Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around May 2027
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 Gracy Woods Nursing Center during CMS and state inspections, most recent first.
A facility failed to protect residents’ dignity and personal space when an aide wore a Bluetooth earpiece while redirecting a resident with dementia and entered another resident’s room while still speaking into it. The facility also stored a roommate’s oxygen equipment and laundry basket in a blind resident’s allotted space, cluttering her room and limiting her usable area. The DON and ADM stated staff were prohibited from using phones, earpieces, or headphones while on duty, and the room setup was acknowledged as violating the resident’s right to her space.
Failure to provide timely nail care for three residents was identified during observation, interview, and record review. Two residents with significant functional dependence had fingernails that were about 1/2 inch long, thick, and yellow, and one resident with DM and limited ability to bend had toenails about 1/2 inch long. Staff interviews showed that overgrown nails should be reported and that nail trimming was part of resident care, while the DON stated there was no reason the nails had not been cut.
Failure to Provide Privacy During Incontinent Care: A resident with severe cognitive impairment, an indwelling catheter, and assistance needs for ADLs was observed receiving perineal/incontinent care by two CNAs without the privacy curtain being drawn, leaving him exposed from the waist down while his roommate was in the room. The resident stated he felt uncomfortable and wanted the curtain closed every time. Staff acknowledged that privacy during care was required for dignity, but one CNA said he did not pull the curtain because he thought it was not working.
Foley Bag Placed at Bladder Level During Care: A resident with an indwelling Foley catheter, severe cognitive impairment, and obstructive uropathy had his drainage bag emptied and then placed on the bed at bladder level during perineal care. Observation showed urine moving back toward the catheter insertion site while the resident was repositioned. Staff interviews confirmed the bag should remain below the bladder at all times, and the facility policy required the drainage bag to be positioned lower than the bladder to prevent backflow.
Nonfunctioning Resident Call Buttons: Two residents had call buttons that did not work, and testing showed no light or alarm at the nurse’s station. An LVN later gave each resident a handbell as a temporary replacement, but one resident reported ringing it overnight without response and woke up with a soaked brief. Staff interviews showed the handbells were not clearly communicated to all aides, and the MAINTD said the call system problem was related to cords wrapped around bed frames causing a short.
Survey Results Not Posted for Resident Review: A facility failed to keep the most recent survey results available in the survey inspection binder for resident and family review. Surveyor observations found the binder behind the reception desk contained older survey results, but not the latest recertification survey. Residents stated they did not know how to view prior survey results, and the ADM said she was responsible for posting the results and believed they may have been removed.
Unsanitary and Broken Shower Room Conditions: The facility failed to keep multiple shower rooms clean, stocked, and in good repair. A resident shower room had no paper towels or hand soap, broken toilets were covered with plastic bags containing foul-smelling liquid, and another shower room had a broken wastebasket with a brown smear that smelled like feces and a broken mirror. Staff gave conflicting accounts about who was responsible for cleaning, stocking supplies, and reporting repairs, and the DON and ADM acknowledged gaps in oversight and communication.
A facility failed to keep a medication cart clean and stored a resident’s Tramadol in the controlled substance compartment with a punctured blister pack compartment taped over. Staff observed a brown substance on medication packaging and bottles, and the medication room was also found in poor condition with a broken cabinet, crumbling particle board, mold, insects, and a foul odor from the hot water tap. The DON, MAINTD, and pharmacist each acknowledged parts of the condition during interviews, and the facility policy required medications to be stored in a safe, secure, orderly, clean, safe, and sanitary manner.
Medication Room Sink and Cabinet Not Maintained in Safe, Sanitary Condition: The facility failed to keep the medication room under-sink cabinet and sink area in good repair and sanitary condition. Observation showed a broken fascia board, an open cabinet side, crumbling particle board with mildew/water damage and insects, and a foul odor from the hot water connected to the eyewash station. The MAINTD said he had not been aware of the condition, the DON said she knew about it before survey but had no specific repair plan, and the ADM said nurse managers were responsible for room cleanliness and repair, with the DON ultimately responsible for compliance.
A resident with dementia, moderate cognitive impairment, visual loss, and dependence on staff for eating and personal hygiene was assisted with feeding in the dining room while fecal matter was present on both hands. The care plan required that the resident be kept clean, dry, and comfortable before meals and that substantial to maximal assistance be provided for eating and personal hygiene. A family member arriving during dinner detected a foul odor, observed fecal matter on the resident’s hands held at chest level, and became upset. The SW and an LVN both observed the resident being fed by a CNA while fecal matter remained on the resident’s hands; the CNA reported feeding the resident for about 10 minutes before the issue was pointed out and stated he had not noticed or smelled the fecal matter. Facility leadership acknowledged the resident’s known behavior of putting his hands in his pants, the expectation that residents be clean before meals, and that the incident involved dignity and infection control concerns, in contrast to the facility’s resident rights policy requiring treatment with respect and dignity.
A resident with dementia, moderate cognitive impairment, visual deficits, and multiple comorbidities who required substantial assistance with eating and personal hygiene was assisted with a meal in the dining room while fecal matter remained on both hands. The care plan called for ensuring the resident was clean before meals, yet a CNA fed the resident for several minutes before a family member noticed and reported the fecal matter. A social worker and an LVN also observed the resident being fed with fecal matter on his hands, despite the facility’s infection prevention and control policy requiring a safe, sanitary environment to prevent the transmission of infections.
Food Storage Items Left Undated and Improperly Sealed: The facility failed to store food under sanitary conditions in its only kitchen. An observation found an open undated box and partially opened bag of breakfast sausage patties, an unlabeled bag of green peas covered with ice, and leaking vanilla ice cream containers with lids shifted open in the freezer. The refrigerator also contained a container of Italian dressing with no open date or expiration date. The DM and Consultant Dietician both acknowledged the items should have been dated, labeled, and properly sealed.
A resident with multiple medical conditions, including a wound vac and significant assistance needs for ADLs and transfers, was sent to the hospital after a JP drain was dislodged. The record did not include a discharge summary with a recapitulation of the stay or a final status summary, and it also lacked documentation of the reasons for the transfer/discharge and the required notifications to the RP, MD, ADM, and DON. Interviews confirmed staff expected this information to be documented in the EHR, but it was not.
A resident with intact cognition and multiple chronic conditions, including COPD, asthma, heart failure, and depression, had a comprehensive care plan that listed vape use as a problem but included interventions such as showing designated smoking areas, referring to a smoking schedule, and supervising vape use as needed. These approaches were inconsistent with the facility’s smoke-free, tobacco-free policy, which prohibits smoking on campus and states the facility does not oversee or manage resident smoking. Interviews confirmed the MDS nurse was unaware of the inconsistency, while the DON and ADM stated care plans should align with facility policy.
The facility did not maintain required documentation showing that nurse aides had completed skill performance checklists after their training, as confirmed by record review and staff interviews. Although staff stated that skills were checked off, the binder containing this evidence could not be located, resulting in no proof that nurse aides were properly trained and competent according to facility policy and state requirements.
