Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Center At Zaragoza, Llc during CMS and state inspections, most recent first.
An LVN independently removed a resident’s PICC line used for IV antibiotics, despite facility policy and Texas Board of Nursing guidance that only an RN may perform PICC insertion or removal. The resident, who had multiple cardiac conditions and moderate cognitive impairment, reported that the line was removed at the facility and denied pain or complications, and surveyors observed an intact, non-infected site. Documentation and staff interviews confirmed that the LVN performed the removal alone under a provider discontinue order, while the RN, ADON, DON, and Administrator all acknowledged that PICC removal is outside LVN scope and should be done by an RN.
A nurse failed to immediately notify a physician after observing blood-tinged urine and low output in a resident with a catheter. The issue was only reported to the physician after a family member raised concerns during the next shift, resulting in a delay in care.
A CNA did not perform proper hand hygiene or change gloves as required while providing incontinence care to a resident with multiple health conditions, including a history of UTI and bacteremia. The CNA wore gloves into the room, failed to change visibly soiled gloves, and did not wash hands before or after care, contrary to facility policy and infection control standards.
Three residents with significant physical or cognitive impairments did not have their call lights within reach, despite care plans and facility policy requiring this accommodation. Observations showed call lights on the floor or out of reach, and staff confirmed the deficiency and its risks. Residents were unable to request assistance as needed, relying on staff rounds or attempting to call out for help.
Two residents with severe cognitive impairment and multiple medical conditions did not receive proper assistance with fingernail care, resulting in dirty nails with visible debris. Staff interviews confirmed that nail care was the responsibility of nursing staff and CNAs, but there was no monitoring system in place to ensure this care was provided, despite facility policy requiring regular ADL assistance.
Staff failed to properly store and dispose of topical medications, leaving ointments in clear measuring cups exposed and accessible at the bedsides of two residents. Both residents required barrier creams for skin conditions, and staff interviews confirmed that medications should have been disposed of immediately after use. The facility did not have a policy for supervising or disposing of medications after administration.
Surveyors identified failures in food storage and sanitation, including unsealed containers of rice and soup, a torn bag of carrots, improperly sealed frozen turkey patties, a dirty container of tomato sauce, and undated frozen pastries. Staff interviews confirmed these practices did not follow facility policy, which requires all food to be sealed, cleaned, and dated to prevent contamination.
A resident receiving continuous oxygen therapy did not have an oxygen sign posted outside her room, despite staff and leadership acknowledging the importance of this practice for safety and monitoring. The facility lacked a written policy requiring oxygen signs, and the deficiency was confirmed through observation and staff interviews.
A resident with multiple medical conditions did not receive Megestrol Acetate as ordered for several days, and there was no documentation or rationale for the missed doses in the medical record. Staff interviews confirmed that medication aides and nurses did not follow procedures for documenting missed medications or notifying appropriate personnel.
A facility failed to implement a comprehensive care plan for a resident, omitting focus areas for bed rail use and the reassignment of a CNA involved in an incident. The resident, with anxiety and osteoporosis, had no care plan focus on bed rails despite an injury during care. Interviews revealed care plans did not reflect the resident's needs, risking inadequate care.
A resident in a long-term care facility was not assessed for the risk of entrapment from a bed rail before its installation, leading to an incident where the resident injured her wrist. The resident, who was dependent on staff for daily activities, did not have a Bed Transfer Bar Evaluation Assessment, and her care plans lacked a focus on bed rail use. Facility staff interviews revealed no policy for conducting such assessments, potentially placing residents at risk of injury from inappropriate enablers.
Two residents experienced breaches of privacy during personal care in the facility. A staff member failed to close blinds while weighing a resident, and a CNA left a room door open, exposing another resident's private area. Both incidents were acknowledged by staff, highlighting the need for privacy during care.
A facility failed to accurately reflect a resident's use of bed rails in the MDS assessment, despite orders indicating their use for bed mobility. The resident's care plans also lacked focus on bed rail use, and interviews with the DON and MDS Coordinator revealed a lack of awareness regarding the coding and associated risks. This oversight could risk inadequate care for the resident.
