Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Benbrook Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Bathrooms on a secured unit were observed with missing wall tiles and a dark black substance on the floor at the base of the toilet in areas used by five residents with significant cognitive impairment. Staff interviews showed the CNA, LVN, ADON, Maintenance Director, and Administrator all recognized that maintenance issues should be reported, but the issues had not been noticed or reported before the surveyor's observation. The facility policy stated residents are to be provided a safe, clean, comfortable, and homelike environment, including a clean and sanitary environment.
A resident-to-resident incident was documented as a fall, but a CNA later stated she witnessed one resident pull another resident out of bed. The allegation was not promptly reported to the ADM, and the ADON and hospice nurse were not initially informed of the alleged abuse. Both residents had severe cognitive impairment, and the facility’s policy required alleged abuse or neglect to be reported and investigated.
A resident with dementia, leukemia, epilepsy, and DM2 had a hand wound that was not identified in the chart or on skin checks for several days. The resident said she injured her hand on a shower handle with a wire sticking out and later told staff, but the wound was not reported until the surveyor observed it. The wound appeared discolored and red, and staff later stated it may have been infected and that the resident was receiving antibiotic treatment.
A resident with diabetes, CKD, and dementia experienced an unwitnessed fall in the evening and was assessed by an LVN, who documented no apparent injury, elevated blood glucose, and that the NP, POA, and ADON were notified at that time. Later that night, another LVN found the resident diaphoretic and unresponsive, with very high blood glucose and an unmeasurable BP, and arranged EMS transport to the ER, notifying facility leadership and the NP but not the resident’s POA. The family had previously been told the resident was fine after the fall and only learned of the hospital transfer when contacted by the hospital, demonstrating a failure to promptly notify the resident representative of a significant change in condition and transfer, contrary to facility policy.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
Surveyors found that a medication cart on a secure male unit contained Basaglar and Lantus insulin pens that lacked required open dates, and one Lantus pen that also lacked a resident identifier, contrary to facility policy and accepted standards. Several LVNs and the interim DON confirmed that insulin must be dated when opened, labeled with the resident’s name, and discarded after 28 days, and that nurses are responsible for ensuring proper labeling and dating on their carts.
A resident with multiple comorbidities, including CKD, vascular dementia, muscle wasting, and a Stage 3 pressure injury, was care planned for potential nutritional problems and required close weight monitoring. A physician ordered weekly weights for four weeks, but review of the e-chart, MAR/TAR, vitals, and nursing notes showed no documented weights or refusals during the ordered period. Staff interviews revealed that the treatment nurse and CNAs were expected to obtain and record weights, that weekly weights were required for new admissions, and that refusals should be documented, yet no such documentation existed, resulting in an incomplete and inaccurate medical record.
A resident with dementia, ADL self-care deficits, and a sacral wound infection on antibiotic therapy was found to have dried fecal matter smeared on the bed frame during surveyor observation. The resident required substantial/maximal assistance with toileting hygiene. Facility policy required appropriate cleaning of environmental surfaces such as bedrails. The Administrator identified the substance as feces, and interviews with an LVN, a CNA, and the interim DON confirmed that nursing staff and CNAs were responsible for cleaning bodily fluids and ensuring a sanitary environment, and that they had received infection control inservices, yet the fecal contamination had not been noticed or removed before it was pointed out.
A resident with a history of stroke, cognitive and emotional deficits, and hemiplegia was care planned and assessed as totally dependent for transfers, requiring two or more staff for all bed mobility and transfers. Despite this, a CNA, who acknowledged being trained that mechanical lifts require two staff for safety, was observed transferring the resident alone from a wheelchair to bed using a mechanical lift while the Administrator was present. The CNA reported she proceeded alone because the resident became upset when his preferences were not followed and no other staff were immediately available. An LVN stated that staff were not supposed to use mechanical lifts alone and that the charge nurse was responsible for ensuring proper use, and the facility’s policy required at least two nursing assistants for mechanical lift transfers.
The facility failed to maintain an effective pest control program, resulting in one resident with cerebral palsy and moderate cognitive impairment experiencing visible gnats around his bed that interfered with his sleep, while another resident in the same room reported not being bothered. Another resident with Parkinson’s disease and moderate cognitive impairment reported recurrent roaches in her room and refrigerator and stated she had informed the Administrator. Staff acknowledged prior roach infestation in that resident’s refrigerator and reports of gnats throughout the facility. Pest control service reports over several months documented recommendations to seal openings around toilets, sinks, and doors to prevent pest access, but during a walkthrough, the surveyor found that sealing work in the affected room had not been completed and the pest control log remained blank.
Food and drink were not consistently served at an appetizing temperature or in an appealing form. Residents reported cold, flavorless meals, and one resident with dementia and dysphagia was served a baked potato that was hard and difficult to chew due to missing teeth and ill-fitting dentures. Surveyors also found milk and orange juice on a meal cart at unsafe temperatures, and dinner rolls were sometimes replaced with white bread when vendor stock was unavailable.
Food Storage, Labeling, and Holding Temperature Deficiencies: The facility failed to keep multiple food items properly covered, labeled, dated, and secured in the kitchen, standby freezer, standby refrigerator, and dry storage areas. Surveyors found uncovered butter and bread rolls, unsealed frozen and refrigerated items, undated canned goods, and a dented can; the DM acknowledged some items were contaminated or could contaminate food. During meal service, resident drinks were not checked before the tray cart left the kitchen, and the orange juice and milk were found above cold-holding temperature.
Broken toilets, shower plumbing failures, and a room leak left residents without a functional, comfortable environment. Two residents shared a toilet that was covered, smelled of human waste, and had been out of order for weeks, forcing them to use a shower room toilet instead. Residents and staff also reported a cold 100 Hall shower, broken 200 Hall shower faucets that would not adjust normally, and a leak in resident rooms with pooled water and a fan placed near the water.
Surveyors found inconsistent monitoring of personal refrigerators in resident rooms, including missing temp logs for multiple days, refrigerators with thermometers but no logs, and two refrigerators with no thermometers inside. Residents said they cleaned their own refrigerators and that no one had checked them, while staff gave conflicting answers about who was responsible for monitoring. The DON and Administrator stated room refrigerator temps were expected to be checked daily, but the facility policy on foods brought by family and visitors did not address temp checks.
Improper Dumpster Waste Disposal: The facility failed to ensure garbage and refuse were properly placed inside the dumpster and that the dumpster doors were closed and secured. Surveyors observed a commercial-size dumpster about half full with both doors open, with multiple garbage bags and cardboard boxes on the ground beside it, along with 2 mattresses in the dumpster area. The ADM stated that all staff use the dumpster and are expected to keep the doors closed and ensure trash is inside the dumpster.
Incomplete Care Plan for Resident With PTSD and Abuse History: A resident admitted from a psych hospital with PTSD, anxiety, depression, suicidal ideation, COPD, and confirmed financial, sexual, and physical abuse did not have a complete person-centered care plan. The initial care plan addressed only antidepressant use and smoking, while other key areas were added later. The trauma assessment was negative, the MDS care conference record was incomplete, and the resident reported she had not been formally asked about her abuse history and had not seen psych services.
Failure to Monitor Blood Glucose Before Insulin Administration: A resident with DM2, diabetic neuropathy, obesity, HF, HTN, and psychiatric diagnoses did not have blood glucose monitored before insulin was administered as ordered and reflected in the care plan. The MAR showed gaps in BG checks during insulin therapy, and the resident reported her insulin had been changed from what she used at home. An LVN said BG should be checked before giving insulin, while the DON stated staff followed physician orders for BG monitoring.
A resident with a G-tube, dysphagia, GERD, and malnutrition was observed receiving crushed medication and water flushes while lying flat, with the HOB not raised during administration. The LPN also returned the syringe and plunger to the sealed bag without cleaning them first. Record review showed the resident had continuous tube feedings, but there were no orders or care plan instructions to elevate the HOB to 30 to 45 degrees during feeds.
An unlocked Med Cart B was observed unattended outside a resident room with the lock mechanism out, and the LPN identified the cart as hers but did not explain why it was left unsecured. The DON stated staff were expected to lock and secure medication carts when not in use, and the facility policy required carts and other medication compartments to be locked when not in use and not left unattended if open.
CNA Annual In-Service Training Not Completed: The facility failed to ensure 2 CNAs had the required 12 hours of annual in-service training. Record review showed both CNAs lacked the required training, and the Administrator stated the facility could not provide the required training for all CNAs. The DON said the Administrator and DON were responsible for ensuring annual training, and the facility policy required orientation and annual in-service training, including abuse prevention and dementia management.
Failure to Protect a Resident from Verbal Abuse: A resident with mental health and ID diagnoses was verbally abused by another resident with dementia and psychosis, who called him derogatory names and threatened him in the smoke area and dining room. Nursing notes documented repeated aggressive behavior, and interviews confirmed the targeted resident felt threatened and reported being cursed at and having a fist put in his face. Staff and the DON described the incidents as resident-to-resident verbal aggression, but the reporting and documentation of the events were inconsistent.
