Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Denton Village By Purehealth during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, including diabetes, experienced critically high blood sugar levels on several occasions without documented notification to a physician or hospice provider. The resident also missed multiple doses of prescribed diabetic and potassium medications due to unavailability, with no evidence of timely follow-up to obtain the medications or monitor blood sugar. After a fall resulting in a head injury, the resident's blood sugar was not checked, and the resident later deteriorated, was hospitalized with severe hyperglycemia and a brain bleed, and subsequently died. Facility staff interviews revealed failures in communication, documentation, and medication management.
A resident's admission MDS assessment did not include a diabetes diagnosis, despite the individual receiving insulin and metformin for diabetes as documented in their medical records, care plan, and physician's orders. Facility staff, including the MDS Coordinator and DON, were unaware of the omission and could not explain how the diagnosis was missed from the assessment.
A resident receiving insulin and metformin for diabetes did not have a diabetes diagnosis documented in the EMR, face sheet, or care plan, despite physician orders and MAR entries indicating treatment for diabetes. Staff interviews revealed a lack of awareness and accountability for ensuring accurate and complete records, and the facility was unable to provide a medical record policy when requested.
A resident with cystitis and two other residents with bladder and bowel incontinence received incontinent care in which CNA F and CNA E reused the same wipe or towel to clean different parts of the perineal area and, in one case, cleaned the bottom back to front. The CNA involved acknowledged the proper technique was one wipe then discard and stated the actions could cause UTI. The DON, ADON, and Administrator stated staff should use one wipe at a time and clean from front to back.
Missing Orders and Consent for Pivot Assist Bars: Pivot assist bars were observed on the beds of multiple residents without physician orders or documented inclusion in the care plan. The residents had diagnoses including muscle weakness, falls, and cognitive impairment, and staff stated the bed came with the bars and that orders were not thought to be needed.
A facility failed to ensure medications were properly controlled for several residents. A resident with osteoarthritis was observed using diclofenac gel kept on her overbed table, another resident with GERD and cognitive impairment had TUMS, eye drops, and oral analgesic in her room, a cognitively intact resident was left pills on her tray to take after breakfast, and another resident with delirium had eye drops at her bedside. In each case, the record lacked a self-administration assessment or documentation that the resident was competent to manage meds independently.
Surveyors found multiple meds and treatment products left unsecured in resident rooms instead of being kept in locked med storage. Items observed included topical pain gel, TUMS, eye drops, oral analgesia, wound cleanser, hydrogen peroxide, and zinc oxide left on tables, sinks, trays, and dressers for several residents, including one resident with dementia and others with intact cognition. Staff and leadership stated these items should be stored in carts or other secured areas, but they were found accessible in the rooms.
Improper Food Storage and Labeling in Kitchen: The facility failed to store food in accordance with professional standards in its only kitchen. Frozen French fries and a package of beef in the freezer were not dated, and open containers of teriyaki sauce and soy sauce labeled "Refrigerate After Opening" were stored unrefrigerated in dry storage. The DON, Chief Kitchen Manager, Food and Beverage Manager, Dietitian, and Dietary Aide all discussed the facility's food storage practices, with the Dietitian stating he believed room-temperature storage of soy sauce was acceptable despite the label instructions.
The facility failed to maintain infection control during incontinent care and EBP use for several residents. A CNA did not change gloves or perform hand hygiene while moving from contaminated to clean tasks during incontinent care for two residents, and another CNA did not sanitize hands when changing gloves or after touching soiled linen during incontinent care for a third resident. An RN also provided bolus feeding via a g-tube to a resident with an order for EBP without wearing a gown, despite signage indicating EBP was required.
Resident Rights and Dignity Not Honored: A resident with a suprapubic catheter and moderate cognitive impairment reported that the straps holding her catheter leg bag were too tight and twisted, but a CNA ignored her repeated requests to adjust them. The straps were observed to appear too tight, and the CNA later acknowledged he had ignored the resident and that the strap should have been loosened; the LVN, ADON, and DON stated the CNA should have adjusted it when the resident complained.
Failure to Maintain Privacy During Treatment: Two residents received care with their doors open and no privacy curtain pulled. An LVN checked blood sugar and gave insulin to a cognitively intact resident with DM, and an RN provided bolus g-tube feeding to a resident with dysphagia and moderate cognitive impairment while staff, visitors, and other residents passed by and could see the treatments being performed. The LVN and RN both acknowledged the doors should have been closed to protect privacy and dignity.
Failure to Care Plan Nebulizer Use: A resident with atherosclerotic heart disease and moderate cognitive impairment had an order for PRN saline nebulizer treatments, but the quarterly care plan did not include this care. The ADON and DON acknowledged the nebulizer use should have been included in the resident’s plan of care and stated it was missed.
A resident using PRN nebulizer treatment and another resident receiving O2 via NC had their respiratory devices observed unbagged when not in use. An LVN saw the nebulizer mask connected to the device on a chest and the NC sitting on the bed, and stated both should be bagged when not in use to avoid infection. The ADON and DON stated the expectation was for the devices to be placed in a bag when not in use.
