Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Farwell Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, acute respiratory failure, OSA, Afib, and HF had an oxygen therapy care plan, but staff observed an unsecured oxygen cylinder leaning against a dresser and wall in his room while he was in bed, in a wheelchair, and later being transported elsewhere. The LVN, CNA, CNA trainer, and DON all acknowledged the cylinder was not secured, and the facility’s oxygen safety policy required cylinders to be chained or otherwise fastened to prevent falling.
Improper Storage of Oxygen Cannula: A resident with Parkinson's disease, acute respiratory failure, OSA, AFib, and HF had an O2 concentrator running while his nasal cannula was left on the floor beside the bed and remained there during multiple observations. The LVN, CNA, and DON all acknowledged the cannula should not have been on the floor, and the CNA stated she would still use it. The facility administrator said there was no specific policy for storing the cannula off the floor, although the oxygen safety policy required cannulas and tubing to be stored when not in use in clean zip lock bags.
Two residents with dementia, anxiety, and other comorbidities were involved in an altercation in the lobby when one resident stood up, took hold of another resident’s wheelchair, and moved her away from the entrance door, after which the seated resident struck the other resident’s forearm multiple times. The incident was documented only in one resident’s progress note and not in the other’s, and key staff (ADM, DON, ADON, MA) became aware of the event through reports, documentation, and video review. Despite the facility’s written abuse policy requiring that all alleged violations involving abuse be reported to the Administrator, state agency, and APS within two hours, the incident of one resident hitting another was not reported within the required timeframe, constituting a failure to timely report alleged abuse.
A facility failed to provide privacy during resident treatments for multiple residents. An RN entered rooms without knocking or announcing herself and administered PEG-tube medication, insulin, and injectable medication without closing doors or using privacy curtains, and an RN and CNA also performed wound care on a resident without knocking or providing privacy. The affected residents had significant cognitive and functional impairments, and staff interviews acknowledged the actions were privacy and dignity issues.
RN D failed to follow basic privacy, infection control, and med administration procedures while caring for multiple residents. She did not knock or announce herself, did not provide privacy, did not perform hand hygiene or glove changes at required times, left insulin unattended on the med cart, used a dirty bedside table for equipment, and did not verify g-tube placement before giving meds via enteral tube. The residents involved had diabetes and varying levels of cognitive impairment, and one resident also had a g-tube, epilepsy, and functional quadriplegia.
A nurse failed to perform hand hygiene and glove changes during multiple glucose checks, insulin administrations, and a g-tube medication pass for several residents, and also did not clean the glucometer or use a clean bedside surface. A med aide also administered eye drops without hand hygiene or gloves.
Invalid DNR Order Due to Missing Physician Date: A resident with CKD, DM2, HF, and severely impaired cognition had an OOH-DNR on file, but the physician signed the form without dating it, making the DNR invalid per staff interviews. The care plan listed the resident's advance directive as DNR and stated the resident's wishes would be honored, but the form was not fully completed.
Failure to ensure GDRs were considered for a resident receiving multiple psychotropic meds. A resident with Alzheimer's disease, schizoaffective disorder, anxiety, and recurrent MDD had orders for an antipsychotic, anxiolytic, and antidepressants, but the DRR book had no GDR documentation for any of them. The care plan noted dosage reduction should be considered at least quarterly, while staff interviews showed differing expectations about how often GDRs should be reviewed.
A resident with psychosis, depression, anxiety, and chronic PTSD was not referred for a PASRR Level II review after a significant change in status assessment. The resident’s MDS showed severely impaired cognition, his care plan addressed PTSD-related symptoms, and staff interviews showed confusion about PASRR responsibilities, while the ADM said she was unaware of the PTSD diagnosis.
A resident with anxiety disorder, Parkinson's disease, psychotic disorder with hallucinations, and severely impaired cognition was admitted without a PASARR Level 1 screening completed beforehand. The screening was done after admission, and staff interviews showed confusion about PASARR responsibility and awareness, while the ADM acknowledged that admitting without the screening was against regulations.
A facility failed to develop and implement person-centered care plans with measurable goals and time frames for two residents. One resident with PTSD, anxiety, depression, and impaired cognition had a care plan that was not specific to his trauma history or triggers, and multiple staff members said they had not been trained on trauma-informed care for him or did not know his triggers. Another resident had a physician order for TED hose, but her care plan did not include TED hose interventions, objectives, or time frames, and she was observed without the TED hose in place.
A resident with HF, heart disease, dementia, and CKD had a physician order for daily TED hose, but staff did not apply them and the resident was repeatedly observed without them. The resident stated she had no TED hose and needed aide help to put them on, while a family member said the cardiologist ordered them and she had not seen the resident wearing them. Staff also documented the TED hose task as completed on the TAR even though the resident did not have the stockings in the facility and the nurse and CNA interviewed said they had not provided the service.
