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 Golden Acres Living And Rehabilitation Center during CMS and state inspections, most recent first.
Expired Milk Left in Kitchen Refrigerator: Surveyors observed multiple half-pint and gallon containers of milk past their expiration dates in the kitchen refrigerator. The Dietary Mgr said the Dietary Aide was responsible for removing expired milk, while the Aide said he used the milk with the closest expiration date first and did not realize it had expired that morning. The Administrator stated the facility did not have a policy for expired food and followed FDA regulations.
Staff failed to follow the facility’s hand hygiene policy while assisting multiple residents with meals. A Speech Therapist touched her hair twice and continued feeding a resident with severe cognitive impairment and dysphagia without using hand sanitizer. An LVN touched her hair while feeding a dependent resident with vascular dementia and dysphagia and did not sanitize her hands, then moved directly to assist another resident with Alzheimer’s disease and a cognitive communication deficit without performing hand hygiene between residents or before returning to the first. The DON confirmed staff were expected not to touch their hair while feeding and to sanitize hands between residents, and the facility’s policy required hand hygiene before and after assisting with meals.
Surveyors found that staff failed to maintain resident dignity during assisted feeding when a Speech Therapist and an LVN stood over two residents with severe cognitive impairment and dysphagia while feeding them their entire meals. One resident had multiple conditions including MDD, dementia, and anxiety, with a care plan calling for a calm, quiet mealtime setting, while the other had vascular dementia and schizoaffective disorder and was fully dependent on staff for eating. The Speech Therapist acknowledged knowing that standing while feeding was a dignity issue but did so anyway, and the LVN reported not knowing she should sit while feeding. The DON stated staff were expected to sit at the same level as residents when feeding and confirmed there was no feeding policy in place.
Failure to Provide Nail Care for Residents Dependent on ADL Assistance: Several residents with dementia and severe cognitive impairment were observed with long, dirty, or jagged fingernails while dependent on staff for personal hygiene and toileting hygiene. Residents were found in wheelchairs or ambulating in common areas with nails that had dark residue or discoloration, and some stated they wanted their nails trimmed and cleaned. Staff reported that CNAs and nurses were responsible for nail care on shower days and as needed, with nurses trimming nails for residents with diabetes.
Surveyors found expired antibiotic bags stored in a medication refrigerator and multiple controlled-medication blister packs with broken seals on several med carts. Staff said nurses and MAs were responsible for checking refrigerators and carts, but the expired meds and opened blisters were still present during observation. The DON stated broken blister-pack meds should be discarded and that outdated meds should not remain in storage.
Unlabeled meat and spoiled produce were found in the kitchen walk-in refrigerator. Surveyors observed turkey lunch meat without a label or use-by date, along with moldy sweet potatoes and cabbage with rotten, discolored leaves stored in a cardboard box. The acting food service manager, dietitian, and dietary aide all stated that kitchen staff were responsible for labeling food and checking produce for spoilage.
A facility failed to maintain infection prevention and control practices for three residents on EBP or requiring infection control precautions. CNAs provided transfer and incontinence care without proper hand hygiene and without gowns when required, and an RN performed wound care for a resident with a foot wound without wearing a gown despite an EBP sign and available PPE. The residents involved included one with ESBL, one with COPD, and one with diabetes and a transmetatarsal amputation.
Cold, Unappetizing Meal Service: Residents reported that meals were sometimes served cold and did not taste good. During lunch observation, the steam table pasta was 145 degrees F, but a sampled tray later showed pasta at 98 degrees F, with chicken and carrots described as lukewarm. Staff and the DON acknowledged resident complaints, and observations showed the new plate warmer was not functioning properly, leaving plates stacked and not warming enough for meal service.
Improper Foley Catheter Positioning: A resident with an indwelling Foley catheter was observed up in a wheelchair with the drainage bag hanging behind the chair at waist level rather than below the bladder, and urine was seen backing up in the tubing. The resident had multiple chronic conditions including obstructive uropathy, DM, CVA, and dementia, and staff confirmed the bag should always be kept below the bladder; the facility policy reviewed did not document this requirement.
