Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Capstone Healthcare Of Daingerfield during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment was sexually abused by a male visitor who was sitting beside her in the secured unit. A CNA pulled back a blanket and found the visitor’s hand inside the resident’s pants/brief; the visitor then left the building and drove away. Staff documented that the resident had no visible injury and could not recall the event due to her cognitive impairment.
The facility did not update or post daily nurse staffing information for several consecutive days, leaving outdated information visible at the nurse's station. Staff interviews indicated that the night shift nurse was responsible for this task, but it was not completed due to a temporary nurse working at night. The DON and ADON confirmed the lapse and acknowledged that the daily posting was not maintained as required by facility policy.
The facility did not conduct or document a comprehensive facility-wide assessment to determine necessary resources for competent care, resulting in frequent CNA shortages and unmet staffing levels as outlined in its own assessment. Staff and residents reported delays in care, missed showers, and inadequate assistance, with management often unable to fill staffing gaps or provide support. Time sheets confirmed that staffing levels were consistently below required numbers, directly impacting resident care.
Staff failed to maintain the privacy and confidentiality of resident medical records by leaving electronic medical records open and visible on unattended medication carts during medication administration. Both a nurse and a medication aide left sensitive information accessible to others in the hallway, in violation of facility policy and HIPAA regulations.
Surveyors found that the facility did not develop or implement complete, person-centered care plans for three residents. One resident's care plan omitted her use of a vape and smoking, despite staff awareness and her need for supervision. Another resident's care plan failed to address her use of clozapine and her PASRR-identified serious mental illness and intellectual disability. A third resident's care plan did not mention her placement in the memory care unit, even though she had dementia and related diagnoses. These omissions were confirmed by the MDS Coordinator and DON, who cited recent organizational changes as a contributing factor.
A resident with a gastrostomy tube received enteral nutrition without a physician's order specifying the type of feeding formula. Staff and administration confirmed that the order lacked this critical detail, and facility policy required such specificity. The omission was identified through observation, record review, and interviews, with staff acknowledging the risk of administering the wrong formula.
Licensed staff, including nurses and medication aides, administered antihypertensive medications to residents outside of physician-ordered blood pressure parameters, despite clear instructions to hold the medication when readings were too low. Several residents with complex medical conditions received these medications inappropriately, and interviews with staff and administration revealed that competency checks had not been completed or documented as required. Facility policies and assessments called for regular evaluation of staff competency, but these were not followed, resulting in improper medication administration.
Staff administered metoprolol to three residents even when their blood pressure readings were below physician-ordered parameters, as documented in the MAR and confirmed by interviews with nursing staff and facility leadership. This failure to follow medication hold parameters was observed on multiple occasions and involved both nurses and medication aides.
Surveyors found that drugs and biologicals were not properly labeled or secured, including instances where a resident had non-ordered medications at bedside, a lock box with controlled substances was not affixed in the medication room refrigerator, another resident's prescription cream was left unsecured, and medication carts were left unlocked and unattended by staff. These actions were contrary to facility policy and professional standards.
Surveyors found that the facility did not consistently provide meals that were palatable, attractive, or served at an appetizing temperature. Multiple residents reported dissatisfaction with the taste and temperature of the food, and surveyors confirmed that some meal items were bland and not hot. The Dietary Manager tasted foods infrequently and relied on staff to follow recipes, with limited recent training. No policy on recipe adherence was provided during the survey.
Surveyors identified failures in food labeling, dating, and discarding expired items in the kitchen and storage areas, as well as a CNA not sanitizing hands between passing meal trays. The Dietary Manager and Administrator confirmed that all food items should be properly labeled and dated, and that staff are expected to follow hand hygiene protocols, but these procedures were not consistently followed as observed and confirmed in staff interviews and policy reviews.
The facility did not ensure that required HIV and restraint training was completed for several staff members, including the Administrator, DON, ADON, and two LVNs, due to lapses in assignment and monitoring of trainings following a change in ownership. Documentation of training completion and hire dates was missing, and interviews confirmed that not all staff received the necessary education as required.
A resident with severe cognitive impairment and an indwelling catheter did not have her Foley catheter drainage bag covered as required by physician order and facility policy, resulting in the bag being visible to others on multiple occasions. Staff interviews confirmed awareness of the privacy and dignity issue, and the facility's policies emphasized the importance of keeping catheter bags covered.
A resident with left-sided hemiplegia, diabetic neuropathy, and anxiety was found in bed with her call light out of reach, requiring assistance from a surveyor to access it. Staff interviews confirmed uncertainty about why the call light was not accessible, despite facility policy requiring call lights to be within reach. The resident was cognitively intact and dependent on staff for daily activities, and the failure to provide the call light within reach was not in accordance with facility policy.
A resident with intact cognition and multiple medical conditions was not provided showers as requested, receiving bed baths instead on several occasions. Staff and administration acknowledged the resident's right to choose her bathing method, but staffing issues led to her preferences not being honored, contrary to facility policy supporting resident self-determination.
A resident with severe cognitive impairment and multiple medical conditions had a signed OOHDNR order, but the code status in the EMR and on the resident's door was not updated to reflect this change. Staff interviews revealed confusion over responsibility for updating code status, and facility policy requiring prompt documentation of advance directives was not followed, resulting in the resident's wishes not being properly recorded.
