Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Cross Timbers Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Call lights were not kept within reach for two residents. One resident with stroke, HF, impaired mobility, and a contracted R hand could not find her call light while asking for help removing blankets, and the call light was under her pillow. Another resident with HF, renal insufficiency, neurogenic bladder, urinary retention, and an indwelling catheter said her catheter bag needed emptying, but her call light was tied behind her head and out of reach. Staff and the DON confirmed the call lights were not accessible.
Failure to Provide Toenail Care: A resident with dementia, muscle wasting, HTN, and HF had toenails observed to be overgrown, including big toenails curving to the side. The resident said she could no longer bend over to trim them and no one had asked to do so or arrange podiatry. Staff gave conflicting accounts about who was responsible for nail care, and the SW said podiatry consent was still pending.
Catheter Bag Not Emptied in Timely Manner: A resident with an indwelling catheter, neurogenic bladder, urinary retention, and moderate cognitive impairment was observed in bed with a full urine collection bag. The resident said the bag needed to be emptied and that the call light was out of reach. The assigned LVN was unaware the bag was full, estimated it held 800 cc of urine, and stated it had not been emptied by the overnight shift. The DON stated staff were responsible for emptying catheter bags at least every shift.
Failure to Provide Ordered Oxygen Therapy: Two residents with COPD and oxygen orders were observed without their prescribed oxygen in place. One resident had O2 sats below the ordered threshold and was seen breathing deeply and short of breath without a nasal cannula, while the other resident was repeatedly found in bed with oxygen tubing disconnected or set aside, with an O2 sat of 87%. RN and DON interviews confirmed the oxygen orders were not being consistently followed.
A resident with an immunodeficiency disorder did not receive routine specialized lab monitoring to assess treatment effectiveness. The resident said she had previously seen an infectious disease doctor every 3 months for checkups and labs, but this did not continue after admission. The MD relied on routine bloodwork and clinical assessments, while the DON confirmed there had been no routine specialized labs and could not provide documentation of a referral or discussion of the program.
A resident with cognitive impairment and multiple pressure injuries had wound care debris, including a cup of gauze soaked with betadine, left on the bedside table next to the breakfast tray after treatment. Staff interviews confirmed the wound care trash remained in the room after the treatment nurse and NP completed care, and the DON stated the nurse was responsible for disposing of all treatment items after wound care.
A resident with visual impairment from stroke, Asperger's syndrome, and diabetes requested accommodations for a Kosher-style diet after returning to her religious roots. Although the IDT discussed her religious and dietary restrictions and the Dietary Manager informally adjusted menus to avoid serving dairy and meat together, the comprehensive person-centered care plan did not include any specific, measurable interventions or timeframes addressing these religious dietary needs. The Social Worker reported uncertainty about who was responsible for care plans due to the absence of an MDS Coordinator, and the DON confirmed that no dietary restrictions based on the resident's religious beliefs were documented in the care plan, despite facility policy requiring such needs to be incorporated.
A resident with intact cognition was allowed to keep and self-administer ophthalmic eye drops at bedside without an interdisciplinary team assessment or documented authorization, contrary to facility policy. Nursing staff were unaware of any completed assessment or proper orders, and the resident self-administered the medications without staff oversight.
A resident with dementia and a history of wandering was able to leave the facility unsupervised after repeated exit-seeking behaviors were not properly addressed by staff. Despite the wander guard alarm sounding and staff redirecting the resident twice, the charge nurse did not implement one-to-one supervision or notify administration, allowing the resident to elope and be found by police outside the facility.
The facility failed to ensure proper communication and documentation for two residents requiring dialysis, leading to missing dialysis communication forms for several dates. Both residents, diagnosed with end-stage renal disease, had intact cognition and required hemodialysis. The facility's records showed a lack of adherence to the dialysis protocol, which could result in missed medical orders and recommendations. Interviews revealed that the nursing staff acknowledged the responsibility to collect and file these forms, but the forms were not consistently returned from the dialysis center.
The facility failed to maintain accurate narcotic logs for two residents, leading to discrepancies in medication counts. Additionally, a resident's physician order for Lomotil was delayed due to a failure in processing a faxed order, resulting in a delay in medication administration. Interviews revealed lapses in documentation and auditing expectations, with the facility's policy lacking guidance on narcotic administration records.