Failure to report alleged resident abuse: two residents with cognitive and psychiatric diagnoses were involved in repeated verbal aggression, threats, and name-calling, including slurs and threats to knock teeth out and throw a wheelchair. Staff separated the residents and documented the behavior, but the event was not clearly reported to the State Survey Agency within required timeframes. The Administrator and LPN accounts were inconsistent, and the facility policy required immediate reporting of alleged abuse or mistreatment.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, failing to ensure resident safety as required.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of the investigation to the proper authorities as required.
Two shower rooms were found with non-operational toilets covered by clear plastic trash bags, one containing a dried brown substance resembling feces, and a large hole in the wall exposing plumbing. Staff interviews revealed that these issues had not been reported to maintenance, and both the administrator and Director of Maintenance were unaware of the problems. The facility's policy affirms residents' rights to a dignified environment, but maintenance records were not available.
Nurses and medication aides lacked consistent competency in identifying and managing overfilled sharps containers, as shown by an overfilled container in a shower room and staff interviews revealing confusion about proper procedures and responsibilities. The facility had no policies or clear training on sharps disposal, leading to inconsistent practices and a deficiency in staff competency.
A resident diagnosed with ESBL in her urine repeatedly refused to comply with physician-ordered contact isolation, continued to ambulate throughout the facility, and declined the use of a bedside commode. Despite staff education and redirection, the resident was observed in common areas and interacting with others, with no effective interventions in place to enforce isolation or monitor hand hygiene, resulting in a failure to prevent potential infection transmission.
A resident with multiple medical and behavioral diagnoses was allowed to keep smoking materials and smoke unsupervised, despite repeated incidents of using marijuana or THCA products in violation of facility policy. Staff observed and reported the resident's ongoing misuse of these substances, but the facility did not implement additional supervision or effective interventions to prevent these incidents.
A resident with severe cognitive impairment and multiple medical conditions did not have shower documentation completed for several days, with no records of showers given or refusals noted. Staff interviews confirmed the expectation for regular showers and proper documentation, but the facility's system failed to ensure records were complete and accessible.
Surveyors found unsanitary conditions in a shared bathroom, including dried feces and dirty tissue, and poor maintenance in a resident room with a nonfunctional air conditioning unit and wall openings. Staff and management acknowledged lapses in cleaning and maintenance rounds, and a resident reported ongoing discomfort and lack of timely repairs.
The facility did not provide adequate supervision for several residents while smoking, despite care plans and assessments indicating the need for supervision due to visual deficits and other health conditions. Residents were observed smoking unsupervised and keeping their own cigarettes and lighters, contrary to facility policy. Additionally, a resident with moderate cognitive impairment was found with an electric kettle in her room on a secure unit, which was not addressed in her care plan or known to staff.
A CNA took a resident's debit card and used it for both authorized and unauthorized purchases, including personal use, without proper oversight. The resident, who had moderate cognitive impairment and multiple health conditions, was unable to verify which transactions were legitimate. The incident was discovered after a family member noticed suspicious bank activity, leading to police involvement and confirmation that the CNA had the card in her possession. Staff interviews confirmed that facility policy prohibits staff from handling resident money or property.
A resident requiring substantial assistance with ADLs, including showering and personal hygiene, was observed with untrimmed, dirty fingernails and an unshaven beard. The resident expressed a desire for nail and beard care, but staff interviews revealed inconsistent provision of these services and an inability to provide the facility's ADL policy when requested.
A resident with multiple health conditions developed pressure ulcers due to the facility's failure to perform accurate skin assessments and implement adequate prevention measures. Despite being at high risk for skin breakdown, the facility did not provide timely interventions or consult with a wound care physician, leading to the resident's deterioration and hospitalization.
A resident in the Memory Care Unit with severe dementia and other health issues was found with feces on his hands, fingers, and hip due to a lack of timely incontinence care. Despite facility policy requiring checks every two hours, staff were unaware of the resident's condition until later. The resident was usually continent and able to change clothes when soiled, but was waiting for a shower and anxious for care.
A resident's call light system was found to be non-functional, failing to activate in the room, hallway, and nursing station. The resident, who required supervision for ADLs, reported the issue had persisted for over a week. Staff interviews confirmed the malfunction, and the facility's policy required routine maintenance and testing of the call system.
A resident with chronic pain missed scheduled doses of Oxycontin due to the facility's failure to timely order the medication. Despite having a care plan in place, the facility did not ensure the prescription was renewed in time, leading to missed doses and the resident experiencing anxiety. The resident was given PRN Hydrocodone, which managed his pain, but the lack of scheduled Oxycontin caused distress. Communication lapses between the facility staff and the pharmacy contributed to the issue.
The facility failed to develop comprehensive care plans for two residents, leading to potential risks in their care. One resident had an incomplete plan addressing only nutritional issues despite complex needs, while another lacked specific goals and interventions for her conditions. Staff interviews revealed systemic issues in care planning, with delays and inconsistencies impacting resident care. The DON and ADM acknowledged the importance of timely care plan completion but were unclear on why these plans were incomplete.
The facility did not maintain the required RN coverage for 8 consecutive hours on weekends during two quarters of 2024. The DON confirmed the absence of weekend RN coverage due to the loss of their weekend RN and the inability to hire a replacement. Despite the DON's availability to meet RN needs, the facility's staffing policy mandates 24-hour availability of licensed nurses and certified nursing assistants.
A resident with severe cognitive impairment was allowed to sign a form changing her Medicare insurance without involving her designated representative, leading to difficulties in obtaining medications. Facility staff were unaware of the representative's contact information, and the facility lacked a policy on cognitive fitness for signing documents. This oversight resulted in the resident being discharged against medical advice by her frustrated representative.
A resident with severe cognitive impairment and mobility issues was found without access to his call light, which was tucked under his bed frame. Despite being at risk for falls, the resident's call light was not within reach, contrary to his care plan and facility policy. Staff interviews indicated the call light was likely moved during housekeeping and not returned to an accessible position.
A facility failed to develop a baseline care plan for a newly admitted resident with multiple health issues, including dementia and anxiety disorder. Despite staff acknowledging the importance of timely care plans, the plan was not completed, potentially impacting the resident's care. Interviews revealed confusion over responsibility for care plan completion, with the DON and ADM noting the need for timely action.
The facility failed to maintain its garbage storage dumpster in a sanitary condition, leading to trash and debris being left outside the dumpster. Staff interviews revealed that maintenance and kitchen staff were responsible for ensuring the area was clean and the dumpster lid closed. However, the dumpster was observed overflowing, with various trash items scattered around it, posing a risk of attracting pests and causing infection control issues.
A facility failed to maintain an effective pest control program, resulting in flies and gnats in the rooms of three residents. One resident with cerebral infarction and schizophrenia reported insects in his room for two months, while another with seizures and schizoaffective disorder shared the same room and experienced discomfort. A third resident with COPD and asthma also had insects in his room for a month. The facility's pest control program did not address flying insects, focusing instead on crawling pests and rodents, leading to inadequate pest management.
A facility failed to maintain a clean and homelike environment for a resident, as a dried yellowish liquid with a strong urine smell was found on the floor of the resident's room. The resident, who was mildly cognitively impaired and required assistance, expressed discomfort due to the lack of cleanliness. Interviews with staff revealed that the housekeeping department was responsible for maintaining cleanliness, but the presence of the substance indicated a failure to adhere to the facility's cleaning policies.
Bathrooms on secured unit not kept clean and in good repair
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for five residents on the 300 hall male secured unit because the bathrooms serving those residents were not kept in good repair and were not clean. Observation showed approximately 11 missing wall tiles and a dark black substance on the floor at the base of the toilet in the bathroom used by three residents. A separate observation showed approximately 10 missing wall tiles and a dark black substance on the floor at the base of the toilet in the bathroom used by two other residents. The residents involved had significant cognitive impairment. Record review showed diagnoses including non-Alzheimer's dementia, psychotic disorder, schizophrenia, and, for one resident, unspecified severe dementia with agitation. During interviews, several residents were unable to answer questions because of cognitive decline, and one resident was not interviewed. The bathrooms were described as being used by residents who were incontinent and could also be accessed by other residents who wandered into the area. Staff interviews showed that CNAs, nurses, the ADON, the Maintenance Director, and the Administrator all identified maintenance issues as something that should be reported and addressed. However, the CNA and LVN interviewed stated they had not noticed the missing tiles or black substance, and the Maintenance Director stated he had not been notified about the two bathrooms before the surveyor's entrance. The Administrator and ADON stated that staff were expected to report needed repairs, and the facility policy titled Homelike Environment Policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean and sanitary environment.