A facility failed to ensure a safe environment by not following proper procedures for using a mechanical lift. A staff coordinator weighed a resident using a mechanical lift without locking the brakes and without a second staff member, contrary to facility policy. The resident, with a history of falls and various medical conditions, required a Hoyer lift with two aides for transfers. The facility's policy mandates two staff members for mechanical lift use to ensure safety.
A resident with a Foley catheter was at risk for infection due to improper catheter care. The catheter bag was observed to be full, with urine backing up into the tubing, and the resident reported infrequent drainage by staff. Interviews with facility staff revealed a lack of adherence to catheter care protocols, including timely emptying of the catheter bag and reporting issues to nursing staff.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed improper food storage, expired food, and unclean food preparation areas. The Dietary Manager was observed without a beard guard, and there was no tracking system for cleaning tasks, placing residents at risk of foodborne illnesses.
The facility failed to develop and implement baseline care plans for three residents, leading to unmet dietary preferences, unaddressed diabetes management, and lack of necessary pressure reducing boots. Staff were unaware of critical medical needs, and residents were not involved in the care planning process.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific medical needs, including a tracheostomy, a vegetarian diet, and Type 2 Diabetes Mellitus.
A resident with severe osteoporosis and multiple fractures did not receive timely wound care for a knee wound, despite the facility's policy requiring comprehensive skin evaluations and adherence to treatment orders. The wound was first documented but not treated until several days later, with inconsistent care provided thereafter.
The facility failed to label a resident's enteral feeding formula bag with necessary information, risking incorrect feeding. The resident, who was on continuous feedings with Jevity 1.2 via a g-tube, had unlabeled feeding and water bags, which was confirmed by the LVN and DON.
LVN Removed PICC Line Outside Scope of Practice
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses possessed and adhered to the appropriate competencies and scope of practice for resident care, specifically related to the removal of a Peripherally Inserted Central Catheter (PICC) line. A male resident with chronic systolic congestive heart failure, chronic atrial fibrillation, ischemic cardiomyopathy with pacemaker, venous insufficiency, and a history of pulmonary thromboembolism was admitted and had an active care plan for completion of an antibiotic regimen via PICC line. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 11. The care plan documented the use of a PICC line for antibiotic therapy, and the resident later reported that his PICC line had been removed at the facility a couple of weeks prior to the survey. On the date of the incident, a progress note completed by an LVN documented that the resident’s midline was discontinued per MD order using aseptic technique, with the catheter measured, tip intact, pressure applied, and a pressure dressing placed. The LVN documented that the resident tolerated the procedure well and was resting comfortably afterward. During interview, the resident confirmed that he had a PICC line that was removed at the facility, did not recall who was present during the removal, and denied pain or discomfort during or after the procedure. Observation of the site by surveyors showed no swelling, signs of infection, redness, or scabbing at the extraction site. Interviews with staff established that the LVN removed the PICC line independently, without RN presence or oversight, despite acknowledging that LVNs at the facility were only allowed to change PICC dressings and that PICC removal was not within LVN scope of practice. The LVN stated that RNs were responsible for pulling PICC lines and that removal required a provider order. The RN, ADON, DON, and Administrator each stated that only an RN could remove a PICC line per facility policy and Texas Board of Nursing standards, and that LVNs were not allowed to remove PICC lines. The ADON reported learning of the incident by reviewing progress notes and confirmed that the LVN had removed the line under discontinue orders from the NP, with no RN present. The DON confirmed she became aware that the LVN had removed the PICC line and informed the LVN that this was outside LVN scope of practice. Review of the Texas Board of Nursing position statement showed that insertion and removal of PICC lines or midline catheters is beyond the scope of practice for LVNs, confirming that the LVN practiced outside her scope when she removed the resident’s PICC line.
