Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Glenview Wellness & Rehabilitation during CMS and state inspections, most recent first.
Blood was observed on the door frame of a bathroom shared by two residents, with no sign of cleaning or isolation precautions at the time. Housekeeping staff said they were unaware of the blood, though they stated high-touch surfaces such as door frames were to be cleaned daily. One resident had dementia, skin impairment, and dialysis-related enhanced barrier precautions, while the other had impaired mobility and was mostly incontinent; the resident’s family said the blood had been present for 2 days and had not been cleaned.
A cognitively intact female resident with acute and chronic respiratory failure, fully dependent on staff for self-care and with hearing and communication challenges, was moved to a new room where the nameplate outside the door was not updated with her name. During observation, a CNA exited the room without wearing a name tag. The resident reported that staff did not always wear name tags or identify themselves, and she wanted to know who was providing her care. Facility leadership and staff interviews confirmed expectations and training that residents’ rooms should be labeled with their names and that staff must knock, introduce themselves, and wear name tags per resident rights and dress code policies, which were not followed in this instance.
A resident with a diagnosis of C. diff infection did not have required contact precaution signage or PPE available outside her room. Observation and interviews confirmed that staff were aware of the need for precautions, but signage was missing and the PPE cart had been removed for refilling at the time of the survey. The facility's infection control policy referenced isolation protocols but did not specifically require door signage.
Several residents with cognitive impairments were restricted from unsupervised access to the front patio after an incident where another resident left the facility and became lost. The facility implemented a policy based solely on BIMS scores, limiting outdoor time to supervised 30-minute intervals, despite residents' and families' reports that unsupervised outdoor access was previously routine and important for their well-being. Staff confirmed that no individualized assessments beyond BIMS scores were conducted to determine residents' ability to safely use the patio.
Two residents with dementia were involved in an altercation where one struck the other with a hairbrush, causing visible injuries. Although staff documented the incident and separated the residents, the administrator did not report the event to the state agency within the required timeframe, citing the aggressor's severe cognitive impairment and lack of intent. This failure to report the incident as mandated by policy and regulation resulted in a deficiency.
A resident with vascular dementia and a history of skin injuries did not receive a required weekly skin assessment, as documented in her care plan. After an incident resulting in a bruise and skin tear, no further weekly skin checks were recorded, and staff interviews revealed confusion about responsibility for completing the assessment. The facility lacked a specific policy for weekly skin assessments, leading to a failure to follow professional standards and the resident's care plan.
A CNA failed to immediately report an incident where a resident with multiple medical conditions was injured when a motorized wheelchair struck her foot during a transfer. The incident was not reported to nursing leadership or the administrator until the resident self-reported the next day, resulting in a delay in assessment and required notifications.
A resident with paraplegia and multiple diagnoses was injured when a CNA improperly operated a motorized wheelchair during a transfer, causing the wheelchair to strike the resident's foot. The incident was not reported immediately, and the facility lacked a policy on accident hazards, resulting in a deficiency related to supervision and accident prevention.
The facility did not coordinate assessments with the PASRR program or refer a resident for necessary services, resulting in a failure to meet regulatory requirements for assessment and service provision.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failing to ensure that a resident received treatment and supports for daily living in a safe manner.
A medication cart and a treatment cart were found unlocked and unattended, with a resident diagnosed with dementia seated near one of the carts. Staff interviews confirmed that the carts were left unsecured when not in use, contrary to facility policy, and that all staff were responsible for ensuring carts were locked. The carts contained medications and treatment supplies, including potentially harmful items.
A resident dependent on staff for ADL care, including bathing, did not receive scheduled showers or regular bed baths, reportedly due to the presence of a dialysis port. Staff cited the port as a reason for limiting showers, but clinical leadership confirmed that proper covering of the port would allow for showers. Documentation and care planning did not adequately address the resident's bathing needs or refusals, resulting in insufficient personal hygiene care.
A resident with a sacral pressure ulcer was not referred to the wound care consultant upon readmission, as required by facility protocol. The referral was delayed for several days, despite the resident's high risk and existing wound care needs. This lapse was due to staff assuming the referral had been made and the sudden resignation of the treatment nurse, resulting in a failure to follow established wound care procedures.