Failure to Report and Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an alleged abuse/neglect incident involving two residents was investigated and reported to the administrator and other required officials. One resident had diagnoses including metabolic encephalopathy, severe dementia with agitation, and delirium, and was documented as severely cognitively impaired and unable to make daily decisions. The other resident had diagnoses including zoster, encephalopathy, dementia with agitation, Alzheimer's disease, muscle weakness, lack of coordination, and abnormal gait and mobility, and was also documented as severely cognitively impaired and dependent on staff for care. Record review and staff interviews showed that on the evening of the incident, a CNA reported seeing one resident pull the other resident out of bed, after which the second resident was found on the floor in front of the bed. The progress note and incident report described the event as an unwitnessed fall, with documentation that the resident had no injuries, no pain, and normal vital signs. The note also stated that the DON, ADON, family, and provider were notified. However, the CNA later stated she had witnessed the roommate pull the resident out of bed and said she told the 2:00 p.m. to 10:00 p.m. nurse and the 10:00 p.m. to 6:00 a.m. nurse, but did not tell the ADM. Interviews showed the alleged incident was not reported to the ADM at the time it was known to staff, and the ADM stated he was not aware of the allegation until he read the progress note later. The ADON stated no one informed her of the alleged incident in morning meetings or throughout the day, and she believed the event had been documented as an unwitnessed fall. The hospice nurse also stated she was not notified of the alleged incident when it occurred and learned of it later from the CNA. The facility policy required all alleged abuse, neglect, mistreatment, and injuries of unknown source to be promptly reported and investigated, and required the DON to ensure the administrator received a copy of the incident report.
Unidentified Hand Wound Not Addressed Promptly
Penalty
Summary
The facility failed to ensure that Resident #3 received treatment and care in accordance with professional standards of practice when a wound on her hand was not identified and addressed for at least 3 days. Resident #3 was admitted with diagnoses including metabolic encephalopathy, dementia, chronic lymphocytic leukemia, epilepsy, and type 2 diabetes mellitus with diabetic polyneuropathy. Her quarterly MDS showed a BIMs score of 13, indicating intact cognitive function with minimal to no impairments in memory or thinking, and her functional status required only setup or clean-up assistance and supervision. Record review showed no documentation of compromised skin integrity or wounds in progress notes from 04/01/2026 through 05/01/2026, and the most recent weekly skin assessment documented no new skin issues. The ADL tasks MONITOR for skin observation also showed “None of the above observed” or “Not Applicable” selected each day over the 30-day period. However, during an observation and interview, Resident #3 showed the surveyor an injury on her hand and stated she injured it on a shower handle with a metal wire sticking out while showering independently. She said the injury hurt, that she had only been given naproxen, and that she told someone about it on 04/30/2026 but could not remember who. The wound was observed on the bottom right corner of the left hand and appeared slightly larger than pea-sized, with dark purple discoloration in the center, a ring of blue and purple discoloration, and surrounding redness. The ADON later checked the showers and found no metal wires sticking out of the handles, and stated she was not aware of the wound until shown the image by the surveyor. CNA A said Resident #3 told her about the injury and showed her the wound, and that she reported it to LVN B. LVN B said she had just been notified, believed the wound could be infected because of the redness and purpleness, and stated the resident was receiving triple antibiotic ointment and Bactrim. The ADON and ADM both stated the wound appeared old and that staff had not been aware of it until the surveyor’s observation.
Failure to Notify Resident Representative of Significant Change and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition and transfer to the hospital. The resident had a history of Type 2 diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease stage 3, long-term insulin use, and unspecified dementia, and had a POA representative listed on the face sheet. A quarterly MDS showed a BIMS score of 11, indicating moderate cognitive impairment. Facility policy required prompt notification of the resident, attending physician, and resident representative when there is a significant change in the resident’s physical, mental, or psychosocial status. On the evening in question, an incident report documented that during routine rounds at approximately 8:00 PM, LVN B heard a thump, entered the resident’s room, and found the resident behind the door with shoes several feet away and the wheelchair next to the bed. The call light was on the pillow, and the resident did not call for help. The resident was able to get into the wheelchair, denied pain, and had no visible injuries; vital signs were within normal limits. A progress note by LVN B at 8:45 PM described the same fall event and also documented that the resident’s blood sugar was 507, that the resident refused insulin despite coaching, and that the NP, POA, and ADON were notified at that time. Subsequent notes showed the resident up in the wheelchair, denying pain or dizziness after the fall, and neurological checks and vital signs were performed per the neurological flow sheet. Later that night, at around 2:45 AM, LVN A documented that the resident, previously observed ambulating via wheelchair, was found in a chair diaphoretic and unresponsive. LVN A was unable to obtain a blood pressure; oxygen saturation was 99, pulse 78, and blood sugar 550, later reading as “HI.” A sternal rub was ineffective, the resident was unarousable but breathing steadily, and EMS was called. The resident was transported to the ER, where hospital records documented a chief complaint of high blood sugar and diagnoses including subdural hematoma, hypertensive emergency, and chronic anticoagulation, and the resident was later transferred to another hospital for hospice and subsequently expired. Interviews revealed that LVN A notified the ADON, Administrator, and NP of the hospital transfer but did not notify the resident’s POA, stating she forgot due to everything going on. The resident’s family member reported they had been told earlier that the resident was fine after the fall and only learned of the hospital transfer when contacted by the hospital, and the facility physician was unsure if he had been notified of the transfer. This sequence of events demonstrates that the facility did not promptly notify the resident’s representative of the significant change in condition and hospital transfer, contrary to facility policy.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Improper Labeling and Dating of Insulin Pens on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that insulin pens stored on a secure male unit medication cart were properly labeled and dated in accordance with professional standards and the facility’s own medication administration policy. During an observation of one of two medication carts, surveyors and an LVN identified a Basaglar KwikPen and a Lantus KwikPen without open dates, and another Lantus KwikPen without both a resident name and an open date. Facility policy required that multi-dose containers be dated when opened and that insulin pens be clearly labeled with the resident’s name or other identifying information prior to administration. Multiple LVNs interviewed confirmed that insulin should be dated as soon as it is opened, that opened insulin is considered expired after 28 days, and that each nurse is responsible for checking their medication cart to ensure insulin is properly labeled and dated. One LVN stated that insulin without a resident name needed to be labeled to ensure the correct resident received the medication. Another LVN stated that undated insulin could be expired and could cause residents to be hypoglycemic or hyperglycemic. The interim DON stated that nursing staff were responsible for checking their medication carts on every shift and that opened insulin was considered expired after 28 days, underscoring that the undated and unlabeled insulin pens on the cart were not in compliance with facility policy and accepted professional principles.
Failure to Document Ordered Weekly Weights for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records by not documenting physician‑ordered weekly weights for one resident. The resident was an elderly female with multiple diagnoses including hemiplegia/hemiparesis, vascular dementia, muscle wasting and atrophy, chronic kidney disease stage 2, and a Stage 3 pressure injury present on admission. Her admission MDS showed moderate cognitive impairment with a BIMS score of 11, and she was identified as being at risk for developing pressure ulcers. Her care plan identified a potential for nutritional problems related to chronic kidney disease, lung cancer, and a history of pneumonitis, with interventions that included monitoring, recording, and reporting signs and symptoms of malnutrition and significant weight loss. Record review showed that a physician order dated 03/12/26 directed that the resident be weighed weekly for four weeks on the day shift every Thursday for weight monitoring. Review of the resident’s electronic chart, including the March MAR/TAR and vitals tab, revealed that no weights were documented from the time the order was given on 03/12/26 through 03/31/26. Review of nursing progress notes for the same period showed no recorded weights and no documentation of refusals to be weighed. This lack of documentation occurred despite the facility’s policy requiring nursing staff to monitor and document resident weights in a format that permits comparison over time and to report significant weight changes to the physician and dietitian. Interviews with staff confirmed that weights were expected to be recorded and that weekly weights were required for new admissions and readmissions for the first four weeks. LVN A stated that weights should be recorded on the MAR/TAR and that she relied on the treatment nurse and CNAs to complete them, while also stating she was not responsible for verifying whether weights were taken or accurate. The DON stated that weights should be documented under the vitals tab and that refusals required a progress note. The treatment nurse (LVN B), identified as the weight loss monitoring nurse, reported she was responsible for monitoring resident weights, that some residents had weekly weights triggered in the e‑chart, and that she sometimes delegated weights to CNAs due to workload. The ADON stated that if weekly weights after admission were not completed, she would expect a nursing note explaining why, but no such notes were found for this resident, confirming the incomplete and inaccurate medical record.
Failure to Maintain Clean Bed Environment for Resident With Wound Infection
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment for a resident with dementia, ADL self-care deficits, and a sacral wound infection being treated with Bactrim DS. The resident’s care plan documented substantial/maximal assistance with toileting hygiene and an active infection of the sacral wound. During an observation, surveyors noted a brownish dried substance identified by the Administrator as feces smeared on the resident’s bed frame. The resident was not interviewable. The facility’s policy on Standard Precautions stated that environmental surfaces, including bedrails and bedside equipment, are to be appropriately cleaned. Interviews with staff confirmed that the substance on the bed frame was unsanitary and that CNAs and nursing staff were responsible for ensuring residents’ beds and environments were clean and free of bodily fluids and fecal matter. The Administrator, LVN, CNA, and interim DON each acknowledged that nursing staff were primarily responsible for cleaning body fluids from bed frames before housekeeping sanitized the area, and all recognized the risk of infection related to exposure to fecal matter. Staff also reported having been inserviced on infection control, including keeping residents’ beds clean, yet the fecal matter on the bed frame had not been identified or cleaned prior to the surveyor’s observation.