Improper Storage of Controlled Medication in Refrigerator: The facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls in 2 medication rooms. In one medication room, a locked clear plastic box containing Lorazepam oral concentrate was found inside the refrigerator, but the box was not anchored to the refrigerator. An LVN stated she did not know how long it had been stored that way and said anyone could take the box from the refrigerator. The DON stated nurses were responsible for checking medication storage and that controlled substance boxes in the refrigerator were supposed to be anchored for safety.
Defective Call Light Not Available to a Resident: A resident with Alzheimer’s disease, limited mobility, and assistance needs for toileting was found in bed with a call light cord tied around a wall-mounted monitoring device, and he stated it had not been working for days. Multiple CNAs and an LPN were unaware of the issue, while the maintenance director said he learned of it during a routine check and had provided a bell as a temporary means of calling for help. The facility policy required a resident means of communication with nursing staff and immediate reporting of a defective call light.
The facility failed to provide necessary nail care for four residents who were unable to perform activities of daily living, resulting in long and dirty fingernails. Despite residents expressing a desire for assistance, staff did not consistently offer or monitor nail care, contrary to facility policy. This deficiency was observed in residents with varying levels of cognitive impairment and dependence on staff.
The facility failed to provide adequate respiratory care for three residents on oxygen therapy. One resident's room lacked an 'Oxygen in Use' sign, while another resident's nasal cannula tubing and humidity bottle were not changed weekly as required. Additionally, a third resident's nasal cannula tubing was not labeled or dated, increasing the risk of infection. Staff acknowledged these oversights and the potential risks involved.
The facility's kitchen failed to meet food safety standards by not labeling and dating food items in the walk-in freezer and by an employee not following proper hand hygiene during meal preparation. Unlabeled frozen popcorn shrimp were found, and an employee continued food prep after touching a personal phone without changing gloves. Both the Dietary Manager and the employee acknowledged the importance of these protocols to prevent contamination.
A facility failed to maintain an effective infection control program, with a CNA not performing hand hygiene between glove changes during incontinence care for a resident, and a CMA not disinfecting a blood pressure cuff between checks on two residents. Both staff members acknowledged their lapses, which were contrary to the facility's infection prevention policies. The DON confirmed the need for proper hand hygiene and equipment sanitization to prevent infection spread.
A resident with severe cognitive impairment and total dependence on staff was unable to reach the call light while in bed, as it was placed on the nightstand. This oversight was contrary to the resident's care plan and facility policy, which require the call light to be within reach to prevent falls and ensure timely assistance. Staff interviews confirmed the importance of this protocol to avoid risks such as falls and injuries.
A resident with an indwelling catheter was at risk for urinary tract infections due to improper catheter care by a CNA, who placed the catheter drainage bag on the bed above the bladder level, causing urine to back up in the tubing. Despite being aware of the correct procedure, the CNA expressed concern about pulling the tubing, leading to this deficiency. The resident had medical conditions including reflux uropathy, diabetes mellitus, and Alzheimer's disease, which increased her risk for infections.
The facility failed to ensure that the call light system was accessible in resident bathrooms, affecting several residents. Observations showed that call light pull strings were improperly positioned, either hanging over toilet paper dispensers or intertwined on grab bars, making them inaccessible, especially if residents were on the floor. Interviews confirmed the improper placement and the potential risk, with the facility's policy requiring call devices to be within reach.
A resident with severe cognitive impairment reported being raped, but the facility failed to report the allegation to the state within the required two-hour timeframe. The LVN attempted to notify the Administrator, who was the Abuse Coordinator, but there was a delay in communication. The incident was reported to the state later in the afternoon, contrary to the facility's policy for immediate reporting.
A resident's call light system was found hanging from the wall with exposed wiring, causing fear of use despite it functioning. The resident, with a history of falls and other health issues, did not report the issue, assuming staff were aware. Interviews revealed staff were unaware of the problem, and maintenance requests were not properly communicated, leading to a delay in addressing the issue.
