Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Focused Care At Odessa during CMS and state inspections, most recent first.
Laundry equipment was not maintained in safe operating condition. A resident with ESRD on dialysis reported that clothes came back stinking, while the Laundry Supervisor said the industrial washer kept breaking down, hot water was not getting hot, the wrong soap was being used for resident clothing, and the department lacked a hopper for washing soiled linens. Observation showed a small washer overfilled with sheets, and staff gave mixed reports about washer breakdowns and linen shortages.
Medications Left Unattended at Bedside: A resident with ESRD on dialysis and intact cognition had prescribed phosphate binder tablets left in a cup on her bedside table instead of being taken under staff supervision with meals. The DON stated the meds should have been given with supervision and returned to the cart if not taken, and the MA acknowledged leaving them unattended after the resident did not take them during the pass.
Broken Window Blinds and Littered Smoking Area: The facility failed to maintain a safe, functional, sanitary, and comfortable environment in a resident room and the smoking area. Observation showed broken blinds in a room occupied by two residents, and the smoking area and outside patio were littered with smoked cigarette butts. The DON said the blinds had been broken by the resident and had already been replaced once, while the Administrator and Regional Maintenance Supervisor gave differing expectations for cleaning the smoking area, which was documented on a cleaning log.
Improper Food Storage and Labeling in Kitchen: Surveyors observed raw cabbage in the reach-in cooler with black and rotten leaves, and an opened bag of grits in dry storage that was not sealed and had no open date. The FSS and Administrator acknowledged the food items were not properly stored, and the report cited facility policy and FDA Food Code requirements for protecting food from contamination and keeping opened packages sealed, labeled, and dated.
A resident with severe cognitive impairment, Parkinson’s disease, schizophrenia, and significant mobility limitations, dependent on staff for transfers and using a wheelchair/Broda chair, was allegedly pulled up by the shirt in an abusive manner by an LVN, as documented in a CNA’s written note. The note was found under the SW designee’s office door and given to the Administrator, who, along with the SW designee, interviewed the resident; the resident reported sliding down in the chair and being pulled up by the shirt, and other residents reported feeling scared of the LVN. Despite the facility’s abuse policy requiring immediate (within 2 hours) reporting of all abuse allegations to the State Agency, the Administrator did not report this allegation, stating it was because the resident said the LVN had only pulled him up by his shirt.
Missing informed consent for increased psychotropic dose: A resident with dementia-related diagnoses and behavior disturbance had Seroquel ordered for behaviors, then later increased from 25 mg BID to 50 mg BID. The record contained consent only for the original dose, with no updated consent for the higher dose. The DON stated she was not aware a new consent was needed when the dose increased and could not provide a policy on psychotropic medication consents.
Failure to Protect Privacy During Personal Care: A resident with dementia and frequent bowel and bladder incontinence received incontinent care and a clothing change while the window blinds remained open toward the parking lot. During care, the resident's private areas and breasts were exposed. The CNAs stated they should have closed the blinds, and the DON and Administrator said staff were expected to close the door, pull the privacy curtain, and close the blinds during personal care.
Nursing staff lacked competency to read and implement resident care plans. An LVN stated she did not know how to read care plans and had not received training on reading or implementing them, despite working at the facility for years and knowing the plans were in PCC. The MDS Coordinator, DON, and Administrator stated staff were expected to know care plans and that care plans were developed and updated by the MDS Coordinator and DON; however, the only in-service provided as care plan training was a transfer techniques in-service, and it did not include the LVN.
The facility did not ensure that staff received adequate and consistent training on bomb threat preparedness, as evidenced by multiple staff members' inability to describe appropriate procedures and inconsistent responses to a resident's bomb threat. Despite some in-services and policy documents, staff were unclear on key steps such as information gathering, notification, and evacuation, resulting in a deficiency in emergency preparedness training.
Six residents receiving oxygen therapy did not have required 'No Smoking' or oxygen signs posted outside their rooms, despite facility policy mandating such signage. These residents, with diagnoses including heart failure, COPD, and respiratory failure, were observed using oxygen without appropriate door signage. Facility leadership interviews revealed no designated staff responsible for posting signs and a lack of awareness of the policy requirement.
A resident with multiple fall risk factors and a history of falls did not have a floor mat at the bedside as required by the care plan, resulting in a fall with head injury. Staff interviews confirmed the absence of the mat at the time of the incident, despite established protocols and policies for fall prevention.