Failure to Use Required Two-Person Assistance for Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and safe use of a mechanical lift for a resident who required assistance from two staff members for all transfers. The resident was an adult male with a primary diagnosis of cerebral infarction and secondary diagnoses including bipolar disorder, encephalopathy, cognitive and emotional deficits following cerebral infarction, and hemiplegia/hemiparesis. His Interim Payment MDS showed a BIMS score of 13, indicating he was cognitively intact, and Section GG documented that he was totally dependent on staff for bed mobility and transfers, requiring assistance from two or more staff for sitting to lying, lying to sitting, sit-to-stand, chair/bed transfers, and toilet transfers. His care plan identified him as at high risk for falls and documented actual falls on two consecutive days with discoloration to his left hand. On the survey date, a CNA was observed transferring this resident alone from his wheelchair to his bed using a mechanical lift, while the Administrator was present and stated he was observing the activity to ensure safety. The resident reported that it did not bother him that only one staff member used the lift, but did not indicate how often this occurred. The CNA stated she had been properly trained, knew that mechanical lifts required two staff for safety, and acknowledged that she transferred the resident alone because he became upset if his preferences were not followed and no other staff were immediately available. An LVN on the same shift stated that staff were not supposed to use mechanical lifts alone, that the charge nurse was responsible for ensuring proper use, and that she was unaware the CNA was using the lift by herself. The Administrator stated his expectation was that mechanical lifts be used with two or more staff, and the facility’s undated “Lifting Machine, using a Mechanical Level II” policy specified that at least two nursing assistants are needed to safely move a resident with a mechanical lift.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure resident rooms were free of pests, specifically roaches and gnats, in two of five resident rooms reviewed. One resident with cerebral palsy, major depressive disorder, and anxiety disorder, and with moderate cognitive impairment (BIMS score of 11), reported the presence of “little black flies” around his bed. During observation, the surveyor saw gnats around this resident’s bed, and the resident stated it was hard to sleep at night because of the flies around his head. Another resident in the same room reported that the flies did not bother him. Another resident, diagnosed with Parkinson’s disease and mild neurocognitive disorder with a BIMS score of 9 indicating moderate cognitive impairment, reported that she had roaches in her room and that they kept coming back. She stated that the roaches were everywhere in her room and refrigerator and that she had spoken with the Administrator about the roaches. At the time of the surveyor’s observation of this room, no roaches were seen in the bedroom or bathroom, and the roommate denied seeing roaches recently. A separate resident reported seeing the same type of small black flies in her room but stated they did not bother her because they did not bite. Staff interviews and record review showed ongoing pest concerns and uncompleted recommendations from pest control reports. The Dietary Manager reported being told by staff that the resident with Parkinson’s had a roach problem. The Maintenance Director acknowledged that the resident’s refrigerator had previously been full of roaches and that there had been reports of gnats throughout the facility. Pest prevention service reports over several months documented recommendations for caulking and sealing around toilets and sinks and replacing worn weather stripping on doors to prevent pest access, including specific recommendations for the room shared by the resident with Parkinson’s. During a walkthrough of that room, the surveyor observed that the recommended sealing of the toilet and sink had not been completed, and a pest control log the Maintenance Director was working on was blank. The surveyor did not receive the facility’s physical environment or pest control policy before exit.
Food and Drink Served at Improper Temperature and with Poor Quality Substitutions
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature. During observation and interview, resident drink temperatures were not checked before the lunch meal cart left the kitchen, and when temperatures were later taken, the orange juice measured 64 F and the milk measured 67 F. The dietary manager then disposed of and replaced the orange juice and milk cups on the meal tray carts. Resident interviews and observations showed ongoing concerns with meal quality. One resident with COPD, PTSD, anxiety disorder, and a BIMS of 15 said the food had no flavor and that meals were cold, noting that many residents ask to have food heated up. Another resident with vascular dementia, dysphagia, cerebral infarction, missing teeth, and a BIMS of 5 said the food was cold. During lunch observation, this resident was served a baked potato with shredded cheese and sour cream, white bread, and dessert; the resident’s dentures did not fit right and he was missing many teeth. A second resident with fibromyalgia, diabetes, morbid obesity, heart failure, depression, anxiety, and a BIMS of 13 stated the baked potatoes were half cooked and hard. The resident council also reported that food was cold when received, especially for residents who ate in their rooms, and that milk was warmer when received. The dietary manager stated dinner rolls were sometimes unavailable from the vendor and white bread was used as a substitute, although she acknowledged she would not want white bread instead of a dinner roll and that residents complained about it. The registered dietitian confirmed residents occasionally complained about cold food and that the vendor sometimes ran out of stock, leading staff to use substitutes such as sliced white bread instead of dinner rolls.
Food Storage, Labeling, and Holding Temperature Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. During observation on 09/09/2025, an uncovered metal tin of butter with a pastry brush inside was sitting on the stove top griddle. The stand-by freezer contained an unsealed bag of frozen pizza dated 9-3-25 with no use-by date and ice crystals forming on the pizzas, an unlabeled Ziploc bag of chicken tenders dated 9-3 with no use-by date, and a box with an unsealed bag of frozen hamburger patties with no opened-on or use-by date. The stand-by refrigerator contained an opened bag of shredded mozzarella cheese dated 9-3 with no use-by date, an open bag of shredded cheddar cheese dated 9-3 with no use-by date, an unsealed Ziploc bag with half a yellow onion dated 9-4 and no use-by date, and a large opened container of pickles dated 3.5.25 with no use-by date. The dry storage closet contained an unsealed bottle of paprika seasoning, an opened and half-used jar of concord grape jelly with no use-by date and a label stating refrigerate after opening, an opened and used bottle of yellow mustard dated 8/6/25 with no use-by date and a label stating best if used by May 19 2025 and refrigerate after opening, one undated can of tomato soup, one undated can of pinto beans, and one dented can of baked beans. The DM stated the unsealed paprika could be contaminated and acknowledged the dented cans could allow metal to come off, the canned food could go bad, and contaminate food. The facility’s kitchen also had cooked bread rolls sitting uncovered on top of the stove top, while meal tray carts were prepared with trays, dessert items, milk, and orange juice. During lunch meal observation, resident drink temperatures had not been checked before the tray cart left the kitchen. When temperatures were checked, the orange juice was 64 F and the milk was 67 F. The DM stated dietary staff were responsible for labeling and dating items, including opened-on dates and use-by dates, and that food items were used within 3 days after opening. The RD stated opened food items were expected to be covered and sealed, and that hot food should be held at 135 F and cold food at 40 F. The facility’s Food Receiving and Storage Policy and the FDA Food Code were reviewed and reflected requirements for labeling, dating, covering, and proper holding temperatures.
Broken Toilets, Shower Plumbing Failures, and Room Leak
Penalty
Summary
The facility failed to provide a clean, functional, homelike environment in multiple resident areas, including shower rooms and resident rooms. Two residents, one with a BIMS score of 14 and one with a BIMS score of 12, shared a toilet in their room that was broken and covered with a black plastic bag. When the bag was lifted, the toilet smelled of human waste and contained a brown liquid substance appearing to be human waste. One resident stated the toilet had been broken for 3 weeks and that he had to roll his wheelchair to the shower room to use a toilet, where he sometimes had to wait if the shower room was in use. The other resident stated the shared toilet made it harder to use a restroom because he had to go to a shower room to use a toilet. CNA staff reported the toilet had been broken for 1.5 weeks to a month, and the Maintenance Director stated he had placed the toilets out of order because they had not yet been replaced. The facility also had shower room plumbing problems affecting residents who required assistance with bathing. In the 100 Hall shower room, a resident with a BIMS of 14 and dependent on staff for showers stated the shower was always cold and had not worked well since she had lived at the facility. Another resident with a BIMS of 14 and requiring supervision for showers stated the 100 Hall shower was cold and that it took turning the water on 30 minutes in advance to get a warm shower. The Maintenance Director checked the hot water temperature in the 100 Hall shower room and recorded 76.5 degrees Fahrenheit. In the 200 Hall shower room, residents and staff reported broken faucets that would spin without working, requiring staff to use valves in the back of the shower to adjust water temperature and pressure. Residents stated this made the shower room inconvenient and frustrating, and staff reported the water could become too hot and could burn residents. The Maintenance Director observed the faucet spinning, confirmed he could not adjust the temperature with the faucets, and stated he would replace them. The facility also had a plumbing leak in two resident rooms. During observation, water was pooled underneath a sink, on the floor near a window, and inside a closet, with a fan placed on the floor and plugged in near the sink with the cord in the water. The Maintenance Director stated he had noticed the leak two days earlier, was not sure where it was coming from, and had not fixed it because he was waiting for the area to dry and to determine the source. He stated residents were to be moved when rooms flood, but he had not moved the residents in that room. The facility’s TELS work order summary did not reflect work orders for the hot water issue in the 100 Hall shower room or the broken faucets in the 200 Hall shower room. The facility policy stated maintenance service shall be provided to all areas of the building, grounds, and equipment, and that plumbing fixtures are to be maintained in good working order.
