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 Point Wellness during CMS and state inspections, most recent first.
A cognitively intact male resident with hemiplegia, Bell’s palsy, and Type 2 DM was being assisted by an LVN to obtain a blood pressure when he moved and reached for a TV remote, requiring redirection. During this interaction, the LVN told the resident he was "acting like a 2-year-old" or "acting like a child," then removed the blood pressure cuff and left the room. The resident later reported the staff had been rude and indicated he felt very small at the time of the comment. Multiple staff, including nursing leadership and social services, described the remark as demeaning or a dignity issue, and facility policy requires that residents be treated with respect and dignity in a manner that promotes or enhances their quality of life.
A resident with a new G-tube and severe cognitive impairment experienced significant diarrhea while receiving ordered nighttime enteral feedings. On two consecutive nights, an RN independently stopped one feeding early and withheld the next scheduled nighttime feeding without notifying the MD/NP, without obtaining an order to alter the treatment, and without documenting the diarrhea or the missed/shortened feedings in the clinical record. Family video clips and CNA statements showed no feeding bag in place during the night in question, and progress notes contained no mention of diarrhea or tube feeding interruptions. Other nursing staff and the NP reported that the RN did not follow facility policy requiring immediate MD/NP notification and thorough documentation for a change in condition and alteration of ordered enteral nutrition, leading to the cited deficiency.
A resident with hemiplegia, dementia, depression, and a G-tube did not receive multiple ordered PM medications, including atorvastatin, cetirizine, melatonin, ropinirole, venlafaxine, Depakene, gabapentin, and biotin. After the resident returned from the hospital with a feeding tube, orders had been changed to G-tube administration. On a night shift, an LVN left a note listing rooms where 8:00 PM meds were given, but the resident’s room was not included. The oncoming RN misread the note, assumed the G-tube meds had been administered, did not enter the room to give them, yet signed the MAR as if all PM doses were given. Video clips and staff interviews supported that only a CNA entered the room that night. This conduct conflicted with facility policy requiring that medications be administered as ordered and documented only by the person who actually administers them, following the rights of medication administration, including right documentation.
A quarterly MDS assessment for a resident with multiple cardiac conditions and diabetes was completed but not transmitted to CMS within the required 14-day period. The assessment was submitted nine days late, with staff interviews indicating confusion over submission responsibilities and confirmation that the Corporate RN was responsible for uploading the assessment.
The facility did not ensure that a resident received an accurate assessment, resulting in incomplete or inaccurate documentation of the resident's condition and needs.
A CNA did not change gloves or perform hand hygiene between dirty and clean tasks while providing incontinent care to a resident with dementia and severe cognitive impairment. This failure to follow infection control protocol was observed and confirmed by staff interviews, in direct violation of facility policy.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
A resident with moderate cognitive impairment and limited upper extremity mobility was given hot water in a cup without a lid by a medication aide, despite care plan interventions requiring lids and temperature controls for hot liquids. The resident spilled the hot liquid, resulting in a burn, and staff interviews revealed a lack of awareness about the resident's safety needs and inconsistent implementation of required interventions.
A resident with a history of blood clots did not receive Eliquis as ordered due to conflicting physician orders and a lack of medication reconciliation, resulting in the medication being held indefinitely. This led to the resident being hospitalized with acute pulmonary embolism and DVT, requiring surgical intervention. The incident was identified as Immediate Jeopardy.
A resident with multiple complex medical needs was discharged to a hospital and subsequently refused readmission by the facility due to nonpayment, resulting in the resident remaining in the hospital for over a month while alternative placement was sought. Facility records lacked evidence of discharge planning or coordination, and staff interviews indicated a lack of involvement and awareness regarding the resident's discharge process.
A resident with multiple risk factors and existing pressure injuries was not consistently repositioned or provided with appropriate pressure-relieving devices as required by her care plan and facility policy. Staff failed to offload pressure from the resident's buttock and heels, leading to the development of new stage II and stage III pressure injuries. Observations, interviews, and record reviews confirmed that staff did not follow established protocols for pressure injury prevention and care.
A resident's care plan inaccurately documented placement in a secured unit for dementia and elopement risk, even though the facility did not have a secured unit. Staff interviews confirmed the absence of such a unit and a lack of awareness about the care plan error, resulting in the resident's needs not being properly addressed according to facility policy.
A resident with urinary incontinence and mobility deficits did not receive timely assistance with personal hygiene after an incontinent episode. Staff failed to check and provide care, resulting in the resident remaining wet through breakfast. Interviews revealed assumptions about the resident's abilities and lack of adherence to skin care protocols.
Medication carts on two halls were found unlocked and unattended, with keys left accessible or carts left open, allowing unauthorized access to medications. Nursing staff acknowledged leaving the carts unsecured while attending to other tasks, and the DON confirmed that facility policy requires carts to be locked at all times unless in use.
A CNA did not perform hand hygiene or change gloves as required while providing incontinent care to a resident, including after removing soiled items, before handling clean items, and after glove removal. The CNA also used gloves that had been placed on another resident's bed and touched personal items during care without changing gloves or performing hand hygiene, contrary to facility infection control policy.
A resident with a history of dementia and other medical conditions fell and hit her head, leading to hospitalization with a subdural hematoma. The facility failed to perform necessary neurological assessments following the incident, resulting in a delay in recognizing a change in the resident's condition. Confusion among staff and incorrect incident reporting contributed to the oversight, leading to an Immediate Jeopardy situation.
