Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Caprock Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple food items in the prep area, refrigerator, freezer, and pantry that were uncovered, open to air, unlabeled, or undated, including cereal bowls, cheese, prune juice, shakes, produce, ice cream, meat, bread, pesto, oatmeal pies, and pudding. Staff stated labeling and dating food was everyone's responsibility, and the DM confirmed food should be labeled and dated after opening and when delivered from the truck; facility policy required food to be stored covered, labeled, and dated.
A resident with an indwelling catheter and moderate cognitive impairment had his catheter bag and tubing observed on the floor on multiple occasions, including beside his bed and wrapped around a wheelchair tire. Staff said they were responsible for keeping catheter bags off the floor, but several reported they were not trained on catheter care or were unfamiliar with the policy. The resident’s care plan and orders required the drainage bag to be kept off the floor and in a privacy bag.
Failure to Provide Written Notice for Room and Roommate Changes: The facility did not ensure that two residents received required notice before room or roommate changes. One resident with dementia, schizophrenia, and severe cognitive impairment was given a roommate without advance notice to the family, and the roommate later moved after an altercation. Another resident with severe cognitive impairment and wandering behaviors was moved between rooms multiple times, with staff and family reporting that no prior notice was given and staff giving conflicting accounts of who was responsible for notification.
A resident’s OOH-DNR was incomplete because two witness signatures were present but not dated, making the form invalid. The resident was admitted as DNR and had severely impaired cognition, yet the care plan listed her as Full Code with CPR and EMS interventions. Staff stated incomplete DNR forms could lead to CPR or EMS being initiated instead of honoring end-of-life wishes.
A resident with ALS had BiPAP equipment in her room and staff confirmed she used BiPAP every night, but her MDS did not include the therapy. Record review also found no active order or care plan addressing the BiPAP at the time, and the MDS/LVN confirmed the therapy was omitted from the assessment.
A resident with ALS used BiPAP at night, but the therapy was not included in the care plan, MDS, or active orders at the time of review. Another resident with severely impaired cognition had DNR documentation in the chart, yet the care plan listed her as Full Code and included CPR interventions. Staff acknowledged the chart inconsistencies and that accurate code status and therapy documentation were needed in the EHR.
A resident with ALS used BiPAP at night, and a BiPAP machine was observed in her room, but the therapy was not included in her physician orders, care plan, or MDS at the time of review. Staff interviews confirmed the resident had been using BiPAP for months, while the ADON acknowledged the therapy had been missed in the chart because of confusion related to private payment, and the MDS/LVN stated that without orders staff would not know to include the therapy in the resident’s records.
Menu Substitution for Pureed Diets: A facility failed to follow the posted lunch menu for 3 residents on pureed diets when the regular entree was fried chicken but the pureed meals were prepared with chicken strips instead. Staff stated the boneless chicken intended for the pureed meals had not been thawed, so chicken strips were used, and one resident reported that his meal did not taste like the fried chicken served to other residents.
A resident with severe dementia had active EHR orders and care plan interventions stating she should reside on the secure unit, even though she was observed living on a regular hall. Staff interviews confirmed the chart still reflected secure-unit placement, and the DON stated the order should have been removed because the resident was no longer on the locked unit.
A resident with Type 2 DM and multiple comorbidities received 45 units of short-acting insulin instead of the ordered long-acting insulin when an LVN failed to follow facility medication verification procedures. The LVN could not locate the usual insulin pen, found a vial, and relied on an external AI tool rather than facility drug references or consulting the DON/ADON, and did not fully review the information before administering the dose. After realizing the mistake while giving insulin to another resident, the LVN checked the resident’s blood glucose, which decreased from 200 to 145, and the resident was subsequently sent to the hospital for observation following the insulin overdose.
A resident with multiple diagnoses, including severe dementia and mood disturbances, did not have their comprehensive care plan updated within 7 days following a completed MDS assessment. Staff interviews confirmed the care plan was not revised as required, and facility policy mandates timely updates after assessments.
