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 Hughes Springs during CMS and state inspections, most recent first.
The facility failed to maintain a safe, clean, and homelike environment by allowing ongoing roof leaks and damaged ceiling tiles in resident rooms, the dining room, and common areas. Surveyors observed bulging, stained, and loose tiles, visible insulation, and a stained light fixture in the dining area, as well as stained and missing tiles in multiple resident rooms, with one opening exposing the roof and at least one tile appearing damp. Several residents reported recent episodes of water dripping from the ceiling into their rooms and in front of the ice machine, and a family member described trash cans being used to catch leaking water and tiles falling in a high-traffic area. The former maintenance supervisor and other staff stated that the roof had been a long-standing problem, with repeated patching, structural concerns above the ice machine, soaked insulation, and ceiling tiles falling during storms, while administrative staff acknowledged intermittent leaks and recognized that such conditions could negatively affect residents’ sense of dignity and homelike surroundings.
The facility failed to create comprehensive care plans for three residents, neglecting to address specific needs such as depression, aggression, wound care, and dietary requirements. This oversight involved a resident with depression and aggressive behavior, another with multiple wounds lacking enhanced barrier precautions, and a third with severe cognitive impairment and dietary needs. The absence of detailed care plans could lead to inadequate care and increased risks for the residents.
The facility failed to provide palatable and appetizing food, serving burnt dinner rolls to residents during a lunch meal. The Dietary Manager noticed the rolls were burnt but did not instruct staff to discard them or offer an alternative. Staff interviews confirmed the issue, and the facility's policy requires food to be nourishing and attractive.
A long-term care facility failed to maintain an effective infection prevention and control program, as observed in two cases. A CNA did not perform hand hygiene or change gloves appropriately while providing care to a resident, leading to potential cross-contamination. Additionally, a resident on Enhanced Barrier Precautions (EBP) did not have proper signage, and a Treatment Nurse did not wear a gown during wound care. These actions violated the facility's policies and CDC guidelines, increasing the risk of infection.
A resident in a LTC facility was denied the reheating of food brought by family due to facility policy, impacting his dignity and quality of life. The resident, who had intact cognition and required assistance for ADLs, canceled his supper tray expecting to eat the reheated food. The CNA, following dietary and nursing staff instructions, informed the resident of the policy after the fact, leaving him without a meal and upset. Staff interviews confirmed the policy against reheating outside food due to safety concerns, acknowledging the resident's right to have his preferences respected.
A facility failed to ensure proper infection control practices during incontinent and urinary catheter care for a resident with severe cognitive impairment and multiple medical conditions. A CNA did not perform hand hygiene or change gloves appropriately, leading to potential cross-contamination. Staff interviews confirmed the CNA's actions violated infection control policies, increasing the risk of infections for the resident.
The facility failed to ensure proper labeling and storage of medications, resulting in expired drugs being found in the medication storage room. Staff interviews revealed no designated person or schedule for checking expiration dates, leading to the presence of expired Zinc Tablets, Acetaminophen Suppositories, and Bisacodyl Suppositories. This oversight could result in the administration of ineffective medications to residents.
The facility failed to prevent resident-to-resident altercations, resulting in physical aggression between residents. In one incident, two residents engaged in a physical altercation over an ashtray, while in another, a resident slapped his roommate over a dispute about clothing. Both incidents were witnessed by staff, but the facility did not prevent the altercations, highlighting a deficiency in protecting residents from abuse.
The facility failed to maintain the kitchen ceiling in good repair, with observations of stained and damaged ceiling tiles above food preparation areas. Staff confirmed the issue had persisted for months, posing a risk of food contamination.
The facility failed to treat several residents with dignity and respect, including forcing a resident to use a bedside commode, removing food from a resident's plate without permission, not providing knives for cutting meat, and standing over a resident while feeding her. These actions led to significant discomfort and embarrassment for the residents.
The facility failed to provide a safe, clean, and homelike environment for four residents. Three residents had brown water stains on their bedroom ceiling tiles, causing anxiety and discomfort. Another resident was required to use a bedside commode despite having a functional bathroom commode, leading to embarrassment and a lack of privacy. The maintenance director and staff were aware of these issues but did not address them in a timely manner.
