specific policy on mask storage was not available during the survey.
A deficiency was cited when a resident's care plan was found to be incomplete, lacking measurable timetables and specific actions to address all identified needs. Surveyors observed that the care plan did not fully document or plan for the resident's care requirements as required.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
Surveyors found that the facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency related to infection control practices.
A resident with severe cognitive impairment and legal blindness was found without access to her call light, which had been left on a shelf out of reach after care was provided. Staff interviews confirmed the expectation that call lights should always be accessible, and leadership acknowledged that all staff are responsible for ensuring this. The resident's care plan required the call light to be within reach and its location communicated to her due to her blindness.
Two residents requiring oxygen therapy did not receive care consistent with professional standards: one received oxygen through a nasal cannula connected to an empty humidifier bottle, resulting in nasal dryness, while another's nasal cannula was improperly stored unbagged in a drawer, exposing it to contamination. Staff failed to notice these issues during routine rounds, despite facility policy requiring humidification and proper storage of respiratory equipment.
A resident with severe cognitive impairment and multiple medical conditions was not provided with a comprehensive care plan for an indwelling Foley catheter, despite physician orders and facility policy requiring such planning. The resident was observed with improper catheter management, and staff confirmed that care plans should be updated but were not in this case.
Two residents who were dependent on staff for ADLs did not receive necessary nail care, resulting in one having long, dirty fingernails and another with long, cracked toenails. Despite care plans specifying regular nail care and podiatry referrals for diabetic residents, staff did not perform or arrange for these services as required.
A resident with severe cognitive impairment and an indwelling Foley catheter was observed with the catheter drainage bag on the floor and the tubing not properly secured to her leg. The care plan lacked instructions for catheter care, and staff confirmed these practices did not meet facility policy, which requires catheter bags and tubing to be kept off the floor and properly secured.
A resident with dementia and a history of wandering risk eloped from the facility within hours of admission due to incomplete elopement risk assessment and lack of adequate supervision. The resident was missing for approximately two hours before being found by law enforcement and returned to the facility.
A facility failed to notify a physician of changes in a resident's surgical site, leading to an infection and hospitalization. The Treatment Nurse noticed drainage but did not inform the surgeon, and the task was improperly delegated. The attending physician and nurse practitioner were not informed, and documentation was lacking, resulting in a significant oversight in care.
A facility failed to monitor and report a resident's surgical site condition, leading to an infection requiring hospitalization. The resident, with a history of back and pelvis surgery, did not have a baseline care plan addressing surgical care needs. Staff interviews revealed a lack of communication and documentation regarding the resident's condition, and the facility's policy on notifying physicians of changes in status was not followed.
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper sanitation practices. A blood pressure device was not sanitized between use on two residents, and staff failed to use hand sanitizer while distributing lunch trays. These lapses in practice indicate a failure to adhere to established protocols, potentially putting residents at risk of illness.
A facility failed to ensure a resident received proper care to prevent the re-development of a pressure ulcer on her right heel. Despite physician orders for a pressure off-loading boot, the resident was observed without it. The resident's nurse aide was unaware of the requirement, and the resident's nurse confirmed the protector should have been in place. The Treatment Nurse and DON emphasized the importance of the heel protector, as per facility policy.
A resident at risk for falls did not have their fall mat properly placed, as observed during a survey. The resident, with a history of dementia and other conditions, was found in bed without the fall mat on the floor, contrary to their care plan. Staff acknowledged the oversight and corrected the mat's placement, highlighting a lapse in following the facility's fall prevention policy.
A facility failed to develop a baseline care plan within 48 hours of admission for a resident with multiple medical conditions, including a surgical incision site that required care. The plan lacked necessary instructions for surgical site care, placing the resident and staff at risk due to inadequate communication and continuity of care. The oversight was attributed to the facility's policies not addressing surgical site care and the DON's recent start in her role.
The facility failed to maintain an effective pest control program, leading to a gnat infestation in the kitchen and dining hall. Despite a pest control visit a week prior, the treatment was ineffective, and staff interviews revealed the issue had persisted since the start of summer. The maintenance director prioritized other issues over the gnat problem, delaying the installation of recommended bug lights.