A resident with dementia and anxiety experienced a fall resulting in a nondisplaced right humerus fracture, confirmed by X-ray. Although pain management orders were implemented and the responsible party declined aggressive treatment, the care plan was not updated to address the fracture or specify related interventions. Staff interviews confirmed the care plan should have been revised to reflect this significant change, but no update was completed.
A resident with cognitive impairment and a complex medical history was not properly identified as an elopement risk, despite staff and family observations of confusion. The resident exited the facility through a window that was not adequately monitored and was missing for over a day before being found. Staff interviews revealed inconsistent assessment practices and lack of effective supervision, leading to the deficiency.
Kitchen Food Safety and Hygiene Failures: The Dietary Manager was repeatedly observed working in the kitchen with his mustache uncovered and without a beard net while handling food, checking temperatures, and moving through food prep areas. Surveyors also found multiple open food items in the walk-in refrigerator and freezer that were undated and unlabeled, including dairy products, deli meat, vegetables, tortillas, and frozen entrées. Facility interviews and policy review confirmed that staff were trained to wear hair and facial hair restraints and to label and date opened food items, but those practices were not followed during the survey.
The facility failed to reasonably accommodate two residents’ needs and preferences. One resident who spoke only Russian was not consistently provided effective communication support, despite a care plan calling for Russian-language communication aids, and he reported frustration that staff did not understand him and that he could not participate in activities. Another resident did not have his call light button within reach; it was observed out of reach and later on the floor under furniture and equipment, while the resident stated it was not hooked up and he had pain he did not report.
The facility failed to maintain a homelike environment for two residents after their bedroom walls were observed scratched and torn next to their heads. One resident with schizoaffective disorder and intact cognition said the damage had been present since admission and bothered him, while another resident with paranoid schizophrenia and moderate cognitive impairment said the wall had been damaged before he arrived and that his room would not look like that at home. The MM was unaware of the room issues, and the DON acknowledged complaints about the 400 hall room conditions.
The facility failed to accurately document controlled medications and remove a completed controlled medication from a med cart. An aide administered Tramadol to one resident and Clonazepam to another but did not sign the narcotic log after giving the meds, and a med aide left a bottle of Lacosamide in the cart even though the count was completed to zero. The DON and ADMIN stated narcotic counts should be updated right after administration and discontinued or completed meds should be removed from the cart.
A CNA passed lunch trays to multiple residents without performing hand hygiene between residents, despite stating he had been trained on hand hygiene. An LPN also failed to disinfect the treatment cart and resident side tables during wound care for three residents, even though she knew the surfaces were supposed to be sanitized before and after treatment. The affected residents had significant wound care needs and multiple chronic diagnoses, including pressure ulcers, diabetes, vascular disease, CHF, and other complex conditions.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility failed to provide mandatory effective communication training for 16 staff members, including CNAs, LVNs, and RNs. Personnel records showed no evidence of such training, and interviews revealed that the HR Personnel only handled initial orientation, while the DON conducted weekly in-services without a set curriculum. This lack of structured training could risk residents being cared for by untrained staff.
The facility failed to provide mandatory training on the QAPI program to all staff, including CNAs, LVNs, and RNs. Personnel records showed no evidence of QAPI training, potentially placing residents at risk. The HR Personnel handled initial orientation, while the DON conducted weekly in-services without a set curriculum, leading to the deficiency.
The facility failed to provide compliance and ethics training to all 16 employees reviewed, as required. Personnel records showed that annual training in-services did not include the necessary compliance and ethics program's standards, policies, and procedures. Interviews revealed that the HR Personnel was only responsible for initial orientation, while the DON conducted weekly meetings without a set curriculum, leading to a lack of structured training.
The facility failed to provide mandatory annual training on abuse prevention to seven staff members, including LVNs, an RN, and a SW. Personnel records lacked evidence of such training, and interviews revealed that ongoing training was unstructured, with no set curriculum. This deficiency could place residents at risk of being cared for by untrained staff.
The facility failed to maintain a sanitary and comfortable environment for residents, with issues such as missing light strings, peeling wallpaper, and blocked bathrooms. Despite complaints, these issues remained unresolved, affecting residents' comfort and independence.
The facility failed to maintain accurate and comprehensive care plans for residents, leading to potential health risks. Several residents' care plans did not reflect their refusal of staff assistance with personal refrigerated items, resulting in unsanitary conditions. Another resident's care plan was outdated regarding dietary and medication needs, causing confusion during medication administration. Additionally, a resident's care plan inaccurately documented their code status and medical needs, highlighting a lack of communication and updates.
The facility failed to ensure proper labeling and secure storage of medications, with two medication carts left unlocked and medications unattended. Insulin pens lacked pharmacy labels, and two residents had unauthorized medications at their bedside. The DON acknowledged the safety risks and the need for proper labeling and storage.
The facility failed to ensure six dietary staff members had the required Texas Food Handler Certificate, as identified through record review and interviews. These staff members were responsible for washing dishes, and a staff member believed they did not need the certification. The facility's policy mandates that food and nutrition services staff be trained and certified, which was not followed.
The facility failed to maintain food safety standards, including improper handwashing supplies, food storage, and equipment cleanliness. A resident's lunch tray was left uncovered, and the ice machine lacked a cleaning log. These issues could risk foodborne illnesses.
The facility failed to implement a policy for the use and storage of foods brought by visitors, resulting in unsafe conditions. A resident's refrigerator contained spoiled food and lacked a temperature log, while another resident's fridge had expired food and an incomplete log. Staff inconsistently monitored these refrigerators, contrary to the facility's policy requiring regular checks and education on food safety.
The facility failed to maintain an effective infection prevention and control program. An LVN did not perform proper hand hygiene while administering medications to multiple residents. Another LVN failed to wear a gown and change gloves during medication administration for a resident with EBP orders. Additionally, a resident's urinary catheter bag was observed on the floor, contrary to infection control guidelines.
The facility failed to maintain essential laundry equipment, with only one washer and dryer operable, leading to service delays. Residents expressed concerns during a council meeting, and staff confirmed the issue had persisted for over a year. The Administrator and Maintenance Director were aware, but the facility lacked a policy for equipment maintenance.
The facility failed to provide required education on resident rights and facility responsibilities to nine staff members, including CNAs, LVNs, an RN, and a social worker. Personnel records lacked evidence of such training, and interviews revealed that ongoing training was conducted without a set curriculum, potentially leading to this oversight.
The facility failed to provide mandatory infection prevention and control training for seven staff members, as revealed by personnel record reviews and interviews. The HR Personnel was responsible only for initial orientation, while the DON conducted weekly in-services without a set curriculum, leading to the omission of essential training.
The facility failed to provide mandatory behavioral health training for 15 out of 16 staff members reviewed, including CNAs, MAs, LVNs, RNs, and a social worker. Personnel records showed no evidence of such training, and interviews revealed that ongoing training was conducted without a set curriculum or guidelines. This deficiency could place residents at risk of being cared for by untrained staff.