An LPN left a laptop open and unattended on a nurse's cart, displaying the names and room numbers of 15 residents, while administering treatment in a resident's room. Interviews with the LPN, DON, and QAPI Nurse Manager confirmed the screen should have been locked to protect resident information, as per facility policy and HIPAA regulations.
The facility failed to implement comprehensive care plans for three residents, neglecting to include essential medical treatments such as an indwelling Foley catheter and oxygen therapy. A resident with benign prostatic hyperplasia and chronic kidney disease had no care plan for his catheter, while two residents with respiratory issues lacked care plans for their oxygen therapy. Staff interviews confirmed the importance of care plans, yet these were missing for the residents' specific needs.
The facility failed to maintain an effective Infection Prevention and Control Program, with staff not adhering to hand hygiene protocols during care for multiple residents. A CNA did not sanitize hands before changing gloves during incontinence care, and another CNA placed a catheter bag on the floor during a transfer. An LPN also failed to perform hand hygiene after touching a waste basket before wound care. These actions were contrary to the facility's policies, risking cross-contamination and infection.
The facility failed to maintain a clean and safe environment in six resident rooms and high traffic areas, with observations of dirt, dust, rust, and stains. Staff interviews revealed inconsistencies in cleaning practices, with concerns about infection control and resident dignity.
The facility's kitchen failed to meet food safety standards, with issues including unclean ice machines, expired and improperly sealed foods, and improper use of personal protective equipment by the Dietary Manager. An uncovered tea dispenser further exposed food to contamination risks. The Dietary Manager acknowledged these issues, while the Administrator was unaware of some concerns.
A resident with a neuromuscular dysfunction of the bladder was found with an exposed catheter bag lacking a privacy cover, leading to a deficiency in maintaining dignity. Staff interviews revealed a lack of adherence to the facility's policy on resident dignity, as the catheter bag was visible from the hallway, potentially causing embarrassment. The facility's policy emphasizes the importance of using privacy bags to prevent such issues.
The facility failed to ensure that call lights were accessible to two residents, compromising their ability to call for assistance. One resident with muscle weakness and another with severe cognitive impairment had their call lights on the floor, making them unreachable. Staff interviews confirmed the importance of accessible call lights, but observations showed this was not consistently practiced.
A facility failed to accurately document a resident's use of oxygen therapy in the MDS Assessment, despite the resident having COPD and a physician's order for continuous oxygen therapy. Observations confirmed the resident was using oxygen, but the MDS did not reflect this, highlighting a lapse in accurate assessment and documentation.
Two residents in the facility were found with improperly stored respiratory equipment, leading to deficiencies in care. A resident with COPD had a nebulizer mask left exposed on a table without a protective bag, while another resident with pneumonia had a nasal cannula coiled on bed railings without proper storage. Staff interviews confirmed these practices, which contradicted the facility's policy requiring respiratory equipment to be bagged when not in use, posing a risk of cross-contamination and infection.
The facility failed to re-order medications in a timely manner for two residents, leading to a deficiency in pharmaceutical services. A resident with acute kidney failure did not have Torsemide available, and another with renal failure used the last Solifenacin pill without a replacement. Staff interviews revealed that the medication aide was responsible for re-ordering but failed to do so, leading to inappropriate use of the emergency kit. The facility's policy required re-ordering when medications were low, which was not followed, potentially impacting resident care.
A resident requiring total assistance for ADLs did not receive scheduled or unscheduled showers since admission, and his toenails were excessively long, indicating a lack of personal hygiene care. Facility staff noted the resident's refusal of showers, but inconsistencies in documentation and communication led to the oversight. The DON was unaware of these issues, highlighting a failure to adhere to the facility's bathing policy.
Failure to Notify Providers and Administer Diabetic Medications Resulting in Critical Hyperglycemia and Resident Death
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including diabetes, heart failure, chronic kidney disease, and who was under hospice care, was admitted for respite care. The resident was prescribed Metformin twice daily, long-acting insulin at bedtime, and potassium chloride. The care plan did not include diabetes management, despite active orders for diabetic medications. Over several days, the resident's blood sugar (BS) levels were found to be critically high (576 and over 600 on multiple occasions), but there was no documented evidence that the physician or hospice provider was notified of these elevated readings. Additionally, the resident missed two dayshift doses of Metformin and one dose of potassium chloride due to medication unavailability, with no evidence that the pharmacy, physician, or hospice was contacted to obtain the medications or that the resident's BS levels were checked during these times. On the morning of a fall, the resident was found on the floor with a head injury. The nurse assessed the resident, provided basic first aid, and noted that the resident was able to eat breakfast afterward. However, there was no documentation of a blood sugar check following the fall, despite the resident's diabetic status and the incident involving a head injury. Later, the resident exhibited a change in condition, including seizure-like activity and unresponsiveness. Attempts to contact the family member and hospice provider were initially unsuccessful. When the hospice nurse arrived, the resident was found to have a large hematoma, unresponsive pupils, and low blood pressure, and was subsequently sent to the hospital. Hospital records indicated the resident was admitted in critical condition with a subarachnoid hemorrhage, hypotension, and a blood sugar level of 812. The resident was diagnosed with hyperosmolar hyperglycemic syndrome, cardiogenic shock, and ultimately passed away. Interviews with facility staff revealed a lack of awareness regarding the resident's missed medications and high blood sugar levels, as well as failures in communication and documentation. Staff acknowledged that elevated BS levels should have prompted immediate notification of the physician or hospice provider and that missed doses of diabetic medication could have serious consequences. There was also confusion regarding the process for obtaining unavailable medications and the responsibilities for diabetic management in hospice patients.