Two residents in the facility did not receive adequate care for activities of daily living, resulting in deficiencies in personal hygiene. A resident with cognitive decline was found with a yellow liquid substance on his body and bed, and another resident with dementia did not receive scheduled showers. Staff interviews revealed inconsistencies in providing and documenting care, despite facility policies emphasizing the importance of hygiene for comfort and infection control.
Two CNAs at the facility failed to adhere to infection control protocols during incontinent care, leading to potential cross-contamination. CNA M did not perform hand hygiene between glove changes and touched a resident's face without changing gloves after handling soiled items. CNA X used disposable wipes multiple times, placed soiled items on a resident's bed, and did not change gloves after touching contaminated items. These actions were observed during care for two residents, highlighting lapses in infection prevention practices.
A resident with dementia and other health issues fell and hit her head, but the physician was not notified immediately, contrary to facility policy. The RN involved was new and unaware of the notification process, leading to a delay in potential medical intervention.
A resident with a history of dementia and other conditions was found on the floor after a fall, reporting a head injury. The facility failed to review hospital records promptly, leading to a delayed report of the resident's subdural hematoma to the state agency. The DON or ADON was responsible for reviewing hospital updates, which were not checked until two days after receipt, resulting in a late report.
A facility failed to involve a resident and their representative in the care planning process, despite the resident's complex medical needs and requests from the family. The social worker did not set up a care plan meeting, and the MDS Coordinator did not include the resident in the planner for care plan meetings. The facility's policy requires resident participation in care planning, which was not followed.
A facility failed to promptly address grievances from a resident's family member, who raised concerns about the lack of a care plan and COVID care. The social worker did not forward these grievances due to inexperience and misunderstanding, and the facility was undergoing staff transitions. The issues were eventually addressed by the Regional Compliance Nurse after a delay.
The facility failed to develop and communicate baseline care plans within 48 hours of admission for two residents, risking inadequate care. One resident's plan was completed on time but not communicated, while another's was completed late. Both residents had complex medical needs requiring comprehensive care plans.
A medication cart on Hall 100 was found unlocked and unattended, allowing easy access to medications. A medication aide left the cart unsecured after completing her medication pass, contrary to the facility's policy requiring secure storage accessible only to authorized personnel. The Regional Compliance Nurse confirmed the expectation for carts to be locked when unattended.
A facility failed to maintain accurate clinical records for a resident, resulting in an incorrect care plan that included hospice services no longer applicable. The resident's hospice services were revoked to pursue aggressive treatment, but the care plan continued to reflect hospice-related goals and approaches. Interviews revealed the MDS Coordinator's mistake and a lack of specific policy for maintaining accurate records.
The facility failed to complete and transmit discharge MDS assessments for two residents who were discharged to home with a status of return anticipated. The MDS Coordinators were unaware of the oversight, which was identified during interviews. The DON confirmed the expectation for timely completion and transmission of these assessments, as required by regulations.
A facility failed to document a resident's continuous oxygen therapy in their care plan, despite the resident having acute respiratory failure with hypoxia and a physician's order for oxygen use. The resident was observed using oxygen at a higher rate than prescribed, and the DON confirmed the care plan was not updated to reflect this need, potentially risking inadequate individualized care.
A resident with a PICC line did not receive a dressing change as per facility policy, which requires weekly changes using sterile technique. The dressing, dated over a week old, was observed to be loose, increasing the risk of infection. Interviews revealed confusion among nursing staff about the responsibility for changing the dressing, and the DON confirmed the absence of an order for the dressing change until after surveyor intervention.
A resident with acute respiratory failure was not administered oxygen as ordered by the physician, with the oxygen machine set at 4 liters instead of the prescribed 3 liters. The charge nurse did not verify the physician's orders, leading to the incorrect oxygen setting. The DON confirmed the error, noting the facility's policy requires verification of orders for safe oxygen administration.
A medication cart in the 400 Hall was found unlocked and unattended, exposing medications to potential unauthorized access. LVN B, responsible for the cart, forgot to lock it despite being reminded by RN F. The facility's policy mandates that all medication carts be locked when not in use, a standard reiterated by the DON.
Failure to Treat a Resident With Dignity During Blood Pressure Assessment
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and respect during routine care. A male resident with hemiplegia and hemiparesis following a cerebral infarction, Bell’s palsy, and Type 2 diabetes was cognitively intact per a recent MDS, with a BIMS score of 15 and minimal hearing difficulty. His care plan documented hemiplegia/hemiparesis related to a stroke and noted impaired cognitive function/dementia or impaired thought processes and problems communicating. Despite these conditions, he was usually able to understand and be understood by others. During an episode in which a nurse was attempting to obtain the resident’s blood pressure, the resident was moving, wiggling, and reaching for what appeared to be a TV remote, and the nurse repeatedly asked him to be still. While attempting to complete this task, the LVN told the resident he was “acting like a 2-year-old” or “acting like a child,” as confirmed by the LVN herself and by video reviewed by the administrator. After making the comment, the LVN removed the blood pressure cuff and left the room. The resident later reported that a staff member had been rude to him, agreed that she had said something close to calling him a child or 2-year-old, and stated that at the time he felt “about that tall,” indicating a small size with his fingers. Multiple staff members, including the administrator, RCN, RN, CNA, ADON, and social worker, characterized the comment as demeaning, condescending, or a dignity issue, with some staff describing such a statement as verbal abuse that must be reported. The facility’s resident rights policy states that each resident has the right to a dignified existence and must be treated with respect and dignity in a manner and environment that promotes or enhances quality of life and recognizes individuality. The LVN acknowledged making the statement and justified it by describing the resident’s behavior during care, but also stated it might have been wrong to say. This conduct constituted the failure to treat the resident with dignity and respect as required by facility policy and resident rights.