A resident with multiple medical conditions, including hemiplegia and diabetes, was found to have a broken, jagged light cover in her room that remained unrepaired for several weeks despite staff awareness and an open work order. Staff, including the Maintenance Director, LVN, DON, and Administrator, acknowledged the issue and its potential to cause injury, but the repair was not completed, resulting in a failure to maintain a safe and comfortable environment.
Two residents with chronic health conditions reported missing clothing items over several months, repeatedly raising the issue in meetings and to staff. Despite these reports, no formal grievances were filed, and the facility did not promptly investigate or resolve the complaints as required by policy.
Two residents who required assistance with ADLs did not receive scheduled showers due to inconsistent staff assignments and incomplete documentation. When the shower aide was reassigned, other aides did not consistently provide showers, resulting in missed care and residents expressing dissatisfaction with their hygiene. Facility leadership confirmed that showers were not provided as scheduled, contrary to care plans and facility policy.
A resident with a right-hand contracture did not consistently receive a prescribed splint to maintain range of motion, as required by physician orders and the care plan. Observations showed the splint was not in place, and there was no documentation of refusal, despite staff stating the resident sometimes declined due to tenderness. Nursing staff marked the MAR as completed without verifying application, and the care plan was not updated to reflect refusals, resulting in a failure to provide appropriate ROM interventions.
A resident with multiple medical conditions was found keeping a vape device at her bedside without documentation of an assessment for safe use or inclusion in her care plan. Staff interviews revealed confusion about policies regarding vape storage and use, and the facility's policy requiring assessment and documentation for e-cigarette use was not followed.
A resident with severe cognitive impairment and an indwelling foley catheter was found to have the catheter unsecured to her leg, despite care plan interventions and physician orders requiring a securement device. Staff interviews confirmed the absence of the securement and acknowledged responsibility for ensuring proper catheter care, in line with facility policy.
Two residents requiring respiratory care did not receive care consistent with professional standards: one received oxygen at a higher flow rate than prescribed, and another's nasal cannula was repeatedly found improperly stored outside of a bag, contrary to staff expectations for infection control. Staff interviews revealed inconsistent monitoring and lack of recent training on oxygen equipment use and storage.
A resident with severe cognitive impairment and a history of PTSD and anxiety did not receive a trauma assessment or have PTSD addressed in the care plan, despite facility policy and staff acknowledgment that such assessments are required on admission. Staff interviews confirmed the omission and recognized its importance for providing trauma-informed care.
A medication aide failed to document the administration of a controlled pain medication on the narcotic record immediately after giving it to a resident with multiple chronic conditions. This omission was observed during a survey, and both the DON and Administrator confirmed that facility policy requires immediate documentation to ensure accurate reconciliation of controlled substances.
A resident with multiple medical conditions, including hemiplegia and diabetes, was observed using a vape device, but her care plan did not address her tobacco use and no safe smoking evaluation was documented. Staff interviews revealed confusion about who was responsible for completing smoking assessments, and the required quarterly evaluations were not completed as outlined in facility policy.
A resident in a LTC facility exhibited escalating aggressive behaviors, including kicking and attempting to choke other residents. Despite being aware of these behaviors, the facility staff failed to implement effective measures to prevent harm, such as notifying the physician or providing one-to-one monitoring. This inaction led to an Immediate Jeopardy situation, as the facility did not ensure the safety and protection of its residents from abuse.
A resident with severe cognitive impairment and aggressive behaviors was inadequately supervised, leading to an altercation where he attempted to choke another resident. Despite multiple reports of escalating behaviors, the facility failed to implement effective interventions or notify the physician, resulting in a serious safety breach.
A resident kicked another resident's feet in a wheelchair, but the incident was not reported to the administrator or HHSC as required. The resident had a history of severe cognitive impairment and exhibited wandering and aggressive behaviors. Staff failed to complete an incident report or notify authorities, citing a change of shift. Interviews revealed a lack of consensus on whether the behaviors were escalated, and the facility's policy on reporting altercations was not followed.
Resident Exposed to Sexual Abuse by Visitor
Penalty
Summary
The facility failed to ensure a resident with vascular dementia and severe cognitive impairment was free from sexual abuse by a visitor. The resident’s record showed she required assistance with activities of daily living and had impaired cognitive functioning related to dementia. On the day of the incident, a male visitor who was there to see another resident was observed sitting on a couch next to the resident in the secured memory care unit. According to staff statements and progress notes, a CNA noticed the visitor covered by a blanket with the resident and pulled the blanket back, revealing the visitor’s hand inside the resident’s pants/brief. The CNA immediately removed the resident from the couch and confronted the visitor, who then left the unit and exited the building. Other staff reported that the visitor walked past the nurses’ station, was followed to the parking lot, and left the facility in a truck. Staff documented that the police, DON, Administrator, Medical Director, and the resident’s responsible party were notified. The resident was assessed after the incident and no bleeding, redness, or trauma was noted. She was unable to recall the visitor or the event when questioned, and staff documented no acute emotional distress at the time of assessment. The record also reflected that the resident later stated she felt safe and denied distress, while her family member confirmed she had dementia and did not remember the incident. The facility’s abuse policy stated residents are to be protected from abuse by anyone, including visitors.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information, including the current date, resident census, and actual staff hours worked at the beginning of each shift, from 04/20/2025 to 04/24/2025. During an observation, the posted staffing information was found to be outdated, displaying the date 04/19/2025. Interviews with staff revealed that the night shift nurse was responsible for updating the staffing information, but this was not completed for several days, reportedly due to a temporary nurse working at night. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both acknowledged that the daily posting was not maintained as required and that it is typically checked by the ADON. Record review confirmed that the facility's policy requires daily posting of direct care staffing numbers for every shift. Attempts to interview the night shift nurses responsible for the posting were unsuccessful. The lack of updated staffing information could affect residents, their families, and visitors by limiting access to current information about staffing levels and census, as noted in the report.