The facility failed to act on a pharmacist's recommendations for medication regimen reviews for three residents. One resident's antipsychotic medication was not reviewed by a physician as recommended, and consent forms were improperly handled. Another resident's sleep medication was not reviewed, and a third resident's antidepressant dose reduction was not acted upon. The DON, responsible for these reviews, was on medical leave, leading to unaddressed recommendations.
A resident's medications were found unsecured at their bedside, and insulin vials on two medication carts were not labeled with opening dates, posing risks of overuse and ineffective treatment. The resident had moderate cognitive impairment and was not reassessed for self-administration. Charge nurses acknowledged the oversight, and the ADON admitted to not auditing medication carts regularly.
The facility failed to provide properly textured pureed food during a lunch meal, affecting residents on a pureed diet. A staff member used regular spaghetti instead of egg noodles, resulting in chunky pasta that did not meet the required smooth, pudding-like texture. This oversight was confirmed by state surveyors and the DM, who noted the potential choking risk for residents. The facility did not adhere to its policy of ensuring meals are palatable and safe.
A facility failed to prevent urinary tract infections for a resident with a catheter. The resident's catheter tubing was observed dragging on the floor and was stepped on by the Activity Director, who was unaware of the proper protocol. The resident had severe cognitive impairment and multiple diagnoses. The facility's policy required catheter tubing to be kept off the floor to prevent infections.
A facility failed to monitor a resident's weight upon admission and in the following weeks, leading to undetected weight loss. The resident, with multiple health issues, was not weighed as required by facility policy, resulting in a drop from 127 to 119 pounds. Staff interviews revealed a lack of awareness of the weight management policy, compounded by staffing challenges. The Registered Dietitian and Physician were not informed of the weight loss, preventing timely interventions.
The facility failed to limit PRN orders for antipsychotic drugs to 14 days without evaluation, affecting two residents. One resident received Seroquel beyond 14 days without an end date, while another was inappropriately prescribed Seroquel for sleep despite having dementia. Staff interviews revealed missed responsibilities and a lack of adherence to facility policies on psychotropic medication management.
A resident's call light system was found to be non-functional, leaving her unable to request assistance. The resident, with a history of stroke and other conditions, reported the issue after moving to a new room. The Maintenance Director confirmed the malfunction, noting a possible need for cord replacement.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences for two residents by not keeping their call lights within reach. Resident #15 had a history of stroke, heart failure, unsteadiness on feet, and lack of coordination, and was dependent on staff for multiple activities of daily living. During observation, she was lying in bed and stated she needed help removing her blankets because she was hot and no one was coming in to help her. When asked to use her call light, she said she did not know where it was; the call light was found underneath her pillow and not within her reach. She only had use of her left hand because her right hand was contracted and she could not move without assistance of her left hand. Resident #65 had diagnoses including heart failure, hypertension, renal insufficiency, neurogenic bladder, urinary retention, and hip fracture, and used an indwelling catheter. During observation, she pointed to her catheter bag and stated it seemed full and needed to be emptied, but no one had come to empty it yet. The catheter bag was observed to be full. When asked to use her call light, she said she would if she knew where it was, and stated she could not reach it because it was located behind her head and tied to the corner of the bed. Staff interviews confirmed the call lights were not positioned within reach. An LVN stated resident call lights should be kept within reach so residents could communicate their needs, and that all staff were responsible for ensuring this. The DON later observed Resident #15's call light underneath two pillows and Resident #65's call light tied to the left corner of the bed behind her head. The facility's policy stated the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.
Failure to Provide Toenail Care
Penalty
Summary
Provide appropriate foot care was cited after the facility failed to ensure Resident #8 received proper toenail care. Resident #8 was an [AGE]-year-old female admitted with diagnoses including metabolic encephalopathy, muscle wasting and atrophy, depression, non-Alzheimer's dementia, hypertension, and heart failure. Her BIMS score was 11, indicating moderate cognitive impairment, and her care plan directed staff to check nail length and trim and clean nails on bath day and as necessary. During observation, her toenails on both feet were noted to be approximately a quarter of an inch past the tip of the toes, with the big toenails curving to the side. Resident #8 stated she had been cutting her own toenails but had recently been unable to bend over to do so, and she said no one had asked to trim them or arrange podiatry care. Interviews showed inconsistent understanding among staff about who was responsible for toenail care. A CNA stated nurses were responsible for trimming toenails unless the resident was diabetic, while an RN stated that because Resident #8 was not diabetic, CNAs were responsible for trimming her toenails. The RN also observed the toenails and stated they were long and needed to be trimmed by podiatry due to the thickness of the big toenails. The Social Worker stated Resident #8 was not being seen by podiatry and that she was waiting for family to sign a podiatry consent. The ADON and DON stated nurses were responsible for trimming toenails unless the resident was diabetic, and both acknowledged the expectation that toenails be checked and trimmed unless the resident refused. The facility policy stated residents unable to perform ADLs independently are to receive services necessary to maintain good grooming and personal hygiene.