Failure to Notify Physician and Document Changes in Enteral Feeding Due to Diarrhea
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician and representative of a significant change in condition and an alteration in ordered treatment related to enteral nutrition. A female resident with hemiplegia, cerebral infarction, dementia with severe cognitive impairment (BIMS score of 2), and gastrostomy status was receiving tube feeding per physician orders of Glucerna 1.2 at 65 ml/hr with water flushes. She was new to tube feeding following a recent hospital stay and had both daytime bolus feedings and continuous nighttime feedings. The resident’s care plan and orders reflected her dependence on enteral nutrition for hydration and nutrition. On two consecutive nights, the assigned RN independently altered the resident’s ordered tube feeding regimen due to the resident experiencing diarrhea, without notifying the MD/NP and without documenting the change in condition or the withheld treatment. On the first night, the RN stopped the nighttime tube feeding approximately two hours early because the resident had “bad diarrhea.” On the following night, the RN decided not to administer the ordered nighttime feeding at all, stating the resident had “massive diarrhea” and required multiple bed changes. The RN acknowledged she did not call the MD/NP at the time, did not notify them the next morning, and did not document the diarrhea, the early stoppage of the feeding, or the held feeding in the progress notes. Progress notes from other staff during this period also did not reflect diarrhea or any interruption of tube feedings, and there was no documentation of physician notification. The resident’s family, who had a motion-activated camera in the room, reported that the nighttime tube feeding was not running, prompting facility leadership to review video clips. The clips reviewed showed the resident in bed with no feeding bag on the pole and no indication of a feeding running during the relevant nighttime hours, while a CNA provided care and entered the room multiple times. The CNA assigned that night reported not seeing a feeding bag hung or running and stated the resident had multiple episodes of diarrhea since starting the new tube feeding. Interviews with the ADM, RCN, ADON, other nursing staff, and the NP confirmed that the RN did not follow facility policy requiring physician notification and documentation for a change in condition and did not obtain an order to hold the feeding. The NP stated she should have been notified of the diarrhea and that, had she been called, she likely would have agreed to stop the feeding but would have monitored the resident more closely. Facility policies on enteral nutrition and notifying the physician of a change in status required nursing to administer tube feedings as ordered, notify the physician of changes in status, and document signs and symptoms, physician contact, and resident response, which did not occur in this case. Laboratory results drawn during this period showed the resident had low sodium, and the NP later adjusted the water flushes associated with the tube feeding after being informed that a feeding had been missed and one had been stopped early. However, at the time of the events, there was no contemporaneous documentation of the resident’s diarrhea, no record of MD/NP notification, and no record of any physician orders to alter or hold the tube feeding. Interviews with other nurses indicated that their standard practice would be to immediately notify the MD/NP of diarrhea or any change in condition in a resident receiving tube feeding, to obtain orders before holding a feeding, and to document all changes and notifications. The failure to notify the physician and resident representative of the significant change in condition and the need to alter treatment, and the failure to document these changes, constituted the cited deficiency for this resident receiving enteral nutrition.
Missed G-tube Medications and False MAR Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate administration and documentation of multiple medications for one resident with significant medical needs. The resident was an elderly female with hemiplegia following a stroke, dementia with severe cognitive impairment (BIMS score of 2), depression, and gastrostomy status requiring tube feeding. Physician orders directed that she receive several medications via G-tube or orally, including atorvastatin for hyperlipidemia, cetirizine for allergic rhinitis, melatonin for sleep, ropinirole for restless legs syndrome, venlafaxine for depression, Depakene for migraines related to cerebral infarction, gabapentin for neuropathy, and biotin for buccal moisture. After a recent hospitalization and return with a feeding tube, her medications had been changed to G-tube administration, but the MAR still reflected these scheduled PM medications. On the night in question, there was confusion and miscommunication between two nurses regarding which medications had been administered. LVN D reported that she sometimes helped the night shift by giving only PO medications to some residents and left a written note listing specific rooms where she had given 8:00 PM medications; this list did not include the room of the resident in question. LVN D stated the resident did not have any PO medications and that it was possible RN C thought she had given the G-tube medications. CNA E, who worked the 10:00 PM to 6:00 AM shift, reported she did not specifically see RN C enter the resident’s room during that shift. Video clips from the resident’s room, which were motion-activated and not continuous, showed only a CNA entering the room around the start and near the end of the night; there was no visual evidence of either nurse entering to administer G-tube medications. RN C acknowledged that she did not administer the resident’s PM G-tube medications on that night. She stated she arrived at 10:00 PM, saw the note from LVN D, misread it, and believed that LVN D had already given the resident’s G-tube medications. Despite not administering the medications herself, RN C signed off on the MAR as though the PM doses of atorvastatin, cetirizine, melatonin, ropinirole, venlafaxine, Depakene, gabapentin, and biotin had been given. Facility staff, including other nurses and leadership, stated that checking off medications not personally administered is a medication error and contrary to nursing standards and facility policy, which requires medications to be administered as prescribed and documented by the person who actually gives them, following the rights of medication administration, including right documentation. The facility’s own Medication Administration and General Guidelines Policy specified that medications must be administered in accordance with physician orders and that the resident’s MAR is to be initialed by the person administering the medication, adhering to the rights of medication administration, including right documentation. In this case, the resident’s PM medications were not administered as ordered, and the MAR was inaccurately completed to indicate that they had been given. The facility’s internal review, including interviews with the RCN, ADM, NP, and other nursing staff, confirmed that the resident likely did not receive the ordered PM medications and that RN C documented their administration despite not providing them.