A resident reported missing personal items, including laptops and a wallet, after being temporarily relocated due to bed bugs. The facility failed to fully investigate the grievance or assist in replacing identification and bank cards. Staff interviews revealed a lack of proper documentation and skepticism about the resident's claims, leading to a deficiency in addressing grievances effectively.
A resident was forced to leave his room due to a bed bug infestation, and upon returning, found his wallet, DVDs, snacks, and two laptops missing. The facility failed to maintain an inventory of the resident's belongings and did not report the incident as misappropriation. The grievance report was incomplete, and the facility did not assist the resident in replacing his missing items.
A resident reported missing personal items, including laptops and a wallet, but the LTC facility failed to report the alleged misappropriation to the state agency. Staff interviews revealed inconsistencies in inventory management and grievance documentation. The facility's policy required reporting such incidents, but the Administrator did not believe it was necessary as the resident did not explicitly state the items were stolen.
The facility failed to ensure a safe environment for two residents. One resident, with diabetes and intact cognition, had an insulin needle left on her bedside table without proper assessment for self-administration. Another resident, with a history of falls and other health issues, had a power strip with a fan plugged into it in his room, contrary to facility policy. These oversights posed potential safety risks.
A facility failed to maintain proper communication and coordination with a dialysis center for a resident with chronic kidney disease. The resident's dialysis communication sheets were often incomplete or missing, and the facility lacked a policy to ensure their completion. Staff interviews revealed that the responsibility for managing these sheets was not consistently upheld, potentially impacting the resident's care.
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. A medication aide prepared medications for a resident, but an LVN administered them without verifying the medications. In another case, an LVN did not administer the full prescribed dose of an arginine-based powder mixture to a resident with a PEG tube, discarding part of the mixture. These actions violated facility policy and state regulations, potentially putting residents at risk for medication errors.
The facility failed to properly dispose of garbage and refuse, as Dumpster #1 was observed open with trash on the ground. Staff interviews revealed that the dumpster is shared, and sometimes left open, attracting animals. Maintenance is responsible for trash pickup, but any staff can assist.
The facility failed to maintain accurate medical records for two residents, leading to potential risks in their care. One resident's records were not updated to reflect changes in diet and medication administration, while another resident's DNR status was not accurately documented. The DON and MDS Coordinator acknowledged issues with updating care plans, which are crucial for guiding staff in providing appropriate care.
A resident in a LTC facility was found without a privacy curtain, compromising his visual privacy. The resident, who was primarily bedbound and required assistance for all ADLs, did not have a curtain due to it having fallen off and not being replaced. Staff interviews revealed a lack of awareness about the missing curtain until the survey, and the facility's policy emphasized the importance of privacy and dignity for residents.
Three CNAs at a facility failed to follow infection control protocols during peri care for two residents, using dirty gloves to handle clean items and not sanitizing hands. This breach in protocol was acknowledged by the DON, who noted the CNAs' limited understanding of proper practices.
A resident with a history of hypertension and shortness of breath had nasal cannulas and tubing improperly stored, hanging over a wheelchair handle instead of in a protective bag. Despite staff training on proper storage procedures, multiple staff members failed to notice the issue, potentially risking cross-contamination and illness.
A resident with malignant cancer experienced chronic pain due to the facility's failure to provide prescribed pain medications, methadone and hydromorphone, which were frequently unavailable. Despite the resident's severe pain and documented need for these medications, the facility did not ensure their availability, leading to significant distress and inadequate pain management.
Dignity and Personal Space Violations
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity and to protect their right to retain and use personal possessions and furnishings as space permits for three residents. The report identified concerns involving two residents with cognitive impairment and one resident whose room space was cluttered with another resident’s equipment. The facility policy stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to retain and use personal possessions to the maximum extent that space and safety permits. Resident #19 was an older female admitted with Alzheimer’s disease and mood disorder due to a known physiological condition. Her quarterly MDS reflected a BIMS score of 11, indicating moderate cognitive impairment, and her care plan addressed impaired social interaction with redirection, structured routines, and calm boundary-setting. Resident #8 was an older female with hemiplegia and hemiparesis, cognitive communication deficit, mood disorder, anxiety disorder, and need for assistance with personal care. Her quarterly MDS reflected a BIMS score of 12, indicating moderate cognitive impairment, and her care plan addressed impaired cognitive functioning after a stroke with interventions to assist with memory, decision making, safety, orientation, and dignity. During observation, NA K stood in the hall where Residents #19 and #8 lived while wearing a Bluetooth earpiece and talking very quietly and quickly. Resident #19 approached him with paper towels, and he took the towels from her and disposed of them while still speaking into the earpiece. He then told her to go to her room and continued speaking into the earpiece before and after addressing her. Resident #19 appeared angry, and another staff member later directed her to an activity. NA K then walked into Resident #8’s room and stood just inside the doorway talking quietly for about 30 seconds while Resident #8 did not respond. In interview, NA K stated he had worked at the facility for one month, had training on redirecting residents with dementia, and knew it was not acceptable to use the phone while working. He said the Bluetooth earpiece was for English lessons and that he did not mean to be disrespectful. The DON and ADM stated staff were trained to be respectful, that cell phones, earpieces, and headphones were prohibited while on duty, and that such use could cause residents to feel like they were not listened to. Resident #25 was an older female with seizures, cerebral palsy, legal blindness, need for assistance with personal care, muscle weakness, lack of coordination, drug-induced secondary parkinsonism, and muscle spasm. Her care plan stated her bed should be placed against the wall, her personal items should remain accessible, her environment should not be rearranged to enable recognition of objects, and her room should be kept clutter free due to fall risk. Observation and interview showed that her room space contained an oxygen cylinder, an oxygen concentrator, and a laundry basket belonging to her roommate. The FM stated the items were stored in Resident #25’s space for convenience, and LVN B stated the equipment was facility property and should have been placed in the designated area for the roommate. LVN B also stated the setup violated Resident #25’s right to have her allotted space because the items cluttered her area. The DON stated the items diminished the usable space designated for Resident #25 and that alternative arrangements would be needed so she could fully utilize her space.