Failure to Accurately Reflect Resident Diagnoses in MDS Assessment
Penalty
Summary
The facility failed to ensure that each resident's assessment accurately reflected their status and that all individuals completing portions of the assessment signed and certified the accuracy of their contributions. Specifically, for one resident, the admission Minimum Data Set (MDS) assessment did not include a diagnosis of diabetes, despite the resident being prescribed and administered diabetic medications such as insulin and metformin. The resident's medical records, care plan, physician's orders, and medication administration records all indicated active treatment for diabetes, but this diagnosis was omitted from the MDS assessment. Additionally, there was no care plan addressing diabetes for this resident. Interviews with facility staff, including the Regional MDS Coordinator, Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, revealed a lack of awareness regarding the omission and uncertainty about how the error occurred. The MDS Coordinator acknowledged responsibility for ensuring assessment accuracy, while the DON and Administrator indicated that the interdisciplinary team (IDT) and clinical leadership were responsible for maintaining accurate records. The omission was not identified until the survey, and staff could not explain how the resident's diabetes diagnosis was missed from the assessment.
Incomplete and Inaccurate Medical Records for Diabetic Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically omitting a diabetes diagnosis from the resident's face sheet, care plan, and other key documentation, despite the resident receiving diabetic medications and insulin. Record reviews showed that the resident's face sheet, care plan, and Minimum Data Set (MDS) assessment did not list diabetes as a diagnosis, even though physician orders and the Medication Administration Record (MAR) documented the administration of insulin and metformin for diabetes. The care plan also lacked any interventions or goals related to diabetes management. Interviews with facility staff revealed a lack of awareness and accountability regarding the accuracy of resident records. The Admissions Director was responsible for completing face sheets, while the Regional MDS Coordinator was responsible for care plans. The MDS Coordinator stated he was unaware of the inaccuracies and believed the Interdisciplinary Team (IDT) was responsible for ensuring records were accurate and complete. The Director of Nursing (DON) acknowledged that missing diagnoses could result in improper or inadequate care but was unsure how the omission occurred. The Administrator indicated that the clinical leadership team and hospice provider were responsible for ensuring accurate information in the records but was unable to explain why the diabetes diagnosis was missing. Additionally, when asked for the facility's medical record policy, the Administrator stated that no such policy was available. The lack of accurate documentation for the resident's diabetes diagnosis was identified through record review and staff interviews.
Incontinent Care Performed With Reused Wipes and Incorrect Cleaning Technique
Penalty
Summary
The facility failed to ensure appropriate incontinent care was provided for three residents who were incontinent of bladder and bowel. Resident #8 had diagnoses including cystitis with hematuria and kidney failure, a BIMS score of 10, and a care plan intervention for assistance with toilet use and personal hygiene. During observed incontinent care, CNA F washed her hands, donned gloves, and used a wet towel to clean the resident’s perineal area. She cleaned the top and sides of the perineal area, then used the same towel to clean the middle portion of the perineal area. She also turned the resident and used the same towel to clean the resident’s bottom, cleaning from back to front. Resident #15 had a history of UTI, a BIMS score of 10, and was also frequently incontinent of bladder and bowel with a care plan intervention for assistance with toilet use and personal hygiene. During observed incontinent care, CNA F again used a wet towel to clean the resident’s perineal area, cleaned the top and sides, then used the same towel to clean the middle portion of the perineal area. She then turned the resident and used the same towel to clean the resident’s bottom. In interview, CNA F stated the proper technique was to use a wipe and discard it, use one stroke then discard if using wipes, use another face towel for the middle portion, and she acknowledged that her actions could cause UTIs. Resident #21 had chronic kidney disease, was cognitively intact with a BIMS score of 15, and was incontinent of bladder and bowel with a care plan intervention for assistance with toilet use and personal hygiene. During observed incontinent care, CNA E cleaned the top and sides of the perineal area with a wipe, then used the same wipe to clean the middle portion. He rolled the resident and cleaned the bottom, then later cleaned the perineal area again with a wet towel. In interview, CNA E stated the wipe used on the sides should have been discarded and a new wipe used for the middle portion, and he said the wipe used on the sides was already dirty and the resident might get a UTI. The DON, ADON, and Administrator all stated that staff should use one wipe at a time, discard it after use, and clean the bottom from front to back; the DON also stated that using soiled wipes or towels could introduce microorganisms and cause UTI, especially for women.