Late Submission of MDS Assessment to CMS
Penalty
Summary
The facility failed to ensure that an encoded, accurate, and complete Minimum Data Set (MDS) assessment was electronically transmitted to the CMS system within the required 14 days after completion for one resident. Specifically, a quarterly MDS assessment for a female resident with a history of aortocoronary bypass graft, congestive heart failure, atherosclerotic coronary heart disease, and diabetes was completed and signed by the Corporate RN Assessment Coordinator, but was not submitted to CMS until nine days past the required deadline. The MDS was completed on one date, but the submission occurred after the 14-day window, as confirmed by the CMS Submission Final Validation report, which flagged the record as submitted late. Interviews with facility staff revealed that the MDS Coordinators were not responsible for submitting the assessments and were unaware of the reason for the delay. The responsibility for uploading the MDS assessments was assigned to the RN who signed the MDS as completed. The Administrator confirmed that the expectation was for MDS assessments to be completed and transmitted as scheduled, with the Corporate RN responsible for submissions. The facility referenced the RAI 3.0 Manual's schedule for completing and transmitting all MDS assessments, which requires submission within 14 days of completion.
Failure to Provide Accurate Resident Assessment
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that the required assessment process was not properly completed for one or more residents, resulting in inaccurate or incomplete documentation of their condition and needs at the time of the survey. This inaction led to a lack of reliable information necessary for planning and delivering appropriate care to the affected resident(s).
Failure to Follow Infection Control Protocol During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent care for a female resident with dementia and severely impaired cognition. The resident required substantial assistance with all activities of daily living and was always incontinent of bowel and bladder. During care, after cleaning the resident's pubic/groin and rectal areas, the CNA did not change gloves before placing a clean brief and applying barrier cream. Additionally, the CNA did not perform hand hygiene between glove changes, instead donning new gloves without using hand sanitizer or washing hands. Interviews with the CNA and facility leadership confirmed that the expected protocol was not followed, as staff are required to change gloves when moving from dirty to clean tasks and to perform hand hygiene between glove changes. Facility policy also specifies that gloves should be removed and hand hygiene performed before reclothing the resident. The failure to adhere to these procedures was observed directly and acknowledged by the staff involved.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Prevent Burn Injury from Hot Liquid Due to Lack of Supervision and Hazard Controls
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and limited upper extremity mobility was provided with hot water in a cup without a lid by a medication aide. The resident, who required substantial to maximal assistance with eating and had a care plan indicating a need for lids on cups containing hot liquids, spilled the hot liquid in her lap, resulting in a burn to her thigh. The medication aide was unaware of the resident's need for a lid, and the hot water was heated in a microwave without temperature verification or the use of a lid, contrary to the resident's care plan interventions. The incident was documented in nursing notes, which described the resident notifying staff after the spill, with subsequent assessment revealing a scald mark and later a blister on the thigh. The resident reported that the cup slipped from her fingers, and she did not have a lid on her mug at the time of the incident. The care plan for this resident specifically identified a risk for burns from hot liquids and required the use of a cup with a lid and temperature controls for hot beverages, but these interventions were not followed during the event. Staff interviews confirmed that, at the time, there was a lack of awareness among some staff regarding which residents required lids for hot liquids. The medication aide involved stated she was not informed of the resident's need for a lid. The facility had microwaves accessible throughout the building, and there was no system in place to ensure only authorized staff prepared hot liquids or that temperature and safety interventions were consistently implemented for at-risk residents.
Failure to Resume Anticoagulant Results in Significant Medication Error and Hospitalization
Penalty
Summary
A significant medication error occurred when a resident with a history of pulmonary embolism and deep vein thrombosis was not administered Eliquis, an anticoagulant, as ordered by the physician. The resident was readmitted to the facility with orders to hold Eliquis for a specified period due to a scheduled polyp removal. There were two separate physician orders: one to hold Eliquis until a certain date without a restart date, and another to hold the medication for four days and restart on a specific date. The orders conflicted, and the facility's electronic system placed the medication on hold indefinitely due to the lack of a clear restart date in one of the orders. As a result of this error, the resident did not receive Eliquis for an extended period. The medication administration record (MAR) showed that Eliquis was not given from the time of readmission through the following month, with the medication remaining on hold. The facility failed to reconcile the conflicting orders and did not ensure that the medication was restarted as required by the physician's instructions. This lapse in medication administration was not identified or corrected in a timely manner. The resident was subsequently hospitalized with a diagnosis of noncompliance with Eliquis, presenting with syncope and found to have acute pulmonary embolism and right lower extremity DVT, requiring surgical intervention. The failure to administer Eliquis as ordered directly led to the resident's hospitalization and significant harm. The deficiency was identified as Immediate Jeopardy, with the noncompliance period beginning when the resident was hospitalized and ending after corrective actions were implemented.