Failure to Keep Call Lights Within Reach for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents on a specific date. For one resident with severe cognitive impairment, multiple fractures, and a care plan identifying her as a fall risk with an intervention to keep the call light within reach, the call light was observed lying on the floor near the nightstand while she was in bed. The resident stated she needed help with repositioning but did not know where her call light was. A CNA and an LVN both observed and acknowledged that this resident’s call light was out of reach, and the LVN also noted that the resident’s fall mat was not placed alongside her bed despite her fall risk status. Three additional residents were also found with call lights out of reach during observations. One resident with vascular dementia and a history of repeated falls had an active care plan specifying that her call light should be within reach and that she required a safe environment including a working and reachable call light; however, her call light was observed on the floor on the left side of her nightstand, out of her reach while she was in bed. Another resident, who was legally blind and had generalized anxiety disorder, had a care plan identifying her as a fall risk with interventions including a reachable call light and a safe environment, yet her call light was observed on the floor behind the headboard and out of reach while she was in bed. A fourth resident, diagnosed with lack of coordination, difficulty walking, and anxiety disorder, also had an active care plan identifying her as a fall risk with interventions requiring a reachable call light and a safe environment. During observation, this resident’s call light was found on the floor next to her bed and out of reach. Multiple staff interviews, including with CNAs, an LVN, the ADON, and the DON, confirmed that facility policy and expectations required call bells to be within reach of every resident, whether in bed or in a wheelchair, and that all staff were responsible for ensuring this before leaving the room. The facility’s written call light/bell policy stated that staff must leave the resident comfortable and place the call device within the resident’s reach before leaving the room.
Unbagged Respiratory Devices and Missing Oxygen Orders for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards, physician orders, and care plans for three residents who required respiratory support. For Resident #1, a male with congestive heart failure and an active diagnosis of acute respiratory failure, surveyors reviewed his comprehensive MDS and physician orders dated 04/22/26 and found no physician orders for use of a nebulizer device. During observation on 04/22/26 at 8:59 a.m., his nebulizer mask was seen lying unbagged on the nightstand, and he reported he had not used it since the previous night. For Resident #2, a female with congestive heart failure, COPD, and an active diagnosis of acute respiratory failure and COPD, record review on 04/22/26 showed no physician orders for use of an oxygen device. During observation and interview at 9:00 a.m., she was lying in bed with the nasal cannula for the oxygen concentrator on the floor and unbagged. She stated she had complications with the nasal cannula a few days earlier because it had gotten fluid on it and was hurting her nose, that she had been trying to get it replaced but staff had not responded, and that she had not used it for a few days and really needed it to help with breathing. Facility staff, including LVN E, the DON, and ADON J, acknowledged that oxygen use requires physician orders and that the resident did not have active orders for oxygen until 04/22/26. For Resident #6, a female with diagnoses including acute kidney failure, a left femur fracture, and COPD, record review of active physician orders dated 04/16/26 did not show an order for oxygen use or care, while her active care plan dated 03/05/26 listed COPD with an intervention to give oxygen therapy as ordered by the physician. Her quarterly MDS dated 04/03/26 reflected severe cognitive impairment and a diagnosis of COPD. During observation on 04/22/26 at 9:05 a.m., her nasal cannula was seen lying on the floor unbagged. Multiple staff members, including LVN E, ADON K, CNAs U and V, and the DON, stated that nasal cannulas should always be bagged when not in use per facility policy and that all staff were responsible for ensuring this, and they described that failure to bag the devices could result in infection, cross-contamination, respiratory distress, or tripping hazards.