Expired Milk Left in Kitchen Refrigerator
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 reviewed. During an observation on 05/14/26 at 8:30 AM, surveyors found 3 whole 8-fluid-ounce half-pint milks and 1 2% 8-fluid-ounce half-pint milk that had expired on 05/13/26, along with 2 whole 128-fluid-ounce gallons of milk that expired on 05/14/26. During interviews, the Dietary Manager stated the Dietary Aide was responsible for removing expired milk from the refrigerator the prior night. The Dietary Aide stated he used milk with the closest expiration date first and did not recognize that the milk expired that morning. The Dietary Manager later stated the Dietary Aide should have removed the milk in the morning when he first came in, but he was training two other staff and was busy. The Administrator stated the facility did not have a policy for expired food and that it followed FDA regulations. Record review of the 2022 FDA Food Code reflected that refrigerated time/temperature control for safety foods must be consumed, sold, or discarded by the expiration date.
Failure to Perform Hand Hygiene During Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to hand hygiene during meal assistance. Surveyors observed a Speech Therapist feeding a resident with severe cognitive impairment and dysphagia who had a care plan addressing potential nutritional problems and the need for a calm, quiet setting at mealtimes. During this feeding, the Speech Therapist touched her hair twice and continued feeding without using hand sanitizer, contrary to the facility’s hand hygiene policy, which requires hand hygiene before and after assisting a resident with meals. Another resident with vascular dementia, dysphagia, and schizoaffective disorder was care planned as dependent on staff for eating and requiring substantial/maximal staff assistance. An LVN was observed feeding this resident, touched her own hair, and did not use hand sanitizer before continuing to feed the resident, despite having sanitizer gel available. The LVN later acknowledged she did not use hand sanitizer while feeding this resident and stated she was not aware she had touched her hair at the time. The same LVN then moved from assisting the second resident to assist a third resident, an elderly female with Alzheimer’s disease and a cognitive communication deficit who was care planned for potential nutritional problems and ordered a regular diet with thin liquids. The LVN did not sanitize her hands between residents or prior to returning to assist the second resident. The DON stated that staff were expected not to touch their hair while feeding residents and to sanitize their hands between assisting residents, and confirmed that these actions placed the involved residents at risk of infection. The facility’s hand hygiene policy, dated August 2024, identified hand hygiene as the primary means to prevent the spread of infections and required use of alcohol-based hand rub or soap and water before and after assisting a resident with meals.
Failure to Maintain Dignity During Assisted Feeding
Penalty
Summary
The deficiency involves the facility’s failure to treat residents with respect and dignity and to provide care in an environment that promotes quality of life during mealtimes. Surveyors observed that during a lunch meal, a Speech Therapist stood while feeding one resident and an LVN stood while feeding another resident for the entirety of their meals. The facility’s DON stated that staff were expected to sit at the same level as residents when feeding them, and also acknowledged that the facility did not have a feeding policy. The Speech Therapist admitted she had known for over a year that standing while feeding a resident was a dignity issue, but chose to stand because the dining room was full and she wanted to provide the meal quickly, and she did not request a chair. The first resident was an older female with major depressive disorder, type 2 diabetes, dementia, dysphagia, and anxiety disorder. Her MDS showed severe cognitive impairment with a BIMS score of 00, and her care plan for potential nutritional problems and functional decline due to dysphagia included providing a calm, quiet setting at mealtimes with adequate eating time. The second resident was an older female with vascular dementia, dysphagia, and schizoaffective disorder, whose MDS indicated she was severely impaired and dependent on staff for eating, with a care plan focus on ADL self-care performance deficit and an intervention requiring substantial/maximal staff assistance with eating. The LVN who fed the second resident while standing stated she was not aware she should not stand while feeding and acknowledged that the resident could have felt intimidated. The DON and staff interviews confirmed that residents were at risk of choking and not having a dignified experience during their meals when staff stood over them while feeding.