Failure to Ensure Safe and Orderly Discharge for Resident Refused Readmission
Penalty
Summary
The facility failed to ensure a safe, orderly, and properly documented discharge for a resident who was ultimately refused readmission after a hospital stay. The resident, who had multiple medical conditions including anxiety disorder, paralysis, diabetes, amputation, cognitive decline, and housing instability, was initially given a 30-day discharge notice for nonpayment. Despite the notice and a subsequent eviction petition, the resident remained at the facility until he was sent to the hospital for shortness of breath. Upon stabilization, the hospital attempted to return the resident, but the facility refused to accept him back, citing the prior eviction for nonpayment. There was no evidence in the nursing notes or social services documentation of any discharge planning or actions to ensure the resident's needs and preferences were met prior to his hospital transfer and subsequent discharge. The facility did not coordinate with the hospital or other agencies to secure a safe and appropriate placement for the resident after his hospital stay. The resident remained in the hospital for over 30 days while the hospital social worker made numerous unsuccessful placement referrals, as the facility continued to refuse readmission. Interviews with facility staff revealed a lack of awareness and involvement in the discharge process, with the current administration attributing the actions to previous ownership. The Ombudsman was not notified or involved in the discharge, and there was no evidence of adherence to the facility's own resident rights policy, which requires equal access to care and proper discharge procedures regardless of payment source.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure injuries for a resident who was dependent on staff for repositioning and had a history of pressure injuries. The resident was admitted with multiple risk factors, including aftercare following joint replacement, type II diabetes, incontinence, and existing pressure injuries. The care plan required staff to reposition the resident every two hours and to use pressure-relieving devices, but documentation and observations showed these interventions were not consistently implemented. On multiple occasions, the resident was observed lying in bed with her buttock and heels in direct contact with the mattress, despite orders to float the heels and offload pressure areas. The resident and her family member reported that staff did not attempt to reposition her or alleviate pressure, and the family member brought in a wedge to help offload the resident's heel due to lack of staff intervention. Interviews with staff revealed a lack of awareness or mention of repositioning as part of routine care for dependent residents. As a result of these failures, the resident developed a stage II pressure injury to the right heel and a stage III pressure injury to the right buttock, neither of which were present on admission. Facility policy required regular repositioning and use of support devices to prevent pressure injuries, but these protocols were not followed, as evidenced by staff interviews, resident and family reports, and direct observations.
Failure to Accurately Develop and Implement Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected the needs and circumstances of a resident. Specifically, the care plan for one resident indicated placement in a secured care unit due to a diagnosis of dementia and risk for elopement, despite the facility not having a secured unit. This discrepancy was identified through record reviews and staff interviews, which confirmed that no secured unit existed in the facility and that no residents required such placement at the time. Interviews with the Regional Nurse and the DON revealed a lack of awareness regarding the inaccurate care plan documentation. The DON acknowledged responsibility for ensuring care plans were correct but admitted she had not reviewed care plans for references to a secured unit, as the facility did not have one. The facility's policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes, but this was not followed in this instance.
Failure to Provide Timely Incontinent Care and Assistance with ADLs
Penalty
Summary
A deficiency occurred when a resident with a history of overactive bladder, urinary incontinence, muscle weakness, unsteadiness, and difficulty walking did not receive necessary assistance with activities of daily living, specifically grooming and personal hygiene. The resident, who was moderately cognitively impaired and required substantial to maximum assistance with toileting, was observed to be wet from an incontinent episode during the morning hours. Staff interviews revealed that the certified nursing assistant (CNA) responsible for the resident had last checked on her between 6:00 a.m. and 6:15 a.m., but did not check if the resident was wet during subsequent rounds. Another nursing assistant also did not check on the resident, assuming she was able to use the bathroom independently. The resident reported frequently waiting to be changed and noted that it was unusual to have breakfast without being wet. Observations confirmed the resident's nightgown was wet up to the middle of her back. The Director of Nursing (DON) stated that staff are expected to check residents for incontinent episodes, even if they are only occasionally incontinent, to prevent skin breakdown, ensure comfort, and prevent infection. The facility did not have a specific policy regarding incontinent care, but their skin integrity management guidelines indicated that skin should be cleansed at the time of soiling and at routine intervals.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts on two separate halls were left unlocked and unattended, with keys either left on top of the cart or the cart simply left open. On the 200 Hall, a medication cart was found in the hallway unlocked with the keys on top and no staff nearby. The nurse responsible for the cart stated she had been called away to assist with a resident transfer and left the cart unsecured. On the 300 Hall, two medication carts were also found unlocked, with staff walking by without securing them. The nurse responsible for these carts indicated she had left to get trash bags after completing her medication pass, leaving the carts unattended and unlocked. Interviews with nursing staff and the Director of Nursing confirmed that the expectation is for medication carts to be locked at all times unless medications are being accessed. The facility's policy requires that medications and biologicals be stored securely and only accessible to authorized personnel. The observed failure to secure the medication carts and keys resulted in unauthorized access to medications, contrary to both facility policy and regulatory requirements.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a CNA failed to follow proper infection prevention and control protocols while providing incontinent care to a resident. The CNA entered the resident's room without performing hand hygiene, placed gloves on a roommate's bed, adjusted the bed rail, and then put on the gloves without hand hygiene. Throughout the care process, the CNA repeatedly failed to change gloves and perform hand hygiene at appropriate times, including after removing soiled items, before handling clean items, and after glove removal. The CNA also used gloves that had been placed on another resident's bed and touched personal items such as her own glasses during care without changing gloves or performing hand hygiene. Interviews with the CNA and the DON confirmed that the facility's infection control policy required hand hygiene before and after resident care, between glove changes, and when moving from clean to dirty tasks. The facility's policy also emphasized that gloves do not replace the need for hand hygiene and that failure to change gloves between resident contacts is an infection control hazard. The observed actions were inconsistent with these policies and could contribute to the transmission of communicable diseases and infections within the facility.