Missing Refrigerator Temperature Monitoring and Thermometers
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 2 of 8 rooms and for 4 of 8 residents reviewed for in-room refrigerators. Surveyors found that refrigerator temperature logs were missing entries for multiple consecutive days in two rooms, and that two other residents had personal refrigerators with thermometers inside but no temperature logs. In addition, two residents had personal refrigerators with no thermometers inside at all, and both stated they had purchased the refrigerators about two months earlier. During observations, one room had two personal refrigerators with temperature logs attached to the doors, but the logs had no entries for 09/05/25 through 09/09/25. Another room had one personal refrigerator with a temperature log attached to the door, and that log also had no entries for the same dates. Two residents stated no one had checked their refrigerators or kept a log, and they cleaned out their own refrigerators. Two other residents stated their refrigerator temperatures were checked once a week, but there was no temperature log present. Interviews showed staff were unclear about who was responsible for monitoring refrigerator temperatures in resident rooms. A CNA stated she was not aware who was responsible and thought it might be housekeeping or maintenance. An LVN stated night shift nursing staff monitored medication room refrigerators, but she was not aware who monitored resident-room refrigerators and had never been told she was responsible. The DON stated all departments were responsible for refrigerator monitoring and that night shift nursing staff monitored and documented medication room refrigerator temperatures. The Administrator stated he was not aware that two residents had no thermometers in their refrigerators and said temperatures in room refrigerators were expected to be checked daily by nursing staff. The facility policy on foods brought by family and visitors permitted such foods but did not address temperature checks.
Improper Dumpster Waste Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse in accordance with current state laws for 1 of 1 dumpster reviewed. During observation on 09/09/2025 at 8:10 AM, the commercial-size dumpster was about half full of garbage, and both the left-side and right-side doors were open. On the ground beside the left side of the dumpster were 4 full plastic garbage bags, 2 partially filled plastic garbage bags, and 2 empty cardboard boxes. Laying on the ground in the dumpster area were 2 mattresses. During an interview on 09/10/2025 at 3:34 PM, the ADM stated that all staff use the dumpster and are expected to keep all dumpster doors closed. During a later interview on 09/11/2025 at 8:00 PM, the ADM stated that all staff are responsible for making sure trash is inside the dumpster and the lids are closed, explaining that this is important to avoid attracting insects or other undesirable issues.
Incomplete Care Plan for Resident With PTSD and Abuse History
Penalty
Summary
The facility failed to complete and implement a comprehensive person-centered care plan for one resident with a history of abuse and PTSD. The resident was admitted from a psychiatric hospital with diagnoses including COPD, anxiety disorder, PTSD, and confirmed financial, sexual, and physical abuse. Her history and physical also documented depression, suicidal ideation with intent and plan, severe anxiety, hopelessness, impaired sleep and appetite, and active suicidal ideation, along with recommendations for suicidal watch and fall precautions. The resident’s comprehensive care plan initially included only a focus on antidepressant use and smoking. Other care areas were not added until several days later, including the resident’s history of financial, sexual, and physical abuse, full code status, antipsychotic use related to behavior management and PTSD, mood problems related to admission, PTSD, abuse history, and depression, and COPD. The trauma informed care assessment documented that the resident answered no to all questions asked. The multidisciplinary care conference record was incomplete and did not include information about the resident’s problems, needs, evaluation, or goals. During observation and interviews, the resident stated she had told staff about her abuse history but had not been formally asked about it, and she wanted to see psych services but had not been seen. She also stated she did not know who the social worker was and had no consultations since admission. The DON stated care plans were a group effort and that comprehensive care plans should be completed within 7 days, while the SW stated trauma needs to be documented and acknowledged that the resident’s trauma history should have been care planned. The ADM stated the delay in completing the comprehensive care plan was a problem because care plans ensure how care is supposed to be provided for the resident.
Failure to Monitor Blood Glucose Before Insulin Administration
Penalty
Summary
The facility failed to ensure that Resident #83 received treatment and care in accordance with professional standards of practice and the resident’s comprehensive person-centered care plan. Resident #83 was a female admitted with diagnoses including type 2 diabetes mellitus, diabetic neuropathy, morbid obesity, hypercholesterolemia, major depressive disorder, generalized anxiety disorder, heart failure, and hypertension. Her care plan addressed altered endocrine status and included fasting blood glucose monitoring as ordered by the physician, along with monitoring and reporting for signs and symptoms of hyperglycemia and hypoglycemia. Her record showed blood glucose levels were consistently above 100 mg/dL during the reviewed periods. The resident’s insulin orders changed over time, including Lantus at bedtime and later HumuLIN 70/30 twice daily. Review of the medication administration summary showed that in July 2025 blood glucose was monitored before insulin only on July 1-3, and not for the remainder of the month. In August 2025, blood glucose was not monitored from August 1-21, and monitoring resumed on August 22. During interview, the resident stated she had been receiving Lantus instead of the Novolog 70/30 she used at home and said she told her doctor it was not working. An LVN stated she checked blood glucose before giving insulin and monitored after administration because of the new insulin order, while the DON stated staff were expected to follow physician orders and that blood glucose was checked only if ordered by the physician.
G-tube Feeding and Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide appropriate services to prevent complications of enteral feeding for one resident who was observed receiving medication administration via a gastrostomy tube. The resident had a history of traumatic subdural hemorrhage, gastrostomy status, gastro-esophageal reflux disease, protein-calorie malnutrition, and dysphagia. The resident’s MDS indicated a BIMS score of 8 and that he received tube feeding and more than 501 cc/day of fluid through the G-tube. During an observation, an LVN administered water and crushed levetiracetam via the resident’s G-tube while the resident was laid flat on his back. The LVN did not raise the head of the bed during the medication administration and water flush. After the medication was given, the LVN placed the 60 cc syringe and plunger back into the sealed bag without cleaning them first. The LVN stated she forgot to raise the head of the bed and acknowledged that not doing so could cause aspiration risk; she also stated the syringe and plunger should have been washed before being returned to the storage bag for infection control. Record review showed the resident’s physician orders included continuous tube feeding through the G-tube, but there were no orders to elevate the head of the bed to at least 30 to 45 degrees. The care plan also did not include elevating the head of the bed to that level for the resident’s continuous feedings. The DON stated the expectation was for nurses to raise the head of the bed before G-tube medication administration and that residents on continuous feeds should have orders to elevate the head of the bed at least 30 degrees, but she was not sure why this resident did not have such orders or a corresponding care plan entry.
Unsecured Medication Cart Left Unattended
Penalty
Summary
Med Cart B outside room [ROOM NUMBER] was observed unlocked and unattended during a surveyor observation, with the lock mechanism out indicating it was unlocked. The door to room [ROOM NUMBER] was open and staff was not in the room at the time. At 08:27 AM, LVN E walked toward the cart from down the 100-foyer area and identified Med Cart B as hers. She did not state why she had left the medication cart unlocked and unattended. LVN E stated the expectation was that the medication cart would be locked and secure when not in use. In interview, the DON stated staff were expected to follow medication safety policy and procedures and lock and secure the medication cart when not in use, and that all nursing staff were responsible for securing medications when not in use. The facility policy, Storage of Medications, stated compartments containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.
CNA Annual In-Service Training Not Completed
Penalty
Summary
The facility failed to ensure required in-service training was completed for 2 of 5 CNAs reviewed, identified as CNA K and CNA L. Record review showed CNA K had a hire date of 03/20/2014 and CNA L had a hire date of 08/30/2024, and review of in-services showed that neither CNA had the required 12 hours of annual training. The report states the facility failed to ensure nurse aides received no less than 12 hours of training annually. During interview, the Administrator stated the facility could not provide the required training for all CNAs and said they were going to change the training program so everyone would complete the required training on their anniversary date, while still having monthly and annual in-services. The DON stated the Administrator and DON were responsible for ensuring CNAs had the required annual training and said staff should be trained upon orientation, annually, and as needed. The facility policy titled In-Service Training, All staff, revised August 2022, stated all staff must participate in initial orientation and annual in-service training, including training on preventing abuse, neglect, exploitation, misappropriation of resident property, and dementia management and resident abuse prevention.