Catheter Bag Not Emptied in Timely Manner
Penalty
Summary
The facility failed to ensure a resident with an indwelling catheter received appropriate care to prevent urinary tract infections when the resident’s catheter urine collection bag was not emptied in a timely manner. Resident #65 was a [AGE]-year-old female with diagnoses including heart failure, hypertension, renal insufficiency, neurogenic bladder, urinary retention, and hip fracture. Her MDS indicated moderate cognitive impairment, dependence on staff for toileting and personal hygiene, and use of an indwelling catheter. Her care plan directed staff to check tubing for kinks, empty the catheter as needed per shift, and monitor and document intake and output, and physician orders included Foley catheter care every shift and Foley catheter output every shift. During observation, Resident #65 was in bed and pointed to her catheter, stating the bag seemed full and needed to be emptied, and that no one had come to empty it yet. The catheter bag was observed to be full of urine, and the resident stated she could not reach her call light because it was behind her head and tied to the corner of the bed. The LVN assigned to the hall stated she was not aware the bag was full and had not been emptied, and estimated the bag contained 800 cc of urine, indicating it had not been emptied by the overnight shift. The DON later stated the aide scheduled for the hall had gone home sick and another CNA was pulled to cover resident needs, and that aides were responsible for ensuring catheter bags were emptied at least every shift.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who had physician orders for oxygen therapy. Resident #59 had diagnoses including COPD with acute exacerbation, respiratory failure, and heart disease, and her physician’s orders required O2 saturation checks every shift and oxygen at 1-5 LPM to keep O2 saturation above 92%. Record review showed O2 saturation readings of 91% on 04/06/26 and 04/08/26, and it was not documented that oxygen therapy was provided when the saturation was outside normal limits. During an observation on 04/15/26, Resident #59 was sitting on the side of the bed, breathing deeply, appearing short of breath, and not wearing her nasal cannula. Her O2 saturation initially measured 85% and then rose to 90% after about one minute. The resident stated she did not wear oxygen continuously and would put it on when she felt she needed it. RN I stated the resident had an order to keep O2 saturation above 92% and that an O2 saturation of 90% indicated she needed oxygen therapy. The DON stated the resident should have been on continuous oxygen therapy to maintain O2 saturation above 92%, but she was not getting enough oxygen because she continued to smoke and had to remove oxygen to do so. The MD stated the resident required continuous oxygen therapy and that the nurses were expected to follow the order as written. Resident #61 had COPD, moderate cognitive impairment, and was ordered continuous oxygen therapy. His care plan reflected oxygen via nasal cannula at 2-6 liters continuous to keep SpO2 above 90%, and the physician’s order required oxygen at 2-6 liters by nasal cannula continuously every shift for shortness of breath. Multiple observations showed the resident in bed without oxygen, with tubing covered by bedsheets or folded and packed in plastic bags. On 04/15/26, RN D observed the resident without oxygen and checked his oxygen saturation at 87%; she stated she knew the oxygen was not on and could not explain why it had not been put back on. She also stated it was the nurses’ responsibility to ensure residents on oxygen were receiving it as ordered. The DON stated it was the charge nurse’s responsibility to ensure physician orders were followed and that Resident #61’s oxygen was always on, and the MD stated he expected the resident to be on oxygen at all times.