A resident with profound intellectual disabilities and multiple complex medical conditions did not have PASRR recommendations fully incorporated into their assessment and care plan. The facility failed to submit a complete and accurate NFSS request in the required online portal within the mandated timeframe, resulting in delays in obtaining specialized services and equipment identified as necessary for the resident's care.
A resident with a history of seizures, poor coordination, aphasia, and psychiatric conditions was placed in isolation for shingles, but the facility failed to post required isolation signage on the door. Although PPE was available outside the room and staff were aware of the contact precautions, the absence of signage was observed and confirmed by staff interviews, indicating a lapse in the infection prevention and control program.
A resident with a history of mental health diagnoses reported feeling abused when a nurse withheld medication after a hospital return. The incident was communicated to facility leadership, and the nurse was reassigned, but the administrator did not report the allegation to state authorities as required by policy, citing a lack of corroboration and misunderstanding. This failure to report the abuse allegation constituted a deficiency.
A resident with profound intellectual disabilities, physical impairments, and limited mobility was repeatedly observed lying in bed without any individualized or in-room activities, despite care plan requirements. Staff interviews revealed a lack of awareness and implementation of activity provision, and the activities staff had not supplied engagement items or entertainment, resulting in unmet psychosocial and physical needs.
A resident receiving continuous tube feeding was not consistently maintained with the head of bed elevated as required by physician orders and the care plan. Observations showed the resident lying flat despite ongoing feeding, and staff interviews revealed inconsistent understanding and implementation of proper positioning. The facility's policy did not specify required bed elevation, and staff reported a lack of recent training on G-tube monitoring and positioning.
A resident with multiple medical conditions returned from the hospital after a fall, but the assigned LVN did not document the return, including time, new orders, or vital signs. Staff interviews confirmed that required documentation was not completed, and facility leadership acknowledged the deficiency.
The facility's kitchen failed to meet food safety standards, with issues such as rotting food, improper storage, and inadequate staff training on sanitizer use and handwashing. The Dietary Manager acknowledged these problems, noting lapses in staff responsibilities and training.
The facility failed to uphold resident dignity and respect, as staff were observed using cell phones in residents' presence, causing feelings of disrespect and neglect. Residents reported delays in care due to staff phone use, and assigned seating in the dining room was enforced without resident consent. Clothing was labeled in large print, further impacting resident dignity. Interviews with staff, including the DON, confirmed these practices and acknowledged the ongoing issue of cell phone use during care.
A facility failed to provide adequate supervision and safe transfer practices for three residents. One resident had his leg improperly secured to a wheelchair with a gait belt, leading to skin tears. Another resident, with severe mobility impairment, was transferred unsafely by a CNA without assistance or a gait belt. Two CNAs used an improper technique to transfer a resident on hospice care. The facility's policies on safe lifting and movement were not followed, resulting in potential harm.
The facility failed to maintain an effective infection prevention and control program during incontinent care for three residents. CNAs did not change gloves or perform hand hygiene between tasks, leading to potential cross-contamination. Despite competency checks, the CNAs did not adhere to the facility's infection control policies.
A facility failed to implement a comprehensive care plan for a resident's ankle enabler. The resident, with severe cognitive impairment and physical limitations, was observed with his leg secured to a wheelchair using a gait belt, which was not documented in his care plan. The physical therapist and MDS Coordinator were unaware of this practice, indicating a lack of communication and adherence to the facility's policy for individualized care plans.
The facility failed to ensure proper documentation of oxygen orders for two residents who occasionally used oxygen therapy. Despite the presence of oxygen concentrators in their rooms, there were no formal orders or care plans in place, as confirmed by the DON.
The facility failed to date and initial wound dressings for a resident with skin tears on bilateral elbows and shoulders, as required by facility policy. This oversight was confirmed by the DON, who acknowledged that the failure could lead to not knowing when the dressings were last changed and who changed them.
Laundry Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the laundry room’s mechanical and patient care equipment in safe operating condition. During observation and interview, the Laundry Supervisor stated the industrial washer had been breaking down and the hot water was not getting hot. She also stated the facility was using special soap for resident clothing, but the order had not been placed on time and would not be delivered until 6/1/26. She said the soap used for bed linens and towels would eat resident clothing, that she had not obtained regular soap from petty cash or another facility, and that the laundry department did not have a hopper for washing off bowel movements from linens. The Laundry Supervisor further stated the third washer may or may not clean resident clothing and that laundry staff were doing half loads. Observation showed the smallest washer was overfilled with sheets, with too many sheets for the agitator to move them. Resident #1, a female with ESRD on dialysis and intact cognition, stated her clothes came back stinking and that the facility washed poop linens in the same washer as resident clothes. The Housekeeping Supervisor stated there were three laundry detergents available to order and that she did not know to order the soap from the chemical company. CNA staff gave mixed reports about laundry and linen availability, with one stating the washer broke during the week of 5/11/26 through 5/15/26 and another stating there were sometimes issues with enough linens and that residents sometimes went without showers. Review of repair receipts showed routine maintenance on the washing machine, and the Administrator stated there was no policy for essential equipment.