Failure to Protect a Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure Resident #49 was free from verbal abuse by Resident #87. Resident #49 was a male resident with diagnoses including bipolar disorder, anxiety disorder, and unspecified intellectual disabilities, and his annual MDS showed a BIMS score of 13. Resident #87 was a male resident with diagnoses including unspecified dementia and unspecified psychosis, and his admission MDS showed a BIMS score of 14. Resident #87’s care plan identified him as verbally aggressive related to dementia and included interventions for agitation and aggression. Nursing documentation showed that Resident #87 directed verbal abuse toward Resident #49 on more than one occasion. One note stated Resident #87 was calling another resident names and picking on him in the smoke area, and staff educated him about his behavior. Another note documented that Resident #87 became verbally aggressive with Resident #49, threatened to knock his teeth out and throw his wheelchair on top of him, and called him a derogatory name. A separate note also recorded that another resident witnessed verbal aggression toward another resident and called 911. Resident #87 was later relocated to another room, and family and the physician were notified. During interviews, Resident #87 acknowledged calling Resident #49 a derogatory name and stated there had been no fight or argument. Resident #49 stated Resident #87 had cussed him out, got close to him, put his fist in his face, and called him names, and that staff told Resident #87 to stop. Staff interviews confirmed that the incidents were reported to them by others or observed as residents becoming loud, and one nurse stated she had not completed an incident report or witness statement. The Administrator stated he relied on guidance for reporting abuse and that staff were expected to report any instance to him, but he was not able to clearly explain the reporting decision for the incidents described. The facility policy required all reports of resident abuse, neglect, mistreatment, and injuries of unknown source to be promptly reported and thoroughly investigated.
Failure to Report Alleged Resident Abuse
Penalty
Summary
The facility failed to ensure that an alleged resident-to-resident abuse incident was reported to the State Survey Agency within the required timeframe. The deficiency involved Resident #49, a male resident admitted with bipolar disorder, anxiety disorder, and unspecified intellectual disabilities, and Resident #87, a male resident with unspecified dementia and unspecified psychosis. Resident #49’s MDS showed a BIMS score of 13, indicating intact cognition, and Resident #87’s MDS showed a BIMS score of 14, also indicating intact cognition. Record review showed that Resident #87 repeatedly directed verbal aggression toward Resident #49 in the smoking area and hallway, including name-calling and threats to knock his teeth out and throw his wheelchair on top of him. Nursing notes documented that the residents were separated and redirected, and one note stated another resident witnessed the verbal aggression and called 911. An intake worksheet identified the incident date as 09/05/2025 and noted that Resident #49 called police because Resident #87 was cursing at him in the hallway. The worksheet also stated that no incident number was given to the administrator or staff and that no actions were taken by police. Interviews showed inconsistent accounts of when the event occurred and whether it was reportable. Resident #49 stated Resident #87 called him a gay slur, got close to him, and put his fist in his face, and that staff moved Resident #87’s room afterward. Resident #87 acknowledged calling Resident #49 a slur and said police told him to stay away from Resident #49. Staff interviews confirmed that LVN D witnessed the verbal altercation, separated the residents, and documented the event, but did not complete an incident report or witness statement. The Administrator stated he reported the incident after learning police were at the facility, but could not explain which incident was initially reported to HHSC or why the 08/29/2025 event was not reported. The facility policy required all alleged abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of property to be reported immediately, but not later than 2 hours if abuse was involved or 24 hours if abuse was not involved and there was no serious bodily injury.
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 did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Failure to Maintain Clean and Operational Shower Room Facilities
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two of three shower rooms reviewed. In the 200 Hall shower room, a large hole in the wall exposed plumbing pipes, and the toilet was covered with a clear plastic trash bag, beneath which a dried brown substance, appearing to be feces, was visible. The shower room was locked and only accessible to residents when opened by staff, but an unknown resident was observed exiting the room alone with wet hair. Staff interviews revealed that the hole had been present for several weeks and that the toilet's condition had not been reported to maintenance. Staff acknowledged that all were responsible for reporting such issues, but no maintenance request had been submitted. In the 100 Hall shower room, the toilet was also covered with a clear plastic trash bag and was non-operational. Staff were unsure how long the toilet had been broken but believed it had been reported to maintenance. The administrator and Director of Maintenance were unaware of the issues in both shower rooms and had not received any work orders. The facility's policy states that residents have the right to a dignified existence, but maintenance records were not provided to confirm any prior reporting or action.
Failure to Ensure Staff Competency in Sharps Disposal
Penalty
Summary
Licensed nurses and medication aides in the facility did not demonstrate the necessary competencies and skills to care for residents as required by their assessments and care plans. Specifically, staff were unable to properly identify when sharps containers were overfilled, as evidenced by an observation of an overfilled sharps container in the shower room that was still in use. Interviews revealed that nurses and aides had inconsistent knowledge regarding the correct fill line, responsibility for emptying sharps containers, and the procedures for safe disposal. Some staff believed containers should be changed when the lid could no longer close, while others relied on visual cues from the top of the container, and several were unaware of the manufacturer's fill line. The facility administrator and DON confirmed that there were no existing policies related to nursing competency or sharps disposal at the time of the survey. Staff training on sharps disposal was inconsistent, with some staff unable to recall when or if they had received such training. The lack of clear policies and comprehensive training led to confusion among staff about their responsibilities and the correct procedures for handling sharps containers, resulting in the observed deficiency.
Failure to Enforce Contact Isolation for Resident with ESBL
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the case of a female resident diagnosed with ESBL (Extended-Spectrum Beta-Lactamase) in her urine. Despite physician orders for contact isolation, the resident repeatedly refused to remain in her room, declined the use of a bedside commode, and continued to ambulate throughout the facility, including attending smoking activities and visiting common areas. Staff documented multiple instances where the resident was educated on the importance of infection control and isolation, but she remained non-compliant, often removing isolation signage and disregarding staff redirection. The resident's medical history included mixed anxiety and depressed mood, heart disease with a cardiac defibrillator, hypertension, opioid dependence, and seizure disorder. She was cognitively intact according to her BIMS score but exhibited behaviors such as verbal aggression, wandering, and non-compliance with care and facility policies. Staff and the physician noted that the resident was independent with most activities of daily living, including toileting, and wore an adult brief for incontinence. However, there was no effective intervention in place to ensure she remained isolated or to monitor her hand hygiene after toileting, which was identified as a potential vector for infection transmission. Observations and interviews confirmed that the resident was frequently seen outside her room, including entering the kitchen and walking in hallways near other residents, without staff consistently present to redirect her. Staff acknowledged the resident's non-compliance and reported it to nursing, but no additional measures were implemented to enforce isolation. The facility's policy required transmission-based precautions for residents with transmissible infections, but in this case, the interventions were not effective in preventing the resident from potentially spreading ESBL to others.
Failure to Provide Adequate Supervision to Prevent Misuse of Smoking Products
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically related to the misuse of a smoking product containing THCA. The resident, a male with multiple diagnoses including COPD, bipolar disorder, hypertension, generalized anxiety disorder, and a cardiac pacemaker, was assessed as cognitively intact and required supervision with all activities of daily living. Despite documented behavioral issues such as not following the smoking policy and drug-seeking behavior, the resident was allowed to keep smoking materials and smoke unsupervised, as indicated in his care plan. Multiple progress notes and staff interviews revealed ongoing incidents where the resident was observed or suspected of using marijuana or THCA products both inside and outside the facility. Staff reported smelling marijuana on the resident and witnessing him rolling and smoking substances labeled as THCA, which he claimed to have purchased legally from a nearby store. The resident was also noted to sign himself out of the facility to smoke and would return smelling of marijuana. The facility's policy allowed residents assessed as safe smokers to keep their smoking materials, but the resident repeatedly violated designated smoking areas and times, and brought non-tobacco substances into the facility. Despite repeated violations and behavioral issues, the facility's interventions were limited to education, confiscation of visible substances, and attempts to discharge the resident, which were reversed by the state agency. The facility did not provide evidence of additional supervision or changes to the resident's care plan to address the ongoing misuse of smoking products. The facility's smoking policy required evaluation of residents' ability to smoke safely and allowed for confiscation of items in violation, but staff stated they could not search the resident's belongings without violating his rights. The facility's drug policy was requested but not provided by the time of the survey exit.
Failure to Maintain Accurate Shower Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed for shower documentation. Specifically, there were no shower sheets filled out for the resident over two separate periods totaling twelve days, and the electronic medical record corroborated the absence of documentation. There was also no indication in the records that the resident refused showers during these periods. The facility's process for tracking showers involved maintaining shower sheets in a large binder, but this system did not ensure that all showers or refusals were consistently documented. The resident involved was an elderly female with severe cognitive impairment, a history of nontraumatic subarachnoid hemorrhage, anxiety disorder, unspecified dementia, hypokalemia, and lack of coordination. She required partial assistance with bathing. Interviews with staff, including the DON and a CNA, confirmed the expectation that residents receive showers three times a week and that refusals are to be documented. However, the lack of documentation for the specified periods was acknowledged by both the DON and the Administrator, who also failed to provide the facility's shower/bathing policy when requested.