Missing Orders and Consent for Pivot Assist Bars
Penalty
Summary
The facility failed to ensure informed consent and physician orders were in place before pivot assist bars were installed on the beds of Resident #5, #9, #10, #11, #30, and #46. The report states that the facility did not obtain physician orders for the pivot assist bars attached to these residents’ beds, and the bars were observed on both sides of each resident’s bed during survey observations. The facility’s restraint policy stated that if a resident had cause for need of a restraint, the physician would be notified immediately and Texas state regulations would be followed. Resident #5 was admitted with muscle weakness and Alzheimer’s disease and had severe cognitive impairment with a BIMS score of 3. His care plan noted a history of falls, with the last fall occurring on 08/31/25, but it did not include pivot assist bars as an intervention. Resident #9 was admitted with muscle weakness and a history of falls, had an intact cognitive response with a BIMS score of 14, and his care plan also did not include pivot assist bars. Resident #10 had senile degeneration of the brain, moderate cognitive impairment with a BIMS score of 8, and a history of falls, but no pivot assist bars were included in the care plan. Resident #11 had a history of falls and muscle weakness, was moderately cognitively impaired with a BIMS score of 8, and his care plan did not include pivot assist bars. Resident #30 had muscle weakness and needed assistance with personal care, had a BIMS score of 9, and his care plan did not include pivot assist bars. Resident #46 had muscle weakness, osteoarthritis of both knees, moderate cognitive impairment with a BIMS score of 12, and a history of falls, but her care plan did not include pivot assist bars. Staff interviews confirmed that no physician orders were present for the pivot assist bars, and the ADON stated the bed came with the bars and that she did not think physician orders were needed for them.
Medications Left in Resident Rooms Without Self-Administration Assessments
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for four residents. The deficiency involved residents being allowed to keep and use medications in their rooms without documentation of a self-administration assessment or a determination that they were competent to manage medications independently. Resident #4 had osteoarthritis and chronic pain, and her care plan did not indicate that she could self-administer medications. Her record contained an order for Voltaren Arthritis Pain External Gel, but there was no assessment on 09/17/2025 showing she was competent to self-administer. During observation, a tube of diclofenac sodium topical gel was seen on top of her overbed table, and the resident stated she was the one applying it herself and that staff knew she did so whenever needed. The tube was still observed on her overbed table the next day. RN B stated the pain ointment should not have been in the resident’s room and should have been in the nurses’ cart for staff administration. Resident #7 had GERD and moderate cognitive impairment with a BIMS score of 12. Her record included orders for aluminum-magnesium-simethicone suspension and Refresh eye drops, but there was no order for TUMS or oral analgesia and no assessment showing she could self-administer medications. During observation, a bottle of TUMS, two eye drops, and a tube of oral analgesic were found on her side table, and the resident stated they were her medications and that she sometimes took them if needed. RN C later removed the medications and stated residents should not have medications in their rooms unless assessed to self-medicate. Resident #21 had anemia and was cognitively intact with a BIMS score of 15. Her record showed orders for ascorbic acid and metformin, but there was no self-administration assessment. During observation, she was about to take three pills from a cup left on her tray and stated staff had left the medications for her to take after breakfast. MA G stated medications should not be left with residents and acknowledged leaving them because she had gone to assist another resident. Resident #61 had delirium listed in her record and no care plan indication that she could self-administer medications. There was no order for eye drops and no assessment of competency, yet an eye drop was observed on her side table and the resident stated she used it every morning for dry eyes. Staff interviews confirmed they were unaware of the eye drop in the room and stated medications should not be left with residents unless they had been assessed as capable of self-administration.