Failure to Provide Nail Care for Residents Dependent on ADL Assistance
Penalty
Summary
The facility failed to provide necessary ADL services to maintain grooming and personal hygiene for seven residents who were dependent on staff for care. During observation and record review, residents with dementia and severe cognitive impairment were found with fingernails that were long, dirty, or both, and several stated they wanted their nails trimmed and cleaned. The residents identified were dependent or required assistance with personal hygiene and toileting hygiene, and their care plans reflected ADL self-care deficits related to dementia or other cognitive impairment. Resident #3, Resident #54, Resident #69, Resident #134, and Resident #169 were observed with fingernails that were approximately 0.2 to 1.5 centimeters long, with dark residue or discoloration under the nails in several cases. Resident #3 had severe cognitive impairment, was dependent for personal and toileting hygiene, and was observed in a wheelchair with dark residue under his fingernails. Resident #54 had severe cognitive impairment and moderate assistance needs for personal and toilet hygiene, and was observed with long fingernails and dark residue. Resident #69 had dementia, psychotic disorder, depression, respiratory failure, generalized weakness, and severe cognitive impairment, and was observed with long, dirty fingernails and dark brown residue under the nails. Resident #134 had severe cognitive impairment and was observed walking in the hallway with fingernails up to 1 to 1.5 centimeters long and dark residue under the nails. Resident #169 had stroke and dementia, required substantial assistance with toileting hygiene, and was observed with long fingernails and dark residue under the nails. Resident #65 and Resident #103 also had long fingernails that had not been trimmed. Resident #65 had dementia, severe cognitive impairment, and needed supervision with toileting hygiene; he was observed sitting in a wheelchair with fingernails approximately 0.25 to 0.3 centimeters long. Resident #103 had Alzheimer’s disease, depression, anxiety, dementia, severe cognitive impairment, and was dependent on staff for personal hygiene; she was observed with long, jagged fingernails approximately 0.2 to 0.3 centimeters long. Nursing staff stated that CNAs and nurses were responsible for nail care on shower days and as needed, with nurses trimming nails for residents with diabetes, and multiple staff members stated that long or dirty fingernails increased the risk of skin tears and infection. The DON stated that nail care should be provided as needed, especially during shower time, and that the facility did not have a specific policy on fingernails.
Expired Antibiotics and Broken Controlled-Medication Blisters Found in Storage
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for three medication carts and two medication rooms reviewed. Surveyors found medications in unsecure containers that had not been immediately removed from stock, and they also found expired medication in refrigeration. The facility’s policy stated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are to be immediately removed from stock and disposed of according to medication destruction procedures. For one resident, record review showed orders for Ertapenem Sodium Injection solution for a surgical wound. During observation, two bags of the antibiotic solution were found in the refrigerator in a medication room, both dated 01/03/26 with a red label stating do not use after 01/05/26. The RN stated she did not know the antibiotic had expired and said she would dispose of the two bags. She also stated nurses were responsible for checking the refrigerator daily and removing expired medications according to facility policy, and that the resident’s antibiotic order had changed. Surveyors also observed broken seals on controlled medication blister packs on multiple medication carts. One cart contained broken blisters for a resident’s Tramadol 50 mg tablets, another cart had broken blisters for residents’ Tramadol 50 mg, Lorazepam 1 mg, and Zolpidem 6.25 mg tablets, and a third cart had a broken blister for a resident’s Lorazepam 0.5 mg tablet. Staff stated they were unaware when the seals were broken or who damaged them, and they acknowledged the risk of drug diversion. They also stated the broken blisters were supposed to be discarded, but the pills remained inside the opened blisters at the time of observation.