The facility failed to document vital signs and access site assessments for a resident after dialysis, leading to potential risks of missed complications and inadequate care. Interviews and record reviews revealed inconsistencies in post-dialysis assessment protocols and documentation.
The facility failed to ensure proper behavior monitoring for four residents prescribed psychotropic medications, including Zoloft, Lexapro, Ativan, Buspirone, Depakote, and Sertraline. This lack of monitoring could prevent the residents from receiving the intended therapeutic benefits of their medications.
The facility failed to secure a medication cart properly, leaving two insulin pens unsupervised and the cart unlocked. Staff interviews confirmed the cart contained various medications, including narcotics, and emphasized the importance of locking it to prevent unauthorized access.
A resident's MDS assessment inaccurately coded Cilostazol, an antiplatelet medication, as an anticoagulant. The MDS Coordinator admitted to the error, and interviews revealed a lack of consistent auditing processes to ensure assessment accuracy, potentially affecting resident care and facility funding.
The facility failed to ensure accurate PASRR screening for a resident with mental health disorders, leading to the risk of the resident not receiving needed assessments and specialized services. The MDS Coordinator did not verify the accuracy of the PASRR Level 1 assessment, which incorrectly stated that the resident had no mental illness despite a diagnosis of bipolar disorder.
The facility failed to update the comprehensive care plans for two residents to reflect their current medical needs and physician orders. One resident's care plan did not include the current blood thinner medication, while another resident's care plan did not reflect his dietary needs and fluid restrictions. The MDS Coordinator, social service representative, and DON acknowledged lapses in the process of updating care plans after meetings.
A facility failed to ensure proper infection control during wound care for a resident with a chronic venous ulcer. The Wound Care Nurse did not use hand gel or wash hands after removing gloves multiple times, despite handling soiled dressings. This breach in protocol was confirmed by both the WCN and the Director of Nursing, posing a risk of infection to the resident.
Ongoing Roof Leaks and Damaged Ceilings Undermine Safe, Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment, specifically related to an ongoing leaking roof and damaged ceiling tiles in resident rooms, the dining room, and common areas. Surveyors observed multiple bulging, stained, and loose ceiling tiles in the dining room, including two bulging tiles with large brown, apparently damp stains in the far back corner above a metal cabinet, additional stained tiles in the main dining area, and a light fixture with a brown stain inside the fixture. Near the nurse’s station and in front of the ice machine leading into the dining room, several ceiling tiles had brown stains and rings of various sizes, and one tile in the hallway was loose with visible insulation. These conditions were directly observed during the survey and were associated with water intrusion from the roof. In resident rooms, surveyors observed stained, missing, and previously leaking ceiling tiles. In one shared room, a resident reported that about three weeks earlier the ceiling along the outside wall had leaked, with multiple tiles damaged and water visibly dripping into the room; some tiles had been replaced, but one tile above the roommate’s bed remained with a large brown stain covering most of the tile. Another resident stated that the roof leaked in front of the ice machine and that water sometimes dripped into his room from the ceiling; his room contained two tiles with small brown stains near the head of his bed. A third resident in the same shared room confirmed that the corner of the ceiling near the head of her bed had leaked about three weeks earlier, with water dripping into the room and leaving more than half of one tile stained brown. In another room, two ceiling tiles were missing in one corner along the outside wall, exposing the roof, and one remaining tile was stained; in yet another room, two tiles had large faint stains, with one appearing still damp. Staff, residents, and a family member described a long-standing roof problem and repeated episodes of leaking, particularly in front of the ice machine and in the dining room. The former Maintenance Supervisor, who had worked at the facility for three years, stated that the roof had been an ongoing issue, that he had repeatedly patched it with a flexible tar-like substance, and that there was a structural issue above the ice machine where iron beams were rusting through. He reported that residents on one hall, especially in one specific room, had to be moved due to leaks, that insulation in the dining room ceiling became soaked and dripped for days, and that tiles in the area leading into the dining room would fall because the roof could not be properly repaired. A housekeeper and a CNA both reported that tiles had fallen in the dining room and in front of the ice machine, that trash cans and floor blankets were used to catch and manage leaking water, and that the roof had been leaking for years. Administrative staff, including the MDS Coordinator, ADON, DON, and Administrator, acknowledged that the roof had leaked at times, that tiles had fallen or been replaced after storms, and that stained, missing, and leaking tiles could negatively affect residents’ feelings, mood, and perception of their home environment. The facility’s own policies on resident rights and homelike environment required a safe, clean, sanitary, and dignified environment, which contrasted with the observed and reported conditions.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #29, who had a history of depression and aggressive behavior, did not have a care plan that addressed his aggression towards his roommate or interventions for his depression. Despite being aware of his depression and recent aggressive incidents, the facility did not have a trauma-informed care assessment or a comprehensive plan to manage his mental health needs. Resident #41, who had multiple wounds and was at risk for pressure ulcers, did not have a care plan that included enhanced barrier precautions or interventions for his skin concerns. The facility's staff, including the MDS nurse and RN, acknowledged that the care plan was incomplete and that the necessary precautions were not documented. This lack of documentation and planning could lead to inadequate care and increased risk of infection for the resident. Resident #8, who had severe cognitive impairment, anxiety, depression, and anorexia, did not have a care plan that addressed her DNR code status, diet, or use of a plate guard. The MDS Coordinator admitted to missing these care areas when creating new care plans after a software change. The absence of a comprehensive care plan for Resident #8 meant that her specific needs and interventions were not clearly outlined, potentially impacting her quality of care.