A deficiency was identified when the facility did not honor a resident's right to a dignified existence, self-determination, communication, and the ability to exercise personal rights. The report does not provide further details about the specific circumstances or individuals involved.
A resident with multiple chronic conditions experienced a misappropriation of her prescribed Tylenol #3 tablets when 10 pills were found missing, and both the narcotic count sheet and medication card were unaccounted for. The discrepancy was discovered during a narcotic count verification, and the lack of documentation prevented clear identification of the cause of the loss.
A resident with dementia was emotionally and potentially physically abused by another resident in a secure unit. Despite staff witnessing the incident, it was not reported as potential abuse. The male resident continued inappropriate behavior, leading to his discharge to a psychiatric hospital. The deficiency was identified as past non-compliance, as the facility corrected the issue before the investigation began.
A resident with dementia was subjected to emotional and possible physical abuse by another resident, who entered her room and attempted to control her wheelchair, causing distress. Despite staff witnessing the incident, it was not reported as potential abuse according to the facility's policy. Miscommunication and confusion among staff led to a delay in addressing the situation, placing residents at risk of continued abuse.
A resident with dementia was not protected from potential abuse by another resident in a secure unit. The incident involved inappropriate touching and distress, but was not reported to the administrator or state agency as required. Staff cited the victim's dementia as a reason for not considering it abuse, despite visible distress.
A resident with multiple health conditions filed a grievance regarding food preferences and call light response times. The facility failed to provide a written decision, only verbally informing the resident, which led to communication lapses and potential feelings of being unheard. Staff interviews confirmed the lack of documentation, despite the facility's policy requiring written grievance decisions.
Food items found unlabeled, undated, and improperly stored in kitchen areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During observation of the prep area, refrigerator, freezer, and pantry, multiple food items were found uncovered, open to air, unlabeled, or undated. In the prep area, 12 bowls of cereal were sitting on a tray without covers, labels, or dates. In the refrigerator, items included an open package of cheese, two individual prune juice servings, a box of 12 vanilla shakes, a container of oranges, a box of cucumbers, and a bag of lettuce, with several items not dated and some open to air. In the freezer, surveyors observed two cups of ice cream, an opened box of ice cream sandwiches with three remaining, bags of meat patties and other meat, a bag of bread with an unreadable date, three pesto containers, and a container of orange-colored ice cream, with several items not labeled or dated; 15 boxes were also stored on the floor. In the pantry, 15 boxes of individual oatmeal pies and 10 pudding containers were not dated. Staff interviews stated that labeling and dating food was everyone's responsibility, and the DM stated food should be labeled and dated after opening and when delivered from the truck. Facility policies required food to be stored in covered containers, labeled, and dated, with open food sealed or covered and dated when opened.
Catheter Bag Left on Floor
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident with an indwelling catheter. Resident #17 was admitted with diagnoses including obstructive and reflux uropathy, acute kidney failure, dementia, and UTI, and his assessment showed moderate cognitive impairment and need for partial to moderate assistance with toileting hygiene. His care plan noted enhanced barrier precautions and included a task to keep the drainage bag off the floor, and his active orders included keeping the Foley bag in a privacy bag while in bed or in a wheelchair. During multiple observations, Resident #17’s catheter bag and tubing were found on the floor. On 07/14/26, the bag was observed on the floor next to his bed several times, including when he was lying in bed and when the tubing was emerging from the bottom of his pant leg. On 07/15/26, the catheter bag was again observed on the floor next to his bed and not in a privacy bag. On 07/16/26, the bag was on the floor with tubing wrapped around the front left tire of his wheelchair and several inches of tubing lying on the floor. Staff interviews showed inconsistent understanding of catheter care responsibilities and the facility policy. CNAs and nursing staff stated they were responsible for keeping catheter bags off the floor, but several said they were not trained by the facility on catheter care or were unfamiliar with the policy. One CNA stated Resident #17’s catheter bag was often on the floor and that staff tripped over it, and another staff member stated the bag had been on the floor earlier that morning and she tried to prop it on the bed frame. The facility policy stated to keep catheter tubing and drainage bags off the floor, and staff in-services referenced privacy bags and infection control, but the observations showed the resident’s catheter bag remained on the floor on multiple occasions.