Failure to Conduct and Implement Facility-Wide Assessment for Staffing Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. This deficiency was identified through interviews and record reviews, which revealed that the facility did not ensure daily staffing needs were met according to its own facility assessment. Multiple staff members and residents reported frequent CNA shortages, especially during evening and night shifts, resulting in delayed responses to call lights, missed showers, and residents receiving bed baths instead. Staff consistently indicated that management was aware of the staffing shortages but did not consistently provide adequate coverage or assistance. Record reviews of time sheets showed that the number of CNAs working various shifts was consistently below the levels outlined in the facility's own assessment. On several occasions, only one or two CNAs were present for entire shifts when the assessment called for significantly more. Staff interviews confirmed that when CNAs called off or did not show up, their positions were often not filled, and management rarely assisted in covering these gaps. The use of agency staff was only recently implemented, and prior to that, staff were frequently told to do the best they could with the available personnel. Residents reported feeling discouraged from requesting assistance due to staff communicating the ongoing staffing shortages. Staff members expressed concerns that inadequate staffing led to residents not being toileted or changed in a timely manner, increasing the risk for issues such as skin breakdown. The facility's own policy required sufficient and competent nursing staff to meet resident needs as determined by the facility assessment, but documented evidence showed that these standards were not consistently met.
Failure to Maintain Privacy and Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records for four residents. Specifically, LVN C did not close the electronic medical records (EMR) of three residents before entering their rooms to perform blood sugar checks and administer medications. This left the residents' medical information visible and accessible to others. LVN C acknowledged responsibility for closing the EMR and recognized the importance of maintaining confidentiality, stating that leaving the records open was a HIPAA violation. Additionally, a medication aide (MA G) failed to close a resident's EMR before entering the room to administer pain medication. The medication cart, with a laptop displaying the resident's information, was left unattended in a hallway where staff and residents were passing by. MA G admitted to forgetting to lock the screen due to being in a hurry and acknowledged it was her responsibility to ensure the screen was locked when unattended. Interviews with the Director of Nursing (DON) and the Administrator confirmed that leaving resident information visible on unattended screens was a violation of confidentiality policies and HIPAA regulations. Both stated that it was the responsibility of the staff using the medication cart to keep resident information confidential and not visible to unauthorized persons. Facility policies reviewed also emphasized the importance of safeguarding resident privacy and confidentiality.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as identified through observations, interviews, and record reviews. For one resident with hemiplegia, diabetes, and anxiety disorder, the care plan did not address her use of a vape or smoking, despite documentation and staff acknowledgment that she engaged in these activities and required supervision when smoking. The MDS Coordinator confirmed awareness of the resident's smoking and vaping but stated these were not included in the care plan, which was acknowledged as an oversight. Another resident with schizoaffective disorder and mild intellectual disabilities, who was identified by the PASRR process as having serious mental illness and an intellectual disability, was receiving clozapine, an antipsychotic medication. The care plan for this resident did not specify the use of clozapine or include interventions related to its administration, nor did it address the resident's PASRR status. The DON confirmed that these aspects should have been included in the care plan and attributed the omission to a recent change in facility ownership. A third resident, diagnosed with vascular dementia, bipolar disorder, and mild cognitive impairment, resided in the memory care unit. The care plan for this resident addressed risks for wandering and elopement but did not mention the resident's placement in the memory care unit. The MDS Coordinator acknowledged that this information should have been included in the care plan and noted that recent organizational changes contributed to the oversight. Facility policy requires comprehensive, person-centered care plans to be developed and updated to reflect all identified needs and services, but this was not followed for these residents.
Failure to Specify Enteral Feeding Formula in Physician's Order
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition had a physician's order specifying the type of feeding formula to be administered. Record reviews showed that the resident, a female with cerebral palsy, epilepsy, hypertension, and a gastrostomy, had orders and care plans for tube feeding, but none of these documents indicated the specific type of enteral formula required. Observations confirmed that a specific formula (Jevity 1.5 cal) was present in the resident's room, but staff interviews revealed that, due to the lack of specificity in the order, any type of formula could potentially be administered. Nursing staff acknowledged that this omission could result in the resident receiving an incorrect formula. Further interviews with the DON and Administrator confirmed that orders for enteral nutrition should specify the exact product to be used, and that the absence of this information placed the resident at risk of receiving the wrong feeding. The facility's own policy required that enteral nutrition orders be complete, including the product name, but this was not followed in the resident's case. The deficiency was identified through observation, record review, and staff interviews.