Medications Left Unattended at Bedside
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when MA A left Resident #1's medications unattended on the bedside table instead of ensuring they were taken at the time of administration. Resident #1 was admitted with end stage renal disease and was receiving dialysis. Her quarterly MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and she required supervision or cueing for most ADLs. Her care plan directed staff to administer medications as ordered, and her medication orders included sevelamer carbonate 800 mg by mouth at meal times for ESRD. There were no orders for self-medication. During observation on 5/26/26, two large pills were found in a medication cup on Resident #1's bedside table with no staff present. Resident #1 stated she had been asleep when the medication was delivered and said it was just the phosphate binders. The DON stated the medications needed to be given with staff supervision and with meals. In interview, the DON said MA A reported that Resident #1 did not want to take the medication at the time of the medication pass, and the DON stated the MA should have brought the medication back to the cart. MA A stated Resident #1 said she was eating and would take the pills, but did not do so, and MA A acknowledged she should not have left the medications unattended.
Broken Window Blinds and Littered Smoking Area
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 1 of 1 set of window blinds in room [ROOM NUMBER] and 1 of 1 resident smoking areas. On 01/06/2026 at 10:04 AM, observation of room [ROOM NUMBER] revealed broken blinds. Both Bed A and Bed B were occupied and not interviewable at the time of the observation. During an interview on 01/08/2026 at 3:23 PM, the DON stated she was aware of the broken blinds in room [ROOM NUMBER], said the resident had done it, and stated the blinds had been replaced once already. She also stated the blinds could be a safety issue and a privacy issue. On 01/07/2026 at 10:05 AM, observation of the outside patio and smoking area revealed the ground was littered with smoked cigarette butts. During interviews on 01/08/2026, the Administrator stated there was not a policy for cleaning the smoking area and that her expectation was for maintenance staff to clean all grounds daily, including the smoking area. The Regional Maintenance Supervisor stated staff used a chart to document cleaning of the smoking area three times per week and that his expectation was for the area to be free of litter and cigarette butts to prevent fire hazards. The facility's Smoking Policy stated it was the policy of the community to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment, and protecting non-smoking residents. The Smoking Area Weekly Cleaning Log for December 2025 and January 2026 showed the area was marked complete on scheduled cleaning days.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. During observation in the reach-in cooler, two boxes of raw cabbage were seen with a received date of 12/8/2025; the box was opened and cabbage was visible, and approximately 25% of the leaves had turned black or were rotten. During interview, the Food Service Supervisor stated the truck had just come in and they did not have time to clean the refrigerator yet. During observation in the dry storage room, an opened bag of grits was found on a rack rolled over but not sealed or placed in a sealed bag or container, and there was no open date on the package. The Food Service Supervisor stated the grits should have been placed in a sealed bag and that failing to ensure food was properly sealed could result in deterioration in food quality and potential contamination from pests. The Administrator later stated the bad cabbage should have been removed and the grits properly stored, and noted that failing to do so could result in deterioration in food quality, food borne illnesses, and contamination from pests.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Survey Agency immediately, and no later than two hours after the allegation was made. A resident with Parkinson’s disease, schizophrenia, muscle wasting, and atrophy, who was severely cognitively impaired (BIMS score of 5) and dependent on staff for transfers and bed mobility, was the subject of the allegation. The resident used a wheelchair/Broda chair for mobility and required extensive to total assistance, including a two-person assist with a Hoyer lift. An undated written note by a CNA stated that the CNA observed an LVN grab the resident and pull him up by his shirt in what the CNA described as an abusive manner while the resident was in a chair. The CNA documented that the resident said he thought his leg was broken and that the CNA cried because she believed what she saw was very wrong. This note was later found on the floor under the social worker designee’s office door. The social worker designee reported finding the note on a Friday morning and handing it to the Administrator. The DON reported that the incident involving the LVN aggressively pulling the resident up in his Broda chair occurred on or about late December and that the note was found on a Friday in early January. The Administrator stated that she and the social worker designee interviewed the resident, who reported that he had been sliding down in his chair and that the LVN had pulled him up by his shirt. The Administrator also stated that some residents reported being scared of the LVN because he was intimidating. Despite this allegation of abuse and the facility’s own abuse policy requiring that all events involving an allegation of abuse be reported immediately or no later than two hours after the alleged violation, the Administrator acknowledged that she did not report the allegation to the State Survey Agency because the resident said the LVN had only pulled him up by his shirt.