Failure to Complete Routine Specialized Lab Monitoring for Immunodeficiency Disorder
Penalty
Summary
The facility failed to provide laboratory services to meet the needs of a resident with an immunodeficiency disorder by not completing routine specialized laboratory monitoring to assess whether treatment remained effective. The deficiency involved one of five residents reviewed for laboratory services. The resident’s record reflected diagnoses including a cerebrovascular accident, hypertension, viral hepatitis, and an immunodeficiency disorder. Her care plan identified impaired immunity, risk for dehydration and increased infections, and included monitoring for abnormal laboratory values and signs of infection. Record review showed laboratory results dated 04/12/26 that included a low WBC, a nonreactive immunodeficiency-related marker, and a CD4 count of 375. The record review also reflected that these immunodeficiency-specific labs were not documented at any other time. The resident’s consolidated physician orders showed routine general health labs were completed as ordered, and a STAT order for CBC, CMP, CD4, and another immunodeficiency-related lab was completed on 04/06/26, but there were no prior orders for these specialized labs to monitor the disorder. During interview, the resident stated she had previously seen an infectious disease doctor every three months for checkups and lab work and was supposed to continue doing so, but had not seen one since admission to the facility. She stated she had spoken to a nurse about it previously but there was no follow-up. The DON stated she was aware the resident had not had routine specialized labs for the disorder and could not provide documentation of a referral or progress note showing discussion of the program. The MD stated he had managed the resident’s disorder but had not ordered routine specialized labs to monitor effectiveness, relying instead on routine blood tests and clinical assessments. The facility policy stated laboratory services were to meet residents’ needs and results were to be reported promptly to the ordering provider.
Wound Care Debris Left on Bedside Table
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #15’s room when wound care trash and debris were left on the resident’s bedside table after treatment. During observation on 04/14/26 at 11:03 a.m., a cup containing used gauze soaked with betadine and other wound care debris was seen next to the resident’s breakfast tray on the bedside table. Resident #15 stated the items were left there by the wound care treatment nurse and the nurse practitioner when they completed treatment on her feet that morning. Resident #15’s record showed she was a [AGE]-year-old female admitted with a BIMS of 10 and diagnoses including stroke, heart failure, unsteadiness on feet, and lack of coordination. Her care plan identified deep tissue pressure injuries to the right lateral foot, left heel, and left lateral foot, with ordered wound treatments including cleansing, Betadine application, and bordered dressings. Staff interviews confirmed the debris remained on the tray table after wound care, and the Treatment Nurse and DON stated the nurse was responsible for disposing of treatment trash and that nothing should have been left on the bedside table.
Failure to Care Plan for Resident’s Religious Dietary Restrictions
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes to address a resident's religious dietary needs. The resident was an older female with a history of stroke affecting her vision, Asperger's syndrome, and diabetes, who used a wheelchair and required staff assistance with ADLs. Her quarterly MDS and care plan showed she was PASRR positive, and documentation from an IDT meeting indicated that her Kosher (Jewish) diet had been discussed. However, the care plan dated 12/27/25 contained no specific interventions or measurable goals related to her religious dietary restrictions, despite the facility's policy requiring the IDT, in conjunction with the resident, to develop a comprehensive person-centered care plan describing services to maintain the resident's highest practicable well-being. Interviews further demonstrated the lack of integration of the resident's religious dietary needs into the formal care plan. The resident reported that in the last few months she had begun returning to her religious roots and requested accommodations for a Kosher diet, clarifying she did not expect a Kosher kitchen but wanted her restrictions honored. The Dietary Manager confirmed that the resident had recently decided to follow a "Kosher light" diet, with no dairy on the same plate as meat, and described reviewing the 5‑week menu cycle with the resident to identify acceptable foods and alternatives. The Social Worker stated that care plans were developed through care plan and IDT meetings and that the MDS Coordinator typically created and maintained care plans, but there was currently no MDS Coordinator and she was unsure who was responsible for care plans; she was also unaware of the resident's religious beliefs. The DON acknowledged that although the resident's religious and dietary restrictions were discussed in an IDT meeting, no corresponding interventions were documented in the care plan and agreed there were no specific interventions in place to address the resident's dietary needs, noting that staff could only access the IDT meeting notes.