Facility Serves Burnt Rolls to Residents
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for all residents in a confidential group meeting and during a lunch meal review. On April 1, 2025, ten anonymous residents reported being served hard, burnt dinner rolls at the noon lunch meal. The Dietary Manager acknowledged that the rolls were burnt and had been served despite noticing their condition before service. The manager admitted that burnt bread had been served previously due to an unevenly cooking oven, and no alternative was provided to the residents. Interviews with staff, including CNAs and the Director of Nursing, confirmed the issue of burnt rolls being served, with some residents only eating the top portion of the bread. The Dietary Manager and the Administrator both recognized the importance of serving palatable food and acknowledged the failure to provide an alternative to the burnt rolls. The facility's Food and Nutrition Services policy, revised in October 2017, mandates that each resident is provided with a nourishing, palatable, well-balanced diet, and that food trays are inspected to ensure the food appears palatable and attractive.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. One significant issue involved a CNA who did not perform hand hygiene or change gloves appropriately while providing incontinent and urinary catheter care to a resident. The CNA handled various items in the resident's room, including the bed, bedding, and urinary catheter bag, without changing gloves or sanitizing hands after cleaning feces from the resident. This lack of proper infection control practices was acknowledged by the CNA, who admitted to being nervous, and was confirmed by other staff members who recognized the potential for cross-contamination and increased infection risk. Another deficiency was observed with a different resident who was on Enhanced Barrier Precautions (EBP) due to open wounds. The facility failed to display appropriate signage indicating the need for EBP and the use of personal protective equipment (PPE) outside the resident's room. Additionally, a Treatment Nurse did not wear a gown while performing wound care on this resident, contrary to the facility's policy and CDC guidelines. Interviews with staff revealed a lack of clarity and adherence to the EBP protocols, which could lead to cross-contamination and infection. The facility's policies on infection prevention, hand hygiene, and perineal care were not followed, as evidenced by the actions of the staff. The report highlights the failure to implement proper infection control measures, such as changing gloves and performing hand hygiene when moving from contaminated to clean areas, and ensuring the use of PPE during high-contact care activities. These deficiencies were acknowledged by various staff members, including the DON and Interim Administrator, who recognized the potential for increased infection risk due to these lapses in protocol.
Resident's Food Reheating Request Denied, Affecting Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity by denying his request to have food brought by his family reheated. The resident, who had intact cognition and required assistance for most activities of daily living, was upset when a CNA refused to reheat his food due to facility policy. The resident had canceled his supper tray, expecting to eat the food brought by his family, and was left without a meal when the CNA informed him of the policy after the fact. The CNA explained that the dietary staff and nurse had informed her that reheating food from outside was not allowed due to infection control concerns and the inability to regulate food temperature. The resident expressed his frustration and discomfort, feeling that the CNA's actions made him feel unnecessary and uncomfortable. Despite being offered alternative snacks, the resident was upset and cried over the situation. Interviews with staff, including the RN, Social Services Assistant, Dietary Manager, DON, and Interim Administrator, confirmed the facility's policy against reheating outside food due to safety concerns. The staff acknowledged the resident's right to have his food preferences respected and recognized that not accommodating his request could negatively impact his quality of life and satisfaction. The facility's policies emphasized balancing resident choice with safety, but in this instance, the resident's preferences were not met, leading to the deficiency.