Medications and Treatment Products Left Unsecured in Resident Rooms
Penalty
Summary
The facility failed to keep multiple drugs and biologicals stored in locked compartments and failed to prevent medications and treatment products from being left inside resident rooms. Surveyors observed medication-related items in the rooms of eight residents, including pain ointment, TUMS, eye drops, oral analgesia, wound cleanser, hydrogen peroxide, zinc oxide, and other medications or treatment products that were left on overbed tables, side tables, sinks, dressers, or trays rather than being secured in medication storage areas. Resident #4, who was cognitively intact and had osteoarthritis with chronic foot pain, had a tube of diclofenac sodium topical gel observed on top of the overbed table during two observations. The resident stated the ointment had been in the room and had always been kept where she could easily access it. RN B later stated the pain ointment should not have been inside the room and should have been in the nurses' cart because nurses were supposed to administer it. Resident #7, who had GERD and dementia with moderate cognitive impairment, had a bottle of TUMS, two eye drops, and a tube of oral analgesic on the side table, despite no order for TUMS or oral analgesia. Resident #8 had wound cleanser on the sink while being treated for healed skin tears. Resident #21 had three pills left in a cup on the tray and later had two sachets of calmoseptine left on the dresser after incontinent care. Resident #23 had zinc oxide on the overbed table, Resident #31 had hydrogen peroxide on the sink, Resident #51 had zinc oxide and hydrogen peroxide on the sink, and Resident #61 had an eye drop on the side table despite no order for eye drops. Staff and leadership stated these items should not be left in resident rooms and should be secured in carts or other locked medication storage areas.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. During observation of the kitchen, one large sealed bag of frozen French fries and one large sealed package of beef that appeared to be brisket were found in the freezer without a date showing when they were stored. In the dry storage area, one large open container of teriyaki sauce and one large open container of soy sauce, both labeled "Refrigerate After Opening," were stored unrefrigerated. During interviews, the DON acknowledged the importance of proper food storage to prevent foodborne illnesses and stated he was aware of the facility's food storage policies and the risks to residents if food was not stored appropriately. The Chief Kitchen Manager stated the facility's process for perishable condiments included wrapping, labeling, dating, and storing them in the appropriate area, and he acknowledged both sauce containers should have been refrigerated after opening. He stated the items would be discarded and said they may have been mistakenly placed in dry storage by another staff member after use. The Food and Beverage Manager stated sauces such as soy sauce and teriyaki sauce must be labeled, dated, and refrigerated once opened, and that improperly stored products are disposed of. The Dietitian stated soy sauce can be stored at room temperature for up to 1-6 months and said he believed storing these items unrefrigerated was acceptable, despite the label instructions. The facility's Food and Nutrition Services policy required food to be stored properly, with perishable items covered, labeled, and dated upon opening or removal from original packaging, and the FDA Code cited that food shall be protected from contamination.
Infection Control Failures During Incontinent Care and EBP Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for four residents reviewed for infection control. During observed incontinent care for two residents, CNA F washed her hands and put on gloves, but did not change gloves or perform hand hygiene while moving between contaminated and clean tasks. For one resident, she placed a brief and towel on the overbed table, cleaned the perineal area and bottom, and then used the same gloves to handle and place the clean brief without changing gloves or sanitizing her hands. For another resident, she again used the same gloves throughout incontinent care, including after cleaning the resident’s bottom and before touching the brief, and she acknowledged the top of the drawer where the towel had been placed might have been dirty. During incontinent care for a third resident, CNA E washed his hands and began care, but did not sanitize his hands when changing gloves after touching soiled linen and before touching a new brief. He also did not change gloves after touching soiled linen and before handling the brief, and he used a soaking wet face towel to clean the resident’s perineal area and bottom. He later changed gloves without sanitizing his hands first. In interview, he stated he should have sanitized his hands when changing gloves and acknowledged the wet towel could allow germs to seep to other parts of the towel. For a fourth resident with dysphagia and a PEG tube, the care plan and physician order required enhanced barrier precautions due to the g-tube. During observed bolus feeding via g-tube, RN B washed her hands, prepared supplies, washed her hands again, and put on gloves, but did not wear a gown even though a sign outside the room indicated EBP was required. RN B stated she forgot to wear a gown and acknowledged it was needed to prevent transmission of microorganisms. The DON, ADON, and Administrator all stated hand hygiene, glove changes, and EBP were important for preventing spread of infection, and the facility’s policies stated hand hygiene is the primary means to prevent spread of infections, gloves do not replace hand hygiene, and EBP for residents with feeding tubes requires gloves and gown.
Resident Rights and Dignity Not Honored
Penalty
Summary
The facility failed to treat a resident with respect and dignity and to care for the resident in a manner that promoted quality of life for 1 of 6 residents reviewed for dignity. Resident #46, a female with urinary and flaccid neuropathic bladder, moderate cognitive impairment with a BIMS score of 12, and a suprapubic urinary catheter, had a care plan that included use of a catheter leg bag when in her wheelchair and participating in activities. During an observation and interview, the resident stated the straps around her leg that held the catheter bag in place were too tight and that she had repeatedly told CNA E this, but he told her it was not too tight and needed to stay in place. She also stated the strap was twisted in the back and that the situation made her uncomfortable and frustrated because she felt ignored. The resident lifted her pant leg and the catheter bag straps were observed attached to her leg, appearing too tight, with the top strap twisted on the back portion of her leg. In interview, CNA E stated the resident complained the straps were too tight and twisted, but he ignored her, and he acknowledged the strap appeared too tight and that he would need to locate the resident to adjust and untwist it. LVN D, the ADON, and the DON each stated the CNA should have adjusted the strap when the resident complained, and they noted it could affect circulation and the resident's comfort. The facility's Resident Rights policy stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to a dignified existence, to be treated with respect, kindness, and dignity, and to be free from abuse, neglect, misappropriation of property, and exploitation.
