Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Bluebonnet Nursing And Rehabilitation during CMS and state inspections, most recent first.
Two residents with known pressure ulcers and high risk for skin breakdown did not receive accurate weekly skin assessments as required by their care plans and facility policy. For one resident, weekly skin assessments repeatedly documented no ulcers despite concurrent daily wound treatments to the heel and the resident’s report of pressure wounds, which the LVN later admitted she had "over-looked" in her documentation. For the other resident, no weekly skin assessments were recorded for several weeks even though the care plan identified a Stage II buttock ulcer and a DTI heel ulcer and the TAR showed ongoing daily wound care to the heel and sacral area. The DON and Administrator confirmed that weekly skin assessments and documentation of observed wounds were required and that these assessments were not completed or recorded accurately.
A resident with dementia, Parkinson’s disease, and a prior right humerus fracture experienced an unwitnessed fall from a wheelchair, resulting in facial injuries and right elbow pain. The DON assessed the resident, notified the physician, and obtained a STAT order for a right elbow x‑ray, which was entered into the radiology portal, but the imaging was never completed while the resident remained in the facility. Over the next two days, nurses documented ongoing right elbow pain, swelling, and bruising, administered PRN analgesics, and repeatedly contacted the x‑ray company, yet one LVN assumed the x‑ray had been done without confirming, and staff did not notify the physician that the STAT x‑ray was not performed or effectively escalate care despite a single unsuccessful call. The fall care plan was not revised after the event, staff were unclear on STAT radiology time frames and policy access, and existing policies requiring repeated physician contact and emergency action for unresolved changes in condition were not followed. The resident was eventually transferred to the hospital, where a distal humerus fracture requiring ORIF was diagnosed.
A resident with dementia, Parkinson’s disease, and a right humerus fracture experienced a fall from a wheelchair that led to surgical repair of the arm and hospital discharge instructions for post-surgical care, sling use, and fall precautions. On readmission, the resident had a surgical dressing, a sling, and a scheduled surgical follow-up, but the existing fall risk care plan was not updated with new fall-related interventions, nor were any care plan problems or interventions added for the fracture, post-surgical care, or sling management. The MDS Coordinator and DON acknowledged awareness of the fall and surgery, yet the comprehensive care plan was not revised as required by facility policy following this significant change in condition.
A resident with dementia, Parkinson’s disease, and a right humerus fracture experienced a fall with subsequent right arm pain and was transferred to a hospital for treatment and surgical repair. While the resident was hospitalized and not present in the facility, the DON entered fall assessments and progress notes into the EHR for those days, including vital signs, descriptions of bruising, pain assessments, and fall interventions such as a low bed and monitoring, and later signed these entries on a different date. This resulted in erroneous documentation that did not reflect the resident’s actual location or condition, contrary to the facility’s documentation standards.
Surveyors found that controlled drug audit records for four medication and nurse carts were either missing required signatures from on‑coming or off‑going nurses or were pre‑signed for upcoming shifts instead of being completed at the time of the actual narcotic count. An LVN reported not counting her cart and stated another LVN was responsible for counting all carts, while that LVN admitted she had counted but failed to sign the log until prompted by the surveyor. A medication aide stated she never counted narcotics, relied on nurses’ counts done before her shift, and routinely handed off cart keys for breaks without a narcotic count. The DON and Corporate Compliance Nurse acknowledged that staff were not following facility policy, which requires licensed staff to maintain key control, conduct and document controlled medication inventories at each shift change, and avoid pre‑signing narcotic logs.
A resident with cerebrovascular disease, gangrene, knee pain, and osteoarthritis had a significant change MDS showing severe cognitive impairment, frequent pain limiting activities, and receipt of PRN pain meds and hospice services, yet the comprehensive care plan did not address pain or hospice. Although the CAA for pain was triggered, the care planning decision for pain was not selected, and the care plan last revised in early March omitted pain related to gangrene, musculoskeletal pain, and hospice involvement despite active physician orders for opioid analgesics and hospice admission. The resident reported pain from gangrene, a family member noted occasional delays in pain meds and stated hospice had spoken to staff about ensuring pain control, and interviews with the Corporate Compliance Nurse, MDS nurse, and DON confirmed that pain and hospice should have been but were not incorporated into the resident’s person-centered care plan.
A resident with cerebrovascular disease, gangrene, knee pain, and osteoarthritis, and with severely impaired cognition, had a standing order for hydrocodone-acetaminophen every 6 hours for pain related to gangrene. Review of the electronic MAR showed multiple blank entries for scheduled doses and other daily medications, with no codes or initials to indicate if doses were given, refused, held, or unavailable. A paper MAR used during periods of reported internet interruption contained an entry marked "ref" with unknown staff initials and additional entries initialed by an LVN without specifying whether the medication was administered or not, and the staff identification section was incomplete. The resident reported pain and uncertainty about receiving pain medication, and a family member noted that staff were sometimes not present when pain medication was due and that hospice had previously addressed concerns about ensuring timely pain medication.
A resident with severe cognitive impairment and multiple psychiatric conditions had her risperidone dosage reduced without updated consent from her responsible party. The facility did not document that the risks, benefits, and alternatives were communicated prior to the medication change, as required by policy.