Failure to provide trauma-informed care for a resident with PTSD. A resident with severe cognitive impairment and diagnoses including psychosis, depression, anxiety, and chronic PTSD had a trauma screening showing multiple trauma exposures, but there was no evidence of an IDT meeting tied to the screening. Staff interviews showed they did not know his triggers, had not received trauma-informed care training for him, and relied on general approaches such as removing him from situations or letting him lead. The facility policy required individualized, culturally competent care that identifies triggers and minimizes re-traumatization.
Medication Administration and Labeling Discrepancies: A nurse aide prepared meds for 3 residents at once and carried multiple med cups through the dining room while administering them. For one resident with parkinsonism, the Carbidopa-Levodopa bubble pack instructions did not match the MAR order, and staff said the label had been that way for some time. Interviews confirmed staff knew the mismatch and that preparing meds for more than one resident at a time could lead to the wrong resident receiving the wrong medication.
Medication storage and labeling were not consistently maintained. An RN removed a resident’s insulin pen from the treatment cart and left it unattended on top of the cart before entering the resident’s room for a glucose check. Interviews also showed that medication packets and MARs were not matching, and staff described responsibilities for updating orders and placing change-of-order stickers on bubble packs.
Pureed foods were not prepared according to recipe guidance, with dietary staff using leftover sweet potatoes and baked apples to puree bread and altering the flavor, texture, and appearance of the bread, vegetables, and meat. A test tray showed the bread tasted like sweet potatoes or apple pie, the meat was bland, and the vegetables were unidentifiable; the RD stated bread should have been pureed with milk and staff should have followed the preprinted puree recipes.
The facility failed to store and serve food according to food safety standards. Two trays of cake pops were found uncovered, unlabeled, and undated in the walk-in cooler, with one tray stored directly under a pipe with a frozen icicle. Pureed foods were also placed on the steam table about 2 hours before lunch service and remained there until they were served at the end of the meal period, despite the facility policy requiring food to be placed on the steam table no more than 30 minutes before service.
A facility had inaccurate resident records for three residents. One resident’s EHR contained another resident’s NP note, another resident’s TAR showed TED hose as completed even though staff had not applied them and the resident did not have them, and a resident with Parkinsonism had Carbidopa-Levodopa bubble pack instructions that did not match the MAR and physician order.
The facility did not ensure that required trainings—including Abuse, Neglect and Exploitation, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures, and Dementia—were completed by a CNA, dietary aide, housekeeper, LPN, and social worker before they began working with residents. Record reviews showed missing documentation for these trainings, and interviews with the Administrator and DON revealed a lack of oversight and no assigned staff to verify training completion. The facility was also unable to provide a policy on required trainings at hire.
The facility failed to store and label medications properly, with a bottle of Melatonin having an unreadable expiration date and insulin medications with unclear open dates. Additionally, a nurse's medication cart was left unattended and unlocked, posing risks of unauthorized access. Interviews confirmed potential negative outcomes, including drug diversion and uncertainty about medication efficacy.
A resident with severely impaired cognition was fed by an LVN who stood behind her, contrary to the facility's policy requiring staff to be seated at eye level. This action potentially affected the resident's dignity and meal experience, as confirmed by staff interviews and observations.
The facility failed to provide an RN for the required 8 consecutive hours on a specific day, as RN E left her shift early on her last scheduled day. This left the remaining staff without the necessary clinical knowledge to handle emergencies, potentially risking resident care.
A CNA failed to change gloves and perform hand hygiene during incontinent care for a resident with a Foley catheter, leading to a potential risk of cross-contamination. The facility's policies on perineal care and hand hygiene were not adhered to, as confirmed by interviews with the DON and ADON.
Unsecured Oxygen Cylinder Left in Resident Room
Penalty
Summary
The facility failed to ensure that the resident environment remained free from accident hazards and that the resident received adequate supervision to prevent accidents when an oxygen bottle/cylinder was left unsecured in a resident’s room. Resident #1 was an [AGE]-year-old male admitted with diagnoses including Parkinson’s disease, acute respiratory failure, obstructive sleep apnea, atrial fibrillation, and heart failure. His clinical record showed he had been in the facility for 4 days, had not yet had an MDS assessment completed, and had a baseline care plan dated 05/15/2026 listing oxygen therapy use. During observations on 05/19/2026, the resident was seen in his bed, then in his wheelchair outside his room, in the hallway by the physical therapy department, and later being taken to the dining room, while the oxygen bottle remained leaning against the dresser and wall in the corner of his room and was not secured. When asked about the oxygen bottle, the resident gave an unintelligible response. Staff interviews showed the LVN, CNA, CNA trainer, and DON all recognized that the oxygen bottle was unsecured and should have been secured, and the DON stated it was a problem and that the bottle should be secured on the back of a wheelchair or in a small cart. The facility policy titled Oxygen Safety stated cylinders must be properly chained or supported in racks or other fastening devices to secure all cylinders from falling.