Failure to Provide Timely Nail Care for Three Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal care, specifically nail care, for three residents reviewed for ADL care. Resident #88 had a history of CVA, lack of coordination, muscle weakness, muscle spasm, anemia, and hand contractures, and was fully dependent for self-care. On observation, he was in bed with contracted hands and fingernails about 1/2 inch long on both hands that were thick and yellow; he nodded yes when asked if he wanted his nails trimmed. Resident #45 had Parkinsonism, other lack of coordination, weakness, localized edema, chronic pain, wrist drop, and muscle weakness, with severely impaired cognition and full dependence for self-care. On observation, he was in bed with tremors in both hands, and all fingernails on both hands were about 1/2 inch long and thick and yellow. He stated he wanted his nails trimmed and did not remember whether he had been offered nail trimming or when they were last trimmed. Resident #67 had acute respiratory failure with hypoxia, CHF, type 2 diabetes mellitus, muscle weakness, muscle wasting, and lack of coordination. Although his MDS reflected intact cognition and independence with personal hygiene, he stated he could trim his fingernails but could not bend down to trim his toenails. Observation showed toenails about 1/2 inch long on both feet, and he stated that he had neither requested nor been offered toenail trimming. Interviews with CNA staff and the nurse in charge showed awareness that nail care was part of resident care, that overgrown nails should be reported, and that nail trimming was important, while the DON stated there was no reason the residents' nails had not been cut.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure privacy during incontinent care for one resident. During an observation of perineal care with an indwelling catheter, CNA D and CNA E provided care to the resident without pulling the privacy curtain, leaving the resident nude from the waist down while care was being performed. The resident’s roommate was present in the room and was looking at his cell phone during the care. The resident was a male with diagnoses including heart failure, obstructive and reflux uropathy, unspecified dementia, and age-related physical debility. His MDS assessment reflected a BIMS score of 7, indicating severe cognitive impairment. He had an indwelling catheter, including a suprapubic catheter and nephrostomy tube, and required partial/moderate assistance with toileting hygiene, showering/bathing, personal hygiene, and dressing. His care plan stated that he required incontinent care promptly when found wet or soiled and that clothes and linens were to be kept clean, dry, and wrinkle free. During interview, the resident stated he did not feel okay when the privacy curtain was not closed while staff were cleaning his private parts because someone could enter the room, and his roommate could see him being exposed. He stated staff rarely pulled the privacy curtain when changing him or his roommate and that he wanted the curtain pulled every time he received incontinent care. Staff interviews reflected that privacy during incontinent care was expected and related to resident dignity, but CNA D stated he did not pull the curtain because he thought it was not working, and later said it did work when he checked it. The DON stated the facility policy was to have the curtain pulled during incontinent care and that staff were responsible for providing privacy.
Foley Bag Placed at Bladder Level During Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident with an indwelling Foley catheter. Resident #38 was admitted with diagnoses including obstructive and reflux uropathy, dementia, and age-related physical debility. The resident’s MDS reflected severe cognitive impairment with a BIMS score of 07, and the care plan identified the need for an indwelling Foley catheter due to obstructive uropathy related to penile and scrotal swelling, along with a potential for UTI. The care plan also directed staff to keep the urine collection bag below the level of the bladder and off the floor at all times. During observation of perineal care, the resident’s urine collection bag was removed from the bed frame after being emptied and placed inside a clear plastic bag on the resident’s bed next to his left leg. At that time, the Foley bag was at the level of the resident’s bladder. The observation further showed yellow urine moving from the middle of the catheter toward the insertion site at the resident’s penis while the resident was repositioned from his back to his right side. The Foley bag remained on the bed until the incontinent care was completed. Interviews confirmed that staff understood the bag should remain below the bladder to prevent backflow of urine, and the CNA acknowledged it was his mistake that the bag was placed on the bed. The DON stated she instructed the CNA to empty the bag, cover it with a plastic bag, and place it on the bed during care. The facility’s catheter care policy stated that the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.
Nonfunctioning Resident Call Buttons
Penalty
Summary
The facility failed to ensure that two residents had functioning nurse call buttons in their rooms on multiple days. Resident #53 was a male with diagnoses including cerebral infarction, hemiplegia and hemiparesis, history of falling, lack of coordination, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Resident #84 had diagnoses including type II diabetes mellitus, congestive heart failure, history of falling, hemiplegia and hemiparesis, and repeated falls. His quarterly MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and Resident #53’s care plan directed staff to keep the call light within reach and encourage him to use it for assistance. During observation and interview, Resident #84 stated his call button was not working, and testing showed the light outside the room did not come on and no alarm sounded at the nurse’s station. Resident #53 then stated his call button also did not work, and testing showed the same result. The next day, both residents’ call buttons were still not working. LVN C observed the problem and later returned with two handbells, giving one to each resident as a temporary replacement. On the following day, Resident #53 again tested his call button and it did not activate the light outside his room. Resident #53 stated he had tried to ring his handbell overnight and no one responded, and his bed was soaked in urine when he woke up. NA I, who was standing in the hall, did not respond when he rang the handbell and stated she had not heard it. Interviews with staff showed that NA I had not been told the handbells were being used as call bells, and LVN C stated she had told aides about the temporary replacement but was unsure whether the instruction was understood. The MAINTD stated he had been told about the broken call buttons, had tried to replace them, and believed the problem was caused by cords wrapped around bed frames creating a short at the wall panel. The DON and ADM stated the residents should have had functioning ways to call staff, and the ADM stated the responsibility for the call system was ultimately hers.
Survey Results Not Available for Resident Review
Penalty
Summary
The facility failed to post the most recent survey results in a place readily accessible to residents, family members, and legal representatives. Surveyor observation on 06/02/2026 at 10:45 AM found a white binder labeled "Survey Inspection Results" on a shelf behind the reception desk that was reachable to passersby, including those in wheelchairs. The binder contained survey results dating back to 2022, but the most recent survey included was dated 07/31/2025, and the results from the most recent recertification survey dated 12/31/2025 were not present. A follow-up observation on 06/03/2026 at 1:13 PM showed the binder still lacked the 12/31/2025 survey results. During a confidential group interview, five anonymous residents stated they did not know how to view prior survey results, and three said they would like to view the most recent survey. The ADM stated during an interview on 06/04/2026 at 4:00 PM that she had checked a survey readiness checklist on 05/11/2026 and the results were not there, so she printed them and put them in the book, but she could not explain what happened and believed someone must have removed them. She stated she was responsible for ensuring the most recent survey results were posted for the public and that her habit was to place the results right after survey.
Unsanitary and Broken Shower Room Conditions
Penalty
Summary
The facility failed to ensure that the resident shower rooms on halls 200, 300, and 500 were clean, functional, and in good repair, and failed to maintain the medication room environment as observed during the survey. Observation and interview showed that the hall 300 shower room had no paper towels or hand soap at the handwashing sink, and the toilet had a large translucent plastic bag wrapped around the bowl containing yellow and brown liquid and toilet paper. A CNA stated the toilet was broken and that staff were supposed to clean the bathroom between resident showers, but she did not check or clean the toilet if the resident did not use it. She also stated she was unsure who was responsible for restocking soap and paper towels. The hall 200 shower room toilet was out of order and wrapped with a translucent plastic bag, with yellow water underneath the bag and a foul odor. The hall 500 shower room had a broken wastebasket with a large smear of a brown substance that smelled like feces, and the mirror over the sink was broken in several areas. Paper towels were not present in the dispenser or anywhere in the shower room. On the following day, the hall 200 and hall 500 bathrooms were observed in the same condition. Record review showed no work orders related to the shower rooms or the medication room sink and cabinet during the reviewed period, and all listed work orders were completed. Interviews with housekeeping, CNA, nursing, maintenance, DON, and ADM staff showed inconsistent responsibility for cleaning, stocking supplies, and reporting maintenance concerns. Staff gave differing accounts about who cleaned the shower rooms, who replaced paper towels and soap, who provided wastebasket bags, and where maintenance concerns should be reported. The MAINTD stated there were no incomplete work orders in his system and that he was not aware of the shower room issues. The DON stated she could not honestly say she had done a paper in-service with staff about the shower room conditions or policy requirements, and the ADM stated the shower rooms had not been added to the Guardian Angel rounds. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment.