A resident with severe cognitive impairment and multiple medical diagnoses did not have a comprehensive care plan that accurately reflected her needs. The care plan incorrectly listed a dialysis port as a central IV line, omitted an activity care plan, and failed to address the resident's visual impairment, despite her reporting difficulty seeing and participating in activities. Facility staff were unaware of these issues, and the care plan did not align with the facility's policy for person-centered planning.
A resident with severe dementia, Parkinson's Disease, and dysphagia was started on hospice care, but the care plan was not updated by the MDS Coordinator to reflect this change. The facility's policy required care plans to be reviewed and revised after each assessment, but this was not done, resulting in the omission of hospice services from the resident's care plan.
A resident who was always incontinent of bowel and bladder did not receive proper incontinent care when staff failed to perform hand hygiene between glove changes and handled clean items with soiled gloves during perineal care. Both the CNA and student aide acknowledged not following infection control protocols, and the DON confirmed these actions were not in line with facility policy.
A medication aide failed to document the administration of controlled substances, including Xanax and Tramadol, in the narcotic log for two residents with significant medical needs. Although the medications were given and recorded on the MAR, the required narcotic log entries were omitted at the time of administration, contrary to facility policy and expectations stated by the DON.
Surveyors found that a medication cart was left unlocked and unattended, and a resident's Seroquel medication label did not match the physician's order, with the medication aide overlooking the discrepancy. The DON confirmed that facility policy requires medication carts to be locked and medication labels to match physician orders, with discrepancies flagged appropriately.
The facility did not have an infection prevention and control program in place, as observed by surveyors, resulting in a deficiency related to the lack of systematic infection control measures.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
A resident with severe cognitive impairment and multiple medical conditions was not provided grooming according to his preference to be clean shaven with an electric razor by his POA. Staff used disposable razors, causing discomfort, and the care plan did not reflect his wishes. Staff and administration were unaware of his preferences, and the resident's grooming needs were not met in accordance with facility policy on resident rights.
A resident received a feeding tube without documented medical necessity or agreement, and did not receive appropriate care for the feeding tube, resulting in a deficiency.
A resident with multiple diagnoses did not have accurate or complete documentation regarding scheduled baths or showers, with several instances where it was not recorded whether bathing was provided or refused. Staff interviews confirmed that refusals occurred but were not documented in the clinical record or nurses' notes, contrary to facility policy.
Three residents experienced a breach of privacy during incontinent care in a facility. Despite expectations for privacy, staff failed to fully close privacy curtains during care for residents with cognitive impairments, affecting their dignity. Observations revealed that privacy curtains were not fully drawn, even in private rooms, and staff interviews confirmed the expectation for privacy, which was not consistently met.
The facility failed to maintain proper infection control practices during perineal care for three residents and did not ensure clean linen was stored properly. A CNA did not perform adequate hand hygiene between glove changes and used a brief that had fallen on the floor. Linen carts were found uncovered, risking contamination. Staff interviews revealed a lack of adherence to infection control protocols.
A resident with Alzheimer's and a history of UTI received improper incontinent care, as observed when a CNA wiped from the anal to the vaginal area multiple times, contrary to infection control practices. Staff interviews confirmed the expectation to wipe front to back to prevent infections, but the observed practice did not align with these standards.
The facility failed to lock Treatment Cart #1 on D hall, leaving it unattended and accessible to mobile residents. The cart contained medications and wound care treatments, posing a risk of misuse and adverse reactions. Staff interviews confirmed the expectation that carts should be locked, aligning with the facility's policy on secure medication storage.
The facility did not maintain a clean and homelike environment in two shower rooms, where barrels with soiled linen and trash, including soiled briefs, were present during resident showers. A CNA confirmed this as standard procedure, and a resident expressed discomfort with the conditions. This practice contradicts the facility's policy on maintaining a dignified environment.
The facility failed to maintain an effective infection control program, as evidenced by a Medication Aide not sanitizing a blood pressure cuff between residents and two CNAs not changing gloves or washing hands after touching contaminated surfaces during incontinent care. These actions were contrary to the facility's infection control policy, which requires hand hygiene after handling soiled equipment.
The facility's beauty shop on D Hall was found unlocked, containing hazardous materials like hairspray, hair mousse, and hair dye, all labeled with warnings about being flammable and harmful if swallowed. This unsecured environment was confirmed by a CNA during an interview.
A resident with vascular dementia and hemiplegia was observed with long chin hair, which she found embarrassing, indicating a failure in personal hygiene care. Despite being dependent on staff for all ADLs, the resident's grooming preferences were not adequately addressed. Interviews revealed staff oversight, as a CNA did not notice the chin hair, and the DON confirmed that ADL care should include shaving for residents who wish to be clean-shaven.
A resident with a history of falls and cognitive impairments was not provided with a low bed as ordered, leading to a fall and a C2 vertebral fracture. The facility failed to implement and communicate fall prevention measures, resulting in the resident being placed in a regular bed instead of a low bed, contrary to the physician's order.
A resident suffered a head injury and fractures after a nursing assistant attempted a mechanical lift transfer alone, despite the requirement for two-person assistance. The NA did not wait for help, leading to the resident slipping and hitting her head on the lift.
