Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Fair Park Health & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to protect a resident from abuse by another resident. A PTA witnessed one resident strike another resident twice in the chest in the smoking area after an argument. The injured resident, who had COPD, bipolar disorder, and moderate cognitive impairment, said the blows hurt but did not leave bruising. The other resident had schizophrenia and severe cognitive impairment, and the facility had no prior incident history between the two residents.
Two residents with multiple non-pressure and post-surgical wounds did not have consistent documentation of physician-ordered wound care on the treatment administration records. For one resident, daily and PRN wound treatments to a buttock skin tear and an abdominal surgical site were not recorded on numerous days, despite weekly wound physician visits and the resident reporting that care was being provided. For another resident with paraplegia and multiple lower-extremity wounds, daily wound treatments to the ankles and shin were also undocumented on several days, even though the wounds appeared to be healing. The wound care nurse and charge nurses acknowledged that blank entries could mean care was either not provided or not charted, and one RN and an LVN admitted to forgetting or not knowing where to document. The DON stated she expected nurses to document all wound care on the wound administration record and that she reviewed these records but did not detect the missing entries, contrary to facility policies requiring complete documentation of treatments.
Staff failed to follow Enhanced Barrier Precautions, hand hygiene, and aseptic wound care practices for two residents with wounds. For one resident with quadriplegia and protein malnutrition on EBP, an RN and CNA entered the room with an EBP sign posted, placed wound supplies directly on an unclean bedside table, did not wear gowns, repeatedly changed gloves without hand hygiene, reused a saline syringe between wounds, and applied hydrogel and collagen to multiple wounds using a gloved finger. For another resident with metabolic encephalopathy and diabetes, an LVN placed wound supplies on an unclean bedside table, changed gloves multiple times without hand hygiene, left an open tube of hydrogel on the bedside table, and returned partially used gauze, an open hydrogel tube, and an unused dressing from the resident’s room back to the treatment cart, contrary to facility infection control policies.
Several resident rooms were found with trash, spilled liquids, and stained floors and furniture, indicating a failure by housekeeping staff to thoroughly clean and sanitize these areas. Supervisory staff acknowledged lapses in oversight and confirmed that the rooms should have been maintained according to facility policy.
Six residents with cognitive and physical impairments were not properly supervised while smoking, despite care plans and assessments indicating the need for supervision. The assigned CNA was observed using her phone instead of monitoring the residents, contrary to facility policy and expectations. Facility leadership confirmed that staff are required to supervise residents during smoking to prevent accidents.
A resident with chronic respiratory failure and COPD did not have their nasal cannula properly stored in a bag when not in use, as required by facility policy and their care plan. The nasal cannula was found under a pile of clothes on the resident's wheelchair, and staff interviews revealed that checks to ensure proper storage were not performed as expected. This failure was identified through observation, interviews, and record review.
Two residents with significant physical and cognitive impairments were found in bed with their call lights out of reach, making them unable to summon assistance. Staff interviews confirmed that call lights are expected to be within reach and acknowledged lapses in ensuring this, sometimes due to clips falling off or being moved during care. Facility policy requires resident access to communication, but documentation was lacking for one resident.
The facility did not ensure that residents were protected from all forms of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by anyone.
A resident with multiple mental health diagnoses and a positive PASARR screening did not have a complete and accurate NFSS request submitted through the required SIMPLELTC portal. The request was denied, and facility staff did not follow up to ensure approval, resulting in the resident not receiving needed specialized services.
A resident with significant physical impairments and a care plan requiring physical and occupational therapy did not receive these specialized rehabilitative services as ordered. Documentation and staff interviews confirmed the absence of therapy provision, and the facility could not produce relevant therapy service policies when requested by surveyors.
A medication cart was found unlocked and unattended in a hallway, with staff unable to account for the keys or how the cart was left unsecured. Facility policy requires medication carts to be locked or attended by authorized personnel at all times, but this was not followed, resulting in unauthorized access to medications.
Surveyors found that food items in the kitchen's dry storage, refrigerator, and freezer were left unsealed, expired, or dented, and that kitchen A/C vents were dirty and lacked a specific cleaning policy. Dietary staff were unaware of these issues, despite facility policies requiring proper food storage and sanitation.
A resident with impaired cognition and physical limitations did not receive a scheduled shower, despite documentation indicating it was completed. Staff interviews revealed the CNA responsible assumed the shower had been given and documented it without confirmation. The resident reported the missed shower, and records showed the required care was not delivered or accurately documented.
A resident with a history of stroke and muscle spasms did not receive a scheduled dose of Robaxin due to the facility's failure to timely reorder the medication. Staff interviews and records showed that the medication supply was not monitored and reordered as required, resulting in a missed dose. The resident expressed concern about medication availability, and staff acknowledged the oversight and lack of a written policy for medication ordering.