Failure to Maintain Privacy During Treatment
Penalty
Summary
The facility failed to ensure resident privacy during treatment for two residents. One resident was a cognitively intact female with type 2 diabetes mellitus and orders for finger-stick blood sugar checks before meals and at bedtime with sliding-scale insulin. During observation, an LVN checked the resident’s blood sugar and later administered insulin while standing in the resident’s room with the door open and without pulling the privacy curtain. The nurse was facing the hallway, and staff and residents were observed passing by while the treatment was being performed. A second resident was a male with dysphagia, moderate cognitive impairment, and a feeding tube. His care plan and physician orders reflected tube feeding via g-tube with bolus/gravity feedings and scheduled water flushes. During observation, an RN prepared and administered the resident’s bolus feeding with the door open and without pulling the privacy curtain. The resident was facing the hallway, and staff, visitors, and residents were passing by while the nurse raised the resident’s shirt to connect the syringe to the g-tube and held the syringe up with formula in it. Interviews confirmed the privacy concerns. The LVN stated she forgot to close the door and acknowledged it should have been closed to provide privacy during treatment. The RN stated she should have closed the door during the bolus feeding and that the door should be closed every time the resident received the feeding to provide dignity and privacy. The DON, ADON, and Administrator all stated that doors should be closed or privacy curtains pulled during care and treatment to protect resident privacy and dignity. The facility policy stated that employees shall treat all residents with kindness, respect, and dignity, including privacy and confidentiality.
Failure to Care Plan Nebulizer Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #10 that included measurable objectives and timeframes to meet his identified medical, nursing, mental, and psychosocial needs. Record review showed the resident was an [AGE]-year-old male admitted on [DATE], with diagnoses including atherosclerotic heart disease. His quarterly MDS assessment dated 07/27/25 reflected moderate cognitive impairment with a BIMS score of 8 and an active diagnosis of coronary artery disease. Physician orders dated 09/18/25 included saline nebulizer 0.9% to be given 1 vial via nebulizer every 4 hours as needed, but the resident's quarterly care plan dated 07/21/25 did not include the nebulizer use. During interview, the ADON stated the nebulizer should have been care planned because it was a care provided to the resident and acknowledged it had been overlooked. The DON stated the resident had orders and that it was a plan of care needed for the resident, but the nebulizer use was missed and not added to the care plan.
Respiratory Devices Left Unbagged When Not in Use
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for two residents who required respiratory support. Resident #10 was a male with diagnoses including atherosclerotic heart disease and coronary artery disease, and his quarterly MDS reflected moderate cognitive impairment with a BIMS score of 8. His physician orders included saline nebulizer 0.9% every 4 hours as needed, but his quarterly care plan did not reflect a care plan for nebulizer use. During an observation and interview, LVN D saw Resident #10's nebulizer mask connected to the nebulizer device and sitting on top of a 3-drawer chest without being bagged, and stated it should be bagged when not in use to avoid infection. Resident #11 was a male with acute respiratory failure and moderate cognitive impairment with a BIMS score of 8. His comprehensive care plan included oxygen therapy and use of an oxygen concentrator, and his physician orders included oxygen at 2 liters via nasal cannula for hypoxia/SOB every shift. During an observation and interview, LVN D saw Resident #11's nasal cannula sitting on top of the resident's bed without being bagged, and stated it should be bagged when not in use to avoid infection. The ADON and DON were informed of both observations and stated the expectation was for the devices to be placed in a bag when not in use.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure the privacy of residents' personal and medical records for 15 residents. This deficiency was observed when an LPN left a laptop open and unattended on a nurse's cart in the hallway, displaying the full names and room numbers of these residents. The LPN was inside a resident's room administering treatment at the time, leaving the computer screen visible to anyone passing by, although no visitors or other residents were near the laptop during the observation. Interviews with the LPN, the Director of Nursing (DON), and the QAPI Nurse Manager confirmed that the screen should have been locked or the computer closed when not in use to protect resident information. The facility's policy on resident dignity, revised in November 2023, emphasizes maintaining an environment where confidential clinical or personal information is not visible to visitors or other residents. The failure to lock the computer screen was acknowledged as a violation of HIPAA regulations by the LPN and recognized as a privacy issue by the DON and QAPI Nurse Manager.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which were necessary to address their specific medical needs. Resident #9, a cognitively intact male with benign prostatic hyperplasia and chronic kidney disease, was admitted with an indwelling Foley catheter. Despite this, his comprehensive care plan did not include any mention of the catheter, which was observed hanging on his wheelchair during a survey. Resident #15, a cognitively intact male diagnosed with chronic respiratory failure and hypoxia, was receiving oxygen therapy via nasal cannula. However, his care plan did not reflect this critical aspect of his treatment, even though he had been using oxygen continuously for almost two years. This oversight was confirmed during an interview with the resident, who stated his reliance on oxygen day and night. Similarly, Resident #106, a cognitively intact female with pneumonia and anxiety disorder, was prescribed oxygen therapy at night. Her care plan also lacked documentation of this therapy, despite observations confirming her use of oxygen at bedtime. Interviews with facility staff, including the ADON, DON, and MDS Nurse, highlighted the importance of care plans in ensuring residents receive appropriate care, yet these plans were missing for the residents' specific needs.