Failure to Accurately Complete Weekly Skin and Pressure Ulcer Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate and complete weekly skin and pressure ulcer assessments for residents with known pressure injuries, as required by facility policy and professional standards. For Resident #2, records showed she was at risk for pressure ulcers and had documented pressure ulcers to both heels, with care plan interventions directing weekly assessment and documentation of wound healing, including measurements and wound status. Despite this, weekly skin assessments completed on 4/4/2026, 4/11/2026, and 4/18/2026, and signed by LVN A, documented that there were no pressure, venous, arterial, or diabetic ulcers. This conflicted with the Treatment Administration Record (TAR), which showed daily wound care to the right heel throughout April, and with the resident’s own report that she had pressure wounds on her foot and bottom and received daily wound care. For Resident #3, who had diagnoses including cerebral infarction, malnutrition, and incontinence, the MDS and care plan documented that she was at risk for pressure ulcers and had an unstageable pressure ulcer, a Stage II pressure ulcer to the left buttock, and a deep tissue injury (DTI) to the right heel. Her care plan required weekly assessment, measurement, and documentation of wound healing for these ulcers. However, the weekly skin assessment record showed that the last assessment was completed on 3/24/2026, with an alert indicating that the weekly skin assessment was 24 days overdue as of 3/31/2026, and no subsequent weekly skin assessments were documented. This was inconsistent with the April TAR, which showed that wound care treatments were being provided daily to the right heel and to the sacral area daily and three times a week. Interviews confirmed the documentation failures. Resident #2 reported that she received weekly skin assessments and ongoing wound care to her foot and bottom, while Resident #3 reported current pressure wounds and daily wound care to her heels and tailbone. LVN A acknowledged that Resident #2 had a pressure wound she treated and admitted that the inaccurate weekly skin assessments were due to her having "over-looked it," recognizing that something could be missed as a result. The DON and the Administrator both stated that residents were required to receive weekly skin assessments and that wounds should be documented when observed, and they acknowledged that inaccurate or missed assessments meant the facility would not know the resident’s skin condition and could not provide proper care. Facility policies on Skin Assessment and Documentation required weekly skin assessments for all residents, weekly ulcer assessments for any type of ulcer, and complete and accurate documentation in the clinical record, which were not followed for Residents #2 and #3.
Failure to Obtain STAT Elbow X‑Ray and Notify Physician After Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely treatment and care in accordance with physician orders and professional standards following a fall. The resident was an elderly female with dementia, Parkinson’s disease, and a history of a right humerus fracture, who was non‑ambulatory and dependent on staff for movement and dressing. She had a documented high risk for falls and an existing fall care plan that included general fall‑prevention interventions, but this care plan was not revised with any new interventions after her fall on the evening in question. On that evening, the resident sustained an unwitnessed fall from her wheelchair in the hallway, resulting in a right cheek laceration, a forehead bruise, and right elbow pain. The DON assessed the resident, documented the injuries and right elbow pain, and notified the physician, who ordered a STAT right elbow x‑ray. The STAT x‑ray order was entered into the x‑ray company portal that night. Despite the STAT order, the x‑ray was not completed while the resident remained in the facility. Progress notes the following day documented that the resident continued to have right elbow pain, described as intermittent and associated with movement, and that she had swelling and bruising from the elbow down most of the arm. Nursing staff administered PRN acetaminophen and other ordered pain medications, elevated the arm, and performed neuro checks, but did not verify that the ordered STAT x‑ray had been done. One LVN assumed the x‑ray had been completed when the x‑ray company came for another patient and did not direct the technician to the resident or follow up at that time. When the LVN later realized the order had been missed, she placed another order and called the x‑ray company multiple times as they gave changing estimated times of arrival, but she did not notify the physician that the STAT x‑ray had not been completed. Overnight and into the next morning, another LVN documented that the x‑ray remained pending despite repeated calls to the radiology company, and that the resident continued to complain of right arm pain with movement, with noted pain, swelling, and bruising. This nurse attempted to call the physician once without receiving a response and did not make additional attempts or escalate beyond that single call, despite facility policy requiring further attempts and emergency action if a physician did not return a call within a reasonable time. The DON was aware the x‑ray had not been done on her shift and reported passing this information to the day nurse, but there was no documented physician notification that the STAT imaging was not obtained. The resident was ultimately transferred to the hospital two days after the fall, with documentation that the ordered x‑ray had not been done and that she continued to complain of right elbow pain. Hospital records showed she required surgery for an open reduction internal fixation of a distal humerus fracture. The physician later stated he had ordered a STAT elbow x‑ray, expected it to be done right away, and was not informed that it had not been completed until the resident was being sent to the hospital. The deficiency also includes the facility’s failure to have or follow clear procedures for STAT radiology and timely physician notification related to abnormal or pending diagnostic tests. The DON acknowledged she was not certain how soon a STAT x‑ray should be completed and that the facility did not have a specific radiology or STAT x‑ray policy at the time of the incident. Nursing staff reported they were not told what an acceptable time frame was for a STAT x‑ray, were unsure how to access facility policies, and did not know the expectations for escalating when a STAT service was delayed. The facility’s existing policies on falls and notifying the physician of a change in status required immediate assessment after a fall and physician notification for abnormal x‑ray reports, as well as repeated attempts to contact the physician and use of emergency services if the physician did not respond in a reasonable time. However, these policies were not effectively implemented in this case, as staff did not ensure the STAT x‑ray was obtained, did not timely notify the physician that the imaging was not completed, and did not promptly escalate care despite ongoing pain and visible injury to the resident’s arm.