Failure to Ensure Staff Competency in Medication Administration
Penalty
Summary
The facility failed to ensure that licensed staff, including nurses and medication aides, demonstrated the necessary competencies and skill sets required to safely administer medications according to physician orders. Specifically, three staff members were found to have administered antihypertensive medications to residents even when their blood pressure readings were outside the parameters specified in the physician's orders. Documentation on the Medication Administration Records (MARs) confirmed that medications were given despite blood pressure readings below the required thresholds, and staff interviews corroborated that these medications were administered inappropriately. Multiple residents with complex medical histories, including diagnoses such as cerebral palsy, epilepsy, hypertension, chronic obstructive pulmonary disease, and end-stage heart failure, were affected by these actions. For example, one resident with severe cognitive impairment and hypertension received metoprolol on several occasions when her blood pressure was below the ordered parameters. Similar incidents occurred with other residents who had orders for blood pressure medications to be held if their readings were too low, yet the medications were still administered by staff. Interviews with staff and administration revealed a lack of current competency checks for nurses and medication aides. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that competency checks had not been completed under the current company, and there was no accountability system in place to monitor proper medication administration. Review of facility policies and the facility assessment indicated that staff competency should be regularly evaluated and documented, but these requirements were not met, as evidenced by missing or outdated competency records.
Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically regarding the administration of metoprolol, a blood pressure medication, outside of physician-ordered parameters. For three residents reviewed, staff administered metoprolol even when blood pressure readings were below the minimum thresholds specified in the orders. For example, one resident with a history of hypertension, cerebral palsy, and epilepsy received metoprolol on three occasions when her systolic or diastolic blood pressure was below the ordered parameters. The medication administration records (MAR) confirmed that the medication was given despite these readings, and the nurse involved acknowledged the error during an interview. Another resident with chronic obstructive pulmonary disease, heart failure, and hypertension was also administered metoprolol on two occasions when her blood pressure was not within the required parameters. The MAR indicated that medication aides documented the administration of the medication despite blood pressure readings below the physician's specified limits. Similarly, a third resident with end-stage heart failure and hypertension received metoprolol on three occasions when his blood pressure was below the ordered parameters, as documented in the MAR and confirmed by staff interviews. Interviews with nursing staff and facility leadership revealed a lack of consistent monitoring and accountability regarding medication administration. Staff members were not always aware of the specific parameters for holding blood pressure medications, and facility leadership acknowledged challenges in reviewing MARs due to staffing constraints. Medication pass audits indicated previous issues with adherence to physician orders, and the facility's policy required orders to be consistent with safe and effective practices, which was not followed in these instances.
Failure to Properly Label and Secure Medications and Controlled Substances
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of drugs and biologicals. In one instance, a resident with intact cognitive function was found with bottles of Rexall, Purzee, and Melatonin on his bedside table, which had been brought in by a family member. These medications were not listed in the resident's order summary report, and staff interviews confirmed that the medications should not have been at the bedside, as this could result in the resident or others taking them inappropriately. The medications were subsequently removed by staff after the issue was identified. In another case, a lock box containing two bottles of Lorazepam, a controlled substance, was found in the medication room refrigerator but was not permanently affixed as required. The DON and Administrator both acknowledged that the lock box should have been secured to prevent removal, and that it was their responsibility to ensure compliance with this requirement. The lack of proper affixation was recognized as a failure to secure controlled substances according to facility policy and professional standards. Additional deficiencies were observed with another resident who had a prescription cream left unsecured on his nightstand over multiple observations, despite having severe cognitive impairment and a care plan indicating risk for impaired skin integrity. Furthermore, medication aides were observed leaving a medication cart unlocked and unattended, with keys attached to the narcotic drawer, while administering medications to residents. Staff interviews confirmed that medication carts should be locked and keys kept in possession when not in use, and that these lapses were contrary to facility policy and expectations.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide food that was consistently palatable, attractive, and served at a safe and appetizing temperature for at least one of three meals reviewed. Multiple residents reported dissatisfaction with the taste and temperature of the food, with specific complaints about food being cold and bland. During a group meeting, residents also noted that the food often contained too many herbs and was served cold. Direct observation and tasting by surveyors and the Dietary Manager confirmed that some meal components, such as the Spanish rice, were bland and not hot, and the churros lacked expected flavor. The Dietary Manager reported tasting foods in the kitchen only once a week and relied on staff to follow recipes by referencing the recipe book, with the last in-service on recipe adherence conducted over a month prior. The Administrator acknowledged receiving frequent food complaints and stated that test trays were ordered only a few times a month due to time constraints. There was no policy on following recipes provided during the survey, and the facility's approach to food complaints was to offer alternative meals. These actions and inactions contributed to the deficiency in providing meals that met palatability, attractiveness, and temperature standards.
Deficiencies in Food Labeling, Storage, and Hand Hygiene Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations in the kitchen and storage areas, multiple food items were found without proper labeling, preparation dates, or expiration dates. Some items, such as containers of cranberry juice, orange juice, Kool-Aid, unsweet tea, salami lunch meat, rotini pasta, and cilantro, were either missing required information or were not discarded after expiration. The Dietary Manager confirmed that all food items should be labeled and dated with receive, open, and expiration dates, and that staff had been in-serviced on these requirements. Additionally, a CNA was observed not sanitizing her hands between passing meal trays on one of the facility's halls. The CNA admitted to forgetting to sanitize her hands and stated she was aware of the requirement to do so between passing trays. The charge nurse and DON were not initially aware of the incident but confirmed that staff are expected to sanitize hands between meal tray distribution. The DON and Administrator both stated that hand hygiene is important for infection control and that in-services on hand hygiene are conducted, though neither could recall the exact timing of the last in-service for all staff. Record reviews of facility policies confirmed that all food items must be labeled, dated, and stored according to state and federal guidelines, and that hand hygiene procedures must be followed to prevent the spread of infections. The failure to follow these procedures was observed directly by surveyors and confirmed through staff interviews and record reviews.