The facility failed to maintain its garbage storage dumpster and surrounding area in a sanitary condition, leaving the dumpster door open and debris scattered around, including used gloves, metal screws, and broken glass. Interviews with the Dietary Manager, Housekeeping Supervisor, and Maintenance Director revealed that they were responsible for ensuring proper trash disposal. The Maintenance Director confirmed that the observed items were trash and should have been disposed of properly, as per the facility's Operational Manual and Texas Food Establishment Rules.
The facility failed to ensure that call lights were accessible to residents on the secured unit, affecting 7 out of 8 residents reviewed. Observations revealed that call lights were out of reach or not visible around the residents' beds, posing a risk of being unable to obtain assistance.
A resident with severe cognitive impairment and a history of falls was injured during a transfer when a CNA attempted to move her alone, despite the care plan indicating a need for two-person assistance. The incident highlighted discrepancies in staff understanding and communication regarding the resident's transfer needs.
A resident with severe cognitive impairment and a history of falls sustained a fracture during a transfer from a Geri chair to a bed. The fall was witnessed and assisted by a CNA, and initially, no pain was reported. However, pain was later noted during a physical therapy assessment, leading to an X-ray that revealed a fracture. The facility did not report the incident to the state agency as required, due to a misunderstanding of reporting criteria for witnessed falls.
Blood Left on Shared Bathroom Door Frame
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when dried blood was observed on the right side of the door frame of the bathroom shared by Resident #1 and Resident #2, with no signage or indication of ongoing cleaning or isolation precautions at the time of observation. Housekeeper A and Housekeeper B both stated they were unaware of the blood on the door frame and confirmed that high-touch surfaces, including door frames, were expected to be cleaned daily. The report stated the substance appeared dark red brown in color and was located on the door frame during the 05/10/2026 observation. Resident #1 was a [AGE]-year-old female with diagnoses including unspecified dementia with behavioral disturbance, hypertension, and a mood disorder, and her care plan noted impaired skin integrity with scabbed areas and enhanced barrier precautions related to dialysis. Resident #2 was a [AGE]-year-old female with diagnoses including adjustment disorder with mixed anxiety and depressed mood, unspecified lack of coordination, and anxiety disorder, and her care plan noted increased risk for impaired skin integrity and additional skin breakdown due to impaired mobility and being mostly incontinent of bowel and bladder. Resident #2’s family member stated the blood had been there for 2 days and had not been cleaned by staff, and Resident #2 stated she and Resident #1 had shared the room since March 2026 and that their room did not get cleaned on weekends.
Failure to Ensure Resident and Staff Identification for Dignity and Rights
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s rights to dignity, self-determination, and communication by not ensuring proper room identification and staff identification. A cognitively intact female resident with acute and chronic respiratory failure with hypoxia, who was dependent on staff for all self-care activities, had been moved from an isolation hall to a new room. Surveyor observation showed that the nameplate outside this resident’s new room was missing despite the room being occupied, and the door was closed. When the door opened, two staff members exited, including a CNA who was not wearing a name tag. The resident’s care plan indicated she required increased dependence on staff for activities, cognitive stimulation, and social interaction, and that she had communication challenges related to being hard of hearing and needing longer time to process information. During interviews, the resident reported that not all staff wore name tags or identified themselves when asked, and she stated she wanted to know staff names to know who was providing her care. The ADON confirmed the resident had been moved from an isolation room and stated that when a resident moves, their name should be placed on the new room’s nameplate so staff know whom they are caring for, noting the risk of not identifying the right person. A CNA stated staff were trained to knock and identify themselves when entering a room and that missing nameplates and lack of identification could scare residents and affect documentation and care. Another CNA admitted she had forgotten her name tag in her car and acknowledged the importance of name tags for resident identification and rights to dignity, respect, and a safe space. The DON and Administrator both stated that residents have a right to dignity, that their room is their home, and that staff are expected to knock, introduce themselves, and wear name tags as part of the uniform. Policy review showed the Resident Rights policy required employees to treat residents with kindness, respect, and dignity, and the Dress Code policy required employees to wear a name tag to identify themselves and prevent unauthorized individuals from being in the location.