Unlabeled Meat and Spoiled Produce Stored in Walk-In Refrigerator
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen walk-in refrigerator. On 1/20/2026 at 9:33 AM, surveyors observed 3 slices of turkey lunch meat wrapped in a plastic bag that were not labeled and did not have a use-by date. At 9:35 AM, surveyors observed a cardboard box containing about 10-12 raw sweet potatoes that were moldy with white fungus growing on them, along with 2 cabbage heads with rotten leaves and black discoloration in the same box. During interviews, the morning cook and acting food service manager stated she would throw out the turkey meat and spoiled sweet potatoes and cabbage immediately after the interview. The facility dietitian stated her expectation was that all food items be labeled and dated, that opened packages have a use-by date and label, and that fresh produce be checked for freshness and discarded if moldy or spoiled. She also stated the facility did not have a specific food storage policy and used Texas Food Establishment Rules or the FDA Food Code as guidelines. A dietary aide stated everyone working in the kitchen was responsible for dating and labeling food items and that spoiled produce should be thrown away immediately.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to maintain its Infection Prevention and Control Program for three residents observed for infection control. Resident #157, a female admitted on 11/12/24 with ESBL in her urine, had a sign posted on her door indicating Enhanced Barrier Precautions (EBP), but during a mechanical lift transfer CNA M and CNA L entered the room without performing hand hygiene and without gowns. Both CNAs handled the transfer, and CNA L then left the room with the lift without hand hygiene, followed by CNA M leaving without hand hygiene. The resident’s care plan did not address the reason for EBP. Resident #13, a female admitted on 01/08/26 with COPD with exacerbation, was observed receiving incontinence care from CNA L. CNA L entered the room and began care without performing hand hygiene, wore gloves during the care, and changed gloves during the process without performing hand hygiene between glove changes. After cleaning the resident, applying barrier cream, and fastening a clean brief, CNA L removed her gloves and left the room without performing hand hygiene. Resident #127, a female admitted on 01/18/26 with diabetes and a transmetatarsal amputation, had a care plan directing use of EBP for a right foot wound. During wound care, Treatment Nurse P prepared supplies, entered the room, and washed her hands before donning gloves, but did not wear a gown despite the EBP sign posted on the door and gowns being available. She removed the old dressing, changed gloves, performed hand hygiene between steps, and completed the dressing change, then gathered trash, removed gloves, and performed hand hygiene before leaving. The DON stated staff were expected to change gloves and perform hand hygiene before moving from dirty to clean tasks and before entering and leaving resident rooms, and that residents in EBP had signs posted and staff were expected to follow those protocols.
Cold, Unappetizing Meal Service
Penalty
Summary
The facility failed to ensure that residents received food that was palatable, attractive, and served at a safe and appetizing temperature during lunch meal service. During observation of the steam table before service, the lunch entree penne pasta was measured at 145 degrees Fahrenheit. Later, a sampled lunch test tray containing garlic roasted chicken, penne alfredo pasta, parsley carrots, a bread roll, and banana foster cake was tasted by a staff member and surveyors, and the pasta was measured at 98 degrees Fahrenheit; the chicken and carrots were described as lukewarm, and the pasta could have been warmer to taste better. Resident interviews reflected ongoing complaints about cold food and poor taste, with residents stating that food was served cold sometimes, was not tasting good, and was not always hot. In a confidential group interview, seven residents stated that the food was served cold. The Facility Dietitian acknowledged awareness of resident complaints about cold food and stated that food temperatures were checked before each meal service. The Administrator also stated he was aware of complaints about cold food. Staff interviews and observations identified that a new plate warmer had been installed, but the equipment was not working well because plates remained stacked up and did not collapse down enough to warm properly, resulting in plates not heating adequately for meal service.
Improper Foley Catheter Positioning
Penalty
Summary
The facility failed to ensure that Resident #162, who had an indwelling Foley catheter and a BIMS score of 09 indicating moderately impaired cognition, received appropriate catheter care to prevent urinary tract infections. The resident’s active diagnoses included obstructive uropathy, hypertension, diabetes mellitus, cerebrovascular accident, and Alzheimer’s dementia. His care plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. During observation, Resident #162 was up in his wheelchair in his room watching TV. His Foley catheter tubing came out of his pants at waist level, looped to the back, and the drainage bag was inside a cloth holding bag hanging at the back of the wheelchair. Urine was observed backing up in the tubing toward the resident’s bladder. An LVN stated the tubing was not strapped to the resident’s thigh and that the drainage bag should always be kept below the bladder; she also stated the bag should be hanging beneath the wheelchair seat. The DON stated the catheter was to be maintained below the level of the bladder and that placing the drainage bag behind the wheelchair did not maintain it below the bladder. The facility policy reviewed did not document ensuring the urinary collection bag was below the bladder.