Medication Cart Cleanliness and Controlled Substance Storage Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services for 1 of 2 medication carts reviewed because the hall 400 medication cart was not maintained in a clean environment. During observation, a brown substance was seen dripped and dried onto two medication blister packages and the lids of several medication bottles in the cart. The LVN responsible for the cart stated she was responsible for keeping it clean, did not know what the substance was, and said it should have been reported to the DON. The DON later observed the same substance and stated she did not know what it was, while the pharmacist said she would have directed staff to clean the cart if she had seen it. The facility also failed to follow its pharmacy services policy when it stored a dose of Tramadol for a resident in the controlled substance compartment with a broken seal. The resident was a male with diagnoses including schizoaffective disorder, asthma, hypertension, and pain, and his quarterly MDS showed a BIMS score of 14. His physician order included Tramadol 50 mg every 6 hours as needed, but the MAR showed no PRN Tramadol administration during the reviewed period. During the cart audit, the blister package contained 30 pills, but one compartment was punctured and re-covered with adhesive tape. The pharmacist stated that if a blister pack compartment was punctured, the drug should have been wasted. The medication room was also observed to be in poor condition. The bottom fascia board of the cabinet was falling off, the under-sink cabinet was open to the room, and the particle board floor of the cabinet was crumbling with evidence of dead mold and insects in the rear corner. Staff interviews showed the DON knew about the sink and cabinet before the surveyor arrived, the MAINTD had not been informed, and the hot water tap in the medication room gave off a strong foul odor. The MAINTD stated the condition was not suitable for the medication room and that the odor would need a professional plumber to address. The facility policy stated that drugs and biologicals are to be stored in a safe, secure, orderly manner and that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Medication Room Sink and Cabinet Not Maintained in Safe, Sanitary Condition
Penalty
Summary
The facility failed to ensure the medication storage room was maintained in a safe, clean, comfortable, and homelike condition. On observation in the medication room, the bottom fascia board of the under-sink cabinet was broken and falling off, the right side of the cabinet was partially open to the room, and the particle board floor on the right side was crumbling with evidence of dead mildew, water damage, and insects in the rear corner. The report also noted a foul odor coming from the hot water in the medication room sink, which was connected to an eyewash station. Record review showed no work order related to the medication room sink or cabinet during the reviewed period, and all work orders on the list were completed. During interview, the MAINTD stated he had never seen the condition of the cabinet under the sink and had not been told about it. He also stated he was not aware of the hot water issue before surveyor intervention and that the odor would require a professional plumber. He said the condition of the cabinet and the hot water were not suitable for the medication room. The DON stated she knew about the sink and cabinet before the survey began, but she did not identify a specific plan to fix it and said that was the MAINTD's responsibility. She stated the medications were covered and the cold water side did not have a bad odor. The ADM stated she had not been aware of the environmental issues identified during the investigation and said nurse managers were responsible for ensuring medication carts and rooms were cleaned and in good repair, with the DON ultimately responsible for compliance. Facility policies stated residents are to be provided a safe, clean, comfortable, and homelike environment and that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Resident Fed in Dining Room With Fecal Matter on Hands, Violating Dignity and Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was clean and treated with dignity while being assisted with feeding in the dining room. The resident was an older male with moderate cognitive impairment, dementia, visual loss including left eye blindness, generalized weakness, poor endurance, impaired balance, and reduced range of motion in both shoulders. His MDS and care plan documented that he required substantial to maximal assistance with eating and personal hygiene, and that he needed maximum assistance for ADLs and mobility. The care plan also included an intervention to ensure the resident was clean, dry, and comfortable before mealtime and to provide assistance as needed for meal completion. On the evening in question, the resident’s family member arrived during dinner and went to the dining room, where the resident was being assisted with his meal. As the family member approached the table, he smelled a foul odor like bowel movement and then observed fecal matter on both of the resident’s hands, which were at chest level. The family member became extremely upset and demanded that the resident be cleaned. The social worker, who was present in the facility, went to the dining room and also observed fecal matter on both of the resident’s hands while the resident was being fed by a CNA. The social worker stated he was shocked and alarmed by what he saw and noted that the resident was known to scratch himself and put his hands in his pants. The CNA who was feeding the resident reported that he had not assisted the resident to the dining room and was unsure who had done so. He stated that after passing out meal trays, he sat down to assist the resident with feeding and had been feeding him for approximately 10 minutes before the family member arrived and alerted him to the fecal matter on the resident’s hands. The CNA stated he had not noticed the fecal matter because the resident did not use his hands during feeding and that he did not smell it, believing it had dried. A LVN in the dining room became aware of the situation when he heard the family member and saw the resident being fed with fecal matter on his hands. Both the CNA and LVN acknowledged that residents were expected to be groomed and cleaned prior to going to the dining room. Facility leadership, including the DON and administrator, confirmed that the resident had known behaviors of putting his hands in his briefs and that it was their expectation that residents be clean when fed. The facility’s resident rights policy stated that employees shall treat all residents with kindness, respect, and dignity, and that residents have the right to a dignified existence and to be treated with respect, kindness, and dignity. Interviews indicated that the resident himself did not recall the event when interviewed later. The social worker stated that at the time of the incident the resident was calm, did not recognize he had fecal matter on his hands, and only responded to the family member’s upset reaction by asking why he was upset. The CNA reported that the resident told the family member to “shut up,” which the CNA believed was due to embarrassment. The social worker acknowledged that he did not complete a psychosocial evaluation related to the incident and stated that he "dropped the ball" in not asking psychosocial questions within 72 hours. The DON and administrator both acknowledged awareness of the incident and described it as an unfortunate situation involving infection control and dignity issues, occurring despite the resident’s known behavior of putting his hands in his pants and the care-planned need for assistance with personal hygiene and to ensure cleanliness before meals.
Failure to Ensure Hand Hygiene and Cleanliness Before Assisting Resident With Meal
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program when a resident with known behaviors and significant ADL dependence was assisted with eating while fecal matter remained on his hands. The resident was an older male with moderate cognitive impairment (BIMS score of 11) and active diagnoses including progressive neurological conditions, hypertension, viral hepatitis, diabetes mellitus, and non-Alzheimer’s dementia. His MDS and care plan documented that he required substantial/maximal assistance with eating and personal hygiene, had visual deficits including blindness in one eye, and needed maximum assistance for personal hygiene tasks. His care plan also included interventions to ensure he was clean, dry, and comfortable before mealtime and that he required substantial assistance for meal intake. On the evening in question, the resident’s family member arrived during dinner and, upon approaching the dining room table, smelled a foul odor like bowel movement and observed fecal matter on both of the resident’s hands, which were at chest level, while the resident was being assisted with his meal by a CNA. The family member reported being extremely upset that the resident was being fed without his hands being cleaned. The social worker, who was in the facility at the time, responded to the complaint, went to the dining room, and also observed fecal matter on both of the resident’s hands while the CNA was feeding him. The social worker stated the amount of fecal matter was enough to be noticed and that the resident was known to scratch himself and put his hands in his pants. The CNA who was feeding the resident reported that he had been assisting the resident with his meal for approximately 10 minutes before the family member alerted him to the fecal matter on the resident’s hands. He stated he had not noticed the fecal matter because the resident did not use his hands during feeding and that there was no smell, describing the fecal matter as appearing dried. An LVN working in the dining room as the nurse checking meal trays stated he became aware of the situation when he heard the family member bring attention to it and then saw the CNA feeding the resident while the resident had fecal matter on his hands. The DON and ADM both acknowledged that the resident had known behaviors of putting his hands in his briefs and that residents were expected to be clean when being fed. The facility’s Infection Prevention and Control policy required implementation of a program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, which was not followed in this instance.