Failure to Maintain Contact Precautions and PPE Availability for Resident with C. diff
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident diagnosed with enterocolitis due to Clostridium difficile. During observation, there was no signage on the exterior of the resident's room indicating that contact precautions were required, nor was there any personal protective equipment (PPE) available outside the room. Record review confirmed the resident had a history of C. diff infection and was under physician orders for an infectious disease consult. The resident reported ongoing symptoms, including diarrhea, and stated she was in isolation due to her infection. Interviews with facility staff, including the DON, confirmed that the resident was on contact precautions and should have had appropriate signage and PPE available at the room entrance. The DON acknowledged that the PPE cart had been removed for refilling and was not present at the time of observation, and that staff were expected to use gowns and gloves when providing care. Review of the facility's infection control policy did not specifically address the requirement for posting signs on doors but did reference the need for isolation precaution protocols and ensuring protective supplies are readily accessible.
Failure to Honor Resident Rights to Outdoor Access and Self-Determination
Penalty
Summary
The facility failed to honor the rights of several residents to a dignified existence, self-determination, and communication by restricting their access to the front patio. This restriction was implemented after an incident in which a resident left the facility, went to the hospital, and became lost. Following this event, residents with BIMS scores less than 13 were no longer permitted to go outside unsupervised, regardless of their individual preferences or previous routines. Staff interviews confirmed that residents were only allowed outside when accompanied by staff, typically for 30 minutes at a time, and that this policy was based solely on BIMS scores, weather conditions, and perceived safety concerns. Multiple residents expressed dissatisfaction with the new restrictions, stating that they previously enjoyed the freedom to sit outside as they wished. One resident, who had severe cognitive impairment and required continuous oxygen, reported feeling upset and suffering due to the new limitations. Another resident with moderate cognitive impairment also expressed a desire to go outside more frequently, while a third resident indicated that the restrictions felt like punishment for the actions of another resident. Family members corroborated that these residents previously spent time outside unsupervised and that this activity was important to their well-being. Staff, including the DON and Administrator, stated that the decision to restrict unsupervised outdoor access was based on residents' BIMS scores and recent changes in their medical conditions. However, the facility did not conduct individualized assessments beyond the BIMS score to determine each resident's ability to safely use the patio unsupervised. The facility's policy referenced supporting residents' rights and making reasonable efforts to ensure safety, but in practice, the restriction was applied broadly without consideration of individual needs or preferences.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, as required by regulation. Specifically, an incident occurred involving two residents, both with dementia and cognitive impairment, where one resident struck the other with a hairbrush, resulting in visible injuries such as bruising and skin tears. Despite the incident being documented in nursing notes and witnessed by staff, the event was not reported to the state survey agency or other required authorities within the mandated timeframe. The records show that the resident who was struck had a history of vascular dementia and moderate cognitive impairment, while the resident who struck her had severe cognitive impairment and a history of behavioral symptoms. Staff documented the injuries, separated the residents, and notified responsible parties and the nurse practitioner, but the administrator decided not to report the incident to the state agency. The administrator cited the aggressor's severe cognitive impairment and lack of intent as the reason for not reporting, referencing a provider letter and facility policy, despite the policy stating that cognitive impairment does not preclude a resident from engaging in deliberate or non-accidental behavior. Interviews with staff and review of facility policy confirmed that the incident met the criteria for abuse reporting, as it involved a willful action resulting in physical injury. The facility's own policy and regulatory guidance require immediate reporting of such incidents, regardless of the cognitive status or intent of the resident involved. The failure to report the incident as required constituted a deficiency in the facility's abuse reporting procedures.