Failure to Maintain Cleanliness and Timely Repairs in Resident Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by unsanitary conditions in a shared bathroom and poor maintenance in a resident room. In the shared bathroom used by three residents with varying degrees of cognitive impairment, surveyors observed multiple brown fingerprint smears on the door frame, small brown droppings and dirty tissue on the floor, dirty footprints, a dried brown stain on the commode, a pool of dried brown substance at the base of the commode, and a ball of brown substance stuck to the wall. The DON confirmed these substances appeared to be feces and acknowledged that staff should have cleaned the area immediately. Housekeeping staff reported not being aware of the bathroom's condition and stated that it was an oversight that the restroom had not been checked during rounds. The housekeeper explained that staff typically call housekeeping to sanitize after the bulk of a mess is picked up, and that CNAs have access to cleaning supplies for such situations. The administrator and DON both stated that all staff are responsible for maintaining cleanliness and that managers are expected to check rooms and bathrooms during daily rounds, but acknowledged that this process had not been effective in this instance. In a separate incident, a resident's room was found with a nonoperational air conditioning unit covered by a blanket and a towel placed on the windowsill to block drafts. The wall behind an unoccupied bed had two openings, which the maintenance director described as dents. The resident reported that the air conditioning unit had been nonfunctional for weeks and that the wall openings had been present since a previous roommate. The maintenance director was aware of the issues but found no active work orders for repairs. The resident expressed dissatisfaction with the facility's lack of timely repairs and attention to room conditions.
Failure to Supervise Smoking and Address Environmental Hazards
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, specifically in relation to smoking practices and environmental hazards. Four residents who were identified as smokers were not properly supervised while smoking, despite care plans and assessments indicating the need for supervision due to visual deficits or other health conditions. Observations revealed that these residents were able to access smoking areas and smoke without staff present, and were in possession of cigarettes and lighters, contrary to facility policy and staff statements that such materials should be secured and only distributed under supervision. Documentation for the residents involved showed that their care plans and smoking assessments required supervision while smoking, with some residents unable to light their own cigarettes and having visual impairments. However, interviews with staff and residents confirmed that residents routinely kept their own smoking materials and smoked unsupervised. Staff interviews indicated a lack of clarity and consistency regarding the facility's smoking policy, supervision requirements, and assessment procedures. The facility's policy required quarterly reassessment of smoking safety and direct supervision for residents with restricted privileges, but these procedures were not consistently followed. Additionally, the facility failed to address an environmental hazard when a resident on a secure unit was found to have an electric kettle in her room, which was not documented in her care plan. The resident, who had moderate cognitive impairment, stated that the kettle was sent by a family member. The presence of the kettle was not known to the administrator, and staff were not aware of its existence, indicating a lapse in environmental safety monitoring. No other policy on accident hazards was provided by the facility.
CNA Misappropriation of Resident Debit Card and Funds
Penalty
Summary
A certified nursing assistant (CNA) took a resident's debit card and used it for both authorized and unauthorized purchases, as well as personal use, without proper oversight or verification. The resident, an older female with chronic obstructive pulmonary disease, major depressive disorder, anxiety, and moderate cognitive impairment, was living on a secure unit due to elopement risk. The CNA admitted to using the card after being given the PIN by the resident, but the facility was unable to determine which purchases were for the resident and which were for the CNA's personal use. The incident came to light when the resident's family member noticed suspicious activity on the resident's bank account and notified the facility administrator and police. The police recovered the debit card from the CNA, who was found to have the card in her possession at the facility. Bank statements provided by the family member showed multiple transactions, including ATM withdrawals and purchases at gas stations and grocery stores, that were not clearly authorized by the resident. Interviews with staff revealed that facility policy strictly prohibits staff from taking or using resident property, including money or debit cards, and that staff are regularly in-serviced on abuse prevention. Staff members stated they were aware that accepting money or property from residents, even with permission, is not allowed and could be considered abuse or misappropriation. The administrator and DON confirmed that staff are not permitted to run errands or make purchases for residents using their personal funds or cards.
Failure to Provide Necessary ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. Specifically, the resident, a male with osteoarthritis of the knee, depression, and anxiety, required substantial to maximal assistance with showering and personal hygiene, as documented in his records. Observations revealed that his fingernails were untrimmed with a yellow-brownish substance present, and his beard was unshaven. The resident expressed a desire to have his nails cut and beard shaved, and noted that he received showers only occasionally. He was also unable to fully straighten his fingers, further limiting his ability to perform self-care. Interviews with staff indicated that CNAs were responsible for providing showers and nail care unless the resident was diabetic. Staff reported that the resident often refused showers, but could sometimes be persuaded by family members. The CNA stated that the resident did not want his beard or hair touched, while the DON confirmed that CNAs should reattempt care and notify the charge nurse if a resident refused. Despite these protocols, the resident's hygiene needs were not met, and the facility was unable to provide an ADL policy when requested by surveyors.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident did not develop pressure ulcers unless clinically unavoidable and did not provide care and services consistent with professional standards to promote healing and prevent new pressure ulcers. The resident, an elderly female with multiple health conditions including hemiplegia, COPD, and neuromuscular dysfunction of the bladder, was admitted to the facility without any pressure ulcers. However, during her stay, she developed several pressure injuries, including a stage 2 decubitus ulcer on her back and deep tissue injuries on her left hip, thigh, and sacral region. The facility's failure to perform complete and accurate skin assessments contributed to the development of these pressure injuries. Despite the resident's high risk for skin breakdown due to her medical conditions and limited mobility, the facility did not implement adequate pressure prevention measures such as an air loss mattress or skin prep for the buttocks and sacral areas. Weekly skin assessments conducted by the facility's LVN did not consistently document the condition of the resident's skin, particularly in the buttocks and sacral areas, and there was a lack of timely intervention and consultation with a wound care physician. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's skin condition. CNAs and nurses did not consistently report or document skin changes, and the resident missed a scheduled wound care appointment due to being out of the facility for another medical appointment. The facility's Director of Nursing and Administrator acknowledged the expectation for regular skin assessments and timely interventions, but these were not effectively implemented, leading to the resident's deterioration and subsequent hospitalization.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident, resulting in the resident having feces on his hands, fingers, and hip. The resident, who resides in the Memory Care Unit, has severe unspecified dementia with behavioral disturbances, chronic lymphocytic leukemia, and essential hypertension. Despite being usually continent and able to change his clothes when soiled, the resident was found in a soiled condition by LVN A, who was unaware of the situation until entering the resident's room. The resident was not upset or concerned about his condition when informed by LVN A. The facility's policy requires staff to check residents every two hours and as needed, but this was not effectively implemented in this case. CNA B, who was responsible for the resident during the shift, confirmed the policy and noted that the resident was waiting for a shower and was anxious for care. The ADM and DON acknowledged that the resident had not received personal hygiene care before being found in the soiled state. The facility's policy emphasizes providing necessary services to maintain residents' personal hygiene, which was not adhered to in this instance.
Deficiency in Resident Call Light System
Penalty
Summary
The facility failed to ensure that the call light system in a resident's room was functioning properly, which could lead to delays in assistance and affect the resident's quality of life. The resident, a male with a primary diagnosis of spondylosis without myelopathy or radiculopathy, was admitted to the facility and had a care plan indicating a need for supervision and assistance with activities of daily living (ADLs). During an observation and interview, the resident reported that his call light had not been working for more than a week, and when tested, the in-room light, the light outside the room, and the light at the nursing station did not activate. Interviews with staff, including an LVN and the Maintenance Director, confirmed that the call light system was not functioning as intended. The LVN acknowledged the issue and stated that she would have alerted the maintenance department if she had been aware of the malfunction. The Maintenance Director mentioned that the call light system was checked daily, but could not recall who checked the resident's call light on the day of the observation. The facility's policy indicated that the resident call system should be routinely maintained and tested by the maintenance department, but the deficiency in the call light system was not addressed in a timely manner.
Failure to Timely Order and Administer Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the timely ordering and administration of medications for a resident, leading to missed doses of Oxycontin. The resident, a male with multiple diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and chronic pain, was dependent on scheduled Oxycontin for pain management. Despite having a care plan that emphasized the importance of administering medications as ordered, the facility did not order the resident's Oxycontin in time, resulting in missed doses on two consecutive days. The issue arose when the facility's LVN attempted to reorder the medication from the pharmacy, only to be informed that a new prescription was required. Although the LVN communicated this need to the pain management nurse practitioner, the prescription was not sent promptly, leading to a delay in medication delivery. During this period, the resident was given PRN Hydrocodone, which managed his pain, but the absence of the scheduled Oxycontin doses caused the resident anxiety and led him to call emergency services. Interviews with facility staff, including the administrator, LVN, and nurse practitioners, revealed communication breakdowns and procedural lapses in medication management. The facility's policy required medications to be reordered when a four-day supply remained, but this protocol was not followed, resulting in the resident missing critical doses of his pain medication. The facility's failure to adhere to its medication administration policies placed the resident at risk of increased pain and anxiety.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which could place them at risk of not receiving necessary care and services. Resident #17, a male with severe cognitive impairment and multiple medical conditions, had an incomplete care plan that only addressed nutritional issues, despite having complex needs such as assistance with personal hygiene and medication management. Similarly, Resident #25, a female with various psychological and physical conditions, had an admission care plan lacking specific goals and interventions related to her diagnoses and medication management. Interviews with facility staff revealed systemic issues in the care planning process. The Social Worker (SW) and Licensed Vocational Nurse (LVN) A indicated that comprehensive care plans were supposed to be completed within 30 days of admission or within 7 days of the Minimum Data Set (MDS) completion. However, there were delays and inconsistencies in the process, with the SW and MDS LVN responsible for monitoring completion. LVN A mentioned that baseline assessments triggered alerts for care plan completion, but acknowledged that missing care plans could impact resident care. Further interviews with other staff, including LVN B, Certified Nursing Assistants (CNAs), and the Director of Nursing (DON), highlighted the potential negative impact of incomplete care plans on resident care. Staff expressed concerns about not knowing residents' specific needs, such as dietary requirements, behavioral interventions, and risk factors, which could lead to inadequate care. The DON and Administrator (ADM) acknowledged the importance of timely care plan completion and the responsibility of nurse managers to ensure this, but there was a lack of clarity on why the care plans for Residents #17 and #25 were incomplete.