Improper Storage of Oxygen Cannula
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained for one resident who was receiving oxygen therapy. The resident was admitted with diagnoses including Parkinson's disease, acute respiratory failure, obstructive sleep apnea, atrial fibrillation, and heart failure. His baseline care plan listed oxygen therapy, and during observation he was in bed with the O2 concentrator on, but his nasal cannula was on the floor beside the concentrator. When asked about the cannula, the resident gave an unintelligible response and could not provide a clear answer. The nasal cannula remained on the floor during repeated observations while the resident was in his wheelchair in his room, in the hallway, and being taken to the dining room. The LVN responsible for the shift stated the tubing should not be on the floor and identified it as an infection control issue. The CNA responsible for the resident stated she would check oxygen but was not allowed to touch it, said she would use the same cannula even though it had been on the floor, and stated it was not an issue. The DON also observed the cannula on the floor and said it was an issue that should have been addressed. The facility administrator stated there was no specific policy for storing the nasal cannula and tubing off the floor, although the facility's oxygen safety policy stated cannulas and tubing are to be stored when not in use in clean zip lock bags accessible to residents.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged resident-to-resident abuse incident to the State Survey Agency and other required authorities, as required by regulation and the facility’s own abuse policy. On 03/27/2026, an altercation occurred between two residents in the lobby near the facility’s front entrance. Video footage reviewed later by the Administrator showed one resident (a male with dementia, behavioral disturbances, weakness, reduced mobility, and major depressive disorder) standing from a chair, walking to a female resident seated in a wheelchair, and placing both hands on her wheelchair handles to move her backward away from the door after an unknown individual attempted to enter. The female resident, who had COPD, anxiety disorder, hypertensive heart disease with heart failure, muscle weakness, was on hospice, and had moderate cognitive impairment (BIMS 11), attempted to push the male resident away with her left arm and then struck his right forearm three times with her right forearm. Record review showed that the incident was documented only in the male resident’s progress note on 03/27/2026 at 11:45 AM as him grabbing another resident’s arm and causing a bruise; there was no documentation of the incident in the female resident’s progress notes. The male resident’s care plan, dated 01/30/2026, already identified him as exhibiting behaviors such as trying to assist other residents, physically aggressive behaviors (hitting, pushing, or kicking), and verbal outbursts, and noted that he received cognitive-enhancing medication for dementia. The female resident’s care plan, dated 03/24/2026, identified her as having excessive worry and anxiety, being prescribed antianxiety medication with associated risks, and having impaired cognitive function and thought processes. Despite these identified behavioral and cognitive issues, the altercation was not treated and reported as an allegation of abuse within the required timeframe. Interviews revealed that the ADM, ADON, DON, and MA were aware of the incident to varying degrees but did not ensure it was reported as required. The ADM stated she did not witness the incident but learned of it from the female resident and initially felt it was not reportable; she later acknowledged that a resident hitting another resident is reportable and should be reported within two hours. The ADON documented the incident in the male resident’s note and stated she did not feel it was reportable because it was not intentional, and she did not view the video or know its contents at that time; she later stated that a resident hitting another resident is reportable. The MA viewed the video, confirmed that the female resident struck the male resident, documented his observations, and emailed the video to the ADM on 03/30/2026. The DON stated the altercation had been reported to her (she could not recall by whom) and that she felt the facility should have reported the incident. The facility’s 2024 Abuse, Neglect, and Exploitation policy defined abuse and alleged violations and required reporting all alleged violations to the Administrator, state agency, APS, and other required agencies immediately but not later than two hours when the events involve abuse, which did not occur in this case.
Failure to Provide Privacy During Resident Treatments
Penalty
Summary
The facility failed to ensure residents were provided personal privacy during medical treatments for 4 of 15 residents reviewed for privacy. During observations, RN D entered Resident #4’s room without knocking or announcing herself and did not close the door before administering medication via the resident’s PEG tube. RN D also entered Resident #38’s room without knocking or announcing herself and did not provide privacy before administering an injectable medication after a blood glucose check. Similar observations were made with Resident #14 and Resident #1, where RN D did not knock or announce herself before entering the rooms and did not close the door or pull the privacy curtain before performing blood glucose checks and insulin administration. Resident #1 was a male with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, heart failure, schizoaffective disorder, bipolar disorder, delusional disorders, major depressive disorder, and intermittent explosive disorder. His most recent MDS assessment showed a BIMS of 06, indicating severe cognitive impairment, and he required varying levels of assistance with bathing, dressing, toileting, hygiene, oral hygiene, and eating. Resident #4 was a female with diagnoses including epilepsy, major depressive disorder, type 2 diabetes mellitus, functional quadriplegia, and dementia. Her most recent MDS assessment showed a BIMS of 00 and total dependency in all care areas. Resident #14 was a male with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, heart failure, schizoaffective disorder, and mild cognitive impairment. His most recent MDS assessment showed a BIMS of 03 and total dependency with toileting, bathing, lower body dressing, footwear, and personal hygiene, with maximal assistance needed for upper body dressing. Resident #38 was a female with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, heart failure, metabolic encephalopathy, dysphagia, cognitive communication deficit, and acute kidney failure. Her most recent MDS assessment showed a BIMS of 12 and moderate cognitive impairment, with maximal assistance needed for toileting, bathing, lower body dressing, and footwear. During a separate observation, RN A and CNA F entered Resident #38’s room to perform wound care without knocking or announcing themselves and without closing the door or pulling the privacy curtain. Interviews with RN D, RN A, CNA F, I-DON, and CN reflected that not knocking, announcing presence, or providing privacy was a privacy and dignity issue and could embarrass residents or invade their privacy. Facility policies reviewed stated residents have a right to personal privacy and confidentiality, that staff are responsible for resident rights, and that privacy must be provided during medication administration and enteral tube medication procedures.