Failure to Maintain Resident Dignity During Feeding and Catheter Care
Penalty
Summary
The deficiency involves failures to honor residents' rights to dignity and privacy in two separate situations. For one resident with severe cognitive impairment and a diagnosis of difficulty swallowing, the comprehensive care plan noted a nutritional problem but did not include any intervention indicating the need for assisted feeding. During a noon meal observation, a medication aide was seen feeding this resident while standing over him as he sat in his wheelchair, rather than sitting at eye level. Two LVNs present observed the aide feeding in this manner and acknowledged that staff were expected to sit at eye level when feeding residents for reasons of dignity and to ensure residents did not choke. The DON and ADON also stated that staff were to sit at eye level when feeding residents for dignity and safety. The medication aide later stated she knew she should be sitting down when feeding the resident but chose to stand so she could monitor the entire dining area to ensure other residents did not choke. She also stated that staff were supposed to sit at eye level to feed residents but thought it was acceptable to stand. This conduct, combined with the lack of a specific assisted-feeding intervention in the resident's care plan despite his swallowing difficulty and severe cognitive impairment, contributed to the dignity-related deficiency identified by surveyors. In a separate incident, another resident with severe cognitive impairment, acute kidney failure, and a left femur fracture had an active physician order for an indwelling urinary catheter that specified the Foley drainage bag must be in a privacy bag while the resident was in bed or in a wheelchair on every shift. The resident's active care plan contained no problem, goals, or interventions related to indwelling urinary catheter care. During observation, the resident was seen lying in bed with the catheter drainage bag visible from the hallway and not covered by a privacy bag, contrary to the physician's order. Multiple staff members, including an LVN, the ADON, a CNA, and the DON, stated that the Foley catheter drainage bag should always be covered with a privacy bag to maintain dignity and privacy, and that it was the responsibility of nursing staff to ensure the privacy cover was in place. The facility's resident rights policy stated that residents have the right to a dignified existence and personal privacy, which was not upheld in this instance.
Failure to Provide and Document Scheduled Showers and ADL Care
Penalty
Summary
The facility failed to ensure that a dependent resident received necessary ADL services, specifically scheduled showers, to maintain personal hygiene. The resident, a morbidly obese female with an intact BIMS score of 13, was admitted in late March 2026 and required maximum assistance for ADLs, with a comprehensive care plan documenting total dependence on staff for self-care and no mention of shower refusals. Review of progress notes from admission through late April 2026 showed no documentation of shower refusals, and there were no shower sheets on file for the resident for March and April 2026. Facility policy required that bathing frequency and type be based on resident preference, skin condition, tolerance, and energy level, and that showers be documented on shower sheets. During interviews, the resident reported she had been in the facility about a month and had only received one shower and one bed bath, stating she had never refused a shower and preferred showers over bed baths. She reported staff told her there were issues with the Hoyer lift and that she wanted her hair washed. An LVN stated he was unfamiliar with the resident but confirmed that a shower sheet should be completed for each shower and that refusals should be addressed by the floor nurse. The DON and ADON stated the resident was scheduled for showers three evenings per week and that CNAs were responsible for completing shower sheets, which were to be signed by the charge nurse. A CNA reported providing a bed bath on April 18 and said he completed a shower sheet but left it in a basket instead of giving it to the charge nurse; he also described difficulty using the Hoyer lift because the shower chair was too small and uncomfortable for the resident. The facility’s own bathing policy emphasized the role of bathing in removing soil, microorganisms, and body odor and promoting comfort and cleanliness.
Failure to Implement Care-Planned Fall Mat for High-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a resident’s environment as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents. Record review showed that the resident was an elderly female with severe cognitive impairment (BIMS score of 7) and active diagnoses including fractures of the neck and femur, and a history of rib fractures. Her MDS indicated she required maximum assistance with toileting and showering. The resident’s comprehensive care plan, dated 10/01/25, identified her as a fall risk and specified use of a fall mat as an intervention to provide cushioning to the landing area if she fell from bed. On observation, surveyors found the resident lying in bed with her fall mat leaning against the wall instead of being placed alongside the bed as care-planned. A CNA, when interviewed, confirmed that the resident was a fall risk and stated that the bed should be in a low position with the fall mat placed next to it to limit injury if the resident fell out of bed. An LVN similarly acknowledged that the resident should have a fall mat in place and that staff should be checking for this during rounds. The DON and ADON also confirmed that the resident was a fall risk, that a fall mat alongside the bed was a planned intervention, and that staff were responsible for ensuring the resident’s area was set up for fall prevention when she was in bed. The facility’s Resident Rights policy stated that residents have the right to be free from neglect.