Failure to Immediately Notify Physician of Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical condition. Specifically, a nurse observed that a resident with a history of urinary retention and benign prostatic hyperplasia, who had an indwelling catheter, had red-tinged urine and low output during a shift. The nurse documented the finding and intended to notify the oncoming shift, but did not immediately inform the physician. The next shift was notified by a family member about continued issues with the catheter, including clots and dark red urine, at which point the physician was contacted and further interventions were ordered. Interviews with staff confirmed that changes in urine color and output should be promptly reported to the physician, and that it is the nurse's responsibility to ensure timely notification of any change in condition. The facility's policy also requires immediate physician notification for such changes. Documentation and staff statements indicated that the initial nurse did not follow this protocol, resulting in a delay in physician notification regarding the resident's change in condition.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to follow proper infection control procedures while providing incontinence care to a 73-year-old female resident with a history of urinary tract infection, bacteremia, abdominal pain, pancreatic cancer, and muscle weakness. The resident required moderate assistance with activities of daily living and was always incontinent of bowel and bladder. During observed care, CNA A did not wash her hands before donning gloves, put on gloves in the hallway, and proceeded to remove a soiled brief and clean the resident without changing gloves, even when the gloves became visibly soiled with urine and fecal matter. CNA A also failed to perform hand hygiene or change gloves before retrieving and applying a clean brief, and did not wash her hands after removing gloves or before exiting the resident's room. In interviews, CNA A acknowledged awareness of the correct procedures, stating she should have washed her hands before starting care and changed gloves during care, but attributed her failure to not paying attention. The Director of Nursing (DON) confirmed that staff are expected to follow facility protocols, including hand washing and glove changes as needed, and that infection control training is provided annually. Review of the facility's hand hygiene policy confirmed the requirement for hand washing before care, glove changes as needed, and hand hygiene after glove removal.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, as required by their care plans and the facility's own policy. Observations and interviews revealed that one resident was found lying in bed with the call light on the floor, out of reach and not visible to her. She stated she needed assistance to get out of bed and would have to wait for staff to check on her if she needed help, as she could not reach or see the call light. Another resident was observed in bed with the call light on the floor, three feet away, and he was unaware it had fallen. He stated he could not get up and would have to wait for staff rounds or try to shout for help in an emergency. A third resident, who was dependent for all self-care and unable to move independently in his wheelchair, was observed with the call light placed on the bed frame on the opposite side of the room, out of his reach. Staff interviews confirmed that the call light was not accessible to him and acknowledged the risk of injury or unmet needs when call lights are not within reach. Multiple staff members, including CNAs, RNs, the ADON, and the DON, stated that call lights are to be kept within reach of residents at all times, and that staff are responsible for monitoring their placement during regular rounds. Record reviews for all three residents showed significant physical and/or cognitive impairments, with care plans specifically directing that call lights be kept within reach to accommodate their needs and reduce fall risk. Despite these documented requirements and staff awareness, the facility did not ensure compliance, resulting in residents being unable to request assistance as needed. The facility's policy also required call lights to be within easy reach for residents in bed or confined to a chair, which was not followed in these cases.
Failure to Provide ADL Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically in the area of fingernail care, for two residents who required substantial or maximal assistance due to severe cognitive impairment and other medical conditions. Observations revealed that both residents had dirty fingernails with visible debris, and one resident expressed a desire for his nails to be cleaned and cut. Record reviews indicated that both residents had care plans and assessments documenting their need for assistance with personal hygiene, including grooming and nail care, due to diagnoses such as Alzheimer's disease, dementia, diabetes, and muscle weakness. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed that nursing staff and CNAs were responsible for monitoring and providing nail care, with nurses specifically assigned to diabetic residents. However, it was acknowledged that there was no system in place to monitor or ensure that nail care services were consistently provided. Facility policy required assistance with ADLs, including grooming, every shift as appropriate, but this was not followed for the two residents identified in the report.