Failure to Follow Privacy, Hand Hygiene, and Medication Administration Procedures
Penalty
Summary
RN D failed to demonstrate appropriate competencies while providing care to multiple residents during medication administration and glucose monitoring. For a resident with a g-tube and diagnoses including epilepsy, type 2 diabetes mellitus, functional quadriplegia, and dementia, RN D did not knock or announce herself, did not provide privacy, did not perform hand hygiene before administering medication via the g-tube, and did not verify g-tube placement before giving the medication. RN D later stated she trusted the prior nurse had checked placement and did not know the facility policy. RN D also failed to knock or announce herself and did not provide privacy while performing blood glucose checks and administering insulin to several residents with diabetes and cognitive impairment. During these observations, RN D did not perform hand hygiene or change gloves before or after preparing the glucometer, checking blood glucose, preparing insulin, or administering insulin. For one resident, RN D left the insulin pen on top of the medication cart unattended in the hallway before entering the room. For another resident, RN D used a bedside table that was dirty from an unidentified spilled liquid to place the glucometer. RN D also removed gloves in the hallway at the medication cart and, when gloves would not fit, wiped her hands on her scrubs before putting on clean gloves. RN D continued using the same gloves between residents and did not perform hand hygiene between treatments of one resident and another. She also did not perform hand hygiene after completing care for residents. During interviews, RN D stated that not knocking or announcing oneself would affect privacy and that hand hygiene or glove changes could lead to infection control issues. Facility policies reviewed included resident rights, quality care, training requirements, medication administration via enteral tube, medication administration, and hand hygiene, all of which required privacy, hand hygiene, glove use, and verification of enteral tube placement before medication administration.
Infection Control Lapses During Medication and Glucose Monitoring
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 6 of 15 residents reviewed for infection control. During observations, RN D did not perform hand hygiene or change gloves before or after preparing a glucometer, checking blood glucose, preparing insulin, and administering insulin for Resident #1, Resident #14, Resident #38, and Resident #57. RN D also failed to perform hand hygiene before administering medication via g-tube to Resident #4. MA E did not perform hand hygiene or don gloves before administering eye drops to Resident #27. Additional observations showed RN D did not clean the glucometer before or after the glucose check for Resident #38 and used the same gloves while moving between residents and tasks. RN D placed the glucometer, lancet, and alcohol wipe on Resident #57's bedside table even though the surface was dirty from an unidentified spilled liquid. RN D also removed gloves in the hallway at the medication cart, wiped her hands on her scrubs when gloves would not fit, and then placed her hands in clean gloves before administering insulin to Resident #57. RN D did not remove gloves or perform hand hygiene between treating Resident #14 and Resident #1.
Invalid DNR Order Due to Missing Physician Date
Penalty
Summary
The facility failed to ensure that Resident #1 had a valid advance directive for a DNR order because the physician did not date the OOH-DNR document, rendering it invalid. Resident #1 was a [AGE]-year-old male admitted with diagnoses including chronic kidney disease, type 2 diabetes, and heart failure. His quarterly MDS showed a BIMS score of 6, indicating severely impaired cognition, and his care plan identified his advance directive as DNR and stated that his wishes would be honored throughout the review period. Record review of the Texas OOH-DNR form showed that Resident #1 and a notary signed the document, and the physician signed it, printed his name, and provided his license number, but the physician date line was blank. During interviews, RN A, I-DON, CN, and ADM stated that staff were responsible for ensuring advance directives were honored and that a DNR not dated by the physician was not valid. The facility policy stated that it supports and facilitates a resident's right to formulate advance directives, and the OOH-DNR instructions stated that a fully and properly completed order is sufficient evidence of the original order and shall be honored.