Failure to Provide Required HIV and Restraint Training to Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for both new and existing staff members, specifically regarding HIV and restraint training. Record review revealed that five employees, including the Administrator, DON, ADON, and two LVNs, did not complete required HIV and restraint training upon hire. The employee files did not indicate that these trainings were completed, and there was also a lack of documentation for hire dates. Interviews with facility and corporate staff confirmed that not all employees had received the necessary trainings, attributing the lapse to a change of ownership and a failure to assign and monitor required trainings. Further interviews indicated that responsibility for ensuring completion of these trainings was shared between corporate HR, the facility HR manager, and supervisors. The corporate HR coordinator acknowledged that HIV and restraint training should be completed upon hire and annually, and that monitoring should occur during morning meetings. The Administrator also stated that corporate was responsible for providing information on required annual trainings, while the HR coordinator was responsible for ensuring completion. The facility's policy on required trainings was requested but not provided.
Failure to Maintain Resident Dignity by Not Covering Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure that a resident's right to dignity and privacy was maintained by not providing a privacy cover for the resident's Foley catheter drainage bag on two separate occasions. Observations showed that the catheter bag was left uncovered and visible to others, both from the resident's room and from the hallway, as the door was open. The resident, who had severe cognitive impairment and was unable to express whether the lack of privacy bothered her, had a physician's order and care plan intervention requiring the catheter bag to be covered at all times. However, the order was not reflected in the medication administration record, and staff interviews confirmed that the responsibility for ensuring the privacy cover was in place was shared among nurses and aides. Staff, including a CNA, LVN, DON, and the Administrator, acknowledged during interviews that not covering the catheter bag was a violation of the resident's privacy and dignity. The facility's dignity policy specifically prohibited practices that compromise dignity, including failing to keep urinary catheter bags covered. The facility's catheter care policy did not address privacy for catheter drainage bags. The resident involved had multiple diagnoses, including diabetes, dementia, malnutrition, and urinary retention, and was dependent on staff to uphold her rights and dignity due to her cognitive impairment.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach while the resident was in bed, as observed on 04/21/2025. The resident, a female with hemiplegia and hemiparesis affecting her left side, type 2 diabetes mellitus with diabetic neuropathy, and anxiety disorder, was found to have her call light hung over the foot of the bed, out of her reach. The resident requested assistance from the state surveyor to retrieve the call light so she could call for help with repositioning. The resident stated she did not know who placed the call light there and that it had been out of reach for too long. Her comprehensive MDS assessment indicated she was cognitively intact and dependent on staff for several activities of daily living, with functional limitations on one side of her body. Interviews with staff, including an LVN, CNA, DON, and the Administrator, revealed that staff were unsure why the call light was not within reach and acknowledged the importance of ensuring call lights are accessible to residents. The facility's policy required that each resident be provided with a means to call staff directly for assistance from their bed. The failure to ensure the call light was within reach was not in accordance with this policy and could prevent the resident from being able to request assistance when needed.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing showers as requested, instead giving bed baths on multiple occasions. The resident, a female with diagnoses including diabetes, stroke, and irritable bowel syndrome, was cognitively intact and able to communicate her preferences. Her care plan indicated a need for assistance with activities of daily living, including bathing, and specified maintaining a consistent daily routine. Documentation showed that on at least two occasions, bed baths were given instead of showers, and there was a lack of documentation for showers over a ten-day period. Interviews with the resident and staff confirmed that the resident had missed three showers in the past two weeks and that her preference for showers was known to staff. Staff reported that when the designated shower aide was reassigned, the responsibility for showers fell to the hall aide, who sometimes could not provide showers due to staffing constraints. Both the DON and the Administrator acknowledged that the resident had the right to receive showers as preferred and that her requests should have been met. The facility's policy also emphasized the right to self-determination and respect for resident preferences.
Failure to Update Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically an Out-of-Hospital Do Not Resuscitate (OOHDNR) order, was properly updated in the medical record after it was signed by the physician. The resident, a female with severe cognitive impairment and multiple diagnoses including cerebral palsy, epilepsy, hypertension, and gastrostomy status, had a face sheet indicating a full code status, despite her guardian having requested and signed a DNR that was later signed by the attending physician. The care plan noted the need to complete and update the advance directives document, but the order summary continued to reflect a full code status. Interviews with facility staff revealed a lack of clarity and follow-through regarding responsibility for updating the resident's code status. The Social Services Designee stated that after receiving a signed OOHDNR, she provided a copy to the nurses and uploaded it to the electronic medical record (EMR), but expected the nurses to update the code status. The ADON and LVN both indicated that in an emergency, they would rely on the code status displayed in the EMR or on the resident's door, and not review uploaded documents. The DON and Administrator both confirmed that the code status should have been updated immediately upon receipt of the signed OOHDNR, and acknowledged that failure to do so could result in actions contrary to the resident's wishes. Facility policy required that advance directives be honored and that copies be maintained in a readily retrievable section of the resident's medical record. The policy also specified that the DNS or designee notify the attending physician of any changes so that appropriate orders could be documented. Despite these requirements, the resident's code status remained listed as full code after the OOHDNR was signed and uploaded, resulting in a failure to honor the resident's advance directive as documented.