Inadequate Infection Control During Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices during the provision of incontinent and urinary catheter care for a resident with severe cognitive impairment and multiple medical conditions, including dementia, diabetes, and chronic kidney disease. The resident, who was dependent on staff for most activities of daily living, had an indwelling urinary catheter and was always incontinent of bowel. The care plan for the resident included specific interventions for catheter care and bowel incontinence management. During an observation, a CNA did not perform hand hygiene or change gloves appropriately while providing care to the resident. The CNA handled a fall mat from the floor, assisted in repositioning the resident, and performed incontinent care without changing gloves or sanitizing hands. The CNA then proceeded to provide urinary catheter care and continued to touch various surfaces and items in the resident's room without changing gloves or performing hand hygiene. Interviews with staff, including another CNA, an LVN, an RN, and the DON, confirmed that the CNA's actions were against the facility's infection control policies and procedures. The staff acknowledged that the failure to change gloves and perform hand hygiene could lead to cross-contamination and increase the risk of infections, such as urinary tract infections, for the resident. The facility's policies on perineal care, catheter care, and hand hygiene emphasize the importance of preventing infections through proper hand hygiene and glove use.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, specifically regarding expiration dates. During an observation, it was found that the medication storage room contained expired medications, including an unopened bottle of Zinc Tablets 50mg with an expiration date of March 2025, a package of Acetaminophen Suppositories 650 mg with an expiration date of December 10, 2024, and an opened box of Bisacodyl Suppositories 10mg with an expiration date of February 28, 2025. These expired medications were found in the medication storage room and refrigerator, indicating a lack of proper monitoring and management of medication expiration dates. Interviews with facility staff, including the Medication Aide (MA), Assistant Director of Nursing (ADON), Registered Nurse (RN), Director of Nursing (DON), and the Administrator, revealed that there was no designated person responsible for checking expiration dates, nor was there a set schedule for these checks. The staff acknowledged that expired medications should not be stored in the facility as they could be mistakenly administered to residents, potentially leading to reduced therapeutic effects. The facility's policy indicated that nursing staff were responsible for maintaining medication storage, but the lack of a systematic approach to checking expiration dates contributed to the presence of expired medications in the storage room.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving four residents. Resident #1 and Resident #2 were involved in an altercation in the smoking area over an ashtray, which escalated to both residents slapping each other. Despite the presence of a staff member, the altercation was not prevented, and both residents engaged in physical aggression. The incident was witnessed by a laundry aide, who reported that neither resident sustained visible injuries, although Resident #1 had bruising on her arm from being grabbed by Resident #2. In another incident, Resident #4 and Resident #5, who were roommates, were involved in a physical altercation. Resident #4 approached and slapped Resident #5 after being accused of taking his pants. This incident was witnessed by two CNAs, who intervened to separate the residents. No injuries were reported, but the altercation highlighted the facility's failure to prevent resident-to-resident aggression. The facility's records indicate that both incidents were discussed in QAPI meetings, and in-service training on resident-to-resident altercations and behavior awareness was conducted. However, the facility's inability to prevent these altercations and ensure the safety of its residents constitutes a deficiency in protecting residents from abuse.