Failure to Conduct Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified for a resident who experienced a fall and hit her head, resulting in hospitalization with a subdural hematoma. The facility did not perform the necessary neurological assessments following the incident, which was documented in an incident report dated 1/9/25. The lack of appropriate monitoring and assessment led to a delay in recognizing a change in the resident's level of consciousness, prompting the family to request hospitalization. The resident, a female with a history of dementia, anxiety, hemiplegia, cerebral infarction, and chronic kidney disease, was admitted to the facility with a care plan indicating a risk for falls. Despite this, the facility did not conduct the required neurological checks after the resident's fall on 1/9/25. The incident report was incorrectly entered, and the electronic medical record system did not generate the necessary prompts for neurological assessments. This oversight was compounded by confusion among staff regarding the incident, as evidenced by conflicting accounts from the nurse involved and the CNA who assisted. Interviews with facility staff revealed a lack of adherence to the facility's Neurologic Checks policy, which outlines specific procedures and frequency for conducting neurological assessments after a fall or head injury. The Director of Nursing (DON) confirmed that such assessments were expected but not performed in this case. The failure to conduct these assessments and recognize the resident's change in condition resulted in an Immediate Jeopardy situation, highlighting significant lapses in the facility's care and monitoring processes.
Removal Plan
- Resident #1 had a head to toe and neurological assessment completed by the charge nurse. No change in condition noted.
- Resident #1's nurse from 1/9/25 is no longer employed with the facility.
- A neurological assessment was completed on all residents that had an unwitnessed fall or hit their heads within the last 30 days. No changes in condition were identified.
- The Administrator, DON, ADON, or designee will review all falls during the morning clinical meeting to ensure that all neuro assessments have been completed for all unwitnessed falls or residents who hit their heads.
- The Medical Director was notified of the immediate jeopardy.
- An ADHOC QAPI was completed with medical director and interdisciplinary team to discuss the immediate jeopardy and plan of removal.
- The Compliance Nurse in-serviced the Administrator, DON, and ADON 1:1 on the following topics: Abuse and Neglect Policy, Fall Prevention Policy, Neurological Assessment Policy, Incident reporting, Notification of Change in Condition Policy, Documentation.
- The following in-services were initiated by the Regional Compliance nurse, Administrator, DON, and ADON. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN staff will in-serviced prior to start of their next shift. All agency staff will in-serviced prior to their assignment.
- All Staff: Abuse and Neglect, Notification of Change in Condition Policy.
- Licensed Nurses: Abuse and Neglect Policy, Fall Prevention Policy, Incident reporting, Neuros Assessment Policy, Notification of Change in Condition Policy, Documentation.
Deficiencies in Resident Hygiene and Care
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADLs) to two residents, leading to deficiencies in personal hygiene and grooming. Resident #4, a male with cognitive decline and Guillain-Barre Syndrome, was observed with a yellow liquid substance on his mouth, gown, sheets, and blanket, indicating a lack of immediate cleaning and care. His breakfast tray was also out of reach and untouched, suggesting neglect in ensuring his needs were met. The resident was scheduled for showers three times a week but received significantly fewer showers than scheduled in November and December 2024. Resident #1, a female with dementia, anxiety, and hemiplegia, also experienced deficiencies in personal care. She was scheduled for showers three times a week but had no records of receiving showers for extended periods in January 2025. Interviews with staff revealed that CNAs were responsible for providing showers and bed baths, and nurses were to ensure these tasks were completed. However, there was a lack of documentation and follow-up when residents refused showers, and staff did not consistently clean residents when visibly dirty. The facility's policy indicated the importance of regular bathing for hygiene, comfort, and infection control. Despite this, the facility did not adhere to its policy, as evidenced by the lack of scheduled showers and immediate cleaning for the residents. Interviews with staff and the Regional Compliance Nurse highlighted expectations for shower frequency and the importance of maintaining residents' hygiene, but these expectations were not met, leading to the observed deficiencies.
Infection Control Deficiencies in CNA Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs, M and X, during the provision of incontinent care. CNA M did not perform hand hygiene between glove changes and failed to change gloves after picking up barrier cream from the floor. Additionally, CNA M touched a resident's face and swabbed her mouth without changing gloves after handling a trash bag containing soiled items. These actions were observed during care provided to Resident #2, who was receiving incontinent care. CNA X also demonstrated lapses in infection control practices while providing care to Resident #3. She used disposable wipes multiple times on the same area, placed soiled items on the resident's bed, and did not change gloves or perform hand hygiene after touching contaminated items. These actions were observed during the care of a resident with a colostomy bag, which required careful handling to prevent contamination. The facility's Regional Compliance Nurse confirmed that the CNAs did not have documented checkoffs for proper incontinent care procedures. The facility's infection control policy emphasizes the importance of hand hygiene and proper glove use to prevent the transmission of infections. The observed deficiencies in infection control practices could lead to cross-contamination and the spread of infections within the facility.