Failure to Repair Broken Light Cover in Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for a resident by not repairing a broken light cover in the resident's room. The broken light cover was observed to be jagged, and both the resident and multiple staff members, including the Maintenance Director, LVN, DON, and Administrator, were aware of the issue. The Maintenance Director acknowledged having a replacement part but had not yet completed the repair, and the work order for the repair had been open for several weeks. The resident, who had intact cognition and was dependent on staff for several activities of daily living, reported that staff could see the broken cover but could not recall when it broke. The resident's medical history included hemiplegia and hemiparesis following cerebrovascular disease, type 2 diabetes mellitus with diabetic neuropathy, and anxiety disorder. Staff interviews confirmed awareness of the broken light cover and its potential to cause injury, as the resident could reach and touch the jagged edge. The facility's policy on resident rights referenced a dignified existence but did not specifically address maintaining a homelike environment. The deficiency was identified through observation, interviews, and review of facility records and policies.
Failure to Promptly Address and Document Resident Grievances Regarding Missing Clothing
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for two residents who reported missing clothing items. One resident, an elderly female with chronic obstructive pulmonary disease, diabetes, and heart failure, reported missing a pair of black pants and a green sleeveless V-neck shirt. She stated that the items had been missing for several months and that she had informed a staff member, though she could not recall who. Despite her reports, the missing items were neither found nor replaced, and no grievance was filed regarding her complaint. Another resident, also an elderly female with congestive heart failure, atrial fibrillation, and muscle weakness, reported missing a pair of black pants for several months. She consistently brought up the issue during resident council and town hall meetings, and it was documented in meeting notes. Despite her repeated complaints, the missing pants were not replaced until much later, and no formal grievance was filed. Interviews with staff confirmed that the missing clothing was reported to laundry and supervisors, but there was no documentation of a grievance or timely resolution. Record reviews and staff interviews revealed that the facility's grievance policy was not followed, as grievances regarding missing clothing were not documented or investigated as required. The social services designee and other staff acknowledged that complaints about missing clothing were brought to their attention, but grievances were not always filed unless the resident expressed significant distress. The facility's policy required prompt investigation and written response to grievances, which was not observed in these cases.
Failure to Provide Scheduled Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for two residents who required help with these tasks. Both residents had care plans indicating the need for assistance with bathing and maintaining a consistent daily routine, yet records and interviews revealed missed scheduled showers. Documentation showed gaps in shower records for both residents, with several dates lacking evidence that showers were provided as scheduled. One resident, an older female with diagnoses including congestive heart failure, atrial fibrillation, and muscle weakness, required supervision or touching assistance for personal hygiene and showering. She reported not receiving a shower since her last scheduled day and expressed feeling dirty as a result. Another resident, also an older female with diabetes, stroke, and irritable bowel syndrome, required substantial to maximal assistance with showering and upper body dressing. She reported missing three showers in the past two weeks and stated that she received bed baths instead when the shower aide was reassigned. Interviews with staff revealed that when the designated shower aide was reassigned to floor duties, the responsibility for providing showers shifted to the aides on each hall. However, this transition was not consistently managed, leading to missed showers and incomplete documentation. The DON and Administrator confirmed that showers were expected to be provided according to schedule and that the charge nurse was responsible for ensuring this occurred. The facility's policy emphasized the importance of bathing for cleanliness, comfort, and skin observation, but the lack of adherence to scheduled showers resulted in the deficiency.
Failure to Apply and Document Splint Use for Resident with Contracture
Penalty
Summary
A deficiency occurred when a resident with a right-hand contracture did not receive appropriate treatment and services to maintain or improve range of motion as ordered. The resident, who had a history of cerebral infarction, right upper arm muscle wasting, and right-hand contracture, was care planned to use a right palm guard splint to minimize contracture. Physician orders required the splint to be applied daily and removed at bedtime, with cleaning of the hand. However, multiple observations over several days showed the resident without the splint in place, and there were no interventions observed for the right hand. Record reviews revealed no documentation of the resident refusing the splint, despite staff interviews indicating that the resident sometimes refused the splint due to tenderness. The care plan did not indicate any refusals, and the treatment administration record showed the splint was being documented as applied, even when it was not. Nursing staff acknowledged that refusals should be documented in the progress notes and care plan, and that the splint should not be signed off as applied unless it was actually in place. The nurse responsible admitted to marking the medication administration record as completed before verifying the splint was applied. Interviews with the DON and Administrator confirmed that the nurse was responsible for ensuring the splint was applied as ordered, documenting refusals, and notifying leadership if there were issues. The facility's policy required residents with limited range of motion to receive treatment and services to prevent further decline, and for care plans to include specific interventions. The lack of proper application and documentation of the splint represented a failure to follow these requirements for the resident with a right-hand contracture.