Failure to Provide Written Notice for Room and Roommate Changes
Penalty
Summary
The facility failed to ensure that residents received written notice, including the reason for the change, before a room or roommate assignment was changed for two residents reviewed for resident rights. The deficiency involved Resident #5 and Resident #24, both of whom were on the secure unit and had significant cognitive impairment and behavioral concerns documented in their records. Resident #5 was an elderly female admitted with diagnoses including unspecified dementia, paranoid schizophrenia, psychotic disorder with delusions, and major depressive disorder. Her quarterly MDS showed a BIMS score of 7, indicating severely impaired cognition, and her care plan noted agitation and anxiety related to dementia and delirium or an acute confusional episode. A family member stated that Resident #5 was given a roommate without advance notice to the family. The family member said she learned of the roommate only after asking CNAs on the hall and overheard staff discussing that the family had not been told. She also stated there was an altercation between Resident #5 and the roommate, during which the roommate pushed Resident #5, and then the roommate was moved to another room. Resident #24 was an elderly male admitted with diagnoses including unspecified dementia, psychotic disorder with delusions, hallucinations, and major depressive disorder. His admission MDS showed a BIMS score of 3, indicating severely impaired cognition, and he had behaviors including disrobing in public, rejecting care, and wandering. Staff observed him sleeping in an extra bed in a room that was not his, and CNA staff stated he often slept there because he did not like his roommate. Staff also reported that he had moved rooms multiple times and became confused about where his room was. His family member stated she was not informed of his room changes and found out only when she visited and he was no longer in the room she expected. Facility staff gave conflicting statements about who was responsible for notifying residents and families, and the DON stated she was unfamiliar with the facility policy on room and roommate changes. The facility policy required prompt written notice for room or roommate changes, including the reason for the change, and stated that notice should be given before a resident is relocated whenever possible.
Incomplete DNR Form Left Resident’s Advance Directive Invalid
Penalty
Summary
The facility failed to ensure Resident #43 had a valid advance directive for a DNR order because the OOH-DNR form was signed by the physician and a family member, but the two witness signatures were not dated. Resident #43 was an [AGE]-year-old female admitted on [DATE], and her admission record identified her as DNR. Her admission MDS completed on [DATE] showed a BIMS score of 7, indicating severely impaired cognition. The resident’s care plan, initiated on [DATE], listed her as Full Code and included interventions for initiating CPR, notifying EMS, and notifying the charge nurse if she was without a heartbeat or not breathing. The facility’s interviews showed staff understood that incomplete DNR forms could result in CPR being initiated or EMS being called instead of honoring end-of-life wishes. The facility policy stated the OOH-DNR form must be signed and dated by two witnesses, and the Texas OOH-DNR instructions stated a properly completed OOH-DNR order is sufficient evidence and should be honored.
MDS Assessment Did Not Reflect Resident’s BiPAP Therapy
Penalty
Summary
The facility failed to ensure Resident #11’s assessment accurately reflected her status by omitting her BiPAP therapy from the MDS. Resident #11 was a female resident admitted with diagnoses including ALS and malaise. Her completed MDS dated 6/02/2026 listed a BIMS of 12 and described her as needing supervision or touch assistance for some ADLs, but it did not identify her as using any non-invasive mechanical ventilator, including BiPAP therapy. Record review showed Resident #11 had a respiratory therapy assessment indicating CPAP or BiPAP therapy, with BiPAP to be used at night, and the note was signed by the ADON. During observation on 07/14/2026, a BiPAP machine was seen on her bedside dresser, and the resident reported through her iPad that she had been using BiPAP therapy for a couple of months. The ADON later confirmed the resident had used BiPAP since admission and used it every night, and staff interviews also confirmed she wore BiPAP at night. Additional record review found no BiPAP order on the active order summary and no care plan addressing the therapy until after the issue was identified. The MDS/LVN stated that if BiPAP was not on the MAR or in the orders, it would not be included on the MDS assessment, and she confirmed it was not included. The DON stated the therapy had been missed because of confusion related to the resident privately paying for it, and the MDS/LVN reported the facility followed the RAI manual for completion of the MDS.