Failure to Update Care Plan After Fall and Post-Surgical Fracture Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident following a significant change in condition. The resident, an elderly female with dementia, Parkinson’s disease, and a right humerus fracture, was non-ambulatory and dependent on staff for movement and dressing. She sustained a fall from her wheelchair while leaning forward in the hallway, after which she complained of discomfort in her upper right extremity and the MD was notified with an x-ray ordered. The resident was later transferred to the hospital due to right elbow pain and lack of completed x-ray, where she underwent surgery on her right humerus and received discharge instructions for post-surgical fracture care, including activity guidelines, sling use, and fall precautions. Upon readmission, documentation showed the resident had a surgical dressing to the right arm and a sling, and a follow-up appointment with the surgeon was scheduled. However, review of the comprehensive care plan revealed that the existing fall risk care plan, last revised months earlier, had not been updated with any new interventions following the recent fall and injury. The care plan also lacked any problem statements or interventions related to the fractured right humerus, post-surgical care, or sling use. Interviews with the MDS Coordinator and DON confirmed that both were aware of the fall and subsequent surgery, but the care plan had not been revised to reflect the resident’s current status. The facility’s policy required development and revision of a comprehensive person-centered care plan after each admission or significant change MDS assessment, but this had not been carried out for this resident’s post-fall and post-surgical needs.
Inaccurate Clinical Documentation Entered for Hospitalized Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when the DON documented assessments and progress notes on days when the resident was not in the facility and was hospitalized. The resident, an elderly female with dementia, Parkinson’s disease, and a right humerus fracture, sustained a fall from her wheelchair, after which she complained of right upper extremity discomfort and the MD ordered an x-ray. The resident was later transferred to the hospital for right arm pain related to the fall and an x-ray that had not been completed, and hospital records showed she was admitted for a right humerus fracture with surgical repair and discharged back to the facility several days later. Despite the resident being hospitalized and not present in the facility during that time, the DON documented fall nurse note assessments and progress notes in the electronic medical record for dates when the resident was in the hospital. These entries included vital signs, descriptions of bruising to the cheek, forehead, and right arm, pain assessments, and fall interventions such as use of a low bed and monitoring every two hours and PRN. The DON later stated she did not know why she had documented these assessments and progress notes for days when the resident was not in the facility and acknowledged that the assessments were dated for those days but not signed until a later date. The facility’s documentation policy required accuracy, completeness, legibility, and appropriate timing of clinical record entries.
Failure to Properly Count and Document Controlled Medications on All Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of controlled medications for all four medication/nurse carts reviewed. During observations and record reviews, surveyors found that the controlled drug audit record for one medication cart lacked the oncoming nurse’s signature for the 6 a.m. to 6 p.m. shift, and another nurse cart’s record lacked the off‑going nurse’s signature for the overnight shift ending at 6 a.m. For two additional carts, the controlled drug audit records were pre‑signed for the upcoming 6 p.m. shift by the off‑going nurse before the end of the shift, rather than being completed at the time of the actual count at shift change. Staff interviews further demonstrated inconsistent and improper practices related to controlled medication counts and documentation. One LVN using a nurse cart stated she had not counted the cart medications and reported that another LVN was responsible for counting all carts at the start of the shift, a practice she was unfamiliar with as a new employee. When the narcotic log for a medication cart was reviewed and found unsigned for the beginning of the shift, the LVN identified as responsible for counting all carts acknowledged she had performed the count but had forgotten to sign the log, and she then signed it during the surveyor’s presence. A medication aide passing medications from that cart stated that narcotic counts were done at 6 a.m. by the nurse before her shift began, that she never counted the carts herself, and that staff handed off cart keys to others when going on break without completing a narcotic count before transferring possession. Interviews with leadership confirmed that facility expectations and policy were not being followed in practice. The DON stated that both off‑going and on‑coming nurses should count all narcotics on the carts and sign the narcotic count record at that time, but she was initially unsure whether pre‑signing the narcotic count record or handing off keys without a count was permitted and needed to check the policy. The Corporate Compliance Nurse later stated that staff should not pre‑sign narcotic count logs and should sign them at the time the cart is counted at shift change. Review of the facility’s written policy on controlled medications showed that only authorized licensed nursing and pharmacy personnel should have access to controlled medications, that the medication nurse on duty must maintain possession of the key, that a controlled medication accountability record must be completed when receiving and administering controlled medications, and that a physical inventory of all controlled medications must be conducted and documented at each shift change, with any discrepancies reported to the DON and investigated. These documented requirements contrasted with the observed and reported practices on the units.