A resident with multiple complex medical conditions and moderate cognitive impairment was discharged home without a completed discharge summary or medication reconciliation. Staff interviews confirmed the required documentation was missing, and facility policy mandates that such summaries include a recapitulation of the stay, final status, medication reconciliation, and a post-discharge care plan.
The facility failed to maintain sanitary conditions for oxygen equipment for two residents. A resident with severe cognitive impairment had her nasal cannula exposed to contaminants, while another resident with moderate cognitive impairment used oxygen tubing that had not been changed according to policy. These oversights increased the risk of respiratory infection.
A resident with severe cognitive impairment and physical limitations was found in a raised bed, contrary to their care plan for fall prevention. The DON acknowledged the oversight, noting the bed should have been lowered after breakfast. The facility's policy on fall prevention was not followed, as no staff was present to address the situation.
A resident with a history of stroke and moderate cognitive impairment did not receive prescribed Methocarbamol at bedtime on multiple occasions, as indicated by unsigned boxes on the Medication Administration Record. The resident reported increased pain when doses were missed. The DON confirmed these were medication errors, as facility policy requires nurses to sign the MAR and report errors.
The facility failed to ensure proper food storage, preparation, and hygiene practices in their only kitchen. Items in the refrigerator were not dated and labeled, an ice scoop was improperly stored, and Cook A did not perform hand hygiene or change gloves after retrieving items from the walk-in refrigerator before handling food.
The facility failed to maintain good grooming and personal hygiene for two residents who required maximal assistance. Both residents were found with long, discolored, and dirty fingernails, indicating a lack of proper nail care despite their care plans requiring extensive assistance.
A facility failed to provide appropriate care for a resident with a G-tube by not checking gastric residual before administering medications. An LVN used air auscultation instead of checking residual volume, contrary to the resident's care plan and physician's orders. The resident had a history of dysphagia, cerebral infarction, and diabetes mellitus, and received more than 51% of his calories through tube feeding.
A facility failed to label or date the oxygen humidifier bottle for a resident requiring respiratory care, despite physician orders and care plan instructions. Interviews revealed that nursing staff were responsible for this task, but it was not completed, posing a risk of infection.
A facility failed to maintain an infection control program when an RN did not perform hand hygiene and change gloves appropriately during wound care for a resident with venous stasis ulcers. The RN handled clean supplies with contaminated gloves, increasing the risk of infection and cross-contamination.
A facility failed to maintain an infection prevention and control program when a CNA did not perform hand hygiene after changing gloves during incontinence care for a resident with Alzheimer's disease. Despite being prompted to change gloves, the CNA did not wash hands before handling a clean brief, which was against the facility's policy and confirmed by the DON.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to ensure a resident was free from abuse, neglect, and corporal punishment when one resident struck another resident in the smoking area. A PTA reported and observed the incident, in which Resident #2 hit Resident #1 in the chest twice while the two were in the smoking area. Resident #1 stated that Resident #2 was talking trash to her, she told him to do something, and he punched her in the heart twice. She said it hurt at the time but did not bruise her, and she reported no other incidents since then. Resident #1 was a [AGE]-year-old female with COPD, bipolar disorder, and a BIMS score of 12 indicating moderate cognitive impairment. Resident #2 was a [AGE]-year-old male with schizophrenia and a BIMS score of 4 indicating severe cognitive impairment. The PTA stated Resident #2 first struck Resident #1 while seated in his wheelchair and then stood up and struck her again in the chest, and that he separated the residents after the assault. The DON stated she was notified by the PTA that Resident #2 hit Resident #1 twice in the chest area and that she completed a head-to-toe assessment with no marks or bruises observed. Record review of the facility incident logs for the prior four months reflected no incidents between the two residents. The DON and Administrator stated Resident #2 had a history of aggression with staff, but this was the first time he was aggressive with another resident. The Administrator also stated Resident #2 was placed on 1:1 monitoring, referred to psychiatric services, and a urinalysis was completed to check for infection. The facility policy stated residents have the right to be free from abuse by anyone, including other residents, and that abuse includes the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