Failure to Secure and Dispose of Topical Medications at Bedside
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were stored in locked compartments and only accessed by authorized personnel, as required. During observations, two residents were found to have clear measuring cups containing ointments left exposed and within reach at their bedsides. One resident had a cup with zinc oxide pomade and a tongue depressor, while another had a cup with an unknown pink ointment. Both items were accessible to other residents and had not been properly disposed of after use. Record reviews indicated that both residents had medical conditions requiring topical treatments, such as pressure ulcers and skin breakdown, with physician orders for the application of barrier creams. Interviews with staff, including CNAs, LVNs, RNs, and the DON, confirmed that the standard procedure was to apply the medication and immediately dispose of any remaining product. Staff acknowledged that leaving ointments at the bedside was not in accordance with facility protocols and could result in contamination or misuse. Further interviews revealed that staff could not recall recent training on medication storage and supervision, and the facility lacked a policy outlining procedures for supervising medications and disposing of them after administration. The failure to properly store and dispose of medications resulted in medications being left unattended and accessible at residents' bedsides.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and handling of food items. Specifically, containers of rice and chicken soup in the walk-in refrigerator were found with lids slightly open, and a bag of carrots was torn, exposing the contents to air. In the walk-in freezer, a bag of frozen turkey patties was not properly sealed, a container of frozen tomato sauce had dried drippings and residue around the lid, and bags of churros and donuts were undated. These observations were corroborated by interviews with the Executive Chef and a cook, both of whom confirmed that all food containers should be sealed, cleaned, and dated according to facility policy to prevent cross contamination and preserve freshness. The facility's Food Storage Policy requires all frozen food items to be properly sealed and dated, and fresh fruits and vegetables to be stored in bins, cartons, or bags. The staff interviewed acknowledged that the observed practices did not align with their training or facility policy, and that such lapses could result in food not being fresh or potentially contaminated. No specific residents or patient medical histories were mentioned in the report, and the deficiency was limited to the kitchen's food storage and sanitation practices.
Failure to Post Oxygen Sign for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy, as evidenced by the absence of an oxygen sign posted outside the resident's room. The resident, a cognitively intact female with a history of asthma, COPD, or chronic lung disease, was observed receiving continuous oxygen via nasal cannula in her room. Despite the care plan specifying the use of supplemental oxygen and the need for monitoring, there was no visible indication outside the room to alert staff or visitors to the presence of oxygen therapy. Interviews with facility staff, including a CNA, LVN, DON, and the Administrator, confirmed that it was standard practice to post oxygen signs to notify others of oxygen use and potential hazards. However, it was revealed that the facility did not have a written policy requiring the posting of such signs. The lack of an oxygen sign was directly observed during the survey, and staff acknowledged the importance of this practice for safety and monitoring purposes.
Failure to Administer and Document Ordered Medication
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for one resident, resulting in missed doses of Megestrol Acetate over a two-day period. The resident, a cognitively intact female with a history of nontraumatic intracerebral hemorrhage, hemiplegia, generalized anxiety disorder, muscle weakness, malnutrition, and anorexia, was admitted with an active order for Megestrol Acetate to treat loss of appetite. Review of the Medication Administration Record showed that the medication was not administered as ordered on three consecutive days, and there was no documented rationale for the missed doses in the resident's progress notes. Interviews with nursing staff and facility leadership revealed that medication aides are responsible for administering most medications, and are required to notify a nurse if a resident refuses medication or if a medication is not administered as ordered. Nurses are then expected to follow up with the resident, document the refusal or missed dose in the progress notes, and notify the physician and DON. However, in this case, there was no documentation of the missed doses or any follow-up actions in the resident's records, indicating a failure to follow established procedures for medication administration and documentation.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the use of bed rails as enablers and the assignment of a CNA who was involved in a self-reported incident. The resident, an elderly female with anxiety and osteoporosis, was admitted to the facility and had an order for enablers to assist with bed mobility. However, the resident's care plan did not include a focus area for the use of bed rails, nor was it coded in the MDS section for restraints and alarms. Additionally, after an incident where the resident injured her wrist on a bed rail during care, the facility did not update the care plan to prevent the involved CNA from being assigned to the resident again. Interviews with the DON, MDS Coordinator, and Administrator revealed that the care plans were not accurately reflecting the resident's needs and risks associated with the use of bed rails. The DON acknowledged the absence of a focus area or intervention for bed rail use in the care plan, and the MDS Coordinator confirmed that the care plan should have addressed the incident involving the CNA. The lack of a comprehensive care plan could lead to residents not receiving necessary care or services tailored to their needs.