Care Plans Did Not Reflect BiPAP Therapy or DNR Status
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #11 that addressed BiPAP therapy. Resident #11 was admitted with diagnoses including ALS and malaise, had a BIMS score of 12, and required supervision/touch assistance for some ADLs. Although a BiPAP machine was observed in her room and the respiratory therapy assessment documented BiPAP use at night, her care plan and MDS did not include BiPAP therapy, and the order summary contained no BiPAP order at the time of review. Staff interviews confirmed that Resident #11 used BiPAP nightly and that the therapy should have been addressed in the chart, but it had not been included in the resident’s records until later noted by the DON. The facility also failed to ensure Resident #43’s care plan reflected her DNR status. Resident #43 was admitted with a BIMS score of 7, indicating severely impaired cognition, and her admission record identified her as DNR in the advance directive section. However, her care plan listed her as Full Code and included interventions for CPR, EMS notification, and counseling related to that code status. The record also contained an OOH-DNR signed by the physician, showing a DNR order was present in the chart. Interviews with nursing and management staff showed awareness that code status needed to be accurate throughout the EHR and that inaccurate documentation could affect whether a resident’s wishes were honored. The DON, ADON, and MDS staff discussed responsibility for maintaining accurate advance directive information, while the facility policy stated that the completed OOH DNR form should be scanned into PCC and that a physician order for DNR should be entered so the resident’s code status would be displayed in the chart, EMAR, and POC. Despite this, Resident #43’s care plan remained inconsistent with her documented DNR status.
BiPAP Therapy Not Addressed in Resident Records
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with ALS by not addressing her BiPAP therapy in the physician orders and related records. Resident #11 was a [AGE]-year-old female admitted with ALS and malaise, and her MDS completed 6/02/2026 listed a BIMS of 12, indicating moderate cognitive impairment. Record review showed no BiPAP therapy listed on the MDS, no care plan addressing BiPAP therapy, and no active physician orders for BiPAP therapy on the Order Summary Report as of 7/14/2026. During observation on 07/14/2026, a BiPAP machine was seen on the resident’s bedside dresser, and the resident indicated she had been using BiPAP therapy for a couple of months. Staff interviews confirmed she used BiPAP at night, but the therapy had not been addressed in the chart at the time of the review. The ADON acknowledged the BiPAP therapy was missed because of confusion related to the resident privately paying for the therapy, and the MDS/LVN stated that without orders the therapy would not be included on the MDS assessment or care plans and nursing staff would not know what to provide.
Menu Substitution for Pureed Diets
Penalty
Summary
The facility failed to ensure that the posted lunch menu was followed for 3 residents who received pureed diets. The menu for the lunch meal on 07/14/26 listed fried chicken as the entree for both the regular and pureed diets, but the pureed meals were prepared with chicken strips instead. The report states that the facility’s policy required pureed foods to be blended following the regular diet for the day and that menus were to be prepared as written using standardized recipes. Resident #2 was an older female with diagnoses including acute and chronic respiratory failure, mild protein-calorie malnutrition, mild intellectual disabilities, unspecified dementia, and GERD. Her MDS reflected severe cognitive impairment and a mechanically altered pureed diet, and her care plan and physician orders confirmed she remained on a pureed texture. Resident #9 was an older female with dementia, unspecified protein-calorie malnutrition, and dehydration; her MDS reflected she could not complete the cognitive interview and that she was ordered a mechanically altered pureed diet, with physician orders also reflecting a pureed texture. Resident #31 was an older male with CKD, dementia, and GERD; his MDS reflected moderately impaired cognition and a mechanically altered pureed diet, and his physician orders also reflected a pureed diet. During observation, fried chicken was seen being removed from the fryer for the noon meal, while a cook was observed placing chicken strips into a mixer to prepare the pureed meals. The cook stated she chose chicken strips because she did not want to debone the fried chicken, and the DM stated the night shift had failed to thaw the boneless chicken intended for the pureed meals, so chicken strips were used instead. Resident #9 was observed receiving a pureed meal with chicken strips, and RN G stated the pureed chicken tasted different from the fried chicken served on the regular menu. Resident #31 stated he saw other residents eating fried chicken while his meal did not taste like fried chicken and that it bothered him that he did not receive the same meal as the other residents. The DM later stated the planned menu for both regular and pureed diets was fried chicken, but chicken strips were substituted because the boneless chicken had not been thawed.