Failure to Accurately Document Physician-Ordered Wound Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and properly documented medical records for residents receiving wound care. For one resident, an older female with an intact BIMS score and diagnoses including unspecified intestinal obstruction and recent surgery requiring skilled care, the care plan identified a sacral wound and a post-surgical abdominal site, with interventions to follow facility policies for prevention and treatment of skin breakdown. Physician orders directed daily and as-needed wound care for a skin tear on the left buttock and a post-surgical abdominal wound, including cleansing with normal saline or wound cleanser, drying with gauze, and applying specified dressings such as hydrogel with silver, xeroform, and bordered gauze. Record review of this resident’s March wound administration record showed no documentation that the ordered wound care for the left buttock skin tear was provided on multiple specific dates, and no documentation that the ordered abdominal wound care was provided on additional specific dates. The wound care physician’s March report reflected that the resident was seen and treated weekly, with no evidence of wound deterioration and all wounds healed, and the resident herself reported she was receiving wound care and that her wounds were healed. However, the wound care nurse stated she was unaware that the treatment record had been left blank on the identified dates, and that when she arrived on Tuesdays the dressings were dated with a previous day’s date and the wounds were not worsening, making it unclear whether care had been provided but not documented or not provided at all. A weekend LVN reported that blank dates probably meant she had performed the wound care but forgot to check the box, and that on some weekends she did not know where to document the wound care; she acknowledged she did not go back to document missed entries or notify the DON. For a second resident, an older male with paraplegia, chronic pain syndrome, muscle weakness, orthostatic hypotension, and moderate cognitive impairment, the MDS and care plan documented non-pressure wounds and skin tears on the lower extremities, including non-pressure wounds to the left and right ankles. Physician orders specified daily and as-needed wound care for multiple trauma and non-pressure wounds on the right lateral shin, right ankle, right lateral foot, and right distal lateral shin, including cleansing with normal saline or wound cleanser, patting dry, applying collagen powder or skin prep, and covering with non-adherent pads, gauze island dressings, or bordered gauze. The March wound administration record for this resident contained no documentation that wound care was provided on several specific dates for the right distal lateral shin, right ankle, and left ankle. This resident reported having wounds on his feet and receiving wound care but was unsure of the frequency, and his dressings were observed dated with a prior date; he stated he did not receive wound care on one day because he was out on pass. On observation, the wounds on his ankles appeared to be healing without signs of infection. The wound care nurse stated she provided wound care Tuesday through Thursday and that charge nurses were responsible on other days; she was not aware the wound administration record had blanks and stated that if the record was not completed, it would be unknown whether wound care was provided or not. An RN assigned Monday through Friday stated she had provided wound care until a new wound care nurse was hired, that she documented in the clinical record, and that blanks on the treatment record meant wound care was not provided or the nurse failed to chart, adding that she was “bad at charting.” Another RN assigned on weekends stated she provided wound care and documented on the treatment record but was unaware of blanks and agreed that blanks could mean care was not provided or not charted. The DON stated that charge nurses were expected to provide wound care when the treatment nurse was absent and to document on the wound administration record, and that she checked treatment records daily but had not realized they were left blank in March; she acknowledged that blank wound reports could indicate wound care was not given. Facility policies on documentation, dressing changes, and wound treatment management required that treatments be documented on the treatment administration record and that documentation reflect care and treatments provided.
Failure to Follow Enhanced Barrier Precautions and Aseptic Wound Care Practices
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program when staff did not follow Enhanced Barrier Precautions (EBP), proper hand hygiene, or appropriate handling of wound care supplies during wound care for two residents. One resident was a male with quadriplegia and protein malnutrition, admitted in November 2025, who had multiple chronic wounds requiring weekly visits from a wound care physician and was care planned for EBP, including use of gown and gloves for wound care and other high-contact activities, and posting of an EBP sign at the room entrance. During an observation, an RN prepared multiple wound care supplies outside the resident’s room, including border dressings, 4x4 gauze, normal saline syringes, hydrogel in a medication cup, and collagen powder in another cup, then entered the room with a CNA where an EBP sign was posted. Inside the room, the RN placed the wound care supplies directly on the bedside table without cleaning the surface or using a barrier. The RN and CNA washed their hands and donned gloves but did not put on gowns despite the resident being on EBP. For the left inner knee wound, the RN removed the old dressing and, with the same gloves, picked up a saline syringe and gauze to clean the wound, then used a gloved finger to dip into the hydrogel cup and apply it to the wound, and did the same with the collagen powder before covering the wound with a border dressing. The RN then removed gloves and re-gloved without performing hand hygiene before proceeding to the right outer ankle wound, where she again used a saline syringe and gauze, laid the partially used saline syringe back on the bedside table with other supplies, opened a package of calcium alginate with the same soiled gloves, applied it to the wound, and covered it with a border dressing. The RN again removed gloves and re-gloved without hand hygiene before performing sacral wound care, using the previously used saline syringe and gauze to clean the wound and applying collagen powder with her gloved finger, followed by calcium alginate and a border dressing. Only after completing all wound care did the RN remove gloves, perform hand hygiene, and leave the