Missing informed consent for increased psychotropic dose
Penalty
Summary
The facility failed to ensure that Resident #2 was informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care and treatment before an increased dose of Seroquel was administered. Resident #2 was a male admitted to the facility with diagnoses including metabolic encephalopathy, diabetes mellitus, and Alzheimer's disease. His MDS indicated a BIMS score was not available because he was unable to complete the interview, and his care plan identified Seroquel use for behavior disturbance with interventions that included educating the resident/family regarding medication risks and benefits and obtaining consent from the resident or responsible party prior to medication use. Record review showed the resident had an order for Seroquel 25 mg twice daily for behaviors, and the dose was later changed to 50 mg twice daily for behaviors. The only consent in the record was for Seroquel 25 mg twice daily, signed by the responsible party, and there was no consent for the increased dosage. The DON stated she would look for an updated consent, was not aware a new consent was needed when doses were increased, and later confirmed there was no updated consent for the increased Seroquel dosage. She also stated she and the ADON were responsible for medication consents and was unable to provide a policy on consents prior to exit.
Failure to Protect Privacy During Personal Care
Penalty
Summary
Resident #13, who was admitted with diagnoses including dementia and muscle wasting and atrophy, was assessed as severely impaired in daily decision-making and as frequently incontinent of urine and always incontinent of bowel. Her care plan directed staff to monitor for incontinence every 2 hours as needed, change her promptly, and apply a protective skin barrier so she would remain clean, dry, and odor free. During an observation, CNA A and CNA B provided incontinent care and changed the resident's clothing while her window mini blinds remained open toward the parking lot area. CNA A undid the resident's brief and wiped her vaginal and rectal areas, exposing her private areas during care, and then helped put pants on her. CNA A later transferred the resident to her wheelchair, removed her shirt, exposing her breasts, and helped her put on another shirt. In interview, both CNAs stated they should have closed the blinds before providing personal care. The DON and Administrator stated staff were expected to knock, close the door, pull the privacy curtain, and close the blinds during personal care. The facility policy stated residents are to be treated with dignity and privacy, including bodily privacy during personal care and treatment procedures.
Nursing Staff Lacked Competency to Read and Implement Care Plans
Penalty
Summary
The facility failed to have nursing staff with appropriate competencies to provide nursing and related services to assure resident safety and attain or maintain the highest practicable well-being of each resident. During an interview, LVN E stated she did not know how to read care plans and had not received training in reading or implementing care plans, even though she had worked at the facility for 7 years and knew the care plans were located in Point Click Care. LVN E stated that not knowing how to read care plans could result in improper care and not meeting resident needs. The MDS Coordinator stated staff had been in-serviced on care plans and that monthly meetings were held, and he said he developed care plans based on assessments. The DON stated staff were trained in reading and implementing care plans and that she and the MDS Coordinator developed and updated care plans as needed. The Administrator stated staff were expected to know how to read and implement care plans and said the risk of staff not being competent in reading and implementing care plans could be a decline in condition. Record review showed an in-service titled transfer techniques with no date, which the DON provided as the care plan training nurses received, and this in-service did not include LVN E. The facility policy titled Comprehensive Care Plan stated every resident will have an individualized interdisciplinary plan of care in place and that the care plan is revised every quarter, with significant change of condition, annually, or as the resident condition changes.