Food Storage Items Left Undated and Improperly Sealed
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in its only kitchen. During an observation on 12/29/2025 at 9:15 AM, the one-door freezer contained an open undated box of breakfast sausage patties and a partially opened bag of breakfast sausage patties exposed to air. The freezer also contained a large clear plastic bag of green peas covered with ice that had no date or label, and 5 individual servings of vanilla ice cream that had leaked into the box, with the lids on two containers slid to the side and exposing the ice cream to the air. During an observation on 12/29/2025 at 9:22 AM, the single-door refrigerator contained a plastic container labeled Golden Italian Dressing with no open date or expiration date. In interview, the DM stated the ice cream box should have been thrown out and the salad dressing should have been dated and labeled. The DM also stated that failure to properly seal bags of food in the freezer could lead to freezer burn and could cause residents to get stomachaches or become sick. The Consultant Dietician stated she understood the importance of labeling and dating food when it comes in and when it is opened, and said residents could become ill if items are not properly dated and labeled.
Missing discharge documentation and notification after hospital transfer
Penalty
Summary
The facility failed to ensure that Resident #94’s discharge documentation included a discharge summary with a recapitulation of the resident’s stay and a final summary of the resident’s status at the time of discharge after the resident was sent to the hospital for a change in condition and the family chose not to readmit the resident. The record also did not include the reasons for the transfer/discharge in the resident’s medical record when the resident was discharged on 11/30/2025. Survey review identified this as 1 of 4 residents reviewed for safe transfer or discharge. Resident #94’s records showed the resident was a female admitted on [DATE] and discharged on 11/30/2025. The continuity of care document listed diagnoses including infection following a procedure, elevated WBC count, muscle weakness, abnormalities of gait and mobility, lack of coordination, type 2 diabetes, GERD, hyperlipidemia, history of malignant neoplasm of breast, acute postprocedural pain, lymphedema, and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. The baseline care plan reflected assistance needs for bed mobility, bathing, grooming/hygiene, locomotion, transfers, walking, toileting, and eating, and further review noted the resident had a wound vac, required a specialty mattress, and needed turning and repositioning. The comprehensive MDS reflected a BIMS score of 14, indicating intact cognition, and section GG showed substantial to maximal assistance for toileting hygiene, shower/bathing, upper body dressing, and putting on footwear, with dependence for lower body dressing and partial/moderate assistance for transfers and personal hygiene. Nursing documentation showed the JP tube was pulled out and EMS was called to transport the resident to the hospital for reinsertion, and later notes indicated the resident remained at the hospital. Interviews with RNC, LVN B, DON, and ADM confirmed that discharge or hospitalization notifications were expected to be documented in the EHR, but the record lacked a progress note documenting the resident discharge and the required notifications.
Care Plan for Vape Use Did Not Match Facility Smoking Policy
Penalty
Summary
The facility failed to develop and implement an accurate comprehensive person-centered care plan for one resident whose care plan included a problem related to vape use. The resident’s record reflected diagnoses including unspecified visual loss, cough, pain, bilateral cataracts, depression, muscle weakness, lack of coordination, asthma, COPD, heart failure, cardiomyopathy, hyperlipidemia, hypertensive heart disease with heart failure, and tremors. The quarterly MDS reflected a BIMS score of 15, indicating intact cognition, and functional status showing the resident needed set up or clean up assistance for eating, toileting, dressing, and personal hygiene, supervision or touching assist for showering and shower transfer, and was independent for transfers. The comprehensive care plan dated 12/17/2025 identified the resident’s vape use as a problem and listed interventions and approaches of explaining and showing where designated smoking areas are, referring the resident to the facility smoking schedule, and supervising vape use as needed. These interventions were documented despite the facility’s smoking policy stating the facility is smoke-free and tobacco-free, smoking is strictly prohibited on campus, residents may smoke only after signing out and leaving the grounds, and the facility does not oversee or manage resident smoking. The care plan therefore contained approaches that were inconsistent with the facility policy. During interviews, the MDS Nurse stated she was unaware the care plan approaches were inconsistent with facility policy and said she and another MDS Nurse were responsible for completing care plans. The DON stated care plans should be tailored to the individual resident and consistent with facility policies and procedures, and the ADM stated the MDS nurse completes the comprehensive part of the care plan and that care plan approaches should coincide with facility policy and procedure. The ADM also stated the MDS Nurse who completed the care plan had previously worked at a smoking facility and that she would be educated on the facility policy and procedures.
Lack of Documentation for Nurse Aide Skill Competency
Penalty
Summary
The facility failed to ensure that nurse aides who had completed more than four months of employment were properly trained and deemed competent, and that those with less than four months of employment were enrolled in appropriate training. Record reviews for 13 nurse aides revealed that, although their training programs were reportedly completed, there was no documented proof of completion of the Nurse Aide Curriculum skill performance checklists in their employee records. This lack of documentation was consistent across all 13 nurse aides reviewed. Interviews with the Director of Nursing (DON), Administrator (ADM), and Staffing Coordinator confirmed that the skill performance checklists, which were supposed to be maintained in a binder, could not be located anywhere in the facility. All three staff members acknowledged that the binder was expected to be up to date and available for review, and that the absence of this documentation would appear as if the required skill checks had not been completed. The DON and Staffing Coordinator both stated that the skills had been checked off, but without the binder, there was no way to validate this claim. The facility's own Nurse Aide Qualification and training requirements specify that nurse aides must undergo a state-approved training program and complete a minimum of 16 hours of training in specific areas before having direct contact with residents. Despite these requirements, the facility was unable to provide evidence that the nurse aides had completed the necessary skill performance checklists, as required by both facility policy and state regulations.
Failure to Update Care Plan After Resident Fracture
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan to address a resident's newly diagnosed right humerus fracture following a fall. After the resident was found on the floor with a skin tear near her bed, an X-ray confirmed a nondisplaced fracture of the medial epicondyle of the right humerus. Despite this significant change in the resident's condition, the care plan was not updated to include the fracture, associated interventions, or measurable goals. The resident had a history of dementia with agitation, anxiety disorder, and required staff assistance with activities of daily living. She was also on hospice care, and her responsible party declined aggressive treatment for the fracture, opting for comfort measures. Orders for pain management were received and implemented, but the care plan continued to reflect only fall risk and did not address the new fracture or specify interventions related to the injury. Interviews with facility staff, including the DON and MDS nurse, confirmed awareness of the fracture and acknowledged that the care plan should have been updated to reflect this significant change. The facility's policy required care plans to be revised when there is a significant change in a resident's condition, but no acute or comprehensive care plan update was completed for the fracture. This omission resulted in a lack of documented guidance for staff on how to address the resident's new medical needs.