Improper Storage of Controlled Medication in Refrigerator
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls in 2 medication rooms, including the medication room for Hall [NAME] 1 Tower and the medication room for [NAME] Hall. During an observation and interview on 01/20/26 at 10:29 AM, the refrigerator in the medication room for Hall [NAME] 1 Tower contained a locked clear plastic box with two boxes of Lorazepam oral concentration 2 mg/ml, a controlled medication used for anxiety. The plastic box was not anchored to the refrigerator, and the LVN stated she did not know how long it had been stored there in that condition. She also stated that anyone could take the controlled substance box from the refrigerator. During an interview on 01/22/26 at 12:55 PM, the DON stated nurses were responsible for checking the refrigerator and medication carts for expired medication and removing it, and that the ADON and DON were supposed to check the cart randomly. The DON also stated in-services had been provided to MAs and nurses on medication storage, including that controlled substance boxes in the refrigerator were supposed to be anchored to the refrigerator for safety and so no one would walk away with the box. Record review of the facility policy Medication Access and Storage/Drug Destruction, revised July 2007, stated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are to be immediately removed from stock and disposed of according to procedures for medication destruction.
Defective Call Light Not Available to Resident
Penalty
Summary
The facility failed to ensure that Resident #67 had a working call light system within reach. Resident #67’s record showed diagnoses including Alzheimer’s disease with early onset, spinal stenosis, thrombocytopenia, and a history of altered musculoskeletal status related to a left olecranon fracture, with care plan interventions directing staff to keep the call light within reach and respond promptly to requests for assistance. The resident also had an ADL self-care performance deficit related to limited mobility and dementia, with staff assistance needed for toilet use and personal hygiene. During observation, Resident #67 was sitting in bed with the call light cord tied around a monitoring device on the wall, and he stated the call light had not been working for a few days and that he had no means to call for assistance other than yelling. Multiple staff members interviewed stated they were not aware the call light was not working and said it was the responsibility of all employees to ensure call lights were working and within reach, with maintenance responsible for repairs. The charge nurse observed the call light wrapped around the wall-mounted monitoring device and stated it was not working. The maintenance director stated he learned during a routine call light check that the resident’s call light was not working, had given a bell to the nurse for temporary use, and had contacted the alarm company and placed a work order. The DON and Administrator both stated they expected residents to always have a working call light device and that staff were responsible for reporting a defective call light. The facility policy stated the resident should be provided a means of communication with nursing staff and that a defective call light or bell should be immediately reported to the unit supervisor.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in four residents who required assistance with personal hygiene, including nail care. Resident #17, who had moderate cognitive impairment and required maximal assistance, was found with long and dirty fingernails. Despite expressing a dislike for his nails being long and dirty, he did not inform the staff about his needs. Resident #91, with intact cognition but requiring extensive assistance, had long fingernails pressing into his palm, posing a risk for skin breakdown. He expressed a desire for nail care and intended to ask the nurse for assistance. Similarly, Resident #28, with severe cognitive impairment and total dependence on staff, had long and dirty fingernails, some of which were chipped. He also expressed a desire for his nails to be trimmed and cleaned. Resident #255, who was totally dependent on staff due to severe cognitive impairment, was found with short fingernails but with dirt underneath, indicating a lack of proper hygiene maintenance. Interviews with staff, including LVNs and the DON, revealed that nail care was not consistently offered or monitored, despite being recognized as a responsibility of the nursing staff. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain grooming and personal hygiene, but this was not adhered to, leading to the observed deficiencies.