Failure to Provide Adequate Bomb Threat Preparedness Training
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff regarding emergency preparedness, specifically related to bomb threats. Interviews and record reviews revealed that five staff members, including CNAs and LVNs, were inadequately trained on how to respond to bomb threats. Staff members provided inconsistent and incomplete responses when asked about their actions in the event of a bomb threat, with some stating they would simply notify a nurse or administration, while others admitted they would not know what to do or had never received specific disaster training for bomb threats. The facility's disaster preparedness training was primarily focused on fire drills, and staff could not recall receiving comprehensive or regular training on bomb threat procedures. A specific incident involved a resident with a history of behavioral issues, including low frustration tolerance and potential for verbal aggression, who made a threatening statement about bombing the facility. Staff responses to this threat varied, with some reporting the incident to administration and others expressing uncertainty about the appropriate steps to take. Interviews indicated that staff were unclear about procedures such as keeping a caller on the line, gathering information, and notifying authorities, as outlined in the facility's emergency procedures. Some staff referenced prior training or town hall meetings, but these were described as brief and lacking in detail regarding bomb threat response. Review of facility documentation showed that while in-services on disaster preparedness and bomb threats were conducted, the content and frequency were insufficient to ensure staff competency. The facility's emergency procedure for bomb threats included specific steps and a telephone checklist, but staff interviews demonstrated a lack of familiarity with these protocols. The absence of a provided checklist and inconsistent staff knowledge contributed to the deficiency in emergency preparedness training.
Failure to Post Required Oxygen Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to ensure that residents requiring oxygen therapy had appropriate oxygen signage posted outside their rooms, as required by the facility's own policy. Observations, interviews, and record reviews revealed that six residents who were receiving oxygen therapy did not have 'No Smoking' or oxygen signs posted on their room doors. Each of these residents had physician orders and care plans specifying the use of oxygen via nasal cannula at various flow rates to maintain adequate blood oxygen saturation levels. During observations, all six residents were noted to be receiving oxygen therapy in their rooms without the required signage present. The residents involved had significant medical histories, including diagnoses such as heart failure, respiratory failure, COPD, pulmonary fibrosis, and nicotine dependence. Their cognitive statuses ranged from severely impaired to relatively intact, as indicated by their BIMS scores. Despite the presence of oxygen equipment in use, there was no visual indication on the room doors to alert staff or visitors to the presence of oxygen, which is a standard precaution outlined in the facility's oxygen therapy policy. Interviews with facility leadership revealed a lack of clarity and accountability regarding the responsibility for posting oxygen signs. The DON acknowledged that there was no designated staff member assigned to ensure the signs were placed, and the administrator was unaware that the facility policy required signage on individual resident doors, mistakenly believing that a sign at the front entrance was sufficient. Review of the facility's oxygen therapy policy confirmed the requirement to post 'No Smoking' signs on the outside of doors to rooms where residents are receiving oxygen.
Failure to Provide Required Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, a resident with a significant history of falls and multiple risk factors—including cerebrovascular disease, seizures, psychotic disorder, muscle weakness, lack of coordination, and cognitive impairment—did not have a floor mat at the bedside as required by his care plan. The care plan, updated prior to the incident, explicitly included interventions such as keeping the bed in a low position and placing a fall mat at the bedside when the resident was in bed. On the day of the incident, the resident was found to have fallen out of bed, sustaining a laceration and hematoma to the left forehead. Staff interviews revealed that the resident had recently been moved to a new room, and the floor mat was not present at the bedside at the time of the fall. CNAs and nursing staff acknowledged that the resident was a known fall risk and that the absence of the floor mat was contrary to established fall prevention protocols. The incident was unwitnessed, and the resident was later sent to the hospital for evaluation, where imaging confirmed a subcutaneous hematoma but no acute intracranial injury. Multiple staff, including CNAs, LVNs, the ADCO, and the DCO, confirmed that fall prevention measures such as floor mats, low beds, and accessible call lights were standard practice for residents at risk of falls. The failure to have the floor mat in place was recognized by staff and administration as a lapse in following the resident's care plan and facility policy. The facility's own policy required that fall prevention programs be implemented and reviewed after any fall, and that interventions be documented and updated in the plan of care.
Failure to Incorporate PASRR Recommendations and Timely Submit NFSS Request
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into the assessment, care planning, and transition of care for a resident identified as needing specialized services. The resident, a male with multiple complex diagnoses including profound intellectual disabilities, cerebral palsy, epilepsy, hemiplegia, and significant mobility limitations, was admitted with a positive PASRR Level 1 screening for intellectual disability and was determined to require specialized services. Despite this, the facility did not ensure that the PASRR recommendations were fully integrated into the resident's care plan and assessment process. Record reviews showed that the resident's quarterly MDS assessment did not include a BIMS score and was marked as moderately impaired for cognitive skills. The PASRR evaluation confirmed the need for specialized services, and an IDT meeting was held to identify necessary services such as durable medical equipment. However, the facility failed to submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the required LTC online portal within 20 days after the IDT meeting, as mandated by state policy. The initial NFSS submission was declined due to missing required assessments, and the resubmission was still pending at the time of the survey. Interviews with facility staff revealed gaps in communication and understanding of the PASRR process, with staff members unaware of the current status of equipment requests and the specific needs of the resident. The delay in submitting the NFSS form and the lack of integration of PASRR recommendations into the care plan resulted in the resident not receiving timely access to the specialized services identified as necessary for his care.