Failure to Protect Resident Privacy and Confidentiality of Medical Information
Penalty
Summary
The facility failed to ensure the confidentiality and privacy of residents' personal and medical information for fifteen out of twenty-five residents reviewed. Multiple lists containing sensitive medical information, such as residents using oxygen, those with Foley catheters, on dialysis, with g-tubes, and with pacemakers, were left unattended and visible on top of a nurse's cart in the hallway. These lists included residents' last names and specific medical interventions or devices, making the information accessible to anyone passing by, including unauthorized individuals. Additionally, a medication blister pack containing a resident's full name, medication details, prescription number, physician's name, and pharmacy information was left unattended on top of a medication cart outside the nurses' station. Observations confirmed that the paper with residents' last names and medical interventions was left in plain view on a nurse's cart, and staff interviews revealed uncertainty about who placed the paper there. The Assistant Director of Nursing (ADON) initially stated that the list was not considered a HIPAA violation because it only included last names, but did not respond when asked if the medical information itself was confidential. The Director of Nursing (DON) acknowledged that the information was medical in nature and should have been kept confidential, regardless of the circumstances that led to it being left out. Further interviews with staff, including the medication aide and the ADON, confirmed that the blister pack left on the medication cart was considered a HIPAA violation due to the presence of identifiable and confidential information. Staff admitted that the information should have been secured or at least flipped over to prevent exposure. The facility's policy on resident rights explicitly states that residents have the right to personal privacy and confidentiality of their personal and medical records, which was not upheld in these instances.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Facility staff failed to store drugs and biologicals in locked compartments as required by state and federal regulations. During observations, surveyors found that medicated creams (zinc oxide), a vial of nebulizer solution, and a tube of topical pain reliever were left inside the rooms of four residents. These items were visible and accessible on top of drawers or side tables, rather than being secured in medication carts or locked storage. Staff interviews confirmed that these medications were not supposed to be left in resident rooms and should have been removed after use. The residents involved had various medical conditions, including hemiplegia, hemiparesis, dementia, incontinence, chronic obstructive pulmonary disease, and pain management needs. All residents were cognitively intact according to their BIMS scores. The medications found included zinc oxide for incontinence care, a solution for breathing treatments, and a topical pain reliever for shoulder pain. Staff members acknowledged that these medications were left in the rooms after care was provided and that they did not notice them during their rounds. Interviews with CNAs, an LVN, the ADON, and the DON revealed a lack of adherence to the facility's medication storage policy, which requires all medications and biologicals to be stored securely and only accessible to authorized personnel. Staff admitted they did not know who left the medications in the rooms and recognized that medications should not be left accessible to residents. The facility's policy, reviewed by surveyors, clearly states that medications must be stored safely and securely, accessible only to licensed nursing or authorized staff.
Failure to Properly Store Nebulizer Breathing Mask
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease (COPD) was observed to have a nebulizer breathing mask left unbagged on a shelf in his room when not in use. The resident, who was cognitively intact and had physician orders for as-needed nebulizer treatments, stated he would use the breathing treatment if experiencing shortness of breath but could not recall the last time it was used. During the observation, the mask was not stored in a clean plastic bag as required for infection control. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that the expectation was for breathing masks to be bagged when not in use to prevent contamination and infection. The LVN admitted she had not noticed the unbagged mask during her morning rounds and was unsure when it was last used. The facility's policy on oxygen administration included goals for safe delivery and infection prevention, but a specific policy on bagging the breathing mask was not provided at the time of the survey.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection prevention and control measures were not established or maintained as expected. The report specifically notes the absence or inadequacy of a program designed to prevent and control infections within the facility, as required by regulatory standards.