Failure to Ensure Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications had gradual dose reductions attempted or documented as clinically contraindicated. Resident #7 was admitted with diagnoses including Alzheimer's disease, schizoaffective disorder bipolar type, anxiety disorder, major depressive disorder recurrent, and generalized anxiety disorder. Her quarterly MDS showed a BIMS score of 5, indicating severely impaired cognition, and her MDS coded her for antipsychotic, antidepressant, and antianxiety medication use. Her care plan noted she received antidepressant, antianxiety, and antipsychotic medications and included an intervention to consult with pharmacy and the MD to consider dosage reduction when clinically appropriate at least quarterly. Record review showed orders for Abilify, buspirone, mirtazapine, and paroxetine, but the facility's Drug Regimen Review book contained no mention of gradual dose reductions for any of these medications. During interview, the CN stated the facility was responsible for ensuring gradual dose reductions were considered for every resident receiving psychotropic medications at least yearly, while the Pharm stated gradual dose reductions should be addressed at least quarterly. Facility policy stated that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable well-being free from unnecessary drugs, but the policy did not address gradual dose reduction for psychotropic medications.
Failure to Refer Resident With PTSD for PASRR Review
Penalty
Summary
The facility failed to refer a resident with a newly evident or possible serious mental disorder to the state designated authority for a PASRR Level II resident review after a significant change in status assessment. Resident #6 was admitted with diagnoses that included unspecified psychosis not due to a substance or known physiological condition, depression, anxiety disorder, and chronic post-traumatic stress disorder. His quarterly MDS showed a BIMS score of 7, indicating severely impaired cognition, and his active diagnoses included PTSD. His care plan addressed excessive worry, nervousness, unease, and PTSD-related symptoms such as anxiety, hypervigilance, sleep disturbance, and intrusive memories. Record review showed the resident’s prior PASRR Level 1 screening, completed by the MDS Coordinator at the previous facility, coded him as having no mental illness, and there were no other PASRRs in the EHR. During observations, the resident was seated in the dining room and common area, did not respond to questions, and made chewing motions while looking into the middle distance. Staff interviews showed RN A did not know what PASRR was, the I-DON was unsure who was responsible for ensuring referrals, and the ADM stated she was responsible for referrals but was unaware the resident had a diagnosis of PTSD. The facility policy stated that any resident with a newly evident or possible serious mental disorder, intellectual disability, or related condition would be referred promptly for a level II resident review.
PASARR Screening Not Completed Before Admission
Penalty
Summary
The facility failed to perform a PASARR Level 1 screening prior to admission for Resident #29, who was admitted from home. The resident's admission record showed diagnoses including anxiety disorder, Parkinson's disease, and psychotic disorder with hallucinations due to a known physiological condition. His quarterly MDS documented a BIMS score of 3, indicating severely impaired cognition, and listed active diagnoses of anxiety disorder and psychotic disorder. His care plan also addressed use of antipsychotic, antidepressant, and antianxiety medications. Record review showed the resident's PASARR Level 1 Screening was completed four days after admission rather than before admission. During interviews, an RN stated she did not know what a PASARR was, the I-DON was unsure who was responsible for ensuring the screening was completed prior to admission, and the CN stated the MDS LVN was responsible for ensuring residents had a PASARR Level 1 Screening prior to admission. The ADM stated she was responsible for ensuring residents had a PASARR Level 1 Screening prior to admission and acknowledged that admitting a resident without it was against regulations.
Incomplete Person-Centered Care Plans for PTSD and TED Hose Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and time frames for two residents. One resident had diagnoses including unspecified psychosis, depression, anxiety disorder, and chronic PTSD, with a BIMS score of 7 indicating severely impaired cognition. His care plan included general statements about trauma history, triggers, coping strategies, and monitoring for re-traumatization, but staff interviews showed they did not know his triggers, had not received trauma-informed care training for him, and the interdisciplinary team could not describe specific details of his trauma. The resident was observed in the dining room on multiple occasions appearing disengaged, not responding to questions, and making chewing motions with his mouth. Staff interviews showed inconsistent knowledge about the resident’s PTSD-related needs. An RN, multiple CNAs, the I-DON, the MA, and the CN all stated they had not received training on providing trauma-informed care for him or did not know his triggers. The I-DON stated the resident was simply monitored, removed from situations if anxious, and sometimes put to bed to calm down, but she did not know details of his trauma. The ADM stated staff had been trained on aggressive behaviors but was not aware the resident had PTSD. A second resident had diagnoses including heart failure, heart disease, muscle weakness, dementia, and chronic kidney disease, and had a physician order for TED hose daily. Her care plan did not include TED hose care, measurable objectives, interventions, or time frames. She was observed without TED hose on, and she stated she had not been aware she was supposed to wear them and would need help putting them on. A CNA stated the resident did not have an order for TED hose and had never put them on, while other staff stated care plans were handled by the interdisciplinary team and should be specific to each resident.