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined whether a resident was able to self-administer medications, specifically Systane ophthalmic eyedrops, for one of five residents reviewed for resident rights. The resident, an older adult female with an intact cognition score (BIMS 14), had orders for Systane and Artificial Tears ophthalmic solutions to be kept at bedside for self-administration. However, there was no documented assessment completed to determine if she was clinically appropriate to self-administer these medications, and her baseline care plan indicated she was not able to self-administer any medications. Observations revealed that the resident had both Systane and Artificial Tears eye drops at her bedside and reported self-administering them at bedtime without staff supervision or confirmation. Interviews with nursing staff, including an RN, ADON, LVN, and Medication Aide, showed a lack of awareness regarding whether the resident had been assessed for self-administration or had appropriate orders. Staff assumed the resident was permitted to self-administer based on her alertness and the presence of the medications at bedside, but none could confirm that the required assessment or interdisciplinary team determination had occurred. The facility's policy required that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determined the resident had the decision-making capacity to do so safely. Despite this, the resident was allowed to keep and self-administer eye drops at bedside without the necessary assessment or documented team decision, resulting in a failure to follow established procedures for safe medication administration.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, non-Alzheimer's dementia, non-traumatic brain dysfunction, and Parkinson's disease was not provided with adequate supervision to prevent elopement. The resident had a history of wandering and exit-seeking behaviors, as evidenced by high scores on multiple Wander Data Collection assessments. On the day of the incident, the resident was observed repeatedly attempting to exit through the front door, triggering the wander guard alarm twice. Staff redirected him both times, but did not implement increased supervision or notify facility administration as required by policy. Despite the resident's ongoing agitation and repeated exit-seeking behavior, the charge nurse failed to place the resident on one-to-one supervision or escalate the situation to administration. The resident ultimately left the facility by following others out the front door, with the wander guard system functioning properly. He was found by police down the street and returned to the facility without injury. Staff interviews confirmed that the resident was visibly upset and determined to leave to find his wife, and that staff were aware of his behaviors but did not take additional steps to ensure his safety. The facility's policy required immediate response to door alarms, investigation of the cause, and accounting for residents at risk for elopement. However, these procedures were not fully followed, as the charge nurse did not notify administration or implement one-to-one supervision after multiple exit attempts. The lack of timely intervention and supervision directly led to the resident's elopement from the facility.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation for residents requiring dialysis services, which is a deficiency in maintaining professional standards of practice. Two residents, both diagnosed with end-stage renal disease, were affected by this lapse. The facility did not consistently receive dialysis communication forms from the dialysis center, which are crucial for ensuring continuity of care and monitoring any changes in the residents' conditions. This lack of communication could lead to missed orders and recommendations from the dialysis center. Resident #26, a female with intact cognition, was admitted with a diagnosis of end-stage renal disease and required hemodialysis. Her care plan included goals to prevent complications from dialysis and interventions to monitor for signs of infection. However, the facility's records showed missing dialysis communication forms for several dates in January 2025, indicating a failure to document and follow up on the resident's dialysis treatment. Interviews revealed that the resident was unsure if she returned the forms to the facility, and the nursing staff acknowledged the responsibility to collect and file these forms. Similarly, Resident #245, also with intact cognition and diagnosed with end-stage renal disease, experienced the same issue with missing dialysis communication forms. Her care plan included monitoring for complications and ensuring proper dressing changes at the access site. Despite the facility's protocol requiring communication forms to be completed and returned, the forms were missing for several dialysis dates. Interviews with the nursing staff and administration highlighted a lack of adherence to the facility's dialysis protocol, which could result in the omission of important medical orders and recommendations.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain accurate narcotic logs for two residents on the 200 Hall nurses' medication cart. For one resident, the narcotic administration record for Xanax showed a discrepancy between the recorded and actual pill count. Similarly, for another resident, the narcotic administration record for Tylenol with Codeine also showed a discrepancy. The LVN responsible admitted to administering the medications but failing to sign off on the narcotic administration log, which could lead to potential medication errors. Additionally, the facility did not follow a physician's order for a resident's medication, Lomotil, which was faxed by a hospice nurse. The order was not entered into the system until two days later, resulting in a delay in medication administration. The resident, who had severe cognitive impairment, was reported to have diarrhea, but the anti-diarrhea medication was not administered as ordered. The order was found sitting on top of the fax machine, indicating a failure in the facility's process for handling medication orders. Interviews with facility staff, including the ADON and Corporate RN, revealed expectations for proper documentation and auditing of medication carts, which were not met. The facility's policy on medication administration did not address the narcotic administration record, contributing to the oversight. These deficiencies highlight lapses in the facility's pharmaceutical services, potentially placing residents at risk for medication errors and delays.