Failure to Ensure Call Light Accessibility for Resident with Visual and Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident's right to reasonable accommodation of needs and preferences was met, specifically regarding the accessibility of the call light system. The resident involved was an elderly female with diagnoses including spondylosis and legal blindness, and she was severely cognitively impaired, requiring significant assistance with daily activities. Her care plan included an intervention to keep the call light within her reach and to inform her of its location due to her visual impairment. On the day of the survey, the resident was observed in bed with her call light placed on a shelf out of her reach. When asked, she was unaware of the call light's location and was unable to find it herself. Staff interviews confirmed that the call light should always be within reach, especially for residents with significant impairments. A nurse and a CNA both acknowledged that the call light was not accessible and that it was their responsibility to ensure it was placed appropriately after providing care. Further interviews with facility leadership, including the DON, Administrator, and ADON, confirmed the expectation that all staff are responsible for ensuring call lights are within reach of residents before leaving the room. The facility's policy on resident rights also states that residents have the right to reasonable accommodation of their needs and preferences, which includes access to communication devices such as call lights.
Failure to Provide Proper Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring oxygen therapy. For one resident with chronic obstructive pulmonary disease (COPD) and moderate cognitive impairment, observations revealed that the humidifier bottle attached to his oxygen concentrator was empty while he was receiving oxygen via nasal cannula. The resident reported nasal dryness and could not recall when the bottle last contained water. The assigned LVN admitted to not noticing the empty humidifier during morning rounds and only refilled it after the deficiency was identified. For another resident with COPD and severe cognitive impairment, her nasal cannula, used for nighttime oxygen therapy, was found unbagged and stored directly inside a drawer, with the prongs in contact with other items. The resident confirmed that staff typically removed the cannula in the morning. The LVN acknowledged that the cannula should have been stored in a plastic bag to maintain cleanliness and prevent infection, but had not noticed its improper storage during rounds. Upon discovery, the LVN discarded the unbagged cannula and planned to replace it. Interviews with the DON, Administrator, and ADON confirmed that facility expectations and policy require humidifier bottles to contain water during oxygen administration and nasal cannulas to be bagged when not in use. The facility's policy on oxygen administration specifies the need for humidification to prevent drying of mucous membranes. Despite these expectations, staff failed to ensure proper respiratory care practices for both residents.
Failure to Develop and Implement Foley Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an indwelling Foley catheter, as required by federal regulations. Despite the resident's significant medical history, including cancer, cerebrovascular accident, metabolic encephalopathy, and severe cognitive impairment (BIMS score 5/15), there was no care plan addressing the management and care of the Foley catheter. The resident had physician orders for specific catheter care, including monthly changes, care every shift, and monitoring for complications, but these were not reflected in the resident's comprehensive care plan. Observations and record reviews revealed that the resident was confused, unable to respond to questions, and had a Foley catheter drainage bag improperly positioned on the floor with the catheter strap detached. Interviews with the DON and Administrator confirmed that care planning is a team responsibility and should be updated upon admission and with any change in condition. Facility policies also require daily review of care plans for changes, but this was not done for the resident's Foley catheter, resulting in the deficiency.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) related to nail care for two residents who were dependent on staff. One resident, a male with a history of cerebrovascular accident, muscle weakness, and moderate cognitive impairment, was observed with long fingernails containing brown matter underneath. He reported that he had requested staff assistance to clean and trim his nails, but this was not done. His care plan included interventions for nail care to be performed on bath days and as needed, but these interventions were not followed. Another resident, a male with diabetes, anxiety, bipolar disorder, and schizophrenia, was found to have long, cracked toenails. He was totally dependent on staff for ADLs and was unsure who could safely trim his toenails due to his diabetic condition. His care plan specified that nail care, particularly for diabetic residents, should be provided by a nurse, and a podiatry consult was available as needed. Observations and interviews with staff confirmed that nail care responsibilities were not carried out as required, and the process for referring diabetic residents for podiatric care was not followed.
Failure to Provide Proper Catheter Care and Prevent UTI
Penalty
Summary
A resident with a history of cancer, cerebrovascular accident, metabolic encephalopathy, and anxiety, who was severely cognitively impaired, was readmitted to the facility with an indwelling Foley catheter. The physician's orders specified monthly catheter changes, catheter care and drainage bag emptying every shift, and monitoring for complications, with instructions to ensure the catheter strap was in place and holding. However, the resident's comprehensive care plan did not include any plan for indwelling Foley catheter care. During observation, the resident was found lying in bed with the Foley catheter drainage bag placed on the floor and the catheter tubing inadequately secured to her leg, as the catheter strap had come off and was draped over the catheter. Nursing staff confirmed that the drainage bag should not be on the floor and the tubing should be properly secured, acknowledging that failure to do so could lead to cross-contamination and infection. Facility policy also required that catheter tubing and drainage bags be kept off the floor and properly secured, but these procedures were not followed in this instance.