Failure to Maintain Kitchen Ceiling in Good Repair
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. Observations revealed brown staining on approximately six ceiling tiles above the area of the tea maker machine, juice machine, and food processor. One ceiling tile had a rounded dropped appearance with loose particles hanging directly above the tea maker and food processor. Additionally, there was a gap around the fire sprinkler head and a crack in the ceiling tile near the air vent. These conditions were observed during the initial tour and subsequent observations, indicating ongoing issues with the ceiling tiles in the kitchen area. Interviews with the Dietary Manager (DM) and Maintenance Supervisor confirmed that the ceiling tiles had been in disrepair since around the beginning of the year. The Maintenance Supervisor had attempted to fix the leak by applying tar on the roof, but the problem persisted during heavy rains. The DM expressed concerns about potential cross-contamination from the particles hanging from the ceiling tiles. The Maintenance Supervisor acknowledged that the damaged ceiling tiles could lead to contamination of food and drinks. The Administrator (ADM) was aware of the issue and was waiting for a repair quote from a roofing company. The facility's policy on food safety and sanitation emphasized the importance of maintaining sanitary conditions to prevent foodborne illnesses, which was not adhered to in this case.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat several residents with respect and dignity, leading to multiple deficiencies. Resident #31 was forced to use a bedside commode instead of the working bathroom commode in her room, causing her significant discomfort and embarrassment. Despite her repeated requests to fix the bathroom commode, the facility did not take timely action, and staff were aware of her dissatisfaction with the situation. The maintenance supervisor confirmed that the bathroom commode was functional but was not being used due to previous plumbing issues caused by the resident flushing wipes. The facility did not provide a specific timeframe for resolving the issue, and the resident continued to feel uncomfortable and undignified using the bedside commode. Resident #18 experienced a lack of respect during a meal when the DON removed an egg roll from her plate without asking for her permission or explaining the reason beforehand. The resident felt humiliated and likened the experience to having food taken away from a dog. Staff interviews revealed that proper protocol was not followed, as they should have explained the situation to the resident before removing the food item. The DON claimed to have explained the situation and offered a substitute, but the resident's account and staff interviews indicated otherwise. Residents #38 and #33 were not provided with knives to cut their meat during meals, leading to frustration and difficulty eating. Both residents expressed their dissatisfaction with the plastic utensils provided and the lack of assistance in cutting their meat. Staff interviews confirmed that the kitchen did not routinely provide knives, and it was up to the staff to assist residents with cutting their food. Additionally, Resident #30 was fed by a CNA who stood over her instead of sitting at eye level, which could have made the resident feel rushed and uncomfortable. The ADON and ADM confirmed that staff were expected to sit while assisting residents with meals to ensure their dignity and comfort.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment for four residents. Resident #1, Resident #29, and Resident #41 had brown water stains on their bedroom ceiling tiles. Resident #1's room had three ceiling tiles with brown water stains above his bed and one near the closet, with buckets placed underneath. Resident #41's room had three slightly bowing ceiling tiles with brown water stains near the window and two above the head of his bed. Resident #29's room had an 18-to-20-inch semicircular brown water stain on the ceiling. The maintenance supervisor acknowledged the issue but had not addressed it, and the DON and ADM were unaware of the problem. Resident #29 expressed anxiety about the potential for black mold due to the water stains and reported the issue to maintenance weeks prior without resolution. Resident #31 was not allowed to use the working commode in her room and was instead required to use a bedside commode. This situation arose because Resident #31 had a history of flushing excessive toilet paper and wipes, causing plumbing issues. Despite the bathroom commode being fixed, the facility continued to restrict its use, citing concerns about the septic system. Resident #31 expressed discomfort and embarrassment about using the bedside commode, feeling it lacked privacy. The maintenance director confirmed the bathroom commode was functional but had not been reinstated for Resident #31's use. The DON and ADM were aware of the situation but had not provided a clear plan for resolving it. Interviews with staff, including CNAs and the maintenance director, revealed that the bedside commode was intended as a temporary measure, but no specific timeframe for its removal was established. The ADM mentioned plans to involve occupational therapy to address Resident #31's compulsive behavior with toilet paper, but no immediate actions were taken. The facility did not have a policy related to maintaining a safe, comfortable, and homelike environment, contributing to the ongoing issues experienced by the residents.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure dialysis services were provided consistently with professional standards of practice for a resident who required such services. Specifically, the facility did not document vital signs and an assessment of the access site after the resident returned from dialysis. This failure was identified through interviews and record reviews, which revealed that the necessary post-dialysis assessments were not performed or documented for the resident, who had end-stage renal disease and required regular dialysis treatments. The resident's care plan indicated that the resident had dialysis related to renal failure and required monitoring of the access site every shift. However, the facility's dialysis communication form did not include sections for post-dialysis vital signs and access site assessments. Record reviews showed that the resident's dialysis communication forms and progress notes lacked documentation of post-dialysis assessments, and the resident confirmed that nursing staff did not check his blood pressure or pulse after dialysis sessions. Interviews with nursing staff and the Director of Nursing (DON) revealed inconsistencies in the understanding and implementation of post-dialysis assessment protocols. The RN stated that post-dialysis assessments were important to monitor for complications, but the facility did not have clear guidelines on where to document these assessments. The DON acknowledged the importance of post-dialysis assessments but was unsure if nursing staff were required to check vital signs after dialysis. This lack of clear guidelines and documentation could lead to missed complications and inadequate care for residents receiving dialysis.