Failure to Post Isolation Signage for Resident with Shingles
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident who was placed in isolation due to shingles. Although the resident was moved to isolation and had personal protective equipment (PPE) available outside her room, there was no signage posted on the door to alert visitors and staff that the resident was under isolation precautions. Multiple staff interviews confirmed that the resident was on contact precautions for shingles, but the required signage was missing. Staff members acknowledged noticing the absence of signage but did not report it, and responsibility for ensuring signage was posted was attributed to nursing administration and the infection preventionist nurse. Record reviews indicated that the resident had a history of seizures, poor coordination, aphasia, anxiety, psychosis, and schizoaffective disorder, and was cognitively severely impaired. The care plan and physician orders documented the need for isolation and antiviral treatment for shingles. Despite these documented precautions, the lack of isolation signage was observed during the survey, and staff interviews confirmed that this omission could result in visitors or staff entering the room without appropriate PPE, increasing the risk of cross-contamination.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving a resident who reported that a nurse withheld medication after the resident returned from the hospital and missed a scheduled dose. The resident, who had diagnoses of generalized anxiety, schizophrenia, and bipolar disorder and was assessed as cognitively intact, stated that he felt abused when the nurse did not administer his inhaler as requested. The resident reported the incident to the facility administrator, expressing that he felt the nurse's actions constituted abuse. Interviews with staff revealed that the nurse in question was reassigned from the resident's care following the complaint, and a disciplinary action was documented for speaking loudly and harshly to another resident. The Director of Clinical Operations and other staff confirmed that the incident was communicated internally, and the nurse was removed from the resident's care. However, the administrator determined that the incident did not constitute abuse and did not report it to the state survey agency or other required authorities, as required by the facility's abuse policy. The facility's abuse policy mandates that all events involving allegations of abuse or suspicious injuries of unknown origin must be reported immediately or within two hours of the alleged violation. Despite this policy, the administrator did not report the resident's allegation to the appropriate authorities, citing a lack of corroboration and a belief that the incident was a misunderstanding. This failure to report the allegation as required by policy and state law constituted the deficiency.
Failure to Provide Individualized Activities for Resident with Complex Needs
Penalty
Summary
The facility failed to provide regular, individualized activities to a resident with significant physical and cognitive impairments. The resident, a male with multiple diagnoses including contractures, muscle weakness, scoliosis, reduced mobility, encephalopathy, profound intellectual disabilities, epilepsy, cerebral palsy, and hemiplegia, was observed multiple times over the course of a day lying in bed, nonverbal, and without any form of engagement or stimulation. The care plan indicated a need for in-room activities as needed and required, but there was no evidence that such activities were being provided. Interviews with staff revealed a lack of awareness and implementation regarding the resident's activity needs. A CNA stated she was not aware of any in-room activities provided to the resident and had only seen him in bed without engagement items. The Activities Director confirmed that no in-room activities or entertainment, such as a radio, were provided and was unable to explain why. The Activities Director also expressed unfamiliarity with the resident's cognitive level and the risks of limited stimulation. Although the Administrator stated the resident participated in some facility events and received bedside engagement, there was no documentation or observation supporting regular, individualized activity provision as required by the facility's guidelines.
Failure to Maintain Proper Head of Bed Elevation During Enteral Feeding
Penalty
Summary
A deficiency was identified when a resident receiving continuous enteral feeding was not maintained with the head of bed (HOB) elevated as required by physician orders and the resident's care plan. The resident, a female with multiple diagnoses including seizures, poor coordination, aphasia, anxiety, psychosis, and schizoaffective disorder, was observed in bed with the HOB at 30 degrees, but her torso and upper body were lying flat halfway down the mattress while tube feeding was ongoing. Staff interviews revealed inconsistent understanding and implementation of the required HOB elevation, with some staff believing a lower elevation was sufficient and others acknowledging the need for a 45-degree angle. The resident was nonverbal and unable to self-advocate for proper positioning. Record reviews showed that both the care plan and physician orders specified maintaining the HOB at a minimum of 30 degrees, preferably 45 degrees, during and after tube feeding to reduce aspiration risk. However, staff interviews indicated a lack of recent training on G-tube monitoring and positioning, and the facility's policy did not directly address required bed elevation during enteral feeding. The resident's tendency to slide down in bed was noted, but regular repositioning to maintain proper alignment was not consistently performed, leading to the deficiency.