Failure to Care Plan Pain and Hospice Services for a Resident with Gangrene
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with significant pain and hospice involvement. The resident, an older male admitted with cerebrovascular disease, gangrene, unspecified knee pain, and osteoarthritis, had a significant change MDS showing severely impaired cognition and pain that frequently limited day-to-day activities. The MDS also documented that he received PRN pain medication and hospice services. The Care Area Assessment (CAA) for pain was triggered, but the care planning decision box for pain was not selected, indicating that this triggered area was not carried forward into the care plan. Record review showed that the resident’s care plan, last revised in early March, did not include his pain related to gangrene, knee pain, osteoarthritis, or his receipt of hospice services, despite active physician orders for scheduled and PRN opioid analgesics specifically for pain related to gangrene and an order for hospice admission and pronouncement at time of death. During an interview, the resident reported having pain due to gangrene and was unsure if he received his pain medication, while a family member stated that sometimes nursing staff were not around when pain medications were due, although overall they usually provided them when he had pain. The family member also stated that hospice had spoken to the facility about ensuring he received his pain medications. When the Corporate Compliance Nurse accessed the care plan in edit view, she stated that the area for potential uncontrolled pain appeared to have been triggered and added, and she added interventions under a different section rather than under pain. However, a previously saved copy of the care plan did not include pain, and the most recent version showed pain with an initiation date corresponding to the survey date, which she acknowledged was not correct. The MDS nurse later stated that when completing the resident’s last MDS, the pain item was not selected and should have been, and that if it had been selected it would have triggered adding pain to the care plan. The MDS nurse acknowledged that pain was not on the care plan and should have been so staff would know how to plan, treat, and monitor for pain. The DON stated that pain should be on the resident’s care plan because it affected his daily care, activities, and eating habits, and that hospice should be on the comprehensive care plan as well.
Incomplete and Inaccurate MAR Documentation for Scheduled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records, specifically the medication administration records (MARs), for one resident receiving scheduled pain medication. The resident, an elderly male with cerebrovascular disease, gangrene, unspecified knee pain, and osteoarthritis, had severely impaired cognition and experienced pain that frequently limited his day-to-day activities. Physician orders dated 3/25/26 showed a standing order for hydrocodone-acetaminophen 10-325 mg every 6 hours for pain related to gangrene, with a start date of 3/9/26 and no end date. Review of the resident’s March 2026 electronic MAR revealed multiple blanks for the scheduled hydrocodone-acetaminophen doses on specific dates and times, with no coding, initials, or documentation to indicate whether the medication was administered, refused, held, or unavailable. Additional review showed that other daily scheduled medications on certain dates were also left blank without any documentation. The facility’s policy required that the person administering medications record administration on the MAR at the time the medication is given, initial the MAR in the space provided, and enter an explanatory note if a regularly scheduled dose is withheld, refused, or given at a time other than scheduled. When the DON and administrator were interviewed, they acknowledged that the electronic MAR contained blanks and suggested that internet interruptions might have led staff to use paper MARs. A paper MAR dated March 19, 2026, for the same hydrocodone-acetaminophen order showed an entry of “ref” with unknown staff initials for one dose, and entries with LVN A’s initials for subsequent doses without any indication whether the medication was administered, refused, held, or unavailable. The section of the paper MAR intended for staff to print their name and initials was completed only by LVN A, and the unknown staff’s identifying information was missing. The resident reported having pain from gangrene and being unsure if he received his pain medication, while a family member stated that nursing staff were sometimes not around when pain medications were due and that hospice had spoken to the facility about ensuring the resident received his pain medications.
Failure to Obtain Updated Consent for Antipsychotic Medication Change
Penalty
Summary
The facility failed to inform a resident or her responsible party in advance about a change in her antipsychotic medication dosage, specifically the reduction of risperidone from 0.75 mg to 0.5 mg. The resident, an elderly female with severe cognitive impairment and multiple psychiatric diagnoses including major depressive disorder, severe unspecified dementia with behavioral disturbance, generalized anxiety disorder, and psychotic disorder with delusions, had a signed consent form on file for the original dosage. However, when the dosage was reduced, no updated consent form or documentation was obtained to reflect this change. During an interview, the MDS Coordinator acknowledged not being aware that a new consent form was required for the dosage adjustment, resulting in the absence of proper documentation. The facility's policy requires that residents or their representatives be informed of the risks, benefits, and alternatives to psychotropic medications prior to any initiation or change, and that this communication be documented in the medical record. This policy was not followed in this instance, as evidenced by the lack of updated consent for the medication change.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including metabolic encephalopathy, end stage renal disease, diabetes with mononeuropathy, and major depressive disorder. The care plan incorrectly identified the resident's dialysis port as a central IV line and included interventions related to IV access that were not applicable, as the resident only had a dialysis port. Additionally, the care plan did not address the resident's activity preferences or her reported visual impairment, both of which were identified through interviews and record review. The resident expressed difficulty participating in activities due to her vision problems and stated a need to see an eye doctor, which had not been addressed in her care plan. Interviews with facility staff revealed a lack of awareness regarding the resident's visual issues and the absence of an activity care plan. The Activity Director noted the resident's preference to stay in her room and her interest in certain personal items, but there was no documented plan to support her activity needs. The MDS Coordinator and DON both confirmed that the care plan contained inaccuracies regarding the resident's IV status and that they were unaware of her visual concerns. The facility's policy requires comprehensive care plans with measurable objectives and timeframes based on resident assessments, but this was not followed in the resident's case.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. Specifically, the care plan for one resident was not updated to reflect the initiation of hospice services, despite a physician's order for hospice being present in the resident's record. The MDS Coordinator confirmed during an interview that the care plan had not been updated to include hospice care for the resident. The resident involved was an elderly female with diagnoses including severe dementia with behavioral disturbance, Parkinson's Disease with dyskinesia, and dysphagia. The facility's policy required care plans to be reviewed and revised after each significant assessment, but this was not followed in the case of the resident who began receiving hospice services. The lack of update to the care plan meant that the resident's current needs and interventions related to hospice care were not documented as required.