Missed Weekly Skin Assessment for Resident with Skin Injuries
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, a weekly skin assessment for a female resident with vascular dementia and moderate cognitive impairment was not completed as required. The resident had a history of being the recipient of aggression from another resident, resulting in skin injuries, and her care plan included interventions for monitoring and addressing skin integrity. Documentation showed that after an incident resulting in a bruise and skin tear, the last recorded weekly skin check was completed on 10/10/2025, with no subsequent weekly skin assessments documented as required. Interviews with facility staff revealed a lack of clarity regarding responsibility for completing the weekly skin assessments, with the assigned nurse unaware of the requirement and unable to provide a reason for the missed assessment. The ADON confirmed that the nurse should have completed the assessment, and the DON acknowledged the importance of timely skin assessments to monitor for changes or complications. The facility did not have a specific policy for weekly skin assessments, but staff agreed that such assessments should be performed and documented, or refusals noted. The absence of the required weekly skin assessment constituted a failure to follow the resident's care plan and professional standards.
Failure to Timely Report Resident Incident Involving Motorized Wheelchair
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to immediately report an incident involving a resident and a motorized wheelchair. The resident, who had paraplegia, personality disorder, anxiety, PTSD, paralytic syndrome, tobacco use, neuromuscular dysfunction of the bladder, and lack of coordination, was being assisted by the CNA for a transfer from bed to wheelchair. During the transfer, the CNA pressed the joystick on the motorized wheelchair, causing it to move quickly into a wall and strike the resident's foot. The resident reported experiencing pain at the time of the incident. Despite the incident, the CNA did not notify the nurse, Director of Nursing (DON), or administrator immediately as required by facility policy. The CNA stated she intended to report the incident but forgot due to being occupied with multiple tasks. The resident later reported the incident and her foot pain to the DON the following day, prompting an assessment and further action. The delay in reporting meant that the incident was not addressed promptly, and the required notifications to facility leadership and authorities were not made within the mandated timeframe. Interviews confirmed that the DON and administrator were unaware of the incident until the resident self-reported the next day. Facility policy requires all known or suspected incidents of abuse, neglect, or accidents to be reported immediately to the administrator or designee. The failure to report the incident in a timely manner constituted a breach of this policy and regulatory requirements.
Failure to Ensure Safe Transfer and Supervision During Wheelchair Use
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and safe transfer for a resident with paraplegia and multiple other diagnoses, including lack of coordination and neuromuscular dysfunction of the bladder. The resident, who used a motorized wheelchair and was care planned to require staff assistance for safe transfers, was being assisted by the CNA from bed to wheelchair. During the transfer, the CNA operated the motorized wheelchair by pressing the joystick, causing the wheelchair to move rapidly into a wall and strike the resident's foot. The resident reported pain in her foot immediately after the incident, though the pain had resolved by the time of the interview. The CNA admitted to not reporting the incident to a nurse at the time, stating she was distracted by other tasks and forgot to do so. The CNA also acknowledged she had not properly operated the wheelchair and was later inserviced on the correct procedure, which involved unlocking and manually pushing the wheelchair rather than using the joystick during transfers. The Director of Nursing (DON) and Administrator only became aware of the incident the following day when the resident reported it. The DON assessed the resident and ordered x-rays, which were negative for injury. The facility did not have a policy on accident hazards available when requested by the surveyor. The lack of immediate reporting and improper handling of the motorized wheelchair during transfer led to the deficiency in providing a safe environment and adequate supervision.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Ensure a Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Medication and Treatment Carts Left Unlocked and Unattended
Penalty
Summary
A medication cart (Cart A) and a treatment cart (Cart B) were found unlocked, unattended, and out of the nurse's view during observations. Cart A was left unlocked near the nursing station with a resident seated across from it, and no staff were present in the area. Cart B was also found unlocked and unattended outside the secure unit double doors, with no staff nearby. Staff interviews confirmed that the expectation was for all medication and treatment carts to be locked when not in use or out of sight, but the responsible nurse admitted to forgetting to lock Cart A and indicated that Cart B may have been left unlocked by another nurse during wound care. The Director of Nursing and Assistant Director of Nursing both acknowledged that the carts should not have been left unlocked and that all staff were responsible for securing them. Record review showed that the resident seated near Cart A had a diagnosis of unspecified dementia, which could increase the risk of harm if medications were accessed. Facility policy required medication carts to be kept closed and locked when out of sight of the nurse, and all sides of the cart to be inaccessible to residents or others passing by. The unlocked carts contained medications and treatment supplies, including items such as betadine, which staff noted could pose a safety risk if accessed by residents.