Failure to Assess Bed Rail Safety Risks for Resident
Penalty
Summary
The facility failed to assess a resident for the risk of entrapment from a bed rail prior to its installation. This deficiency was identified for one resident who was reviewed for the use of enablers, specifically bed rails. The resident, an elderly female with anxiety and osteoporosis, was admitted to the facility without a Bed Transfer Bar Evaluation Assessment to determine the appropriateness of the bed rails for her needs. Despite having a BIMS score indicating little to no cognitive impairment, the resident was dependent on staff for activities of daily living such as toileting and repositioning in bed. The resident's care plans did not include a focus area for the use of bed rails, and the facility lacked a policy for conducting Bed/Transfer/Bar Assessments. An incident occurred where the resident injured her wrist during incontinence care, reportedly hitting it on the bed rail. The injury was noted by an LVN, who observed swelling and tenderness in the resident's wrist. Although x-rays showed no fractures, the incident highlighted the absence of a proper assessment for the use of bed rails. Interviews with facility staff, including the Administrator and DON, revealed that there was no existing policy for Bed/Transfer/Bar Assessments, and the nursing staff were responsible for ensuring such assessments were completed. The lack of assessment and documentation could potentially place residents at risk of injury from inappropriate or unnecessary enablers.
Privacy Breach During Resident Care
Penalty
Summary
The facility failed to respect the personal privacy of two residents during personal care activities. For Resident #4, the Staff Coordinator did not close the room blinds while weighing the resident, which allowed others to see the care being provided. This oversight was confirmed by LVN C, who observed the situation and intervened by closing the blinds. The Staff Coordinator admitted to not closing the blinds, acknowledging the need to do so for the resident's dignity. Resident #4 had moderate cognitive impairment and was dependent on staff for various activities of daily living. For Resident #8, CNA A left the resident's room door open while retrieving incontinence care items, exposing the resident's brief and private area. CNA A acknowledged the importance of closing the curtain or door to maintain privacy during such care. The resident had a history of dementia and was dependent on staff for bed mobility and transfers. Interviews with the NP and DON confirmed that privacy should be maintained during incontinence care, emphasizing the moral obligation and training provided to staff.
Inaccurate MDS Assessment for Bed Rail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding the use of bed rails, also referred to as enablers. This deficiency was identified for one resident who was admitted to the facility with a history of anxiety and osteoporosis. The resident's admission orders included the use of bed rails to assist with bed mobility and control, yet the MDS did not reflect this use in Section P, which covers restraints and alarms. Additionally, the resident's baseline and comprehensive care plans lacked a focus area for bed rail use, despite the resident's dependence on staff for activities of daily living (ADLs) such as toileting and repositioning in bed. Interviews with the Director of Nursing (DON) and the MDS Coordinator revealed a lack of awareness and understanding regarding the coding of bed rails in the MDS. The DON acknowledged the oversight and expressed the need to review the risks associated with not coding the bed rails. The MDS Coordinator confirmed that the resident used bed rails but was not coded for them in the MDS, and was unsure of the risks involved. The facility's MDS policy mandates accurate completion and transmission of MDS assessments, yet this policy was not adhered to in this instance, potentially placing residents at risk of inadequate care.
Failure to Ensure Safe Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent accidents for a resident. The incident involved a staff coordinator who was weighing a resident using a mechanical lift without locking the brakes and without the assistance of a second staff member, as required by the facility's policy. This action was observed by a Licensed Vocational Nurse (LVN) and confirmed during interviews with the staff coordinator and the Director of Nursing (DON). The facility's policy mandates that two staff members are required to operate a mechanical lift to ensure the safety of both the resident and the staff. The resident involved had a history of falls and was diagnosed with conditions such as Diabetes Type 2, right leg pain due to a fall, and ankylosing spondylitis of the thoracic region. The resident was dependent on staff for activities of daily living and required a Hoyer lift with two aides for transfers, as noted in the care plan. The staff coordinator admitted to not applying the brakes on the mechanical lift and acknowledged the risk of injury due to this oversight. The facility's mechanical lifts policy, dated February 2023, emphasizes the need for two staff members during the use of mechanical lifts to ensure safe patient handling and employee safety.