Failure to Act on Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to ensure that the pharmacist's recommendations regarding medication regimen reviews were acted upon for three residents. For one resident, the pharmacist recommended that the antipsychotic medication Quetiapine Fumarate, prescribed as needed for agitation, be reviewed and a new order written every 14 days if extended beyond this period. However, the physician did not review the medication regimen records for October and November, and there was no documentation indicating agreement or disagreement with the pharmacist's recommendation. Another resident was prescribed Quetiapine Fumarate for sleep, and the pharmacist's recommendation for review was not documented as being acted upon by the physician. Interviews with nursing staff revealed that consent forms were not properly completed, and the Director of Nursing (DON) was responsible for ensuring the pharmacist's recommendations were reviewed by the physician. However, the DON was on medical leave, and the necessary forms and reviews were not completed. A third resident was receiving Duloxetine for depression, and the pharmacist recommended a trial dose reduction. This recommendation was not reviewed or acted upon by the physician. The Assistant Director of Nursing (ADON) acknowledged that the DON was responsible for handling pharmacy recommendations, but due to the DON's medical leave, the recommendations were not addressed. The facility's policies require that the pharmacist's findings and recommendations be reported to the DON, attending practitioner, and medical director, but this process was not followed, leading to the deficiencies noted.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage and proper labeling of medications for one resident and on two medication carts. A resident had several medications, including thymus and thyroid capsules, Advil, and Tylenol, stored unsecured at their bedside. The resident, who had moderate cognitive impairment, was initially assessed for self-administration of medications but had not been reassessed after a decline in cognitive status. The charge nurse acknowledged the oversight and noted that the resident did not have orders for the medications found at the bedside, posing a risk of overuse or adverse reactions. Additionally, the facility did not ensure that insulin vials on two medication carts were labeled with the date they were opened. Insulin pens on the carts for Halls 200 and 300 were found opened and partially used without the required labeling. The charge nurses for these halls admitted to knowing the importance of dating insulin pens but failed to check their carts adequately. This oversight could lead to the administration of expired insulin, which may not be effective. Interviews with the ADON and Corporate RN revealed that it was the responsibility of the nursing staff to ensure medications were not left in residents' rooms and that insulin pens were dated upon opening. The ADON admitted to not auditing the medication carts regularly, which contributed to the deficiencies. The facility's policies on administering and storing medications were not followed, leading to potential risks for the residents.
Failure to Ensure Proper Texture of Pureed Food
Penalty
Summary
The facility failed to provide palatable food during a lunch meal, specifically for residents on a pureed diet. On the observed date, the kitchen staff member, [NAME] F, was responsible for preparing pureed spaghetti pasta. However, the pasta was not pureed to the required smooth, pudding-like texture, as it contained chunks of pasta. This was confirmed during a taste test conducted by three state surveyors and the Dietary Manager (DM), who noted the pasta's chunky texture. The DM acknowledged that [NAME] F used regular spaghetti pasta instead of the usual egg noodle pasta, which is easier to puree, and admitted to not checking the texture of the pureed food items. The facility's failure to ensure the correct texture of pureed food could potentially affect nine residents who were on a pureed diet, as per the facility's records. The facility's Food and Nutrition Services policy requires staff to inspect food trays to ensure meals are palatable, attractive, and served at a safe and appetizing temperature. The DM expressed concern that improperly textured pureed food could pose a choking risk to residents. Despite these requirements, the facility did not adhere to its policy, resulting in the deficiency observed during the survey.
Failure to Prevent Catheter-Associated Urinary Tract Infections
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with a urinary catheter. The deficiency was observed when the resident's catheter tubing was allowed to drag on the floor while she was being pushed in her wheelchair by the Activity Director. The tubing was stepped on by the Activity Director, who was unaware that the tubing should not be on the floor and did not inform anyone to address the issue. This oversight was noted during an observation and was confirmed through interviews with the Activity Director, LVN, and ADON. The resident involved was an elderly female with severe cognitive impairment and multiple diagnoses, including depression, bipolar disorder, and a disorder of the kidney and ureter. The facility's policy on catheter care, revised in January 2023, clearly stated that catheter tubing and drainage bags should be kept off the floor to prevent catheter-associated urinary tract infections. The failure to adhere to this policy posed a risk of introducing bacteria and causing infection, as well as potential physical harm to the resident.