Failure to Assess and Supervise Resident Vape Use
Penalty
Summary
A deficiency was identified when a resident was observed keeping a vape (electronic cigarette) on her over bed table, with no documentation that she had been evaluated for safe use of the device. The resident, who had diagnoses including hemiplegia, hemiparesis, type 2 diabetes with neuropathy, and anxiety disorder, was cognitively intact but dependent on staff for several activities of daily living. Her care plan did not mention vape or smoking use, despite her being a tobacco user. Multiple staff interviews revealed inconsistent knowledge and practices regarding the storage and use of vape devices. Some staff were unsure if residents could keep vapes in their rooms, and there was confusion about whether smoking assessments applied to vape use. The Director of Nursing and Assistant Director of Nursing both indicated a lack of awareness about the resident's possession of the vape and the associated risks, while the Administrator stated that vapes should not be kept at the bedside and acknowledged responsibility for ensuring compliance. A review of facility policy indicated that residents using e-cigarettes should be assessed for their ability to safely handle the devices, receive instruction on battery safety, and have this documented in their care plan. However, there was no evidence that these steps had been taken for the resident in question. The facility's incident records did not show any vape-related incidents during the review period.
Failure to Secure Indwelling Catheter as Ordered
Penalty
Summary
A deficiency was identified when a resident with an indwelling foley catheter was observed to have the catheter unsecured to her leg, contrary to physician orders and the facility's care plan. The resident, an elderly female with diagnoses including diabetes, dementia, protein calorie malnutrition, and urine retention, had a care plan and physician order requiring the catheter to be secured with a stabilizer and checked every shift. Despite documentation indicating compliance, direct observation revealed the catheter was not secured, and both a CNA and an LVN confirmed the absence of a securement device during their checks. The LVN noted that the resident often removed the adhesive part of the securement device, but acknowledged the catheter should be properly secured to prevent trauma or bleeding. Interviews with facility staff, including the DON and Administrator, confirmed the expectation that catheters be properly secured and that it was the responsibility of the nursing team to ensure this. The facility's policy on urinary catheter care also required the use of a securement device to prevent complications. The failure to secure the catheter as required was directly observed and acknowledged by staff, representing a lapse in following established care protocols for catheter management.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required such care, as observed and documented by surveyors. For one resident, who had diagnoses including dementia, hyperlipidemia, bradycardia, and hypertension, the physician's order specified oxygen administration at 2-3 liters per minute via nasal cannula as needed for shortness of breath. However, during observation, the resident was found receiving oxygen at 4.5 liters per minute, exceeding the prescribed range. Interviews with the DON and Administrator revealed a lack of documentation regarding any resident manipulation of the oxygen concentrator and uncertainty about when staff were last in-serviced on oxygen concentrator use. Both the DON and Administrator stated that monitoring the oxygen settings was the responsibility of the charge nurses, but neither could confirm consistent oversight or recent staff training on this process. For another resident with chronic obstructive pulmonary disease, heart failure, and hypertension, the care plan and physician's orders required oxygen therapy as needed, with specific instructions to maintain oxygen saturation above 92%. During multiple observations, the resident's nasal cannula was found improperly stored—hanging from the bed rail or placed on top of the oxygen concentrator, and not kept in a bag as required for infection control. The resident confirmed that the nasal cannula was never stored in a bag, and staff interviews corroborated that the cannula should be bagged to prevent contamination. The ADON and DON both stated that all staff were responsible for ensuring proper storage, but acknowledged that this was not consistently done. The facility's policy on oxygen administration outlined procedures for safe oxygen delivery but did not address the storage of nasal cannulas. Despite this, staff interviews indicated an expectation for nasal cannulas to be stored in bags to prevent infection. The lack of adherence to physician orders for oxygen flow rates and improper storage of respiratory equipment constituted failures to follow professional standards of practice for respiratory care.
Failure to Complete Trauma Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma received trauma-informed and culturally competent care in accordance with professional standards of practice. Specifically, the resident, who had diagnoses including post-traumatic stress disorder (PTSD), anxiety disorder, and Wernicke's encephalopathy, did not have a trauma screening or assessment completed upon admission. The resident's comprehensive care plan did not address PTSD, and there was no documentation identifying possible triggers related to the resident's trauma history. Interviews with facility staff, including the Social Worker, DON, and Administrator, confirmed that the trauma assessment was not completed as required by facility policy. The Social Worker acknowledged responsibility for trauma assessments and recognized the importance of such assessments for staff awareness and care planning. The DON and Administrator also confirmed their expectations that trauma assessments be completed on admission and identified the lack of assessment as a failure to provide appropriate care for trauma survivors.
Failure to Accurately Document Controlled Substance Administration
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt and disposition of controlled drugs, specifically for one resident who was prescribed acetaminophen-codeine for pain management. On the observed date, a medication aide (MA) prepared and administered the resident's scheduled dose of acetaminophen-codeine but did not document the administration on the resident's narcotic record as required. The MA acknowledged forgetting to sign the narcotic record due to being nervous while observed by a surveyor and recognized that this omission could result in a miscount of controlled medications. The resident involved was an older adult with chronic obstructive pulmonary disease, diabetes, and heart failure, who was cognitively intact and received regular opioid medication for pain. Interviews with the Director of Nursing (DON) and the Administrator confirmed that facility policy requires immediate documentation of controlled substance administration on the narcotic record by the person administering the medication. Both stated that failure to document could cause discrepancies in the controlled drug count. Review of facility policies further indicated that controlled substances must be reconciled upon administration and that the administering nurse is responsible for recording all required details immediately after giving the medication.