Failure to Monitor Behavior for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic drugs due to inadequate behavior monitoring. Specifically, four residents were affected: Resident #2, Resident #11, Resident #16, and Resident #41. These residents were prescribed various psychotropic medications, including Zoloft, Lexapro, Ativan, Buspirone, Depakote, and Sertraline, without proper behavior monitoring to assess the effectiveness and necessity of these medications. This lack of monitoring could prevent the residents from receiving the intended therapeutic benefits of their medications. Resident #2, a male with diagnoses including bipolar disorder, dementia, and recurrent depressive disorders, was prescribed Zoloft. Despite the care plan indicating the need for behavior monitoring, no such monitoring was documented. Similarly, Resident #11, a male with a history of recurrent depressive disorders, was prescribed Lexapro without documented behavior monitoring, even though his care plan required it. Both residents had no orders for behavior monitoring noted in their consolidated physician orders. Resident #16, a male with diagnoses including depression, alcohol abuse, generalized anxiety disorder, and recurrent depressive disorders, was prescribed Ativan, Buspirone, and Lexapro. Despite care plans indicating the need for behavior monitoring, no such monitoring was documented. Resident #41, a male with Alzheimer's disease, dementia, and depression, was prescribed Depakote and Sertraline. His care plan required behavior monitoring, but no such monitoring was documented. Interviews with facility staff revealed a misunderstanding of the requirements for behavior monitoring, with some staff believing it was only necessary for antipsychotic and antianxiety medications. The facility's policy on medical utilization and prescribing emphasized the need for periodic re-evaluation and monitoring of conditions and symptoms for which medications are prescribed, but this was not adhered to in these cases.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured properly for one of four nurse medication carts. Specifically, LVN D left two insulin pens unsupervised on top of the nursing cart and subsequently left the cart unlocked with the keys in it while attending to a resident's blood glucose check. This incident was observed on multiple occasions, and attempts to contact LVN D for further clarification were unsuccessful. Interviews with various staff members, including a CMA, RN, LVN, DON, and the Administrator, revealed that the medication cart contained several medications, including as-needed medications, insulins, and narcotics. Staff members acknowledged the importance of locking the cart to prevent unauthorized access and potential harm to residents. However, the DON and Administrator were unable to provide specific details on the potential consequences of a resident accessing the cart. The facility's policy on medication storage, which mandates that medication carts be locked when not under direct observation, was not followed in this instance.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the status of a resident, specifically in the case of a male resident with peripheral vascular disease, acute embolism, and thrombosis. The resident's MDS assessment incorrectly coded Cilostazol, an antiplatelet medication, as an anticoagulant. This error was identified during a review of the resident's records, which showed that the resident was taking Cilostazol for acute embolism and thrombosis, but there were no current orders for other anticoagulants like Plavix or Eliquis. The MDS Coordinator admitted to marking the wrong button during the assessment and acknowledged that there was no monitoring system in place to catch such errors. Interviews with the MDS Coordinator, DON, and ADM revealed that the MDS Coordinator was responsible for the accuracy of the MDS assessments, but there was no consistent auditing process to ensure accuracy. The DON and ADM both emphasized the importance of accurate MDS assessments for proper care and facility funding. However, the facility did not have a specific policy on the accuracy of assessments, relying instead on RAI guidelines. The lack of a robust monitoring and auditing system contributed to the inaccurate coding of the resident's medication, potentially affecting the resident's care and the facility's funding.