Failure to Maintain Required RN Coverage on Weekends
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage for 8 consecutive hours, 7 days a week, during two quarters of 2024. Specifically, the facility did not have RN coverage on weekends from January to May 2024. This was confirmed through a review of the CMS Payroll-Based Journal (PBJ) reports and the facility's time-stamped records, which showed a lack of RN coverage on specified weekends in January, February, March, April, and May 2024. In an interview, the Director of Nursing (DON), who has been with the facility for 1.5 years, acknowledged the absence of RN coverage on weekends during the specified period. The DON explained that the facility lost their weekend RN and was unable to hire a replacement. Although the DON stated she made herself available to meet RN needs, the facility's staffing policy requires licensed nurses and certified nursing assistants to be available 24 hours a day to provide direct resident care services.
Failure to Recognize Resident's Right to Designate a Representative
Penalty
Summary
The facility failed to recognize and respect the rights of a resident to designate a representative, leading to a significant deficiency in resident rights. A resident with severe cognitive impairment, as indicated by a BIMS score of zero, was allowed to sign a disenrollment form to change her Medicare insurance without the involvement of her designated representative. The resident's medical records showed she had Alzheimer's dementia and was listed as her own contact, despite having a family member as an emergency contact. This oversight resulted in the resident's insurance being changed without her representative's knowledge, causing difficulties in obtaining necessary medications. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's representative. The HR/BOM admitted to changing the resident's insurance due to the facility's contractual limitations with the existing Medicare advantage plan, but did not have contact information for the resident's representative at the time. The SW, who conducted the BIMS assessment, expressed discomfort with allowing a resident with cognitive impairments to sign such forms and stated that she would typically seek out family contact information in such cases. The facility's administrator acknowledged the chaotic nature of the resident's admission and the lack of clinical information provided by the discharging facility. The facility's failure to include the resident's representative in the decision-making process led to the resident being discharged against medical advice by her representative, who was frustrated by the situation. The facility did not have a policy addressing a resident's cognitive fitness to sign documents or notifying their representative, which contributed to the oversight. This deficiency highlights the risk of residents not having their representatives included in important decisions, potentially leading to delayed treatment or a decline in condition.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for the resident's needs. The resident, a male with severe cognitive impairment, Parkinson's disease, dementia, and mobility issues, was observed without access to his call light. The resident's care plan indicated he was at risk for falls and required the call light to be within reach to request assistance. However, during an observation, the call light was found tucked under the bed frame, out of the resident's reach, which could prevent him from calling for help when needed. Interviews with staff, including a CNA, LVN, and the Administrator, revealed that the call light was likely moved during housekeeping and not returned to an accessible position. The staff acknowledged the importance of ensuring the call light was within reach, especially given the resident's fall risk. The facility's policy requires that residents have a means to call for assistance, but this was not adhered to in this instance, as evidenced by the resident's inability to locate his call light and his reliance on yelling for help.
Failure to Implement Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within the required timeframe, which is crucial for providing effective and person-centered care. The resident, a male with multiple diagnoses including cerebrovascular disease, dementia, and anxiety disorder, was admitted to the facility without a baseline care plan being completed. This oversight was identified during a review of the resident's clinical care plans, which showed no baseline care plan was started or completed from the time of admission until the date of the review. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of baseline care plans. The social worker indicated that the MDS nurse was responsible for completing these plans, while an LVN stated it was the nursing team's responsibility to complete them within the first two days of admission. Another LVN mentioned that care plans were reviewed weekly, and any missing plans would be reported to the DON. However, the baseline care plan for this resident was not completed, which could impact the care provided, as staff would not have the necessary information to meet the resident's needs. The DON and ADM both acknowledged the importance of timely completion of baseline care plans, with the DON stating the goal was to have them completed within 24 hours of admission. The ADM mentioned that nurse managers were responsible for ensuring timely completion. The absence of a baseline care plan for the resident could lead to inaccurate care being provided, as staff would lack critical information about the resident's needs and interventions. Despite these acknowledgments, the baseline care plan for the resident remained incomplete, highlighting a significant deficiency in the facility's care planning process.
Improper Garbage Disposal and Maintenance
Penalty
Summary
The facility failed to maintain its only garbage storage dumpster and the surrounding enclosed area in a sanitary condition, which could attract pests and pose a risk of disease to residents. During an observation, various trash items were found outside the dumpster, including used latex gloves, glass shards, broken furniture, and opened medication blister packets. Interviews with the Director of Maintenance (DM), Maintenance Technician (MTNC), and Administrator (ADM) revealed that the dumpster area was the responsibility of the maintenance and kitchen staff, who were expected to ensure that trash was not left on the ground and that the dumpster lid was kept closed. The DM and MTNC acknowledged the importance of keeping the area clean to prevent pest attraction and infection control issues. The facility's staff were instructed to notify the DM or MTNC when the dumpster was nearing full capacity so that an off-schedule pick-up could be arranged. However, the dumpster was observed to be overflowing, with trash and debris scattered around it. The ADM confirmed that the maintenance and housekeeping staff were responsible for the daily upkeep of the dumpster area and emphasized the importance of keeping the lid closed to avoid odors and pest attraction. The report also referenced the Food and Drug Administration Food Code, which outlines the requirements for storing refuse and maintaining refuse areas to prevent pest access and ensure cleanliness.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats in the rooms of three residents. Resident #1, a male with a history of cerebral infarction, schizophrenia, bipolar disorder, and hemiplegia, was observed in his room with approximately 10-20 gnats and 5 flies. He reported that the insects had been present for two months and had informed the staff, who acknowledged the issue but had not resolved it. Resident #2, who shared a room with Resident #1 and had diagnoses including seizures and schizoaffective disorder, was also affected by the presence of flies and gnats, which made him feel uncomfortable. Resident #3, a male with COPD, asthma, and bipolar disorder, was observed with flies and gnats in his room, which had been present for a month. The facility's pest control program, as per the service agreement with Pest Control Company A, did not include measures for flying insects, focusing instead on crawling pests and rodents. The pest control logs indicated regular treatments for crawling insects and rodents but did not address the issue of flying insects inside the facility. Interviews with staff, including the Maintenance Director and the DON, revealed that the facility was aware of the pest issue but had not effectively addressed it. The Maintenance Director acknowledged the presence of insects and mentioned that the facility contracted with a pest control company, which treated the exterior for various pests but not specifically for flying insects. The Administrator also recognized the potential hazard posed by the insects to the residents' cleanliness and homelike environment, indicating a lack of comprehensive pest control measures within the facility.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as observed during a survey. The resident's room had a dried yellowish liquid substance on the floor, which emitted a strong smell of urine. The resident, who was mildly cognitively impaired, wheelchair-bound, and required maximal assistance, was unsure how long the substance had been present and expressed feeling uncomfortable due to the lack of cleanliness. The resident's care plan indicated a history of incontinence and a risk for falls, necessitating prompt assistance. Interviews with facility staff revealed that the Maintenance Director, who also served as the Housekeeping Supervisor, acknowledged the responsibility of the housekeeping department to maintain cleanliness in residents' rooms. The Administrator confirmed that all staff were expected to ensure that rooms were kept clean, emphasizing that the facility should be as clean as the staff's own homes. The Administrator expressed concern that failing to maintain cleanliness would not provide a homelike environment for the residents. A review of the facility's grievance log showed previous complaints about unsanitary conditions, including feces left on the floor in a hallway. The facility's housekeeping policy outlined procedures for cleaning and disinfecting environmental surfaces, including the use of EPA-registered disinfectants and regular cleaning schedules. However, the presence of dried urine in the resident's room indicated a failure to adhere to these policies, potentially exposing residents to unsanitary living conditions.
What surveyors are citing around you — mapped
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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 718 citations issued within 25 miles in the last 12 months — including the 42 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Benbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Terrace Healthcare Center Of Fort Worth | 2.5 mi | ★★★★★ | 7 | 0 |
| Cityview Nursing And Rehabilitation Center | 2.7 mi | ★★★★★ | 12 | 0 |
| Mira Vista Court | 2.8 mi | ★★★★★ | 2 | 0 |
| Renaissance Park Multi Care Center | 3.2 mi | ★★★★★ | 7 | 0 |
| Ignite Medical Resort Fort Worth, Llc | 3.6 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.