Failure to Provide Scheduled Showers and ADL Assistance for Resident with Dialysis Port
Penalty
Summary
A deficiency was identified when a resident with a history of transient cerebral ischemic attack, sepsis, acute kidney failure, dependence on renal dialysis, unsteadiness, muscle weakness, and cognitive communication deficit did not receive scheduled showers or adequate assistance with activities of daily living (ADLs). The resident was cognitively intact and required extensive assistance with bed mobility, transfers, and toilet use. The care plan indicated total dependence on staff for bathing and noted a behavior problem related to refusal of showers, but did not address how to meet bathing needs when showers were refused or not possible. Observations and interviews revealed that the resident was often dressed in a hospital gown with greasy hair and reported receiving only bed baths, which were infrequent. The resident stated she would like to receive showers but was told she could not due to her dialysis port. Documentation showed only four baths provided in the previous 30 days, and the resident reported the last bed bath was approximately two months prior. Staff interviews confirmed that bed baths were provided instead of showers, citing the dialysis port as the reason, and that the port was not always covered by CNAs, as it was considered outside their scope of practice. Further interviews with clinical staff, including a nurse practitioner and a regional compliance nurse, indicated that the dialysis port could be covered to allow showers and that there was no medical directive prohibiting showers for residents with dialysis ports. The facility's policies required care plans to document necessary precautions for residents with renal conditions and to respect resident rights regarding bathing preferences. However, the care plan and documentation did not adequately address the resident's needs or refusals, leading to missed opportunities for personal hygiene care.
Delayed Wound Care Referral for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services consistent with professional standards of practice. Upon readmission, the resident had a sacral pressure ulcer, but the facility did not refer her to the wound care consultant as required by their wound care management protocol. The referral to the wound care consultant was delayed, occurring several days after the resident's readmission, despite the presence of a significant wound. The resident in question was an elderly female with multiple medical conditions, including a cervical vertebrae fracture, spinal fusion, osteoporosis with pathological fractures, and severe protein-calorie malnutrition. She was cognitively intact but required substantial to maximum assistance with activities of daily living and was always incontinent of bowel and urine. Upon readmission, she had a stage III pressure ulcer and a surgical wound, and was at high risk for further skin breakdown. Documentation showed that wound care orders and pressure-relieving devices were in place, but the required wound care consult was not initiated until several days after admission. Interviews and record reviews revealed that the delay in referral was due to a lapse in following the facility's protocol, compounded by the sudden resignation of the treatment nurse responsible for wound care management. Staff assumed the referral had been made, but it was later discovered that consent for the wound care consult had not been obtained and the referral had not been completed. The resident's family expressed concerns about the effectiveness of the wound care and the functionality of the pressure mattress, and the wound care physician confirmed that the consult was not received until after the delay.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain its only garbage storage dumpster and the surrounding area in a sanitary condition, which could potentially attract pests and pose a risk to residents. During an observation, the dumpster was found to be three-quarters full with its door open, and the surrounding area was littered with various debris, including used latex gloves, a pack of metal screws, a chicken bone, and a piece of broken glass. Additionally, a metal rolling cart with a strong-smelling yellowish/brownish liquid and a 3-tier plastic rolling cart were also present near the dumpster. Interviews with the Dietary Manager, Housekeeping Supervisor, and Maintenance Director revealed that they were collectively responsible for ensuring the proper disposal of trash and maintaining cleanliness around the dumpster area. The Dietary Manager and Housekeeping Supervisor both expressed expectations that staff should use a cart with a lid when transporting trash and ensure that the dumpster door is closed after disposing of trash. They also highlighted the potential risks of attracting rodents and insects, as well as the possibility of residents getting injured by debris such as broken glass or metal screws. The Maintenance Director confirmed that the observed items around the dumpster were indeed trash and should have been disposed of properly. He stated that if staff were unable to dispose of trash themselves, they should have contacted one of the managers for assistance. The facility's Operational Manual and the Texas Food Establishment Rules emphasize the importance of maintaining a clean and safe environment, including ensuring that trash receptacles have tight-fitting lids and that the area around them is kept free of debris to minimize the attraction of pests.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system. This deficiency was observed in 7 out of 8 residents reviewed for the resident call system. Specifically, the call buttons were not accessible to the residents on the secured unit, which could have placed 20 residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. For Resident #1, the call light was observed to be out of reach, located on the wall behind her bed. Resident #2 also had a call light that was out of reach, and she confirmed during an interview that she could not reach it. Resident #3's call light was not visible anywhere around her bed, and similar observations were made for Residents #4, #5, #7, and #8, whose call lights were either out of reach or not observed around their beds. Interviews with staff members, including CNAs and an RN, revealed that they were aware of the importance of ensuring call lights were within reach but failed to consistently check and ensure this during their rounds. The DON and Administrator also acknowledged the expectation for staff to check call lights during rounds and mentioned ongoing retraining efforts. However, the deficiency persisted, as evidenced by the observations made on the secured unit.