TED Hose Order Not Followed and Incorrectly Documented
Penalty
Summary
The facility failed to ensure a resident received treatment and care in accordance with physician orders when TED hose were not applied as ordered. Resident #36 was an 84-year-old female admitted with diagnoses including heart failure, heart disease, muscle weakness, dementia, and chronic kidney disease. Her care plan noted she was sometimes incontinent, at risk for fluid overload, and needed some assistance with ADLs, and her quarterly MDS documented a BIMS score of 14 out of 15, indicating intact cognition. Record review showed an active physician order for TED hose to be used daily with a start date of 11/13/25. During observation and interview, the resident stated she had not had TED hose on, had not been aware she was supposed to wear them, and said she was not able to bend over to put them on herself and would need aide assistance. On a later observation, she was again seen without TED hose and stated she had none. A family member stated the cardiologist had written the order, that she had brought it back to the facility front office, and that she had not seen the resident wearing TED hose during repeated visits. Staff interviews and record review showed the TED hose task was documented as completed even though the resident did not have TED hose in the facility and had not been wearing them. The I-DON stated she had initialed the TAR boxes and later said she must have clicked the wrong box by mistake, and also stated the facility had not ordered the TED hose yet. CNA B stated she had never put TED hose on the resident and did not know there was an order. RN A stated she had not provided the service and had just clicked the boxes on the TAR. The CN stated the nurse providing the treatment was responsible for checking the TAR and that it was never correct to check the boxes without providing services.
Failure to Provide Trauma-Informed Care for a Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma and PTSD received trauma-informed and culturally competent care. Resident #6 was admitted with diagnoses that included unspecified psychosis, depression, anxiety disorder, and chronic PTSD. His quarterly MDS showed a BIMS score of 7, indicating severely impaired cognition, and his care plan identified that his history of trauma and PTSD could affect his emotional well-being, daily functioning, and response to care. The care plan also listed interventions to assess trauma history and triggers, develop individualized approaches that avoid known triggers, educate staff on trauma-informed care, monitor for re-traumatization, and document triggers and calming strategies. Record review showed a Brief Trauma Questionnaire was completed by the resident representative and indicated yes responses to multiple trauma-related events, including war-related exposure, life-threatening illness, serious injury or fear of injury, violent death of a close family member or friend, and witnessing serious injury or death. The form also indicated that an IDT meeting regarding interventions and plan of care was to occur, but the ADM stated there was no evidence that such a meeting had taken place. The facility policy required trauma-informed care that accounts for resident experiences and preferences, identifies triggers, and uses screening and assessment tools to minimize re-traumatization. During observations, Resident #6 was often nonresponsive to questions, looked into the middle distance, and made chewing motions with his mouth. Staff interviews showed multiple employees did not know his trauma triggers and had not received training on trauma-informed care for him. Some staff described only general approaches such as keeping him comfortable, removing him from situations, or letting him lead, while others identified possible triggers such as Westerns on TV, loud voices, moving too quickly, or getting too close to his personal space. The I-DON stated she did not know the details of his trauma, and the ADM stated she was not aware he had PTSD. The CN stated the resident’s PTSD could be negatively affected if staff did not know his triggers and might inadvertently place him near situations that could trigger him.
Medication Administration and Labeling Discrepancies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet each resident’s needs, including procedures to assure the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals. During a medication pass observation, MA C prepared medications for 3 separate unidentified residents and carried 3 medication cups around the dining room while administering medications. MA C stated the cups contained medications for 3 different residents and that she had written the residents’ names on the cups. Resident #41 was admitted with diagnoses including parkinsonism and had a BIMS of 15 on the most recent MDS, indicating no cognitive impairment. The resident’s physician order directed Carbidopa-Levodopa 25-100 mg, 1 tablet by mouth three times daily at 12:00 pm, 5:00 pm, and 9:00 pm, and the MAR reflected that order. However, during medication pass observations, the bubble pack for Resident #41’s Carbidopa-Levodopa showed instructions to take 1 tablet by mouth four times daily, which did not match the current MAR order. Staff interviews confirmed the discrepancies and the medication administration practices. MA E stated the bubble pack had always been like that and that she had told the supervisor, but nothing was changed. MA H stated staff question the label all the time. I-DON stated it was her and the charge nurses’ responsibility to ensure orders were updated in the system when a new or changed order was received, and she was unaware that medication packets and MARs were not matching. I-DON and CN also stated that preparing medications for more than one resident at a time could lead to the wrong resident receiving the wrong medication, and the facility policy required staff to compare the medication source with the MAR to verify the resident name, medication name, form, dose, route, and time.