Failure to Complete Required Smoking Assessments for Resident Using Vape Device
Penalty
Summary
The facility failed to follow its established smoking policy for one resident who was reviewed for smoking practices. The resident, a female with hemiplegia, hemiparesis, type 2 diabetes with neuropathy, and anxiety disorder, was observed with a vape device on multiple occasions. Her comprehensive assessment indicated intact cognition and dependence on staff for several activities of daily living, and it was documented that she used tobacco. However, her care plan did not mention vaping or smoking, and there was no record of a completed safe smoking evaluation in her electronic health record. Interviews with staff revealed confusion and inconsistency regarding responsibility for completing smoking assessments. Some staff believed the MDS nurse was responsible, while others thought social services or charge nurses handled the assessments. The DON and ADON acknowledged that quarterly smoking assessments were required by policy, but could not confirm that these had been completed for the resident in question. The ADON also stated that the smoking assessment did not apply to vaping, despite the resident's use of a vape device. The facility's smoking policy required evaluation of smoking status and safe smoking ability upon admission, quarterly, and upon significant change in condition. Despite this, the resident's records lacked documentation of a safe smoking evaluation, and staff interviews confirmed that the required assessments had not been completed as per policy. This failure to follow the established policy was observed and confirmed through record review and staff interviews.
Failure to Protect Residents from Abuse Due to Inadequate Response to Escalating Behaviors
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving two residents who were subjected to physical aggression by another resident. The incidents occurred over a period of several days, during which the aggressive resident exhibited escalating behaviors that were not adequately addressed by the facility staff. Despite being aware of the resident's potential for aggression due to dementia, the facility did not implement effective measures to prevent harm to other residents. The aggressive resident, who was severely cognitively impaired, displayed a series of behaviors including wandering, entering other residents' rooms, and physical aggression towards staff and residents. On one occasion, the resident kicked another resident's feet, and on another, the resident attempted to choke a fellow resident. These behaviors were documented in progress notes, but the facility staff failed to recognize the escalation and did not take appropriate action to mitigate the risk. Interviews with staff revealed a lack of communication and inadequate response to the escalating behaviors. The staff did not notify the physician or implement one-to-one monitoring, which could have prevented the incidents. The Director of Nursing and Assistant Director of Nursing were informed of the behaviors but did not consider them to be escalated, and the facility did not have sufficient staff to provide the necessary supervision. This inaction led to an Immediate Jeopardy situation, as the facility did not ensure the safety and protection of its residents from abuse.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent accidents and resident-to-resident altercations. This deficiency was particularly evident in the case of a male resident with severe cognitive impairment and a history of aggressive behaviors. Despite displaying increased agitation and aggressive behaviors towards other residents, the facility did not increase supervision or implement effective interventions to manage his behavior. This lack of action led to a serious incident where the resident physically attacked another resident, attempting to choke her, which was only stopped by the intervention of a CNA. The resident in question had a history of dementia and was on multiple medications for behavior management, including Diazepam, Seroquel, Trazodone, and Wellbutrin. Despite these measures, the resident exhibited wandering, physical, and verbal aggression, and was not adequately assessed for his needs in various daily activities. The facility's records indicated multiple instances of the resident's escalating behaviors, such as entering other residents' rooms, removing his pants in common areas, and physically interacting with other residents, yet these behaviors were not effectively managed or reported to the physician for further intervention. Interviews with staff revealed a lack of adequate staffing and supervision, which contributed to the incident. Staff members reported the resident's behaviors to the Director of Nursing (DON) and Assistant Director of Nursing (ADON), but no effective measures were taken to address the escalating situation. The facility's failure to provide 1:1 supervision or to notify the physician of the resident's change in condition resulted in a serious safety breach, culminating in the resident's attack on another resident. This incident highlighted the facility's inability to manage residents with challenging behaviors, placing other residents at risk of harm.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents within the required timeframe. On January 12, 2025, a resident kicked another resident's feet while he was sitting in his wheelchair. This incident was not reported to the facility administrator or the Health and Human Services Commission (HHSC) as required by the facility's policy and state law. The incident was also not documented in the facility's Incident and Accidents Report. The resident who committed the act had a history of severe cognitive impairment and exhibited wandering behavior, as well as physical and verbal behaviors towards others. Despite these behaviors, the facility did not take appropriate action to report the incident or investigate it as a potential case of resident-to-resident abuse. The staff involved, including an LVN, failed to complete an incident report or notify the appropriate authorities, citing a change of shift as a reason for the oversight. Interviews with facility staff, including the DON and ADON, revealed a lack of consensus on whether the resident's behaviors were considered escalated. The DON initially downplayed the incident, suggesting it could have been accidental, but later acknowledged it should have been reported and investigated. The facility's policy clearly states that all altercations should be reported and investigated, yet this protocol was not followed, placing residents at risk of abuse and harm.
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 98 citations issued within 25 miles in the last 12 months — including the 4 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 Daingerfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capstone Healthcare Of Hughes Springs | 6 mi | ★★★★★ | 1 | 0 |
| Avir At Pittsburg | 14.3 mi | ★★★★★ | 13 | 0 |
| Focused Care At Mount Pleasant | 18 mi | ★★★★★ | 10 | 0 |
| Pleasant Springs Healthcare Center | 18.1 mi | ★★★★★ | 13 | 1 |
| Greenhill Villas | 18.8 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.