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of improper hand hygiene and handling of medical equipment. Specifically, CNA C did not perform hand hygiene before putting on new gloves during incontinence care for Resident #7 and Resident #39. This lapse in protocol occurred despite the CNA's acknowledgment of the importance of hand hygiene in preventing the spread of germs. Additionally, CNA C failed to change gloves after handling potentially contaminated items, such as waste cans and soiled briefs, before touching clean items. In another instance, CNA B improperly handled Resident #29's catheter bag by placing it on the floor during a transfer. This action was contrary to the facility's policy, which states that catheter bags should never touch the floor to prevent contamination. CNA B acknowledged the mistake and understood that the catheter bag should have been kept off the floor to avoid the risk of infection. Furthermore, LPN D did not perform hand hygiene after touching a waste basket and before putting on new gloves during wound care for Resident #40. This oversight occurred despite the LPN's awareness that the waste basket was considered dirty and that hand hygiene was necessary to prevent infection. The facility's policies clearly outline the importance of hand hygiene and proper glove use to prevent cross-contamination and infection, yet these protocols were not followed in these instances.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in six of the twelve rooms reviewed, as well as in high traffic areas. Observations revealed that resident rooms had dirt particles and built-up dust in the corners of the bathrooms and behind toilets. Additional issues included rust on sink drain holes, stains on bedside tables, and unsanitary conditions of trashcans. These deficiencies were noted during observations conducted on specific dates and times. Interviews with staff highlighted inconsistencies in cleaning practices. A housekeeper expressed concerns about her peers not consistently cleaning rooms, leading to dirt accumulation. The Environmental Services Supervisor acknowledged that not all areas could be cleaned daily and recognized the observed issues as infection control concerns. The facility's administrator was unaware of the specific concerns until shown pictures and acknowledged the risk of infection and impact on resident dignity due to inadequate cleaning.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed through various deficiencies. The ice machine and ice scoop holder were not thoroughly cleaned, with dust, dirt, and rust-like substances present, potentially contaminating the ice. Expired foods were found in the refrigerator and freezer, including a large piece of cooked ham and a bag of bread rolls, which were not discarded according to guidelines. Additionally, foods such as seedless red grapes and another unspecified item were not properly sealed, exposing them to air-borne contamination. The Dietary Manager did not wear a beard covering properly while preparing and serving breakfast, leaving his beard exposed. Furthermore, a tea dispenser in the dining area was left uncovered, exposing the tea to potential contaminants. The Dietary Manager acknowledged these issues, stating that it was his responsibility to ensure compliance with food safety standards, although he cited difficulty breathing as a reason for not wearing the beard covering correctly. The Administrator was unaware of some of these concerns but recognized the risk of infection control issues if they were not addressed.
Failure to Maintain Resident Dignity Due to Exposed Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of Resident #19, who was observed with an exposed catheter bag lacking a privacy cover. This deficiency was identified during observations and interviews conducted by surveyors. Resident #19, a cognitively intact female with a neuromuscular dysfunction of the bladder, was found with her catheter bag visibly hanging from the bed railings, exposing its contents to the hallway and room entrance. The resident was unaware of the exposure, which was confirmed by a Certified Nursing Assistant (CNA) who acknowledged the absence of a privacy bag and the potential for embarrassment. Further interviews with staff, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), revealed a lack of adherence to the facility's policy on maintaining resident dignity. The LPN admitted to not noticing the exposed catheter bag and emphasized the importance of using privacy bags to prevent embarrassment. The ADON reiterated the expectation for staff to ensure residents' dignity by using privacy bags for catheter bags, highlighting the need for staff mindfulness regarding residents' feelings. The Director of Nursing (DON) and the Administrator also acknowledged the deficiency, emphasizing the importance of providing a dignified existence for all residents. They confirmed that the absence of a privacy bag for the catheter was a dignity issue, as it could lead to embarrassment if visible from the hallway. The facility's policy on resident dignity explicitly states the need to refrain from practices that demean residents, such as leaving urinary catheter bags uncovered.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system in the rooms of two residents was accessible, which is a deficiency in accommodating the needs and preferences of residents. Resident #4, a female with generalized muscle weakness and chronic pain, was observed in her wheelchair with her call light on the floor between the bed and the wall, making it inaccessible. Despite requiring limited assistance for transfer and toileting, the call light was not within her reach, which she confirmed during an interview, expressing her need for the call light to call for staff assistance. Similarly, Resident #23, who had a history of falling and severe cognitive impairment, was observed with her call light on the floor at the end of the bed, also making it inaccessible. During an observation, the resident was unable to respond verbally about the call light's location, indicating a lack of access to this essential communication tool. The resident required moderate assistance for transfers, and the care plan included ensuring a safe environment, which was compromised by the inaccessible call light. Interviews with staff, including an LPN, the ADON, the DON, and the Administrator, confirmed that call lights should be within reach of residents at all times to ensure their needs are met and to prevent potential falls. The facility's policy also stated that call lights should be placed within easy reach when leaving the room. However, the observations and interviews revealed that this policy was not consistently followed, leading to the deficiency in accommodating the residents' needs.