Failure to Provide Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling Foley catheter, leading to a risk of urinary tract infection. The resident, who was admitted with a history of diabetes and a severe ankle fracture, was observed with a catheter bag that was full of dark brownish urine, and the tubing contained a pink, cloudy substance. Despite the resident's ability to recall and make daily decisions, the catheter bag was not emptied in a timely manner, allowing the urine to back up into the tubing. This oversight was noted during an observation and interview with the resident, who reported that the nursing staff drained the catheter bag 3-4 times a day. Interviews with facility staff, including a CNA and the NP, revealed that the CNAs were responsible for checking and draining catheter bags at the end of each shift. The CNA acknowledged that a full catheter bag could cause reverse backflow, potentially leading to infection. The NP emphasized the importance of preventing full or cloudy tubing to avoid bacterial growth and UTIs. The DON confirmed that CNAs should report any issues with the catheter, such as sediment or discoloration, to the nurse and that catheter bags should be emptied when they are half full. The facility's Foley Catheter Policy mandates routine catheter care and notification of the DON/ADON for any issues, which was not adhered to in this instance.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed multiple instances of improper food storage and cleanliness in the kitchen. Food containers had accumulations of dried drippings and residue, and food preparation areas had dust, encrusted grease deposits, and other soiled accumulations. Additionally, food in the refrigerator was found with expired dates, and bananas were stored next to a dirty trash bin. The Dietary Manager was observed entering the kitchen without a beard guard, which was later corrected but not fully compliant as the mustache was not covered. Interviews with the Dietary Aide and the Dietary Manager confirmed the risks associated with these practices, including potential contamination and foodborne illnesses. The Dietary Aide acknowledged that residues on bottles and storing expired vegetables could lead to illness for the residents. The Dietary Manager admitted that using expired flour tortillas could pose a risk of bacteria growth and digestive infections. Furthermore, the kitchen had no tracking system in place to record when cleaning tasks were completed, and the grill, griddle, and deep fryer were found dirty with food residues and grease. The facility's policies and procedures on food storage, use of gloves/hairnets, and general sanitation of the kitchen were reviewed and found to be comprehensive. However, the observations and interviews indicated that these policies were not being followed. The lack of adherence to proper food safety and sanitation practices places residents at risk of foodborne illnesses, as confirmed by the Dietary Aide and the Dietary Manager.
Failure to Implement Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for three residents, which included necessary instructions to provide effective and person-centered care. Resident #35, who had severe osteoporosis and multiple fractures, was not provided with a baseline care plan that included her preference for a vegetarian diet. Despite her dietary needs being documented in her medical records and communicated to the dietary staff, the baseline care plan did not reflect this preference, leading to concerns about her nutritional intake and overall health. The dietary manager and dietitian were aware of her vegetarian diet but did not ensure it was included in the care plan, resulting in the resident relying on family members to supplement her diet. Resident #89, who had Type 2 Diabetes Mellitus with renal complications, did not have her diabetes management included in her baseline care plan. Her medical history indicated the need for monitoring blood sugar levels and insulin administration, but there were no orders or care plans addressing her diabetes. Staff members, including an RN and the MDS Coordinator, were unaware of her diabetes diagnosis, which led to a lack of necessary monitoring and treatment for her condition during her stay at the facility. Resident #192, who required pressure reducing boots as per physician orders, did not have this need included in his baseline care plan. Additionally, neither the resident nor his representative was involved in the care planning process or provided with a copy of the baseline care plan. The DON acknowledged the oversight and the risk it posed to the resident's care. The facility's policy required the development and implementation of a baseline care plan that reflects the resident's goals and needs, but this was not adhered to in these cases.