Failure to Ensure Accurate PASRR Screening for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to ensure that individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening. Specifically, the facility did not review Resident #2's PASRR Level 1 assessment for accuracy. Resident #2, who was diagnosed with bipolar disorder, had the mental health question answered as 'no' on the PASRR screening. This oversight could place residents at risk of not receiving needed assessments, individualized care, and specialized services to meet their needs. The resident's records indicated diagnoses of bipolar disorder, dementia, and recurrent depressive disorders, and the MDS assessment showed moderate cognitive impairment and active diagnoses of bipolar disorder and depression. Despite these indicators, the PASRR Level 1 Screening incorrectly stated that there was no evidence of mental illness. Interviews with facility staff revealed that the MDS Coordinator was responsible for PASRRs and admitted to inputting the referring entity's referral paperwork into the system without verifying its accuracy. The MDS Coordinator acknowledged awareness of Resident #2's bipolar disorder diagnosis but did not consider the resident PASRR positive due to the presence of dementia. The Director of Nursing (DON) and the Administrator (ADM) also confirmed that there was no process in place to ensure the accuracy of PASRR referrals from the referring entity until the incident with Resident #2. The ADM stated that a new process had been implemented to review referrals before submission, but this was only after the deficiency was identified. The facility did not have a PASRR policy until the date of the interview.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plans for two residents were not updated to reflect their current medical needs and physician orders. Resident #1's care plan did not include the current blood thinner medication, Cilostazol, that he was prescribed, instead listing outdated medications Plavix and Eliquis. This oversight occurred despite the resident's medical records indicating the correct medication and diagnosis for acute embolism and thrombosis of the right lower extremity. The MDS assessment also confirmed that Resident #1 had moderate cognitive impairment and was taking an anticoagulant during the assessment period, yet the care plan was not updated accordingly. The MDS Coordinator acknowledged that the care plan should have been updated to reflect the current medication orders but admitted that changes were not always made after care plan meetings. The DON and social service representative also confirmed that the care plans should be revised to accurately reflect the resident's needs but noted lapses in the process of updating care plans after meetings. Resident #11's care plan was similarly outdated and did not reflect his current dietary needs and fluid restrictions. Despite being on a mechanically altered diet with increased protein intake and a liberal fluid restriction of 1200 milliliters a day, these details were not included in his care plan. The resident's medical records and physician orders clearly indicated these dietary requirements, but the care plan was not updated to reflect them. The MDS Coordinator, social service representative, and DON all acknowledged that the care plan should have been updated to include these details. The MDS Coordinator admitted that it was her responsibility to ensure care plans were current but noted that changes were not always made after care plan meetings. The social service representative also confirmed that if she was not directly told to update a problem on a care plan during the meeting, it could get missed. The DON emphasized that care plans should be revised to accurately reflect the resident's needs and guide their care, but noted lapses in the monitoring process to ensure care plans were updated. The ADM also confirmed that care plans should be updated to reflect current physician orders and that monitoring of care plan revisions happened during IDT meetings. However, the facility's Care Area Assessment policy indicated that care plans should be individualized and updated based on clinically significant events, which was not consistently followed in these cases.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to ensure an infection prevention and control program during wound care for a resident with a chronic venous ulcer. The Wound Care Nurse (WCN) did not practice proper infection control measures by failing to use hand gel or wash hands after removing gloves multiple times during the dressing change procedure. This lapse in protocol was observed during a wound care dressing change, where the WCN removed gloves and put on new ones without sanitizing hands, despite handling soiled dressings and other materials. The resident involved was an elderly male with a history of peripheral vascular disease, acute embolism, thrombosis, and a non-pressure chronic ulcer on the right calf. The resident's care plan required daily wound treatment, and the resident was noted to have moderate cognitive impairment but was generally independent in personal hygiene and dressing. During the dressing change, the WCN acknowledged the failure to wash hands or use hand gel after glove removal, which she admitted could place the resident at risk for infection. Interviews with the WCN and the Director of Nursing (DON) confirmed the breach in infection control protocol. The WCN admitted to not using hand gel or washing hands during the procedure and recognized the potential risk of infection this posed to the resident. The DON stated that hand washing or using hand gel is necessary after removing soiled gloves to prevent the spread of contaminants, especially during procedures involving soiled dressings. Facility policies also mandated hand washing after removing contaminated gloves, which was not followed in this instance.
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 114 citations issued within 25 miles in the last 12 months — including the 5 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 Hughes Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Capstone Healthcare Of Daingerfield | 6 mi | ★★★★★ | 1 | 1 |
| Avir At Pittsburg | 14.9 mi | ★★★★★ | 13 | 0 |
| Gilmer Nursing And Rehabilitation | 19.8 mi | ★★★★★ | 27 | 0 |
| Focused Care At Linden | 19.8 mi | ★★★★★ | 10 | 1 |
| Focused Care Of Gilmer | 20.6 mi | ★★★★★ | 19 | 2 |
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