room, while the CNA assisted with repositioning and offloading, then removed gloves and performed hand hygiene. For the second resident, a male with metabolic encephalopathy and diabetes admitted in April 2024, an LVN was observed preparing wound care supplies at the treatment cart, including a large package of 4x4 gauze, a tube of hydrogel ointment, tubes of normal saline, and a border gauze dressing. The LVN placed these supplies on the resident’s bedside table without cleaning the table or using a clean field. The LVN washed her hands, donned gloves and a gown, and removed the old dressing from a right upper thigh wound. She then removed her gloves and re-gloved without performing hand hygiene before pulling 4x4 gauze and opening a tube of normal saline to clean the wound. After cleaning, she again removed gloves and re-gloved without hand hygiene, requested a smaller border dressing from the DON, and, upon receiving it, opened the dressing and a tube of hydrogel, squeezing hydrogel onto the dressing and then placing the open tube of hydrogel on the bedside table without closing the lid. After applying the dressing, the LVN removed her gown and gloves, washed her hands, and returned the partially used package of gauze, the open tube of hydrogel, and the unused large border dressing to the treatment cart. Facility policies on EBP and fundamentals of infection control required targeted gown and glove use for residents with wounds, hand hygiene before and after resident contact and after glove removal, and setting up wound care supplies on a clean field, with unused supplies that entered the resident’s room to be discarded. Interviews confirmed staff awareness of some, but not all, of these requirements. The RN acknowledged that any resident with a wound required EBP and recognized she had not worn a gown, stating she had simply forgotten and was not aware she had to set up wound care supplies on a clean field, believing she only needed to change gloves between wounds. The CNA stated she had received training on EBP and knew that residents with a Foley catheter or wound required gown and gloves, but said she forgot to put on a gown when assisting with turning the resident. The LVN stated she knew she was supposed to change gloves when moving from cleaning to treating the wound and should have performed hand hygiene, but was not aware she had to set up supplies on a clean field or that unused supplies brought into a resident’s room could not be returned to the treatment cart. The DON stated that staff were expected to change gloves and perform hand hygiene before going from dirty to clean, before entering and leaving a resident’s room, to follow EBP protocols for residents with posted signs, to set up supplies on a clean field, to avoid applying wound treatments with gloved hands, and to discard any unused supplies brought into a resident’s room, and stated that failing to follow these protocols placed residents at higher risk of infections.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
Surveyors observed that four resident rooms on the 100-hall were not maintained in a clean and sanitary condition. Specific findings included trash and spilled milk on the floor near a resident's bed, large patches of brown and black stains under beds, brownish dirt stains, a large reddish fluid stain near a bed, and a heavily stained bedside table. These observations were made during a facility visit and were confirmed through interviews with housekeeping staff and supervisors, who acknowledged that the rooms should have been cleaned and that the observed conditions were unsanitary. The Housekeeping Assistant Supervisor stated she was absent for two days and that another staff member was responsible for cleaning during that time. The Housekeeping Supervisor admitted that he had not been checking the rooms as required, despite being responsible for ensuring thorough cleaning. The Administrator also confirmed that the expectation was for daily thorough cleaning of resident rooms and recognized the situation as a sanitary and resident rights concern. Facility policy requires consistent cleaning procedures to maintain a safe and odor-free environment for residents, families, and staff.
Failure to Supervise Residents During Smoking Activities
Penalty
Summary
The facility failed to ensure that six residents who were identified as smokers received proper supervision and assistance devices as required to prevent accidents while smoking. Record reviews showed that these residents had various diagnoses, including asthma, COPD, stroke, lack of coordination, schizoaffective disorder, and cognitive impairments ranging from moderate to severe. Care plans and smoking assessments for most of these residents indicated a need for supervision during smoking, yet not all residents had completed smoking assessments or care plans addressing their smoking status. During an observation, all six residents were seen smoking in the designated area while the assigned CNA was present but not actively supervising them. Instead, the CNA was observed sitting and looking at her phone for at least five minutes, failing to monitor the residents as required. The CNA acknowledged in an interview that she was responsible for monitoring the residents, distributing cigarettes, lighting them, and applying smoking aprons when needed, but admitted she was distracted by her phone and not watching the residents as she should have been. Interviews with facility leadership, including the DON and Administrator, confirmed that staff are expected to supervise residents during smoking to prevent accidents and that staff should not be distracted by personal devices. The facility's smoking policy requires regular safe smoking assessments and mandates direct supervision for residents classified as unsafe smokers, specifying that supervisors must maintain direct view and be able to respond quickly in emergencies. Despite these policies, the observed lack of supervision constituted a failure to prevent accident hazards for these residents.