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific medical needs. Resident #11, a female with multiple complex medical conditions including a tracheostomy, did not have her tracheostomy care included in her comprehensive care plan. Despite having orders for tracheostomy care, the MDS Coordinator missed including this critical aspect in the care plan, which could result in staff not identifying and addressing her care needs properly. The DON acknowledged that comprehensive care plans were not completed accurately due to a lack of training and stated that it was the MDS Coordinator's responsibility to complete them accurately. This oversight was confirmed by the MDS Coordinator, who admitted to missing the tracheostomy in the care plan, potentially leading to unaddressed care areas for the resident. Resident #35, who had severe osteoporosis and multiple fractures, had a preference for a vegetarian diet that was not included in her comprehensive care plan. Although her diet order and MAR indicated she was to receive a vegetarian diet, her care plan only mentioned maintaining her nutrition without specifying her dietary preference. The resident expressed concerns about not receiving a balanced diet and had to rely on family members to supplement her meals. The Dietary Manager and Dietitian were aware of her dietary needs, but the MDS Coordinator admitted that the resident's vegetarian preference should have been care planned to ensure the facility followed vegetarian guidelines. The lack of a specific care plan for her dietary preference posed a risk of not meeting her nutritional needs. Resident #89, who had Type 2 Diabetes Mellitus with kidney complications, did not have her diabetes care adequately addressed in her comprehensive care plan. Although her medical history and discharge instructions emphasized the need for monitoring her blood sugar, her care plan only mentioned risks related to skin breakdown and nutrition due to diabetes, without including blood glucose monitoring. The RN who worked with the resident was unaware of her diabetes diagnosis, and the MDS Coordinator admitted to not knowing about the diagnosis, which should have been care planned. The DON confirmed that the diabetes diagnosis should have been included in the care plan to ensure proper monitoring and availability of medications. This oversight could lead to unmonitored diabetic issues for the resident.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to ensure that Resident #35 received appropriate treatment and care for a wound on her left inner knee from 03/30/2024 to 04/09/2024. Despite the resident's medical history of severe osteoporosis, multiple fractures, and systematic lupus erythematosus, which put her at risk for wound healing complications, the facility did not provide the necessary wound care as per professional standards and the comprehensive person-centered care plan. The resident's baseline care plan did not identify any skin conditions at the time of admission, and the wound was first documented on 03/30/2024 but was not treated until 04/09/2024 when a physician's order was initiated for wound care treatment. However, the treatment was inconsistently provided, with several instances noted where wound care was not administered because the resident was asleep. Interviews and observations revealed that the resident was aware of the wound and reported that the facility did not address it until a physical therapist noticed it. The resident stated that the wound care nurse had difficulty locating her to provide treatment. The Director of Nursing (DON) could not explain the delay in wound care and acknowledged the risk of the wound worsening and potential infection due to the delay in treatment. The facility's policy required comprehensive skin evaluations and adherence to treatment orders, which were not followed in this case. The deficiency was identified through record reviews, interviews, and observations, highlighting the facility's failure to provide timely and appropriate wound care for Resident #35. This lapse in care could result in residents not receiving the necessary treatment for wounds, posing a risk to their health and well-being.
Failure to Label Enteral Feeding Formula Bag
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding. Specifically, the facility did not label the enteral feeding formula bag with the resident's name, type of feeding, frequency, time, and date administration started. This deficiency was observed for one resident who was receiving continuous feedings with Jevity 1.2 via a g-tube. The lack of labeling could lead to the resident receiving incorrect feeding formula or an incorrect quantity of formula. The resident involved was [AGE] years old and had been admitted to the facility with diagnoses including diabetes and intractable nausea and vomiting. The resident was to receive nothing by mouth and was on continuous enteral feedings. During an observation, it was noted that the feeding formula bag and water bag hanging beside the resident's bed were not labeled. Interviews with the LVN and DON confirmed that the bags should have been labeled according to the facility's policy, but they were not. The DON was unable to provide documentation or a policy on labeling of enteral feeding bags before the survey exit.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort El Paso, Llc | 1.1 mi | ★★★★★ | 23 | 3 |
| Avir At Tierra Este | 1.8 mi | ★★★★★ | 29 | 1 |
| El Paso Health & Rehabilitation Center | 3 mi | ★★★★★ | 11 | 0 |
| Pebble Creek Nursing Center | 3.3 mi | ★★★★★ | 10 | 0 |
| Edgemere Estates | 3.6 mi | ★★★★★ | 4 | 0 |
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