Inaccurate Assessment of Resident's Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the status of a resident, specifically regarding the use of oxygen therapy. The resident, a female with chronic obstructive pulmonary disease (COPD) and pleural effusion, was observed using oxygen therapy via nasal cannula, which was not documented in her Quarterly MDS Assessment. Despite having a physician's order for oxygen therapy and a care plan indicating continuous oxygen therapy, the MDS Assessment did not reflect this critical aspect of her care. Interviews with facility staff, including the ADON, DON, and MDS Nurse, revealed a consensus that accurate assessments are crucial for providing appropriate care. The MDS Nurse confirmed that the resident's MDS was not triggered for oxygen use, which could lead to missed care. The facility's policy on resident assessment emphasizes the importance of identifying care needs, yet the discrepancy in documentation suggests a lapse in following this policy, potentially impacting the resident's care and services.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the storage of respiratory equipment. Resident #27, diagnosed with chronic obstructive pulmonary disease (COPD) and pleural effusion, was observed with a nebulizer mask improperly stored on a table without a protective bag. This mask, which should have been bagged to prevent contamination, was left exposed, potentially compromising the resident's respiratory care. The resident confirmed the use of the nebulizer twice daily but was unaware of any bagging procedure for the mask. Similarly, Resident #106, who had pneumonia and an anxiety disorder, was found with a nasal cannula coiled on the bed railings without a bag. The resident used the nasal cannula occasionally, but it was not stored properly when not in use. The improper storage of the nasal cannula could lead to cross-contamination and infection, as the bed railings were not clean. The resident also reported never seeing a bag for the nasal cannula. Interviews with staff, including an LPN, RN, ADON, DON, and the Administrator, confirmed the improper storage practices and acknowledged the risk of cross-contamination and infection. The staff admitted to not following the facility's policy, which required respiratory equipment to be bagged when not in use. The facility's policy aimed to maintain the cleanliness and condition of oxygen equipment, but this was not adhered to, resulting in the deficiencies observed.
Medication Re-ordering Deficiency
Penalty
Summary
The facility failed to ensure that medications were re-ordered in a timely manner for two residents, leading to a deficiency in pharmaceutical services. Resident #19, a cognitively intact female with acute kidney failure, was prescribed Torsemide 20 mg for edema. During an observation, it was noted that the medication was not available in the blister pack, and the medication aide (MA) had to request it from the emergency kit. Similarly, Resident #48, a male with severe cognitive impairment and renal failure, was prescribed Solifenacin 5 mg. The MA used the last pill from the blister pack and did not have a replacement available. Interviews with staff revealed that the MA was responsible for re-ordering medications but failed to do so despite noticing that the medications were running low. The Licensed Practical Nurse (LPN) confirmed that the emergency kit was used inappropriately for Resident #19's medication, which should have been re-ordered earlier. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both emphasized the importance of timely re-ordering to prevent medication shortages, noting that the facility's policy required re-ordering when medications reached the last line of the blister pack. The facility's policy on medication ordering was reviewed, indicating that emergency kits should be used for new admissions or emergencies, not for routine re-ordering failures. The Administrator acknowledged the issue and planned to coordinate with the DON to address it. The deficiency highlights a lapse in the facility's medication management process, as staff did not adhere to the established procedures for re-ordering medications, potentially impacting resident care.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary services for a resident who required assistance with activities of daily living (ADLs), specifically in maintaining personal hygiene. The resident, a cognitively intact male with kidney failure, required total assistance for transfers, toileting, and bathing. Despite being scheduled for showers on specific days, the resident did not receive any scheduled or unscheduled showers since admission. Observations revealed the resident's clothing was dingy and stained, and his toenails were excessively long, indicating a lack of personal hygiene care. Interviews with facility staff, including a CNA and an RN, revealed that the resident was noted to have refused showers on multiple occasions, as documented in the facility's records. However, the CNA and RN both indicated that the resident was not known for refusing showers, suggesting possible issues with specific staff members. The CNA mentioned that the resident's toenails were in poor condition, but she had not informed a nurse due to her recent reassignment to the resident. The RN confirmed the resident's toenails were long and stated that the resident was on a podiatrist list, but no action had been taken since his admission. The Director of Nursing (DON) was unaware of the resident's refusal of showers and the condition of his toenails. The facility's policy on bathing aimed to promote cleanliness, hygiene, and safety, but the lack of adherence to this policy resulted in the resident not receiving necessary care. The DON acknowledged that the resident's refusal of showers should have been documented and care planned, and the failure to address the resident's feet could lead to potential health issues.
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 371 citations issued within 25 miles in the last 12 months — including the 8 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 Denton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottonwood Nursing And Rehabilitation | 0.5 mi | ★★★★★ | 17 | 0 |
| Vintage Health Care Center | 1.8 mi | ★★★★★ | 24 | 0 |
| University Rehabilitation Center | 4.5 mi | ★★★★★ | 7 | 1 |
| Lake Forest Village By Purehealth | 5.6 mi | ★★★★★ | 13 | 0 |
| Denton Rehabilitation And Nursing Center | 7.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.