Failure to Properly Store Nasal Cannula for Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure and COPD, who required oxygen therapy via nasal cannula, did not have their nasal cannula properly stored in a bag when not in use. During an observation, the nasal cannula was found under a pile of clothes on the resident's wheelchair, rather than being bagged as required by facility policy and professional standards. The resident's care plan and physician orders specified the use of oxygen therapy, and the facility's policy outlined the need for safe and effective delivery of oxygen, including infection prevention measures such as bagging the nasal cannula when not in use. Interviews with facility staff revealed that the LVN on duty had not checked to ensure the nasal cannula was bagged at the start of her shift, and she indicated that CNAs were responsible for this task. The DON confirmed that nasal cannulas should be bagged when not in use to prevent the transmission of germs and stated that nurses are primarily responsible for checking this during their rounds. The failure to properly store the nasal cannula was identified through observations, interviews, and record review, and was not consistent with the resident's care plan or facility policy.
Call Light System Not Accessible to Residents in Bed
Penalty
Summary
The facility failed to ensure that the call light system was accessible to residents while in bed or other sleeping accommodations for two of five residents reviewed for reasonable accommodation of needs. Observations revealed that one resident, who had a history of stroke, lack of coordination, moderate cognitive impairment, and required total assistance for activities of daily living, was found lying in bed with the call light pull cord hanging from the wall behind him and out of reach. The resident was unaware of the location of the call light. Another resident, with diagnoses of muscle weakness, unsteadiness, moderate cognitive impairment, and extensive assistance needs, was also observed lying in bed with the call light approximately three feet away and out of reach. This resident also did not know where the call light was and requested assistance from the surveyor. Interviews with multiple staff members, including LVNs, a CNA, and the DON, confirmed that call lights are expected to be within reach of residents and that it is the responsibility of all staff to ensure this during their rounds. Staff acknowledged that the call lights had clips to keep them in place, but these sometimes fell off or were moved during care activities such as meal delivery. The facility's policy on resident rights emphasized the importance of treating residents with dignity and ensuring their ability to communicate and access services, but there was no care plan intervention documented for one resident regarding call light use.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, but does not provide specific details about the actions, inactions, or events that led to the deficiency, nor does it mention any particular residents or incidents.
Failure to Submit and Follow Up on PASARR NFSS Request
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Level II PASARR review upon a significant change in status assessment. Specifically, the facility did not submit a complete and accurate request for nursing facility specialized services (NFSS) in the required LTC Online Portal within the mandated 20 business days after the Interdisciplinary Team (IDT) meeting. The NFSS request was submitted electronically but not through the required SIMPLELTC web portal, resulting in a denial, and there was no evidence of follow-up by the facility to ensure the request was approved. The resident involved was an older adult female admitted with multiple diagnoses, including acute kidney failure, major depressive disorder, anxiety disorder, brief psychotic disorder, and generalized anxiety disorder. Her comprehensive MDS assessment indicated she was considered by the state Level II PASARR process to have a serious mental illness, with an intact cognitive status. Her care plan reflected the need for specialized services as recommended by the local authority, and her most recent PASARR Level 1 screening was positive for both a primary diagnosis of mental illness and intellectual disability. Interviews with facility staff revealed that the MDS Coordinator was responsible for completing PASARRs and submitting NFSS requests through the SIMPLELTC portal. However, the submission was not completed as required, and there was a lack of monitoring and follow-up to ensure acceptance of the NFSS request. The facility's policy required timely and accurate submission of NFSS forms, but this process was not followed, resulting in the resident not receiving the necessary specialized services.
Failure to Provide Required Rehabilitative Therapy Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically physical and occupational therapy, as required by the comprehensive care plan for one resident. The resident, a 39-year-old female with diagnoses including acute myocardial infarction and age-related physical debility, was documented as having significant upper and lower extremity impairments and required assistance for all self-care activities. Despite the PASARR Comprehensive Service Plan and PT evaluation indicating a need for daily physical therapy and occupational therapy, there was no evidence in the clinical record that these services were provided as ordered. The resident's care plan also noted the need for assistance with ADLs and risk for falls, with interventions including rehab therapy screening, but no documentation supported that therapy services were delivered. Record reviews showed the absence of active therapy orders and a lack of therapy minutes received, despite the resident's documented needs. Interviews with facility staff confirmed that therapy services should have been arranged, and that delays in therapy approval would typically result in enrollment in restorative care, which also was not documented. The facility was unable to provide therapy service policies when requested by surveyors, and the resident was unaware of the therapy services she was supposed to receive.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on Unit 2 was found unlocked and unattended in a hallway across from the nurses' station. No nurse or medication aide was present in the vicinity at the time of observation. Staff interviews revealed confusion regarding the location of the medication cart keys, with one medication aide stating she did not have the keys and believed the nurse had them, while the nurse stated she had briefly handed the keys to another nurse. The nurse who had counted the cart and received the keys from the night shift was unsure how the cart was left unlocked. Staff acknowledged that the cart should remain locked at all times when not in use and recognized the risk of leaving it unsecured. The facility's policy requires that medications and biologicals be stored securely and only accessible to authorized personnel, with medication carts locked or attended at all times. The incident involved a failure to adhere to this policy, resulting in the medication cart being left accessible for an unknown period. No specific residents were identified as being directly involved or affected at the time of the deficiency.