Medication Storage and Labeling Deficiency
Penalty
Summary
Drugs and biologicals were not consistently stored in locked compartments and were not always labeled in accordance with accepted professional principles. During an observation on 12/14/2025 at 7:17 PM, RN D removed Resident #38’s insulin pen from the treatment cart and placed it on top of the cart, leaving it unattended before going into the resident’s room to perform a glucose check. Resident #38 was a female admitted with type 2 diabetes mellitus with diabetic neuropathy, and her most recent MDS dated 12/02/2025 showed a BIMS of 12 with moderate cognitive impairment and need for assistance with multiple activities of daily living. Record review and interviews also identified concerns with medication storage and order accuracy. I-DON stated she was unaware that medication packets and MARs were not matching, and stated it was her responsibility and the charge nurses’ responsibility to ensure orders were updated in the system when new or changed orders were received. CN stated that the nurse who takes a new order is responsible for placing it into the MAR and for placing a change-of-order sticker on the bubble pack for the medication. The facility policy titled Medication Administration, dated 09/01/2023, required staff to follow the six rights of medication administration and to compare the medication source with the MAR to verify the resident name, medication name, form, dose, route, and time.
Pureed Foods Prepared Improperly
Penalty
Summary
The facility failed to prepare pureed foods by methods that conserve nutritive value, flavor, and appearance for 3 of 5 pureed food items reviewed for meal service, including pureed bread, pureed vegetables, and pureed meat. During an observation on 12/14/25, dietary staff stated the lunch pureed foods had already been prepared and that leftover sweet potatoes from the day before had been used in the bread. The staff member also stated she regularly used leftover cake, fruit, and sweet potatoes to puree bread for the 4 residents on pureed diets. At the lunch meal test tray, the pureed bread was described as thick, extremely sweet, and tasting like sweet potatoes rather than bread; the beef roast was very bland and needed salt; and the pureed vegetables were unidentifiable and tasted sweet. On 12/15/25, dietary staff stated the bread had been pureed with baked apples, which were also being used for dessert that day, and the bread tasted like apple pie and was thick in consistency like glue. The RD stated foods should not be prepared with leftover foods like sweet potatoes or fruit, that bread should have been pureed with a liquid like milk, and that staff should follow the preprinted puree recipes. The DM stated there were no recipes for pureed bread and no policies for pureed foods, and that the cooks used a handout titled Pureed Food Guidelines.
Food Storage and Meal Service Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observation of the walk-in cooler, two trays of cake pops were found on the top shelf of the cooler rack, with one tray sitting directly under a pipe that had a frozen water icicle hanging from it. Both trays were uncovered, unlabeled, and undated. The facility policy stated refrigerated foods are to be dated, labeled, tightly sealed, and stored away from overhead pipes and other contamination. The facility also failed to follow its own food holding and service procedures for pureed meals. A kitchen staff member stated the pureed foods for lunch were prepared and placed on the steam table at 10:00 a.m., even though lunch service was not scheduled to begin until 12:00 p.m. Observations showed the pureed foods remained on the steam table at 11:00 a.m., 12:00 p.m., and 12:30 p.m., and were not served until 12:40 p.m. The facility policy stated food is to be placed on the steam table no more than 30 minutes prior to meal service. The RD and DM both stated the cake pops should have been covered, labeled, and dated, and the DM stated the pureed foods were not usually put on the serving line that early.
Inaccurate resident records and mismatched treatment and medication documentation
Penalty
Summary
The facility failed to maintain accurate medical records for three residents reviewed for record accuracy. For one male resident with diagnoses including unspecified psychosis, depression, anxiety disorder, and chronic PTSD, the electronic health record contained a nurse practitioner progress note dated 01/24/25 for a female resident with the same last name. The resident’s quarterly MDS showed a BIMS score of 7, indicating severely impaired cognition, and his care plan had been completed earlier in the year. Staff interviewed stated that resident records needed to be accurate and that another resident’s progress note should not be in his chart. The facility also failed to ensure that documentation of treatment matched the care actually provided for a female resident with chronic systolic heart failure, diastolic heart failure, and chronic kidney disease. Her physician’s order directed daily TED hose use, but observation and interview showed she was not wearing TED hose and stated she did not have any. She also stated she had not been aware she was supposed to wear them and could not bend over to put them on without help. A CNA stated she had not been aware of any TED hose order and had never applied them. Review of the TAR showed the TED hose boxes had been checked as completed by nursing staff, and the I-DON and RN stated they had clicked the boxes even though they had not provided the treatment and the resident did not have TED hose in the facility. The facility further failed to ensure that a female resident with Parkinsonism had medication packaging that matched her current medication order. Her physician’s order and MAR directed Carbidopa-Levodopa 25-100 mg three times daily, but observation of the bubble pack showed instructions to take one tablet four times daily. Staff stated the bubble pack had always been labeled that way, that the discrepancy had been brought to supervision before, and that the medication cards and MARs were not matching. The I-DON and CN stated it was the responsibility of nursing staff to ensure orders were updated and that the medication source matched the MAR, and staff acknowledged that inaccurate instructions could result in the wrong dosage being given.