Failure to Monitor Resident's Weight Leads to Unidentified Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by the lack of weight monitoring for a resident upon admission and in the subsequent weeks. Resident #68, an elderly female with multiple diagnoses including depression, bipolar disorder, dorsalgia, kidney disorder, cognitive impairment, and malnutrition, was admitted without an initial weight being recorded. The facility's policy required new admissions to be weighed weekly for the first four weeks to establish baseline weights, but this was not done for Resident #68, resulting in her weight loss going unnoticed. The resident's weight was recorded at 127 pounds in her hospital records prior to admission, but subsequent facility records showed a decrease to 119 pounds within a few weeks. Despite the resident's meal intake records indicating she was eating a significant portion of her meals, the weight loss was not identified or addressed. Interviews with staff revealed a lack of awareness and adherence to the facility's weight management policy, with the ADON unaware of the requirement for weekly weights and the Registered Dietitian noting the absence of a recorded weight in the system. The oversight was compounded by staffing challenges, including an ice storm and the DON being on medical leave, which may have contributed to the missed weight checks. The Registered Dietitian and Physician both indicated that had they been informed of the weight loss, they would have implemented measures to address it. However, due to the failure to monitor the resident's weight as per policy, these interventions were not initiated, placing the resident at risk for further nutritional decline.
Failure to Limit PRN Antipsychotic Orders and Inappropriate Use for Sleep
Penalty
Summary
The facility failed to ensure that PRN orders for antipsychotic drugs were limited to 14 days and could not be renewed without an evaluation by the attending physician or prescribing practitioner. This deficiency was identified for two residents who were reviewed for unnecessary medications. Resident #35 had a PRN order for Seroquel, an antipsychotic medication, which extended beyond 14 days without an identified end date. The resident, who had a diagnosis of post-traumatic stress disorder and moderate cognitive impairment, received the medication on multiple occasions without the required evaluation. The ADON acknowledged the oversight and stated that the responsibility to follow up on such orders was missed. Resident #44, who had severe cognitive impairment and a diagnosis of unspecified dementia, was receiving Seroquel for sleep, which is not an appropriate use of the medication. The care plan for this resident indicated a goal to reduce the use of psychotropic medication, yet the resident was prescribed Seroquel for sleep. The MDS Coordinator and the ADON both acknowledged that the resident should not have been on this medication for sleep, and the Corporate RN noted that alternative medications should have been considered. The facility's policies on psychotropic medication management were not followed, as PRN antipsychotic medications should be re-evaluated every 14 days, and Seroquel is not approved for the treatment of dementia-related psychosis. The failure to adhere to these policies placed residents at risk for receiving unnecessary medications and potential adverse drug reactions. Interviews with facility staff revealed a lack of awareness and oversight regarding the appropriate use and monitoring of antipsychotic medications.
Resident Call Light System Malfunction
Penalty
Summary
The facility failed to ensure that a resident's room was equipped with a functioning call light system, which is essential for residents to request assistance from staff. This deficiency was identified during an observation and interview with a resident who had recently been moved to a new room. The resident, who had a history of stroke, depression, bipolar disorder, and obstructive sleep apnea, reported that her call light was not working when she attempted to use it to request assistance. Upon testing the call light, it was confirmed that it did not activate, indicating a malfunction. The Maintenance Director was unaware of the issue until it was brought to his attention during the interview. He confirmed the malfunction after testing the call light himself and noted that the cord might need replacement. The facility's policy requires that the resident call system remains functional at all times, but this was not adhered to in this instance, potentially leaving the resident without a means to call for help when needed.
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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.
Illustrative
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Nursing homes near Flower Mound
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hollymead | 0.6 mi | ★★★★★ | 2 | 0 |
| Rambling Oaks Courtyard Extensive Care Community | 2.5 mi | ★★★★★ | 17 | 0 |
| Lake Village Nursing And Rehabilitation Center | 4.4 mi | ★★★★★ | 14 | 0 |
| Avir At Grapevine | 6.6 mi | ★★★★★ | 11 | 0 |
| Vista Ridge Nursing & Rehabilitation Center | 7.1 mi | ★★★★★ | 13 | 0 |
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