Failure to Prevent Elopement Due to Incomplete Admission Assessments and Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate monitoring, supervision, and implementation of assistive devices to prevent accidents for a resident with dementia who was newly admitted. The resident, who had a history of impaired cognitive function, risk for falls, and was at risk for wandering, was admitted from a short-term general hospital. Upon admission, the resident was oriented to his room and directed to the dining area for lunch. After lunch, he was last seen at the nurse's station and later in his room unpacking. Within approximately two hours and twenty minutes of admission, the resident could not be located, and a code orange was initiated. The facility did not identify potential hazards or follow internal systems in place to prevent the resident's elopement. The required elopement risk assessment and other admission assessments had not been completed at the time of the incident, as the resident eloped before the four-hour window for completing these assessments. The facility's leadership team had reviewed pre-admission clinical documents but did not find concerning information related to wandering or elopement risk, and the secured unit available was female-only, which influenced the admission decision. The resident was missing for approximately two hours before being located by local law enforcement about a mile from the facility. Interviews with staff confirmed that the resident did not express a desire to leave or appear confused immediately prior to the incident. The facility's policy required an elopement risk assessment upon admission, but this was not completed before the resident's elopement. The failure to complete timely assessments and implement appropriate safety measures resulted in the resident's unsupervised exit from the facility.
Failure to Notify Physician of Surgical Site Changes
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident representative of a significant change in the resident's physical status. This deficiency was identified in the case of a post-operative resident who had undergone back and pelvis surgery. The resident's surgical incision site showed signs of drainage, which was not promptly reported to the attending physician or surgeon, leading to an infection that required hospitalization and further surgical intervention. The report details that the facility's Treatment Nurse noticed the drainage from the surgical site and informed the facility's wound care doctor, who was not the resident's provider. The wound care doctor advised the Treatment Nurse to notify the surgeon, but this was not done. The Treatment Nurse delegated the task of notifying the surgeon to another nurse, who did not follow through. As a result, the resident's condition worsened, and the infection led to a return to the hospital for additional surgery. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's condition. The attending physician and the nurse practitioner were not informed of the changes in the resident's incision site, and there was no documentation of any assessment or notification to a provider about the incision site drainage. The facility's Director of Nursing and Administrator acknowledged the failure to notify the surgeon and the attending physician, which was crucial for infection control and the resident's safety.
Removal Plan
- 100% skin sweep of all residents completed by the DON, ADON, and Charge Nurses.
- All residents with wounds including surgical wounds were assessed by the DON for potential decline in wound status. No acute changes noted.
- Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e., new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified.
- All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site. DON/designee to monitor weekly for compliance.
- All surgical wounds/incisions changes or decline in condition will be reported to the surgeon of the incision site and attending physician. DON/designee to monitor weekly for compliance.
- DON/designee to ensure surgeon contact information is available in resident's EMR upon admission. DON/designee to monitor weekly for compliance.
- DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds. DON/designee to monitor weekly for compliance.
- Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect.
- The DON or Designee will review the clinical dashboard daily for any documentation that notes a change in condition in wounds including surgical wounds. The DON or Designee will ensure that the wound was assessed and notification to the Attending MD as well as the Surgeon was completed timely.
- An ADHOC QAPI meeting was completed to include the IDT team and Medical Director.
- The following in-services were initiated by the DON, ADON and regional nurse. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation prior to taking an assignment. All agency staff will be in-serviced prior to their scheduled shift.
- All Charge Nurses: Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e. new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified.
- Non-licensed nursing staff: Abuse and Neglect Policy- failure to report a change in condition on a resident such as a new or worsening wound, could be considered neglect.
- Notification of Change in Condition Policy- Reporting negative changes in condition involving wounds to the charge nurse immediately. Changes include a soiled dressing, foul odor, redness, or complaints of pain to the wound. If the charge nurse is not available, the DON or ADON will be notified.