Inaccurate EHR Orders for Secure Unit Placement
Penalty
Summary
The facility failed to maintain accurate medical records for one resident by leaving active orders and care plan interventions in the EHR indicating that the resident should reside on the secure unit, even though the resident was observed living on a regular hall. The resident was an elderly female admitted with diagnoses including severe dementia with psychotic disturbance, and her quarterly MDS showed severely impaired cognition. Her care plan identified her as at risk for wandering and stated she would reside in the secure unit, with the focus area and interventions having been initiated previously. Record review showed an active order directing admission to the secure unit due to a history of elopement and active exit-seeking behavior. During observation, the resident was seen sleeping in her bedroom on 300 hall, which was not the secure hall. The resident’s emergency contact stated she no longer resided on the locked hall because she was no longer as mobile or exit seeking as before. Staff interviews confirmed the EHR still contained the secure-unit order, and the DON stated she should have removed the order because the resident was no longer on the locked unit.
Significant Insulin Administration Error Due to Failure to Verify Medication Type
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a nurse administered the wrong type of insulin. The resident was an older female with multiple diagnoses, including Type 2 diabetes, dementia, Parkinson’s disease, pancreatic disease, malnutrition, hypothyroidism, hypertension, and atherosclerotic heart disease. Her MDS showed she was cognitively interviewable and independent with ADLs. Her care plan for diabetes included administration of diabetes medications as ordered and monitoring for side effects and effectiveness. Physician orders specified two long-acting insulin glargine (Lantus) regimens—one pen injector dose in the evening and one vial dose in the morning—and a short-acting insulin aspart (Flasp) pen on a sliding scale three times daily. On the day of the incident, the LVN assigned to the resident went to the medication cart after already taking the resident’s vital signs. The resident typically received insulin via a pen and preferred it at a certain time. The LVN reported that she was looking for two insulin pens for the resident, as she had seen two pens previously, but on this occasion found only one pen in the cart. She then located a vial of insulin, which she believed to be the long-acting insulin needed at that time. Instead of using facility-provided drug reference materials or consulting the DON, ADON, or a more experienced nurse, she used an external AI tool (ChatGPT) to verify the insulin type and admitted she did not read the full response. Based on this incomplete external check, she proceeded to administer the insulin. After administering the insulin, the LVN went on to give insulin to another resident and then realized that the insulin she had given the first resident was actually the short-acting insulin, not the long-acting insulin ordered for that time. This error resulted in the resident receiving 45 units of short-acting insulin instead of the prescribed long-acting insulin. The LVN then checked the resident’s blood glucose, which was 200, and rechecked it 10 minutes later, finding it at 145. The resident recalled receiving insulin via a regular syringe instead of her usual pen and later learned she had received the wrong insulin. The facility’s written policy required staff to familiarize themselves with medications using facility drug references, to verify the type of insulin and dosage, and to read the label three times and check it against the MAR and the order, as well as to follow the five rights of medication administration. The events described show that these established procedures were not followed, leading to a significant medication error and the resident’s transfer to the hospital for observation after an insulin overdose. The nurse practitioner reported being informed that the nurse was out of long-acting insulin and had used an internet search to determine if another insulin was equivalent, then administered 45 units of short-acting insulin in error. The NP emphasized that this was a very serious situation and stated that a nurse should not use internet searches to make nursing judgments but should instead consult the DON or ADON. The NP indicated that the resident’s blood sugars remained within a normal range for her and did not drop below 120. The resident expressed discomfort with new or PRN nurses and stated she trusted the older nurses who had been at the facility longer, and she was glad that someone was following up on the incident because she believed it should never have happened.