Inadequate Supervision During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident during a transfer, resulting in a fall and a fracture of the distal left femur. The resident, who had severe cognitive impairment and was dependent on staff for transfers, was being transferred by a single CNA from a Geri chair to a bed. The care plan indicated that the resident required a two-person Hoyer lift for transfers, but the CNA attempted the transfer alone, leading to the resident being assisted to the floor in a seated position. The resident had a history of dementia, muscle weakness, and repeated falls, and was dependent on staff for movement and transfers. Despite this, the care plan was not updated to reflect the need for two-person assistance consistently, and the CNA was not informed of the requirement for two-person transfers. The incident occurred at night when the resident was reportedly more likely to require additional assistance, yet the CNA proceeded with the transfer without seeking help. Interviews with staff revealed discrepancies in the understanding of the resident's transfer needs, with some staff believing the resident was a one-person transfer. The MDS assessment had indicated a need for two-person assistance, but this was not consistently communicated or documented in the care plan. The lack of clear communication and adherence to the care plan led to the resident's fall and subsequent injury.
Failure to Report Fall with Fracture
Penalty
Summary
The facility failed to report an incident involving a resident who sustained a fall resulting in a fracture, which was not reported to the state agency as required. The resident, an elderly female with severe cognitive impairment and a history of falls, was being transferred from a Geri chair to a bed by a CNA when the fall occurred. The CNA assisted the resident to the floor, and the resident was assessed by an LVN who noted no immediate pain or injury. However, the resident later exhibited pain during a physical therapy assessment, leading to an X-ray that revealed a fracture of the distal left femur. The incident was not reported to the state agency within the required timeframe, as the facility's policy did not mandate reporting of witnessed falls. The Director of Nursing (DON) and the Administrator did not report the incident, believing it did not meet the criteria for reporting since the fall was witnessed and assisted. The facility's Reportable Incident Protocol requires reporting of incidents involving serious bodily injury within two hours, but this protocol was not followed in this case. The lack of reporting was based on a misunderstanding of the facility's policy and state requirements, which led to a delay in the investigation of the incident. The facility's failure to report the fall with a fracture could potentially place residents at risk of injury or worsening conditions due to the lack of timely investigation by the state agency. The facility's staff, including the CNA and LVN involved, had been provided with the abuse and neglect policy and reporting requirements upon hire, but these were not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Richland Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Richland Hills | 1.3 mi | ★★★★★ | 6 | 0 |
| Richland Hills Rehabilitation And Healthcare Cente | 1.7 mi | ★★★★★ | 13 | 0 |
| Avir At North Richland Hills | 1.7 mi | ★★★★★ | 5 | 0 |
| Hurst Plaza Nursing & Rehab | 2.8 mi | ★★★★★ | 6 | 0 |
| North Pointe Nursing And Rehabilitation | 3.4 mi | ★★★★★ | 1 | 1 |
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