Failure to Document Resident's Return from Hospital
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who returned from the hospital. Specifically, there was no documentation by the assigned LVN regarding the resident's return, including the time of return, new orders, or vital signs. The expectation was for staff to document these elements upon a resident's return from the hospital, but this was not completed. The LVN responsible acknowledged that the readmission assessment was not performed, citing a busy shift and communication issues as contributing factors. The resident involved was an older male with multiple complex medical diagnoses, including cerebrovascular disease, seizures, psychotic disorder, substance dependence in remission, generalized anxiety disorder, major depressive disorder, lack of coordination, muscle weakness, rhabdomyolysis, mild cognitive impairment, and a history of stroke. He had recently experienced a fall in the facility, resulting in a laceration and hematoma to his left forehead, and was sent to the hospital for evaluation. Upon his return, there was no documentation in the medical record to reflect his condition, any new orders, or interventions performed at the hospital. Interviews with facility staff confirmed that documentation was not completed as required. The ADCO and DCO both stated that staff are expected to document upon a resident's return from the hospital, including any new orders and interventions, and that failure to do so could impact continuity of care. The facility did not have a specific policy on accuracy of documentation, but training was provided to staff on documentation expectations. The lack of documentation was identified during the survey process and acknowledged by facility leadership.
Deficiencies in Food Safety and Staff Training
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. The deficiencies included the presence of rotting food, such as discolored bananas and slimy potatoes, which were not discarded. Additionally, food items were not dated according to the facility's policy, and some were stored improperly, such as canned goods on the floor and food debris under shelves in both the dry storage and walk-in freezer. The Dietary Manager (DM) acknowledged these issues, noting that the night shift was responsible for certain tasks like putting up cans and cleaning under shelves, but these tasks were not consistently completed. Further deficiencies were noted in staff training and practices. Staff members were not adequately trained on checking the sanitizer level in the dishwasher, as evidenced by an employee using incorrect test strips. Handwashing practices were also inadequate, with an employee observed turning off the faucet with bare hands after washing. The DM admitted to not regularly checking the walk-in freezer and assumed that staff had been trained on certain procedures at other facilities. The facility's policies on food preparation and storage were not followed, contributing to the risk of foodborne illness and cross-contamination for residents receiving meals from the kitchen.
Deficiency in Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by several observations and interviews. Staff were observed using cell phones in the presence of residents, which made the residents feel disrespected and ignored. During a confidential resident council meeting, residents unanimously agreed that staff were frequently on personal calls, causing delays in care, such as a resident waiting 40 minutes for assistance, resulting in a rash. Additionally, staff were seen moving residents to different tables in the dining room without their consent, and residents were subjected to assigned seating, which was likened to being on house arrest. Furthermore, residents' clothing was labeled in large print, which was confirmed by a laundry aide and the Director of Nursing (DON), who acknowledged the labeling practice. Interviews with staff, including Licensed Vocational Nurses (LVNs) and the DON, revealed that cell phone use by aides was a known issue, with some aides being more frequent offenders than others. The DON admitted that staff cell phone use was a constant battle and that aides were observed using phones in resident rooms and during smoke breaks. The DON and Assistant Director of Nursing (ADON) also discussed the practice of assigned seating in the dining room, which was primarily for residents needing assistance with eating. The DON expressed that she would feel uncomfortable receiving care from someone on the phone, indicating awareness of the issue's impact on resident dignity.
Inadequate Supervision and Unsafe Transfer Practices
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for three residents. Resident #17, who had severe cognitive impairment and hemiplegia, was found with his right leg secured to his wheelchair with a gait belt, which was not ordered or documented in his care plan. The nursing staff and the resident's doctor were unaware of this practice, which was initiated by the therapy department for transport purposes but continued by aides without proper assessment or instruction. This unauthorized use of the gait belt led to skin tears and discomfort for the resident. Resident #18, diagnosed with dementia and severe mobility impairment, was transferred by a CNA from his bed to his wheelchair without assistance or a gait belt, despite being dependent on staff for transfers. The CNA admitted that the transfer method was unsafe and acknowledged the risk of injury to both the resident and herself. The facility's Kardex did not specify the number of staff required for transfers, leading to confusion and improper handling of the resident. Resident #51, who was on hospice care and required moderate assistance for transfers, was moved by two CNAs using an improper technique. They lifted him by his arms and the waistband of his pants, which was not in line with safe transfer practices. The CNAs claimed they were trained to perform transfers this way, indicating a lack of proper training and understanding of safe transfer protocols. The facility's policy on safe lifting and movement of residents was not adhered to, resulting in potential harm to the residents involved.