Failure to Timely Update Comprehensive Care Plan After Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment for one resident. Record review showed that the resident, a male with diagnoses including severe dementia with mood disturbances, major depressive disorder, type 2 diabetes mellitus, hypertension, and generalized anxiety disorder, had an annual MDS assessment completed, but the care plan was not updated or revised within the required timeframe. The care plan on file had a start and completion date prior to the most recent MDS assessment, and there was no evidence of an update following the assessment. Interviews with facility staff confirmed that it was the responsibility of the MDS LVN to ensure care plans were timed correctly with MDS assessments, and that failure to update the care plan could result in the resident not receiving appropriate care. The DON also acknowledged that the care plan should have been updated within 7 days of the MDS completion and that not doing so leads to inaccurate care plans. Facility policy requires that comprehensive care plans be developed within 7 days after completion of the comprehensive assessment and be reviewed and revised after each MDS assessment.
Failure to Honor Resident Rights
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. The report identifies a deficiency related to the lack of respect for resident rights, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No information is given regarding the residents involved, their medical history, or their condition at the time of the deficiency.
Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of her prescribed medication, specifically Tylenol #3 tablets. The resident, an older female with a history of malignant neoplasm of the breast, polyneuropathy, osteoarthritis, gout, and restless leg syndrome, was prescribed Tylenol #3 for pain management. Her medication administration record indicated an order for one tablet every six hours as needed for pain, with a recent fill of 30 tablets. Upon review, it was found that 10 tablets were unaccounted for, and both the narcotic count sheet and the medication blister pack/card were missing, making it impossible to verify the exact circumstances of the loss. The incident was discovered after a nurse received a call from Hospice to verify the narcotic count, which revealed a discrepancy in the number of pills remaining. The nurse confirmed that she had previously reported a count of 13 pills, but subsequent checks indicated that 10 pills were missing. The DON confirmed that, according to the medication administration record, only 20 pills had been administered, leaving 10 unaccounted for. The missing documentation and medication raised concerns about the potential diversion or misappropriation of the resident's medication. At the time of the incident, the resident reported no issues with her medications and did not appear to have missed any doses, as the facility was able to provide the necessary medication from an emergency kit until a refill was obtained. However, the lack of proper documentation and the disappearance of both the medication and the narcotic count sheet constituted a failure to ensure the resident's right to be free from misappropriation of property.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from emotional and potential physical abuse by another resident. The incident began when the resident, who had dementia and was residing in a secure unit due to a high risk of elopement, was emotionally abused by another resident. This resident, who also had dementia and was admitted to the facility with a history of anxiety and potential for physical behaviors, was seen entering the female resident's room, waking her, and touching her inappropriately. The female resident was visibly distressed, crying, and attempting to escape the situation. Despite the incident being witnessed by staff, it was not reported as potential abuse. The staff removed the female resident from the secure unit for her safety and attempted to manage the male resident's behavior with medication adjustments. However, the incident was not communicated to the facility administrator or reported as abuse, which is a requirement under the facility's policy. The male resident continued to exhibit inappropriate behavior, including kissing the female resident on the forehead, which was later reported and led to his discharge to a psychiatric hospital. The deficiency was identified as past non-compliance, as the facility corrected the issue before the investigation began. However, the failure to report the initial incident and protect the resident from further emotional abuse highlights a significant lapse in the facility's duty to safeguard its residents from abuse and neglect. The staff's inaction and miscommunication contributed to the deficiency, as they did not follow the established protocols for reporting and addressing potential abuse.