Failure to Monitor and Report Surgical Site Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive resident-centered care plan for a resident who was reviewed for quality of care. The facility did not ensure that physician orders for treatment, care, and monitoring of the resident's surgical site incision were obtained upon admission, which resulted in a subsequent infection that required hospitalization and surgical intervention. Additionally, the facility did not complete or document any skin/incision/wound assessments of the resident's surgical incision site, leading to the infection. The resident, a cognitively intact female with a BIMS score of 15, was admitted to the facility with relevant diagnoses including metabolic encephalopathy, subluxation of lumbar vertebra, wedge compression fracture of thoracic vertebrae, protein-calorie malnutrition, anxiety, and major depressive disorder. Despite having undergone back and pelvis surgery prior to admission, the facility's baseline care plan did not address the resident's surgical care needs. There was no evidence of surgical site assessment, treatment, or care documentation in the resident's records, and physician orders for monitoring the surgical site were not observed for the month of September. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's surgical site condition. The treatment nurse reported the incision site drainage to a wound care doctor, who was not the resident's provider, and delegated the responsibility to notify the surgeon to another nurse, who did not recall being asked to do so. The attending doctor and nurse practitioner were not informed of any incision site changes or concerns, and the facility's policy on notifying physicians of changes in status was not followed. This failure to monitor and report changes in the resident's condition led to a delay in medical intervention and a decline in the resident's health, resulting in hospitalization and further treatment.
Removal Plan
- 100% skin sweep of all residents completed by the DON, ADON, and Charge Nurses.
- All residents with wounds including surgical wounds were assessed by the DON for potential decline in wound status.
- The Administrator and DON were in-serviced 1:1 on Notification of Change in Condition Policy.
- All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site.
- All surgical wounds have treatment orders, upon admission.
- All skin assessments, upon admission and weekly reflect any surgical incision.
- DON/designee to monitor new surgical incision resident orders during daily stand up to ensure treatment orders are in place and admission assessment includes surgical incisions.
- DON/designee to ensure surgeon contact information is available in resident's EMR upon admission.
- DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds.
- Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect.
- The DON or Designee will review the clinical dashboard daily for any documentation that notes a change in condition in wounds including surgical wounds.
- An ADHOC QAPI meeting was completed to include the IDT team and Medical Director.
- All Charge Nurses were in-serviced on monitoring surgical wounds daily and reporting changes, ensuring treatment orders are in place, and updating baseline care plans.
- Non-licensed nursing staff were in-serviced on Abuse and Neglect Policy and Notification of Change in Condition Policy.
Infection Control Lapses in Equipment and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by two specific incidents involving improper sanitation practices. In the first incident, a Medical Assistant (MA) did not sanitize a blood pressure measurement device between its use on two residents. The device was used on a male resident with multiple health issues, including major depressive disorder, type 2 diabetes, and hemiplegia, and a female resident with dementia, chronic kidney disease, and heart disease. The MA acknowledged the oversight during an interview, and the Director of Nursing (DON) confirmed that the device should have been sanitized between uses to prevent infection spread. In the second incident, a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) failed to use hand sanitizer while distributing lunch trays to residents. The RN was observed placing trays in front of residents without sanitizing hands between each tray, and the CNA was instructed by a corporate staff member to sanitize hands after passing multiple trays without doing so. Both staff members acknowledged the importance of hand hygiene to prevent cross-contamination, and the DON reiterated the expectation for staff to use hand sanitizer before and after handling each tray. The facility's policies on infection control and hand hygiene emphasize the importance of sanitizing reusable equipment and performing hand hygiene to prevent infection transmission. Despite regular in-service training on these procedures, the observed lapses in practice indicate a failure to adhere to established protocols, potentially putting residents at risk of illness and exposure to communicable diseases.