Failure to Prevent Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically failing to prevent the elopement of a cognitively impaired resident. The resident, who had a history of cerebral infarction, language disorder, heart failure, cardiomyopathies, aphasia, substance abuse, and confusion, was admitted to the facility and was noted by multiple staff members and family to be confused and cognitively impaired. Despite these observations, the resident's elopement risk assessment did not indicate cognitive impairment or identify the resident as an elopement risk. Staff interviews revealed inconsistent recognition of the resident's confusion and potential for elopement, with some staff considering the resident at risk and others not, based on the absence of exit-seeking behaviors at the time of admission. The resident was last seen in his room early in the morning and was discovered missing a few hours later. Upon searching, staff found a window open with the screen removed, indicating the resident had exited through the window. The facility did not have a plan in place for monitoring windows to ensure resident supervision and prevent such incidents. The lack of accurate assessment and monitoring contributed to the resident's ability to leave the facility undetected, and the resident was found 26 hours later at a family member's home, displaying agitation and confusion. Interviews with staff and family members highlighted gaps in communication, assessment, and supervision. Staff had received training on elopement assessments, but there was confusion about when to identify a resident as an elopement risk, particularly for new admissions with cognitive impairment but no immediate exit-seeking behavior. The facility's policy required identification and care planning for residents at risk of wandering or elopement, but this was not effectively implemented for the resident in question, resulting in the deficiency.
Kitchen Food Safety and Hygiene Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observations, the Dietary Manager was seen performing kitchen duties without a facial hair restraint while his mustache was exposed. This was observed repeatedly while he walked through the main kitchen area, food preparation area, and walk-in refrigerator, and while he scooped gravy into a cup, flipped chicken fried steak in a deep fryer, and checked food in the hot table station and food temperatures. He never put on a facial hair restraint during the survey observations. Observations in the walk-in refrigerator and walk-in freezer also revealed multiple open food items that were undated and unlabeled. In the refrigerator, these included garlic, white cheddar cheese, yellow cheddar cheese, parmesan cheese, cranberry juice, deli ham, sliced carrots, and tortillas. In the freezer, open undated items included frozen hamburger patties, broccoli, cheese pizzas, okra, mixed vegetables, and biscuit dough. A later observation again found open undated white cheddar cheese, deli ham, tortillas, frozen mixed vegetables, and frozen biscuit dough in the refrigerator and freezer. Interviews with kitchen and facility leadership showed that staff had been trained on facial hair restraints and on labeling and dating food products, and they described the expectation that all staff entering the kitchen wear hair and facial hair restraints and that opened food be labeled and dated. The facility’s Food Safety and Sanitation policy stated that hair restraints are required and that beard nets are required when facial hair is visible, and that all foods should be covered, labeled, and dated. The Preventing Foodborne Illness policy also stated that beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Despite these stated expectations and policies, the observations documented the Dietary Manager working in the kitchen without a facial hair restraint and multiple open food items stored without labels or dates.
Failure to Provide Communication Support and Call Light Access
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents. For one resident, the facility did not ensure he could communicate his needs and preferences in his preferred language, Russian. His care plan identified impaired verbal communication related to language differences and directed staff to involve him using Russian, communication boards, visual aids, gestures, or translation apps when appropriate. During interview, he stated he was frustrated because staff failed to attempt to communicate with him, that he had to use a paper dictionary to translate requests, and that he could not participate in activities because nobody understood him. He also stated he asked to receive morning medication with food, but staff continued to bring it before breakfast. The resident’s record showed he was cognitively intact with a BIMS score of 14 and physically independent with ADLs. He was observed ambulating independently and became emotional when he was finally able to speak with someone who understood him. Staff interviews showed inconsistent communication practices: some staff used gestures or wrote notes, one nurse used Google translator during therapy-related communication, and others stated they did not use translation tools with him. The DOR stated the resident had been given Russian-English paper printouts, but she was not aware of his frustration or that communication with nursing staff was a problem. The SW and DON acknowledged the need for translation support and staff training, and the resident stated he wanted to see a cardiologist for his cardiac conditions. The facility also failed to ensure another resident had access to his call light button. That resident’s care plan stated staff needed to assess and ensure adequate access to the call bell, light, and personal items on the open side. During interview, the resident stated the call button was not hooked up and reported pain in multiple areas, including both knees, feet, and shoulders, but said he did not report it to nurses because he forgot. Surveyor observation found the call light not within reach: first at the top of the headboard, and later on the floor under the bedside table, curled under a medical boot, with a trash can in front of it. Staff acknowledged responsibility for the call button and stated the resident may not get the care he needs if he cannot reach it.
Homelike Environment Not Maintained in Two Residents’ Rooms
Penalty
Summary
The facility failed to establish and maintain a homelike environment for two residents whose bedroom walls were observed to be scratched and torn next to their heads. Resident #87 was a male admitted to the facility with diagnoses including schizoaffective disorder, muscle weakness, hyperlipidemia, and hypothyroidism; his BIMS score was 14, indicating he was cognitively intact. During an observation, his bedroom wall was noted to be scratched and torn next to his head, and he stated the wall had been ripped and scratched since he arrived at the facility, that he did not damage it, and that it bothered him. Resident #14 was a male admitted to the facility with diagnoses including paranoid schizophrenia, unspecified convulsions, and benign prostatic hyperplasia without lower urinary tract symptoms; his BIMS score was 8, indicating moderate cognitive impairment. His bedroom wall was also observed to be scratched and torn next to his head, and he stated the wall had been damaged since before he arrived at the facility and that his bedroom, or home, would not look like this if he were at home. The Maintenance Manager stated he was not aware of any bedroom issues on the 400 halls and that the expectation when room conditions are not good was to fix it. The DON stated she was aware of complaints about the condition of residents' rooms on the 400 halls and that the expectation when room conditions are not good would be to work on it right away.
Failure to Document Controlled Medications and Remove Completed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not accurately documenting controlled medications on narcotic count sheets for Resident #44, Resident #41, and Resident #103. Resident #44 was admitted with diagnoses including displaced intertrochanteric fracture of the right femur, muscle spasms, acute pain due to trauma, and osteoarthritis, and had an active order for Tramadol 50 mg three times daily for pain. During observation of the medication cart, CMA A administered Tramadol to Resident #44 but did not complete the narcotic medication log after administration, and the MAR showed the medication was given on that date. Resident #41 was admitted with generalized anxiety disorder and had an active order for Clonazepam 0.5 mg twice daily. During the same medication cart observation, CMA A administered Clonazepam to Resident #41 but did not document the administration on the narcotic medication log. In interview, CMA A stated she gave the medications to Resident #44 and Resident #41 but failed to document the administrations on the narcotic records, and acknowledged she should have signed out the narcotic medication immediately after administration. For Resident #103, observation and record review of the 500 hall medication cart showed a bottle of Lacosamide 10 mg/mL solution with a completed count of zero on the controlled narcotic administration record, but the bottle remained in the cart with approximately 5 mL left in it. MA C stated she counted the medication as completed but failed to remove the bottle and take it to the DON for storage and further destruction. The DON and ADMIN stated staff were responsible for updating narcotic counts immediately after administration and for removing discontinued or completed medications from the medication cart.