Deficiencies in Respiratory Care for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents who required oxygen therapy. For one resident, the facility did not display an 'Oxygen in Use' sign on the resident's doorway, which is necessary to alert staff and visitors of the oxygen therapy and prevent the introduction of flammable materials. Both a CNA and an RN acknowledged the absence of the sign and recognized the importance of having it for safety and emergency purposes. Another resident's nasal cannula tubing and humidity bottle were not changed in a timely manner, as required by the physician's orders. The tubing and bottle were dated 10 and 11 days prior to the observation, respectively, despite the requirement for weekly changes. An LVN confirmed the oversight and noted that such delays could lead to breathing problems and infection control issues. For the third resident, the nasal cannula tubing was not labeled or dated, which is necessary to ensure timely changes and prevent infection. An LVN admitted to assuming the tubing was dated by another nurse and acknowledged the risk of infection due to the lack of labeling. The DON confirmed the expectations for signage and equipment changes, noting that the facility lacked a specific policy for oxygen signage but followed standard nursing protocols.
Food Safety and Hand Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. The first deficiency involved the improper labeling and dating of food items in the facility's walk-in freezer. Specifically, three large bags of unidentified food items were found without any labels or dates. The Dietary Manager confirmed that these items were frozen popcorn shrimp and acknowledged that it was the cooks' responsibility to ensure all food items were labeled with a received date and a use-by date. The second deficiency was related to inadequate hand hygiene practices during meal preparation. An employee, referred to as [NAME] A, was observed preparing chicken salad sandwiches while wearing gloves. During the preparation, [NAME] A touched a personal phone and then continued to mix the chicken salad without changing gloves or performing hand hygiene. This action was contrary to the facility's infection control policy, which requires handwashing and sanitizing between tasks to prevent contamination. Interviews with the Dietary Manager and [NAME] A revealed that both were aware of the facility's policies regarding food labeling and hand hygiene. The Dietary Manager expressed that all kitchen employees were expected to follow these protocols to prevent cross-contamination and foodborne illnesses. [NAME] A admitted to the error and acknowledged the importance of proper hand hygiene and food labeling to ensure resident safety.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving staff members. In the first incident, a CNA did not perform hand hygiene between glove changes while providing incontinence care to a resident. This resident, who was moderately cognitively impaired and always incontinent of bladder and bowel, was at risk due to the CNA's failure to wash hands after removing dirty gloves and before donning clean ones. The CNA acknowledged the lapse, attributing it to nervousness and lack of sanitizer. In the second incident, a CMA did not disinfect a blood pressure cuff between checks on two residents. Both residents had moderate cognitive impairments and were being monitored for hypertension. The CMA, who had recently started working at the facility, admitted to not having wipes available to sanitize the equipment, recognizing the risk of germ transfer between residents. The Director of Nursing (DON) confirmed the expectation for staff to perform hand hygiene before and after care, and between glove changes, to prevent infection spread. The facility's policies on hand hygiene and infection prevention were not adhered to, as evidenced by the staff's actions during resident care. The DON stated that random checks would be conducted to monitor compliance with infection control practices.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had access to the call light system while lying in bed, which is a necessary accommodation for resident needs and preferences. This deficiency was identified during an observation where the resident, who was trying to get up to use the bathroom, was unable to reach the call light placed on top of the nightstand. The resident, a male with severe cognitive impairment and total dependence on staff for activities of daily living, was at risk due to this oversight. The resident's care plan specifically included the intervention to keep the call light within reach to prevent falls and ensure timely assistance. Interviews with facility staff, including an LVN and the DON, confirmed that the call light should always be within reach of residents to prevent risks such as falls and injuries. The staff acknowledged the responsibility to ensure the call light is accessible before leaving the room. The facility's policy also mandates placing the call device within the resident's reach and reporting any defects immediately. Despite these protocols, the call light was not within reach, posing a risk to the resident's safety and ability to communicate with caregivers.