Deficient Food Storage and Kitchen Sanitation Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, preparation, and kitchen sanitation practices. During an inspection of the kitchen's dry storage, refrigerator, and freezer areas, several food items were found in unsealed packages and containers, including taco seasoning mix, cream cheese icing, chocolate fudge icing, noodles, tri-color pasta, apple sauce, American cheese, ketchup, soy milk, vanilla ice cream, chocolate ice creams, wonton strips, and croissants. Additionally, an expired can of artificially flavored strawberry dessert topping and two dented cans (pineapples and mandarin oranges) were found stored with other canned foods. These items were not properly sealed, labeled, or removed according to professional standards and the facility's own food storage policy. Further observations revealed that six A/C vents in the kitchen had a black substance on them, with two vents located directly above the food preparation table. The vents were found to have dust, dirt, and grease buildup, and there was no specific facility policy for cleaning A/C vents in the kitchen. The maintenance supervisor confirmed that the vents were unclean and that the facility relied on a maintenance management software for logging requests, but did not maintain a physical maintenance log or a specific cleaning schedule for the vents. Interviews with dietary staff indicated a lack of awareness regarding the presence of expired, unsealed, and dented food items in the kitchen. Both the newly hired dietary staff member and a dietary aide with five years of experience stated that all staff were responsible for checking and storing food items properly, but neither was aware of the deficiencies until informed by surveyors. The facility's food storage policy required open packages to be stored in sealed containers and expired or spoiled foods to be discarded, but these procedures were not consistently followed, as evidenced by the survey findings.
Failure to Provide Scheduled Shower and Accurate Documentation for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who required substantial to maximum assistance with activities of daily living, including bathing, did not receive a scheduled shower. The resident, a female with moderately impaired cognition, hemiparesis due to stroke, contractures, and other medical conditions, was scheduled to receive showers on specific days and shifts. Documentation indicated that her shower was marked as completed by a CNA on the scheduled day, but interviews and progress notes revealed that the shower was not actually provided. The resident reported to staff that her shower was missed, and this was confirmed through interviews with multiple staff members. The CNA responsible for documenting the shower admitted to marking it as completed based on an assumption rather than direct knowledge or confirmation that the shower had been given. The CNA also stated that she did not offer the shower because she believed another aide had already provided it, and later realized this was a mistake. The resident did not report the missed shower to the charge nurse at the time, stating that previous complaints had not resulted in changes. Facility records, including the care plan and shower schedule, outlined the expectation that showers be provided as scheduled and refusals be documented and reported to nursing staff. However, in this instance, the required care was not delivered, and the documentation did not accurately reflect the care provided. The failure to provide the scheduled shower and the inaccurate documentation were confirmed through observation, record review, and staff and resident interviews.
Failure to Timely Order and Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring timely ordering and administration of a prescribed medication. A female resident with a history of stroke, hemiparesis, contractures, hypertension, anxiety disorder, and pain was prescribed methocarbamol (Robaxin) 750 mg twice daily for muscle spasms. On the morning of 5/13/25, the resident did not receive her scheduled dose because the medication was not available, as indicated in the Medication Administration Record and confirmed by staff interviews. The resident reported that she had been informed the previous evening that her Robaxin supply was running low and received her last dose at bedtime. She did not receive her morning dose and was told she would have to wait until the evening for the next dose. Staff interviews revealed that the medication should have been reordered when the supply reached the 'blue line' on the medication card, typically about a week before running out. However, the charge nurse acknowledged that he noticed the medication was running low but did not reorder it in time, citing being busy and overlooking the task. The medication was not available in the facility's emergency kit, and the pharmacy only delivered in the evenings on weekdays. The Director of Nursing (DON) and other staff confirmed that all nurses were trained to reorder medications when supplies were low, but there was no written policy available for medication ordering and reordering. The resident expressed concern about the need for medications to be available when needed, although she reported being okay with her pain at the time. The failure to order the medication in a timely manner resulted in the resident missing a scheduled dose, as documented in the facility records and staff interviews.