Failure to Follow Proper Incontinent Care and Infection Control Procedures
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate incontinent care and infection control for a resident who was always incontinent of bowel and bladder and had a history of hemiplegia and hemiparesis. During observed care, a CNA cleaned the resident's buttock and anal area, then handled a clean brief with the same soiled gloves, placing it on the bed. Both the CNA and a student aide then assisted the resident, removed their gloves, but did not perform hand hygiene before donning new gloves. The student aide applied barrier cream, again changed gloves without hand hygiene. Both staff members acknowledged during interviews that they had not followed proper hand hygiene protocols and recognized the risk of cross contamination. The facility's policy required hand hygiene before and after glove use and specified that perineal care should be performed from clean to dirty areas to avoid contamination. The DON confirmed that staff were expected to wash or sanitize hands between glove changes and when moving from dirty to clean areas. Audits showed both staff had previously satisfied requirements for hand washing and perineal care. The failure to follow these procedures was directly observed and confirmed by staff and the DON, constituting a deficiency in infection control and incontinent care practices.
Failure to Document Controlled Drug Administration in Narcotic Log
Penalty
Summary
The facility failed to maintain accurate records of receipt and disposition of controlled drugs for two residents, as required by state and federal regulations. Specifically, a medication aide administered Xanax to a resident with dementia, anxiety disorder, and major depressive disorder, and Tramadol to another resident with multiple fractures and pain, but did not document the administration of these controlled substances in the narcotic log at the time of administration. The medication administration records indicated that the medications were given, but the corresponding narcotic logs were not updated as required. During an inspection, it was observed that the narcotic log for Xanax did not reflect the medication being signed out, and the medication aide attempted to retroactively document the administration of Tramadol. The medication aide acknowledged forgetting to document in the narcotic logs immediately after administration, which was confirmed by the DON as a violation of facility policy and procedure. Facility policy required that all controlled medications be documented on the control sheet immediately after administration, and the failure to do so resulted in an inaccurate narcotic count.
Medication Cart Left Unlocked and Medication Labeling Error Identified
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and secure storage of drugs and biologicals on two of four medication carts reviewed. Specifically, one medication cart (C/D Hall) was found unlocked and unattended in the hallway in front of the nurse's station. The DON confirmed that the cart was assigned to an LVN, who admitted to forgetting to lock it after becoming sidetracked. Facility policy requires medication carts to be locked or attended by authorized personnel at all times, and the DON acknowledged that leaving the cart unlocked was a safety concern. Additionally, a review of a resident's medication revealed that the pharmacy label on a bottle of Seroquel did not match the current physician's order. The label indicated a dosage of 50 mg at bedtime, while the physician's order specified 50 mg twice daily. The medication aide administering the drug recognized the discrepancy but stated she overlooked it due to being in a hurry. The DON confirmed that the facility's expectation is for staff to match medication labels to physician orders and apply a change of direction sticker if there is a discrepancy. Facility documents reviewed by surveyors outlined these requirements for medication storage and administration.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents or staff members were mentioned in the report, and no additional details regarding individual medical histories or conditions at the time of the deficiency were provided.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care in accordance with their needs. Specific details about the actions or inactions of staff, the resident's medical history, or the resident's condition at the time of the deficiency are not provided in the report excerpt.
Failure to Honor Resident's Grooming Preferences and Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not honoring his grooming preferences. The resident, who had severe cognitive impairment and multiple medical diagnoses including encephalopathy and Alzheimer's disease, required assistance with personal hygiene. Despite his care plan addressing some aspects of personal hygiene, it did not include his specific preference to be clean shaven or his desire to be shaved with an electric razor by his POA, rather than by staff using disposable razors. Observations showed the resident had a full, unkempt mustache and goatee, and both the resident and his POA expressed dissatisfaction with his facial hair and the discomfort caused by staff shaving him with disposable razors. Interviews with staff revealed a lack of awareness regarding the resident's grooming preferences, and documentation did not reflect his wishes. The POA had previously complained about the resident's facial hair not being properly shaved, and the resident himself stated he preferred to be clean shaven and did not like staff shaving him due to discomfort. The facility's policy on resident rights includes the right to reasonable accommodation of resident needs and preferences, but this was not followed in the resident's case.
Inappropriate Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the intervention. Additionally, appropriate care and services related to the feeding tube were not provided as required. These actions resulted in a deficiency related to the use and management of feeding tubes.
Failure to Accurately Document Resident Bathing and Refusals
Penalty
Summary
The facility failed to ensure that medical records for a resident were maintained in accordance with professional standards and were complete and accurately documented. Specifically, for one resident with diagnoses including schizoaffective disorder, anxiety disorder, and hypertension, there was a lack of documentation regarding whether scheduled baths or showers were provided or refused on nine occasions over a one-month period. The resident's care plan and shower schedule indicated a need for assistance with personal hygiene and specified bathing days, but the electronic clinical record did not reflect whether the resident was bathed or had refused on those dates. Additionally, there were no corresponding notations in the nurses' notes to indicate refusals. Interviews with the Regional Compliance Nurse confirmed that the CNAs responsible for bathing the resident on the missing documentation dates reported that the resident had refused on several occasions, but these refusals were not documented in the clinical record or nurses' notes as required by facility policy. The resident herself recalled refusing some showers but could not specify which days. The facility's documentation policy requires prompt and complete documentation of care or treatment, but this was not followed in the case of the resident's bathing records.