Improper Catheter Care Increases UTI Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident who was incontinent of bladder, which could lead to an increased risk of urinary tract infections. During an observation, it was noted that a CNA placed the resident's urinary catheter drainage bag on the bed by the resident's feet during incontinent care, which is above the level of the bladder. This action caused urine to back up in the tubing toward the resident's bladder. The resident, who had a moderately impaired cognition and required maximal assistance with activities of daily living, had an indwelling catheter and was at risk for urinary tract infections due to her medical conditions, including reflux uropathy, diabetes mellitus, and Alzheimer's disease. The facility's policy and the resident's care plan both required that the catheter bag be kept below the level of the bladder to prevent urine from backing up and to reduce the risk of infection. Despite being aware of this requirement, the CNA expressed concern about pulling the tubing, which led to the improper placement of the catheter bag. The Director of Nursing confirmed that the catheter should be maintained below the bladder level to prevent urine from backing up and increasing the risk of infection. The CNA had previously been verified as competent in catheter care, according to the facility's skills verification checklist.
Inaccessible Call Light System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the call light system was accessible to residents in the bathrooms and bathing areas, affecting seven residents. Observations revealed that the call light pull strings were improperly positioned, either hanging over toilet paper dispensers fixed six feet from the floor or intertwined on grab bars, making them inaccessible to residents, especially if they were lying on the floor. This deficiency was noted in shared toilets between adjacent rooms in a female secured unit. Interviews with the Maintenance Supervisor and the Director of Nursing (DON) confirmed the improper placement of the call light pull strings. The Maintenance Supervisor demonstrated that the pull strings were too long, causing them to lay on the floor, and acknowledged the potential for serious problems. The DON emphasized that call lights should always be within reach of residents, even if they are on the floor, to ensure they can call for assistance when needed. The facility's policy requires that call devices be placed within the resident's reach before leaving the room, highlighting a failure to adhere to this policy.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required timeframe. The Abuse Coordinator was informed of the allegation at 8:25 AM but did not report it to the State Agency until 2:25 PM, exceeding the mandated two-hour reporting window. This delay in reporting could place residents at risk of abuse and neglect. The resident involved was an elderly female with severe cognitive impairment, requiring assistance with personal hygiene and supervision with toilet transfers. She was occasionally incontinent and had a history of dementia and muscle weakness. On the morning of the incident, the resident reported to a family member and a nurse that she had been raped the previous night, which led to her being taken to the hospital for evaluation. Interviews with staff revealed a breakdown in communication and reporting procedures. The LVN attempted to notify the Administrator, who was the Abuse Coordinator, but was unable to reach him immediately. The Administrator claimed to have learned about the incident later in the morning and reported it to the state in the afternoon. The facility's policy required immediate reporting of abuse allegations, but this was not adhered to in this case.
Deficiency in Call Light System Maintenance
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident due to the malfunctioning call light system in the resident's room. The call light wall mount was observed to be hanging from the wall with exposed electrical wiring, which made the resident afraid to use it, despite it still functioning. The resident had not reported the issue, assuming staff were aware since they had been in the room for other maintenance concerns. The resident's care plan emphasized the importance of having the call light within reach due to her risk of falls and other health conditions, including cerebrovascular disease, hemiplegia, and vascular dementia. Interviews with facility staff revealed a lack of awareness and communication regarding the maintenance issue. The CNA assigned to the resident's hall was unaware of the call light's condition, and the engineer technician responsible for maintenance had not noticed the problem during a recent visit to the room. The charge nurse recalled an aide mentioning a call light issue but could not identify who reported it. The facility's policy required maintenance issues to be entered into an electronic system, but this was not done, leading to a delay in addressing the problem. The administrator was also unaware of the issue until informed by the engineer technician.
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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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Leaves | 2.6 mi | — | 0 | 0 |
| Villages Of Lake Highlands | 2.6 mi | ★★★★★ | 4 | 2 |
| Le Reve Rehabilitation & Memory Care | 2.8 mi | ★★★★★ | 20 | 3 |
| Palomino Place | 3.2 mi | ★★★★★ | 13 | 1 |
| Christian Care Communities And Services Mesquite | 3.3 mi | ★★★★★ | 4 | 1 |
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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.