Infection Control Deficiency in Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs during incontinent care for three residents. CNA A did not change her gloves after they became contaminated and failed to wash or sanitize her hands between glove changes while assisting a resident with severe cognitive impairment and frequent incontinence. This resident was at risk for skin breakdown, and the care plan required monitoring and prompt changing of incontinence products. CNA B also failed to change gloves after they became contaminated while providing care to two other residents. One resident, who was cognitively intact, required assistance due to limited mobility and frequent bowel incontinence. CNA B did not change gloves after removing soiled items and before handling clean items. Similarly, while assisting another resident with frequent incontinence, CNA B did not change gloves after applying barrier cream and before handling clean briefs and clothing. Interviews with the CNAs revealed a lack of adherence to proper infection control procedures, with CNA A acknowledging her mistake and CNA B unaware of the facility's policy. The facility's policies on hand hygiene and infection control were reviewed, indicating that hand hygiene should be performed before and after glove use, and that all personnel should be trained on these practices. Despite competency checks, the CNAs did not follow the established procedures, leading to potential cross-contamination and infection risks.
Failure to Implement Comprehensive Care Plan for Resident's Ankle Enabler
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, specifically regarding the use of an ankle enabler. The resident, a male with severe cognitive impairment and physical limitations due to a stroke and hemiplegia, was observed multiple times with his right leg secured to his wheelchair using a gait belt. This practice was not documented in his care plan, and there was no order for such an enabler. The resident's care plan, initiated months prior, addressed his mobility issues but did not include any interventions related to the use of a gait belt for his leg. Interviews revealed that the physical therapist was unaware that the gait belt was being used outside of therapy sessions and had not assessed the resident for its use. The MDS Coordinator also stated they were not informed about the use of the gait belt and only care planned it after being made aware. The facility's policy requires an individualized interdisciplinary care plan, but this was not adhered to in the case of this resident, leading to a deficiency in providing individualized care and services.
Failure to Document Oxygen Orders for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as observed during a survey. Resident #41, a cognitively intact female with diagnoses including end-stage renal disease and heart failure, occasionally used oxygen when experiencing shortness of breath. However, there were no documented orders for oxygen in her medical records, despite the presence of an oxygen concentrator in her room. Similarly, Resident #20, also cognitively intact and diagnosed with conditions such as obstructive sleep apnea and morbid obesity, used oxygen as needed but lacked a formal order for oxygen therapy in her records. The Director of Nursing (DON) acknowledged awareness of the residents' use of oxygen but was uncertain why there were no official orders or care plans in place. The absence of documented orders for oxygen therapy for these residents indicates a failure to adhere to professional standards of practice, potentially compromising the residents' respiratory care needs.
Failure to Date and Initial Wound Dressings
Penalty
Summary
The facility failed to ensure that a resident received necessary treatment and services consistent with professional standards of practice to promote wound healing, prevent infection, and prevent new ulcers from developing. Specifically, the facility did not date and initial the wound dressings for a resident with skin tears on bilateral elbows and shoulders, as required by facility policy. This was observed during a skin assessment, where the resident's bandages were found to be undated and uninitialed. The resident was not interviewable at the time of the assessment. The Director of Nursing (DON) confirmed that the wound dressings should have been dated and initialed by the nurse performing the wound care, per facility policy. The DON acknowledged that the failure to date and initial the dressings could lead to not knowing when the dressings were last changed and who changed them. The facility's policy on skin management, effective since 11/01/19, mandates that wound care dressings be dated and initialed to ensure proper treatment and monitoring.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 42 citations issued within 25 miles in the last 12 months — 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 Odessa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sienna Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 2 | 0 |
| Deerings Nursing And Rehabilitation, Lp | 1.1 mi | ★★★★★ | 1 | 0 |
| Buena Vida Nursing And Rehab Odessa | 4 mi | ★★★★★ | 6 | 0 |
| Madison Medical Resort | 5 mi | ★★★★★ | 0 | 0 |
| Parks Health Center | 7.7 mi | ★★★★★ | 0 | 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.