Failure to Complete Discharge Summary and Medication Reconciliation
Penalty
Summary
The facility failed to complete a required discharge summary and medication reconciliation for a resident who was discharged home. The resident, an older adult male with multiple complex diagnoses including traumatic subarachnoid hemorrhage, Type 1 diabetes, chronic kidney disease, cerebral infarction, and other significant medical conditions, was admitted from a short-term general hospital and had a moderate cognitive impairment as indicated by a BIMS score of 10. Upon planned discharge, there was no documentation in the clinical record of a discharge summary or reconciliation of pre-discharge and post-discharge medications, both prescribed and over-the-counter. Interviews with facility staff revealed that the RN was unable to locate the discharge summary for the resident, and the DON confirmed that the summary had not been completed. The DON acknowledged that discharge summaries are required for all residents who leave the facility and noted the risks associated with not having this documentation, such as the lack of medication reconciliation and missed opportunities for care planning and follow-up appointments. The administrator also confirmed that discharge summaries should be completed and that there was no oversight to ensure that nursing staff managers were completing them for all discharges. A review of the facility's policy indicated that discharge summaries must include a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all medications, and a post-discharge plan of care developed with the resident and their representative. In this case, these required elements were missing from the resident's record at the time of discharge.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in maintaining sanitary conditions for oxygen equipment. Resident #1, a female with severe cognitive impairment and a history of COPD and pneumonia, was observed with her nasal cannula exposed to airborne contaminants on her nightstand instead of being stored in a sanitary container when not in use. Despite being care planned for this behavior, staff did not ensure the nasal cannula was bagged, increasing the risk of respiratory infection. Resident #4, a female with moderate cognitive impairment and diagnosed with COPD and asthma, was found using oxygen tubing that had not been changed since the date marked on it, which was beyond the facility's policy of weekly changes. The tubing was dated 10/07/24, but observations on 10/22/24 and 10/23/24 confirmed it had not been replaced. This oversight was acknowledged by RN A, who stated the tubing should have been changed on the previous Sunday night, as per the facility's policy, to maintain hygiene and prevent infection.
Failure to Maintain Bed in Low Position for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards, specifically by not maintaining the resident's bed in the lowest position as required for fall prevention. The resident, an elderly male with severe cognitive impairment and physical limitations, was care planned for falls with an intervention to keep the bed in a low position. However, during an observation, the resident was found sleeping in a bed that was raised, contrary to the care plan. The Director of Nursing (DON) acknowledged the oversight, noting that the resident was a fall risk and the bed should have been lowered after breakfast. The observation revealed that the bedside table was not moved, and no staff was present on the floor to address the situation. The facility's policy on fall prevention emphasizes minimizing fall risk by managing contributing factors, which was not adhered to in this instance.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident, specifically for one resident who was reviewed for pharmaceutical services. This resident, a female with a history of cerebral infarction affecting the left non-dominant side and moderate cognitive impairment, was prescribed Methocarbamol to be administered at bedtime for muscle spasms. However, the Medication Administration Record indicated that the resident missed several doses of this medication in September and October. The resident reported that she did not always receive her medication at bedtime and that the pain was worse when she missed a dose. The Director of Nursing confirmed that the unsigned boxes on the Medication Administration Record meant the medication was not administered on those dates, identifying this as a medication error. The facility's policy requires nurses to sign the medication administration record and report any medication errors, but this protocol was not followed, leading to the deficiency.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage, preparation, and hygiene practices in their only kitchen. Observations revealed that items in the refrigerator, such as a box of celery and a box of tomatoes, were not dated and labeled. Additionally, an ice scoop was found inside the ice bin, touching the ice cubes, which is against food safety standards. During a lunch meal service, Cook A did not perform hand hygiene or change gloves after retrieving items from the walk-in refrigerator before handling food, which is a breach of sanitation protocols. Interviews with Cook A and the Dietary Manager confirmed these lapses in food safety practices. Cook A acknowledged the importance of hand hygiene and proper labeling but admitted to not following these procedures. The Dietary Manager also emphasized the necessity of dating and labeling food items to prevent food-borne illnesses and confirmed that the ice scoop should not be stored inside the ice bin. The facility's Food Storage and Supplies policy and the FDA Food Code were reviewed, highlighting the importance of these practices to maintain food safety and prevent contamination.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to provide necessary services for residents who are unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #19, a [AGE] year-old female with hemiplegia and contractures, was observed with discolored and dirty fingernails. Despite requiring maximal assistance with personal hygiene, her nails had not been cleaned or trimmed recently. Resident #19 expressed dissatisfaction with the condition of her nails and could not recall the last time they were cleaned by the CNAs. Her care plan indicated she needed extensive assistance with personal hygiene, but this was not adequately provided. Similarly, Resident #22, a [AGE] year-old male with hemiplegia and type 2 diabetes mellitus, was also found with long, discolored, and dirty fingernails. He required maximal assistance with personal hygiene and could not manage his nail care independently. Resident #22 did not inform the staff about his nail condition. Interviews with the CNA and DON revealed that while CNAs were responsible for trimming non-diabetic residents' nails, this care was not consistently provided. The DON acknowledged that nail care should be performed as needed and observed daily, but this standard was not met for these residents.