Failure to Notify Physician of Resident's Fall
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's condition following a fall. The resident, an elderly female with a history of dementia, anxiety, hemiplegia, cerebral infarction, and chronic kidney disease, experienced a fall on January 9, 2025, during which she hit her head. Despite the incident being documented, the physician was not informed until the following week, which delayed potential medical intervention. The resident was moderately cognitively intact and required substantial assistance with daily activities, as indicated in her care plan. The incident report noted that the resident was found on the floor with her head against the wall, and although vital signs and a neuro assessment were conducted, the physician was not notified. An RN involved in the incident stated she did not notify the physician or the family due to being new to the facility and not knowing how to access the necessary information. The facility's policy requires immediate physician notification in the event of significant changes in a resident's condition, but this protocol was not followed, as confirmed by interviews with the Regional Compliance Nurse and the Administrator.
Delayed Reporting of Resident's Subdural Hematoma
Penalty
Summary
The facility failed to report an alleged violation involving a resident's subdural hematoma in a timely manner, as required by regulations. The resident, an elderly female with a history of dementia, anxiety, hemiplegia, cerebral infarction, and chronic kidney disease, was found on the floor by a nurse after attempting to walk to the bathroom. She reported hitting her head, and although vital signs and a neurological assessment were conducted, the incident was not immediately reported to the state agency. The resident was later admitted to the hospital with a subacute subdural hematoma, among other diagnoses. Hospital records indicating the brain bleed were uploaded to the facility's system, but the information was not reviewed by staff until two days later. The facility's Administrator reported the injury to the state agency on the same day the records were reviewed, acknowledging the delay in reporting. Interviews with facility staff revealed that the Director of Nursing (DON) or Assistant Director of Nursing (ADON) was responsible for reviewing hospital updates, which should have been done upon receipt. The failure to review these updates promptly led to a delay in reporting the subdural hematoma to the state agency, which should have been done within two hours of receiving the information. This oversight was attributed to a lack of daily review of hospital updates and communication lapses among staff responsible for monitoring hospitalized residents.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and/or their representative were involved in the development and implementation of a person-centered care plan. This deficiency was identified for one resident who was admitted to the facility with multiple medical conditions, including rheumatic aortic insufficiency, hypertension, orthostatic hypotension, peripheral vascular disease, and anxiety disorder. The resident had a BIMS score indicating moderately impaired cognition and required substantial assistance with daily activities. Despite these needs, there was no documentation that the resident or their representative was invited to participate in care plan meetings during their stay. The facility's social worker (SW) admitted to not setting up a care plan meeting for the resident or their representative, despite receiving multiple requests from the resident's family member. The SW, who was new to the role and still learning, did not seek assistance or notify the facility's administration about the family's concerns. The SW also misunderstood the facility's responsibilities, incorrectly informing the family that the facility did not establish medical care plans. Additionally, the MDS Coordinator acknowledged that the resident's name was not included in the planner used to schedule care plan meetings. The coordinator met with the resident to complete the admission MDS assessment but did not involve the resident or their family in a formal care plan meeting. The facility's policy requires the development of a comprehensive care plan with the participation of the resident and their representative, but this was not adhered to in this case.
Failure to Address Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident, as evidenced by the lack of investigation or action taken regarding grievances voiced by the resident's family member. The resident, an elderly female with multiple medical conditions including rheumatic aortic insufficiency, hypertension, orthostatic hypotension, peripheral vascular disease, and anxiety disorder, was admitted to the facility and later discharged to an acute care hospital. Despite the family member's repeated attempts to communicate concerns and request a medical care plan, the facility did not document or address these grievances. The facility's social worker (SW), who was new and under supervision, did not forward the family member's emails to the administrator or notify the Regional Compliance Nurse. The SW misunderstood the nature of the grievances, considering them as mere concerns, and failed to set up a care plan meeting due to a lack of knowledge and initiative. The facility was undergoing a change of ownership and staff transitions, which contributed to the communication breakdown and lack of response to the family's concerns. The family member's emails highlighted issues such as the absence of a care plan, lack of specific COVID care, and concerns about pneumonia prevention. The Admission Coordinator eventually forwarded the concerns to the Regional Compliance Nurse, who addressed them promptly. However, the delay in response and lack of proper grievance handling procedures were evident. Additionally, there were no postings in the facility to inform residents on how to file grievances, contrary to the facility's grievance policy.
Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure continuity of care and communication among staff. For Resident #1, although a baseline care plan was completed on the day of admission, there was no documentation that the resident or their representative received a summary of this plan. This resident had multiple diagnoses, including rheumatic aortic insufficiency, hypertension, orthostatic hypotension, peripheral vascular disease, and anxiety disorder, which necessitated a comprehensive care plan to address these complex needs. For Resident #2, the baseline care plan was completed late, five days after admission, and similarly, there was no documentation that a summary was provided to the resident or their representative. This resident had conditions such as hemiplegia affecting the left nondominant side, hypertension, and gastroesophageal reflux disease without esophagitis. The lack of timely and communicated care plans could potentially place newly admitted residents at risk for not receiving necessary services. The Regional Compliance Nurse, who took over after a change in facility management, confirmed the absence of documentation and noted that the previous management did not ensure the provision of care plan summaries.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications were stored securely, as evidenced by an unlocked and unattended medication cart on Hall 100. During an observation, the medication cart was found against the wall, with all drawers accessible, allowing easy access to medications. This incident occurred when a medication aide, after completing her medication pass, left the cart unlocked while she went to find a nurse to count medications. The Regional Compliance Nurse confirmed that the expectation was for all medication carts to be locked when unattended. The facility's medication storage policy mandates that medications and biologicals be stored securely and only accessible to authorized personnel.