Failure to Report and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified during a review of an incident involving two residents. Resident #1, a female with dementia and other mental health conditions, was reportedly subjected to emotional and possible physical abuse by Resident #2, a male with dementia and other diagnoses. The incident occurred when Resident #2 entered Resident #1's room, touched her inappropriately, and attempted to take control of her wheelchair, causing her distress. The facility's staff, including nurses and CNAs, witnessed the incident but failed to report it as potential abuse according to the facility's Abuse/Neglect policy. Despite being trained to recognize and report abuse, the staff did not inform the administrator or take immediate action to protect Resident #1. The incident was not documented in Resident #1's progress notes for the day it occurred, and the facility did not initiate a self-report protocol until a later incident involving the same residents was observed. Interviews with staff revealed confusion and miscommunication regarding the incident, with some staff members believing Resident #2's actions were protective rather than abusive. The DON and ADM acknowledged that the incident should have been reported as possible abuse, especially considering the distress exhibited by Resident #1. The facility's failure to report and address the incident in a timely manner placed residents at risk of continued and unrecognized abuse or neglect.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of emotional and possible physical abuse involving two residents in a timely manner, as required by regulations. The incident occurred when one resident, who had a history of behaviors and was residing in a secure unit due to dementia and risk of elopement, was seen entering another resident's room, waking her up, and touching her inappropriately. This led to the female resident panicking and trying to get away, resulting in a situation where the male resident was grabbing the handles of her wheelchair and dragging her back. Despite the distress exhibited by the female resident, the incident was not reported to the administrator or the state survey agency as potential abuse. The female resident involved in the incident had a medical history that included dementia, major depressive disorder, and a psychotic disorder with hallucinations. She was residing in a secure unit due to her diagnosis and risk for elopement. The male resident, who was involved in the incident, also had dementia and was noted to have potential for physical behaviors. He was later discharged to a behavioral health hospital. The facility's staff, including the DON and ADON, did not report the incident as potential abuse, citing the female resident's dementia as a reason for not considering the situation as abuse. Interviews with staff revealed that the female resident was visibly distressed during the incident, crying and trying to avoid the male resident's advances. Despite this, the incident was not reported as potential abuse, and the facility's administrator was not informed until later. The facility's policy on abuse and neglect requires that any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse must report it to the appropriate authorities, which was not done in this case.
Failure to Provide Written Grievance Resolution
Penalty
Summary
The facility failed to ensure that efforts were made to resolve resident grievances effectively, as evidenced by the case of a resident who did not receive a written decision after filing a grievance. The resident, a cognitively intact male with a history of cellulitis, diabetes mellitus, chronic kidney disease, and an acquired absence of the left leg below the knee, had a grievance filed on his behalf concerning food preferences and call light response times. Although the facility's administrator verbally informed the resident of the grievance outcome, there was no documentation of a written notification provided to either the resident or his representative. Interviews with the resident, his family representative, and facility staff revealed a lack of communication and documentation regarding the grievance process. The resident's family representative expressed that she did not receive any outcome of the grievance and was denied access to the resolution details. Facility staff, including the administrator, DON, and SW, acknowledged the absence of written notification and recognized potential negative outcomes, such as residents feeling unheard or forgetting the grievance resolution. The facility's grievance policy mandates that the grievance official, typically the administrator, issue written decisions, which was not adhered to in this instance.
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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.
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Nursing homes near Borger
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Borger | 0.7 mi | ★★★★★ | 0 | 0 |
| Avir At Pampa | 24.8 mi | ★★★★★ | 12 | 0 |
| Pampa Nursing Center | 24.8 mi | ★★★★★ | 4 | 0 |
| Great Plains Nursing And Rehabilitation | 34.4 mi | ★★★★★ | 0 | 0 |
| Memorial Nursing And Rehabilitation Center | 35 mi | ★★★★★ | 0 | 0 |
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