Privacy Breach During Incontinent Care
Penalty
Summary
The facility failed to ensure privacy for three residents during incontinent care, which compromised their dignity and quality of life. Resident #2, who was admitted with Alzheimer's Disease, Dementia, and other cognitive impairments, was observed receiving perineal care without the privacy curtain being fully drawn, despite being in a private room. This oversight occurred during an observation on November 26, 2024, at 2:18 pm, involving CNA A and CNA B. Similarly, Resident #4, who was readmitted with Alzheimer's Disease, Dementia, and Hemiplegia, experienced a lack of privacy during incontinent care. On November 26, 2024, at 1:43 pm, CNA A and CNA B provided care without fully closing the privacy curtain, allowing the resident's roommate to attempt to view the care being provided. This resident had a severely impaired cognition as indicated by a BIMS score of 1. Resident #5, diagnosed with Cognitive Communication Deficit and Dementia, also faced privacy issues during care. On November 26, 2024, at 3:21 pm, CNA B did not fully close the privacy curtain while providing incontinent care, even though the resident was in a private room. Interviews with staff, including CNA B, CNA A, LVN C, the DON, and the Administrator, revealed an expectation for privacy to be maintained during care, yet this was not consistently practiced, affecting the residents' dignity.
Infection Control Deficiencies in Perineal Care and Linen Storage
Penalty
Summary
The facility failed to maintain proper infection control practices during perineal care for three residents. For Resident #2, a CNA washed her hands for only 10 seconds before providing care, failed to perform hand hygiene between glove changes, and used a brief that had fallen on the floor. The CNA also did not perform hand hygiene after removing gloves and before touching the resident's personal items. These actions were observed during perineal care, which is critical for residents with incontinence issues. Similarly, for Resident #4, the CNA washed her hands for only 13 seconds before care and did not allow the alcohol-based hand rub (ABHR) to dry before donning new gloves. This improper hand hygiene practice was observed during incontinent care, which is essential for preventing infections in residents with impaired cognition and incontinence. Additionally, the facility failed to ensure that clean linen was stored properly on two occasions. Linen carts on both the A and D halls were found uncovered, which could lead to contamination. Staff interviews revealed a lack of understanding and adherence to proper hand hygiene and linen storage protocols, which are vital for infection prevention and control in the facility.
Improper Incontinent Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a potential risk of urinary tract infection (UTI). During an observation, CNA B was seen wiping a resident from the anal area to the vaginal area on multiple occasions, which is contrary to proper perineal care practices. The resident in question was admitted with several diagnoses, including Alzheimer's Disease, Dementia, and a history of UTI, and was noted to be always incontinent of bowel and bladder. The care plan for the resident required perineal care after each incontinent episode, but the observed practice did not align with these requirements. Interviews with staff, including CNA B, LVN C, and the Director of Nursing (DON), revealed a lack of adherence to infection control practices. CNA B acknowledged the importance of wiping from front to back to prevent cross-contamination and potential infections. LVN C and the DON emphasized the expectation for staff to follow proper infection control procedures, including wiping from front to back and changing gloves when moving from dirty to clean areas. The facility's policy on infection control was reviewed, highlighting the need for a safe and sanitary environment to prevent infections, but the observed practices did not meet these standards.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by state and federal laws. During an observation and interview, it was found that Treatment Cart #1 on D hall was unlocked and unattended, with drawers facing out. LVN D confirmed that the cart was supposed to be locked when unattended because it contained medications that residents could access. The cart contained wound care treatments such as Triad, Ammonium Lactate, Wound Cleanser, and Barrier Ointment. LVN D noted that there were three mobile residents on the hall who could potentially access the cart, posing a risk of adverse reactions or poisoning if they ingested any medications. Interviews with LVN C, the DON, and the ADO revealed a shared expectation that medication and treatment carts should always be locked to prevent unauthorized access by residents or staff. The facility's policy on the storage of medication, dated 2003, mandates that medications and biologicals be stored securely and only accessible to authorized personnel. The failure to lock the treatment cart could lead to medication misuse and drug diversion, as residents who are mobile could potentially access the unlocked cart and ingest harmful substances.
Unsanitary Conditions in Shower Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment in two of the three shower rooms reviewed. Observations revealed that the A and D hall shower rooms contained barrels with soiled linen and trash, including soiled briefs, while residents were receiving showers. This practice was confirmed by CNA D, who stated it was the normal procedure to keep these barrels in the shower rooms during resident use. A resident expressed discomfort with having showers in a space containing other residents' soiled clothing and briefs. The facility's policy on Resident Rights emphasizes the right to a dignified existence and an environment that promotes quality of life, which was not upheld in this instance.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving staff members. In the first incident, a Medication Aide did not sanitize a blood pressure cuff between its use on two residents. This oversight was confirmed by the Medication Aide, who acknowledged forgetting to use a disinfecting wipe to prevent cross-contamination. The Director of Nursing (DON) also confirmed that the blood pressure cuff should have been sanitized between uses to avoid cross-contamination, as per the facility's infection control policy. In the second incident, two Certified Nursing Assistants (CNAs) failed to change their gloves or wash their hands after touching potentially contaminated surfaces while providing incontinent care to a resident. The CNAs touched the privacy curtain and bed remote with their gloved hands and then proceeded to handle the resident and cleaning supplies without changing gloves or performing hand hygiene. Both CNAs acknowledged their mistake, recognizing that the environment around the resident was considered contaminated and that they should have changed gloves and sanitized their hands. The facility's policy on infection control precautions requires hand hygiene after handling soiled equipment or utensils. Despite receiving infection control training within the year, the staff involved in these incidents did not adhere to the established protocols, leading to potential risks of infection transmission among residents.