Failure to Check G-Tube Residual Before Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a G-tube. Specifically, an LVN did not check the placement of the resident's G-tube by checking for gastric residual before administering medications. This failure was observed during a medication administration process where the LVN used air auscultation to check the G-tube placement but did not check for residual volume as required by the resident's care plan and physician's orders. The resident's care plan and physician's orders clearly stated that residual volume should be checked before administering medications, and any residual greater than 100 ml should be reported to the physician and the feeding held. The LVN admitted to not following these protocols during an interview. The resident involved was a male with a history of dysphagia, cerebral infarction, and diabetes mellitus, who received more than 51% of his total calories through tube feeding. The facility's policy on enteral medication administration also required checking the placement of the feeding tube by aspiration of contents or auscultation. Despite being in-serviced on administering medications through an enteral feeding tube, the LVN failed to adhere to these guidelines, potentially putting the resident at risk for complications. The DON confirmed that the staff should always check the placement of the G-tube by checking for gastric residual before medication administration.
Failure to Label and Date Oxygen Humidifier Bottle
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care was provided with appropriate care consistent with professional standards. Specifically, the facility did not label or date the oxygen humidifier bottle for a resident with chronic obstructive pulmonary disease, congestive heart failure, hyperlipidemia, and schizophrenia. The resident's care plan and physician orders indicated the need for oxygen therapy via nasal cannula, with specific instructions to change the oxygen tubing and water weekly. However, during an observation, it was found that the oxygen concentrator was running without a date or label on the humidifier bottle. Interviews with the LVN and DON revealed that the nursing staff was responsible for changing and dating the humidifier bottle weekly, but this was not done in this instance. The LVN acknowledged the oversight and the potential risk of infection due to undated oxygen supplies. The DON confirmed that her expectation was for all oxygen equipment to be dated and labeled, and that the nighttime nursing staff was responsible for this task. The facility's oxygen administration policy aimed to keep residents free from infection, but there was no specific policy for labeling oxygen equipment, which was considered part of routine nursing care.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for a resident with venous stasis ulcers. During wound care, the RN did not perform hand hygiene and change gloves appropriately, which could place residents at risk for infection and cross-contamination. Specifically, the RN did not sanitize her hands after each glove change and handled clean supplies with contaminated gloves. This was observed during a wound care session where the RN repeatedly failed to perform hand hygiene between glove changes while treating the resident's venous ulcers on the left lower leg and foot. The resident involved had a history of peripheral vascular disease and chronic ulcers, requiring moderate assistance with daily activities and occasional incontinence. The RN acknowledged her failure to follow proper hand hygiene protocols, and the Director of Nursing confirmed that staff are required to change gloves and perform hand hygiene when transitioning from dirty to clean tasks. The facility's policy on infection control emphasizes the importance of hand hygiene, particularly before and after changing dressings and after removing gloves.
Infection Control Deficiency During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, which resulted in a deficiency during incontinence care for a resident diagnosed with Alzheimer's disease. During an observation, CNA A did not perform hand hygiene after changing gloves while providing incontinence care. Despite being prompted by CNA B to change gloves, CNA A did not wash her hands before putting on new gloves and handling a clean brief. This lapse in protocol was confirmed through interviews with the Director of Nursing (DON) and CNA A, who acknowledged the importance of hand hygiene in preventing infection transmission. The facility's policy, dated 2019, mandates that staff wash their hands after each direct resident contact when indicated by accepted professional practice. However, this policy was not followed during the observed incident. The DON confirmed that staff are required to perform hand hygiene when changing gloves to prevent the spread of infection. The failure to adhere to this policy placed residents at risk for infection, as evidenced by the actions of CNA A during the incontinence care of the resident.
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.
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What surveyors actually found near you
We read the 1,153 citations issued within 25 miles in the last 12 months — including the 49 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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Simpson Place | 1.4 mi | ★★★★★ | 16 | 0 |
| Ventana By Buckner | 1.7 mi | ★★★★★ | 3 | 0 |
| Avir At Dallas | 2 mi | ★★★★★ | 1 | 0 |
| Southern Oaks Therapy And Living Center | 3.6 mi | — | 0 | 0 |
| Southern Oaks Therapy And Living Center | 3.6 mi | ★★★★★ | 24 | 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.