Failure to Ensure Completion of Required Staff Training Prior to Resident Care
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, including those providing services under contract and volunteers, as required. Record reviews for five employees—a CNA, a dietary aide, a housekeeper, an LPN, and a social worker—showed missing documentation of required trainings such as Abuse, Neglect and Exploitation, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures, and Dementia. These trainings were not completed prior to or on the employees' first day of employment, and in some cases, multiple required trainings were missing for the same individual. Interviews with the Administrator and DON confirmed awareness of the required trainings but revealed that no staff member was assigned to verify completion of these trainings before staff began working with residents. The Administrator stated that trainings were assigned through the facility's online portal, but it was left to each staff member to ensure completion. The DON acknowledged that there should be oversight to confirm all trainings are completed and understood, but this process was not in place. Additionally, the facility was unable to provide a policy or procedure regarding required trainings at hire when requested.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and labeled according to professional principles. During an observation, a bottle of Melatonin with an unreadable expiration date was found on medication cart #2. Additionally, five insulin medications in the nurse's medication cart had unclear open dates, which the LVN could not interpret. This lack of clarity in labeling could lead to uncertainty about the effectiveness of the medications. Furthermore, the nurse's medication cart was left unattended and unlocked while the LVN went to retrieve a resident for a treatment. This action posed a risk of unauthorized access to medications, which could result in drug diversion or accidental administration to the wrong resident. Interviews with the LVN and the DON confirmed the potential negative outcomes of these deficiencies, including the risk of residents accessing medications unsupervised and the uncertainty of medication efficacy due to unclear labeling.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity during meal assistance, as observed by surveyors. A Licensed Vocational Nurse (LVN) was seen standing behind and to the right of a resident while feeding her breakfast, rather than being seated at eye level. This action was contrary to the facility's policy, which requires staff to be seated and face the resident to provide necessary cues and maintain dignity. The resident, who has severely impaired cognition and requires supervision or touching assistance for eating, was observed being fed in a manner that did not allow for adequate interaction or comfort. The resident's care plan indicated that she should receive assistance with eating by one person while seated at the assist table in the dining room. The care plan also emphasized the importance of minimizing distractions during mealtime and providing only the necessary assistance to ensure adequate meal intake. Despite these guidelines, the LVN was observed feeding the resident while standing, which could potentially affect the resident's dignity and meal experience. The resident's family member, who is also a resident of the facility, noted that the resident usually feeds herself, suggesting that the assistance provided was not in line with the resident's usual routine. Interviews with facility staff, including the LVN, Administrator (ADM), Director of Nursing (DON), and Vice President of Care (VP of C), confirmed that standing while feeding a resident is a dignity issue. The LVN acknowledged that standing to feed the resident was inappropriate and could lead to negative outcomes, such as the resident feeling rushed or not eating as much. The facility's policy on meal supervision and assistance emphasizes the importance of providing a calm and enjoyable environment during mealtimes, which was not adhered to in this instance.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a registered nurse (RN) for at least 8 consecutive hours on September 2, 2024, as required by policy. During a 90-day review period, it was found that on this specific day, only 6 hours of RN coverage were provided. This deficiency was identified through a record review of the facility's RN coverage census. The absence of an RN for the required duration could potentially place residents at risk of not receiving necessary care and services to maintain their highest practicable level of well-being. The deficiency occurred because RN E, who was scheduled to work from 8 AM to 5 PM, resigned and left her shift early, clocking out at 2:34 PM. The Director of Nursing (DON) was aware of RN E's dissatisfaction and her intention to leave the facility early on her last scheduled day. Despite the DON's request for RN E to complete her shift, she left approximately 2.5 hours early. The DON acknowledged that the remaining staff lacked the clinical knowledge to handle emergencies without an RN present. Although the DON considered reporting RN E to the Texas State Nursing Board for abandoning her shift, she ultimately decided against it.
Infection Control Lapse During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA B during the provision of incontinent care to a resident with a Foley catheter. During the care, CNA B did not change gloves or perform hand hygiene after removing a soiled brief and before handling a clean one. This lapse in protocol was observed during an inspection, and CNA B acknowledged the mistake, attributing it to panic and recognizing the risk of cross-contamination. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the potential negative outcomes of such lapses, including cross-contamination and increased infection risk. The facility's policies on perineal care and hand hygiene were reviewed, revealing that they require glove changes and hand hygiene in situations like those observed. However, these protocols were not followed by CNA B during the incident.
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 93 citations issued within 25 miles in the last 12 months — including the 2 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 Farwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clovis Healthcare And Rehabilitation Center | 8.2 mi | ★★★★★ | 23 | 0 |
| St. Anthony Healthcare And Rehabilitation Center | 10.5 mi | ★★★★★ | 37 | 0 |
| Retirement Ranches Inc. | 11.1 mi | ★★★★★ | 9 | 0 |
| Park View Nursing Care Center | 20.4 mi | ★★★★★ | 24 | 2 |
| Coronado Care Center | 23.1 mi | ★★★★★ | 0 | 0 |
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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.