Inaccurate Care Plan Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, leading to a deficiency in the comprehensive care plan. The resident, who was initially admitted for respite services under hospice care, had their hospice services revoked to pursue aggressive treatment. Despite this change, the resident's care plan continued to inaccurately reflect hospice services, including goals and approaches related to hospice care, which were no longer applicable. Interviews with facility staff revealed that the MDS Coordinator mistakenly included hospice services in the resident's care plan, despite the resident not being on hospice at the time. The Regional Compliance Nurse acknowledged the lack of a specific policy for maintaining accurate clinical records but expected care plans to reflect the resident's current status and needs. This oversight in documentation could lead to miscommunication and potential delays in services for the resident.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure that encoded, accurate, and complete Minimum Data Set (MDS) discharge assessments were electronically completed and transmitted to the CMS System within 14 days after completion for two residents. Specifically, the facility did not complete and transmit discharge MDS assessments for two residents who were discharged to home with a status of return anticipated. Both residents did not return to the facility, and their electronic medical records lacked the required discharge MDS assessments. Interviews with the MDS Coordinators revealed that they were responsible for completing these assessments but were unaware that the discharge assessments for the two residents were not completed and transmitted. The MDS Coordinators acknowledged that the assessments were missed and emphasized the importance of timely completion and transmission, as they affect quality of care measures and payments. The Director of Nursing (DON) confirmed that the MDS Coordinators were expected to complete and transmit the assessments as scheduled and required by state and federal regulations.
Failure to Document Oxygen Therapy in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not document the use of continuous oxygen therapy in the resident's care plan. The resident, who was cognitively intact, had diagnoses of hypertension, paroxysmal atrial fibrillation, and acute respiratory failure with hypoxia, and was observed using oxygen therapy set at 4 liters via nasal cannula, despite a physician's order for 3 liters. The Director of Nursing (DON) acknowledged that the care plan should have included the resident's oxygen therapy and that the care plan was not updated to reflect this need. The facility's policy requires that comprehensive, person-centered care plans include measurable objectives and timeframes and be revised as residents' conditions change. The lack of documentation for the resident's oxygen therapy in the care plan could place residents at risk of receiving inadequate interventions not individualized to their care needs.
Failure to Change PICC Line Dressing as per Policy
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a Peripherally Inserted Central Catheter (PICC) line, as per professional standards of practice. The resident, who was admitted with a wedge compression fracture of the fourth lumbar vertebra, had a PICC line dressing that had not been changed since it was applied at the hospital. Observations revealed that the dressing was dated over a week old and was becoming loose, which could increase the risk of infection. Despite the facility's policy requiring weekly dressing changes using sterile technique, the resident's care plan did not address the PICC line, and there was no order for the dressing change until after surveyor intervention. Interviews with various nursing staff, including agency nurses and the Director of Nursing (DON), highlighted a lack of clarity and communication regarding the responsibility for changing the PICC line dressing. Some nurses were unsure of the facility's policy or believed it was the responsibility of an RN to perform the dressing change. The DON confirmed that the resident did not have an order for a PICC line dressing change and acknowledged the risk of infection due to the dressing not being changed in a timely manner. The facility's policy from 2001 emphasized the importance of changing dressings that were damp, loosened, or soiled, and at least every seven days to prevent catheter-related infections.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen to a resident as ordered by the physician, which was identified during observations and interviews. The resident, a cognitively intact female with diagnoses including hypertension, paroxysmal atrial fibrillation, and acute respiratory failure with hypoxia, had a physician's order for continuous oxygen at 3 liters via nasal cannula. However, during multiple observations, the resident's oxygen machine was set at 4 liters, contrary to the physician's order. The charge nurse, LVN A, admitted to not checking the resident's oxygen orders before making rounds, resulting in the incorrect oxygen setting. The Director of Nursing (DON) confirmed that the resident was administered the wrong amount of oxygen because the physician's order was not followed. The facility's Oxygen Administration policy requires verification of physician's orders for safe oxygen administration, which was not adhered to in this case.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with the 400 Hall medication cart. During an observation, the medication cart was found unlocked and unsecured, with the drawers easily accessible, exposing all medications. The CNA assigned to the 400 Hall was nearby but not attending to the cart, and no residents were present in the corridor at the time. LVN B, responsible for the cart, admitted to forgetting to lock it after being reminded by RN F earlier. This oversight was attributed to it being LVN B's first day and feeling unprepared for the task. The Director of Nursing (DON) stated that the facility's policy requires all medication and treatment carts to be locked when not in use, a standard known to all LVNs. The facility's policy, revised in 2019, explicitly states that compartments containing drugs and biologicals must be locked when not in use and that unlocked medication carts should not be left unattended. The Administrator was present during the interview with the DON, reinforcing the expectation that these protocols be followed to prevent unauthorized access to medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 125 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bullard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Heights Of Tyler | 9 mi | ★★★★★ | 7 | 0 |
| Meadow Lake Health Center | 9.7 mi | ★★★★★ | 0 | 0 |
| Oak Brook Health Care Center | 9.8 mi | ★★★★★ | 0 | 0 |
| Reunion Plaza Healthcare & Rehabilitation | 10.2 mi | ★★★★★ | 0 | 0 |
| Providence Park Rehabilitation And Skilled Nursing | 10.7 mi | ★★★★★ | 1 | 1 |
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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.