Failure to Ensure Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #44, received appropriate care to prevent the re-development of a pressure ulcer on her right heel. Despite physician orders to use a pressure off-loading boot every shift, Resident #44 was observed without her heel protector while resting in bed. The heel protectors were found on a table at the foot of her bed, and instructions for their use were posted above them. The resident's nurse aide was unaware of the requirement for the heel protector and had to consult with the resident's nurse, LVN Z, who confirmed that the heel protector should have been in place. Further interviews revealed that the Treatment Nurse emphasized the importance of the heel protector in preventing the reopening of the resident's previously stage four pressure wound, which had since closed. The Director of Nursing (DON) also stated that it was expected for the nursing staff to ensure the use of pressure-relieving devices as per physician orders. The facility's policy on skin integrity management highlighted the need for additional heel protection, yet this was not adhered to, leading to the deficiency.
Failure to Ensure Fall Mat Placement for Resident at Risk
Penalty
Summary
The facility failed to ensure that a fall mat was appropriately placed for a resident identified as a fall risk. On the date of observation, the fall mat intended to prevent injury was found folded and not in use on the floor beside the resident's bed. The resident, who was admitted from an acute care hospital and was on hospice, had a history of dementia, anxiety disorder, pain, and a pressure ulcer. The comprehensive care plan for the resident included the use of a fall mat as a precautionary measure due to her impaired visual function, communication problems, and risk for falls related to dementia, poor balance, and weakness. During the observation, the resident's nurse aide acknowledged the resident's fall risk and corrected the placement of the fall mat upon noticing it was not in use. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) both confirmed that the fall mat should be in place while the resident was in bed to minimize the risk of injury. The facility's policy on preventative strategies to reduce fall risk and comprehensive care planning emphasized the importance of implementing individualized care plans to prevent falls, which was not adhered to in this instance.
Failure to Develop Baseline Care Plan for Surgical Site Care
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, which is a requirement to ensure effective and person-centered care. The resident, a cognitively intact female with multiple medical conditions including metabolic encephalopathy, spinal issues, malnutrition, anxiety, and depression, was admitted to the facility and required substantial assistance with mobility and personal care. Despite these needs, the baseline care plan did not include necessary instructions for surgical incision site care, which was a critical aspect of her immediate care requirements. The deficiency was identified through interviews and record reviews, which revealed that the baseline care plan provided to the resident did not document any assessment, treatment, or care instructions for her surgical incision site. The facility's administrator and Director of Nursing (DON) acknowledged the oversight, with the DON noting that she had just started her role at the time of the resident's admission. The facility's policies on baseline care plans and skin integrity management did not specifically address surgical site care, contributing to the oversight. The lack of a comprehensive baseline care plan placed both the resident and facility staff at risk by not ensuring continuity of care and communication among staff, which is crucial for resident safety and preventing adverse events shortly after admission. The facility's failure to include surgical site care in the baseline care plan was a significant oversight, as it did not meet professional standards of quality care and left the resident's immediate needs unaddressed.
Facility Fails to Control Gnat Infestation in Kitchen and Dining Hall
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in both the kitchen and dining hall. During an observation, at least 20 gnats were seen in the kitchen, and 12 gnats were observed in the dining hall while residents were eating lunch. The facility's pest control log indicated that a pest control company had visited the facility a week prior to treat for flies, fruit flies, and gnats in various areas, including the kitchen and dining hall. However, the treatment was ineffective in eliminating the gnats. Interviews with staff revealed that the gnats had been an ongoing issue since the start of summer. The kitchen staff had informed the maintenance department about the problem, but the maintenance director had prioritized other issues, such as a gas leak and plumbing problems, over addressing the gnat infestation. Although the pest control company recommended using bug lights, they had not been installed until the day of the observation. The facility's policy on insect and rodent control was undated, but it stated that arrangements should be made with a reputable company for regular spraying for insects, including rodent control when required.
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.
Illustrative
What surveyors actually found near you
We read the 260 citations issued within 25 miles in the last 12 months — including the 10 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.
Illustrative
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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Denton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Denton Village By Purehealth | 1.8 mi | — | 15 | 1 |
| Cottonwood Nursing And Rehabilitation | 1.9 mi | — | 3 | 0 |
| University Rehabilitation Center | 4.3 mi | — | 7 | 1 |
| Lake Forest Village By Purehealth | 4.6 mi | — | 13 | 0 |
| Denton Rehabilitation And Nursing Center | 6.4 mi | — | 4 | 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.