Unlocked Beauty Shop with Hazardous Materials
Penalty
Summary
The facility failed to ensure the resident environment was safe, functional, sanitary, and comfortable, specifically in the beauty shop located on D Hall. During an observation, it was found that the beauty shop was unlocked and contained potentially dangerous materials such as hairspray, hair mousse, and hair dye. These items had warnings indicating they were flammable, should be kept out of reach of children, and were harmful if swallowed. This situation was confirmed during an interview with a CNA, who acknowledged the beauty shop was unsecured and contained these hazardous materials.
Failure to Maintain Resident Dignity in Personal Hygiene
Penalty
Summary
The facility failed to uphold a resident's right to a dignified existence by not adequately addressing personal hygiene needs for a resident who was dependent on staff for all activities of daily living. The resident, who had vascular dementia, hemiplegia, and muscle weakness, was observed with two-inch-long chin hair, which she found embarrassing. Despite being wholly dependent on staff for personal hygiene, the resident's care plan and assessments indicated a need for total assistance, which was not adequately provided. Interviews with staff revealed a lack of awareness and action regarding the resident's personal grooming preferences. A CNA responsible for the resident's care admitted to not noticing the chin hair, although she was instructed to shave residents who wished to be clean-shaven. Another CNA confirmed that the resident allowed and sometimes requested assistance with chin hair removal. The DON acknowledged that ADL care included shaving residents who desired it, indicating a lapse in the execution of the facility's policy on resident rights to a dignified existence.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident, who was ordered to have a low bed positioned near the floor. Instead, the resident was placed in a regular bed in the lowest position, which did not comply with the physician's order. This oversight led to the resident falling from the bed and sustaining a C2 vertebral fracture. The resident had a history of dementia, schizoaffective disorder, muscle wasting, difficulty walking, and was at high risk for falls, as indicated by her fall risk assessment score. The resident's care plan included interventions such as a floor mat and a low bed at night to mitigate fall risks. However, these interventions were not properly implemented or communicated to the staff, as evidenced by the absence of the low bed order in the Kardex, which is used by CNAs for resident care. Interviews with staff revealed that the resident was not in a low bed at the time of the fall, and there was confusion among staff regarding the resident's bed requirements. The Director of Nursing (DON) and other staff members were unaware of the active order for a low bed, and the resident's bed was only changed to a low bed after the fall and subsequent hospital visit. The physician confirmed that the order for a low bed was active and necessary due to the resident's unsteadiness and history of falls. This lack of adherence to the physician's order and failure to communicate and implement fall prevention measures contributed to the resident's injury.
Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards and provided adequate supervision for a resident who required mechanical lift transfers. On 01/17/2024, a nursing assistant (NA) transferred a resident alone using a mechanical lift, which required two people for safety. During the transfer, one of the straps holding the sling came loose, causing the resident to slip and hit her head on the mechanical lift. This resulted in a head laceration and fractures to the C4 and C5 vertebrae. The resident was severely cognitively impaired and dependent on staff for activities of daily living (ADLs), requiring two-person assistance for transfers as per her care plan and medical assessments. The incident occurred because the NA did not wait for assistance, despite knowing the requirement for two-person transfers. The NA's written statement indicated that he attempted the transfer alone due to perceived understaffing and the absence of other staff in the hall. The facility's administrator confirmed that sufficient staff were available at the time of the incident, and the NA chose not to wait for help. The NA was subsequently suspended and terminated following the investigation. The resident was immediately assessed by a licensed vocational nurse (LVN) and transferred to the hospital for evaluation. The hospital's CT scan confirmed the fractures and head injury. The facility's records showed that the NA had been trained and signed off on the proper use of the mechanical lift, including the requirement for two-person assistance. The facility's policy and the manufacturer's guidelines also mandated two-person assistance for mechanical lift transfers. Observations and interviews with other staff confirmed that the incident was an isolated case of non-compliance by the NA, who failed to follow established protocols and procedures.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 70 citations issued within 25 miles in the last 12 months — including the 3 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 Karnes City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| John Paul Ii Nursing Home | 10.5 mi | ★★★★★ | 5 | 0 |
| Kenedy Health & Rehabilitation | 10.5 mi | ★★★★★ | 12 | 0 |
| Frank M. Tejeda Texas State Veterans Home | 21.9 mi | ★★★★★ | 12 | 0 |
| Harmony Care At Floresville | 22.2 mi | ★★★★★ | 18 | 0 |
| Prairie Meadows Rehabilitation And Healthcare Cent | 22.7 mi | ★★★★★ | 23 | 3 |
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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.