Infection Control Lapses During Meal Service and Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when CNA A passed lunch trays on hall 500 without performing hand hygiene between residents. During observation, CNA A pushed the meal cart down the hall, picked up a tray for Resident #2 and delivered it without hand hygiene, then did the same for Resident #50, Resident #71, Resident #46, and Resident #72. When interviewed, CNA A stated he would wash his hands before starting to assist residents with eating lunch and said he was passing the lunch trays to all the residents at that time; he also stated he had received training on hand hygiene. The facility also failed to ensure LVN C sanitized surfaces before and after wound care for three residents. During wound care for Resident #2, LVN C did not sanitize the resident side table after treatment. During wound care for Resident #63, LVN C did not sanitize the nursing treatment cart or the resident side table after treatment. During wound care for Resident #33, LVN C did not sanitize the resident side table used for placing supplies after treatment. LVN C stated she knew she was supposed to sanitize the surfaces before and after wound treatment, but said she got nervous and forgot in one instance and had forgotten in the others. Resident #2 was a female with diagnoses including a stage 4 pressure ulcer of the right hip, chronic kidney disease, congestive heart failure, and type 2 diabetes mellitus, and had active wound care orders for the right ischium, left ischium, and sacrococcyx. Resident #63 was a male with diagnoses including cerebral infarction, cirrhosis of the liver, diabetes mellitus type 2, heart failure, hypothyroidism, and peripheral vascular disease, and had an active order for wound care to the right 1st metatarsal. Resident #33 was a female with diagnoses including anemia, need for assistance with personal care, muscle weakness, hyperlipidemia, hypertension, and acquired absence of toe(s), and had an active order for left foot/toes amputation wound care. The DON stated she was responsible for ensuring staff followed infection control measures and that the policy required surfaces and equipment used for wound care to be disinfected, including before the barrier or clean field was placed on the surface.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Facility Lacks Mandatory Effective Communication Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on effective communication for 16 employees, including CNAs, LVNs, RNs, and other staff members. The personnel records of these employees, with hire dates ranging from 2014 to 2023, showed that their annual training in-services did not include evidence of effective communication training. This omission was identified through interviews and record reviews, indicating a lack of structured training programs for effective communication. During interviews, the HR Personnel stated that she was only responsible for initial orientation training, while the Director of Nursing (DON) or Administrator handled all other training. The DON mentioned conducting weekly meetings or in-services based on issues that needed addressing, without following a set curriculum or guidelines. This lack of structured training could place residents at risk of being cared for by untrained staff.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to all staff members, which included 16 employees such as CNAs, LVNs, RNs, and other personnel. The personnel records reviewed showed that none of these employees had evidence of receiving training on the QAPI program as part of their annual in-service training. This lack of training could potentially place residents at risk of being cared for by untrained staff. Interviews with the HR Personnel and the Director of Nursing (DON) revealed that the HR Personnel was only responsible for initial orientation training, while the DON or Administrator was responsible for all other training. The DON stated that she conducted meetings or in-services weekly based on issues that needed to be addressed, but there was no set curriculum or guidelines followed for these trainings. This lack of structured training on the QAPI program contributed to the deficiency identified by the surveyors.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to communicate the compliance and ethics program's standards, policies, and procedures through a training program or other practical manner for all 16 employees reviewed. This deficiency was identified through interviews and record reviews, which revealed that the facility did not provide evidence of training on the compliance and ethics program's standards, policies, and procedures as required. Personnel records for various staff members, including CNAs, LVNs, RNs, and other staff, showed that while annual training in-services were provided, they did not include the necessary compliance and ethics training. Interviews with the HR Personnel and the Director of Nursing (DON) further highlighted the deficiency. The HR Personnel indicated that she was only responsible for initial orientation training, while all other training was managed by the DON or Administrator. The DON stated that she conducted weekly meetings or in-services based on issues that needed addressing, but there was no set curriculum or guidelines followed for these trainings. This lack of structured training could place residents at risk of being cared for by untrained staff, as the facility did not ensure that all employees were adequately informed about the compliance and ethics program's requirements.
Failure to Provide Mandatory Abuse Prevention Training
Penalty
Summary
The facility failed to provide mandatory annual training to staff on the prevention of abuse, neglect, and exploitation of residents. This deficiency was identified for seven out of twenty-two staff members reviewed, including various licensed vocational nurses (LVNs), a registered nurse (RN), and a social worker (SW). Personnel records for these staff members showed no evidence of education on these critical topics, despite their hire dates ranging from 2014 to 2024. The lack of training was confirmed through interviews and record reviews, indicating a systemic issue in the facility's training program. During interviews, the HR Personnel stated that they were only responsible for initial orientation training, while ongoing training was managed by the Director of Nursing (DON) or the Administrator. The DON mentioned conducting weekly meetings or in-services based on issues that needed addressing, but there was no set curriculum or guidelines followed. This lack of structured training could potentially place residents at risk of being cared for by untrained staff, as the facility did not ensure that staff completed their mandatory abuse annual training.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for several residents, as observed during a survey. Resident #69's room had multiple maintenance issues, including a missing pull string for the overhead light, peeling wallpaper, a missing drawer cover, and a torn privacy curtain. Despite the resident's complaints to staff and the Maintenance Manager, these issues remained unresolved, affecting the resident's ability to independently control lighting and contributing to feelings of neglect. Resident #74's room also had significant deficiencies, including a missing light switch and plate cover for the bathroom, which was used as storage, blocking access. This situation was inconvenient for the resident's family during visits, and although the Maintenance Manager was aware of the issue, it had not been addressed. Additionally, room [ROOM NUMBER] had structural damage, including a broken baseboard, peeling wallpaper, and a missing toilet tank cover, which had not been inspected by the Maintenance Manager since his employment began. Other residents experienced similar issues, such as Resident #31, whose room had a stained privacy curtain, and Resident #12, who had broken blinds and a missing drawer. Resident #15's room had a large hole in the wall and a missing pull string for the overhead light, causing distress due to nightmares. Despite the facility's policy for maintaining a homelike environment, these deficiencies persisted, with staff and management failing to address them promptly, as evidenced by the Maintenance Log and interviews with staff and the Administrator.
Inaccurate and Incomplete Care Plans Lead to Potential Risks
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential confusion and improper care. For instance, the care plans for three residents did not reflect their refusal of staff assistance with personal refrigerated items, which resulted in unsanitary conditions and potential health risks. Observations revealed that these residents had expired and moldy food in their personal refrigerators, and staff interviews confirmed that the residents often refused assistance, which was not documented in their care plans. Another resident's care plan was not updated to reflect changes in dietary and medication needs. Despite a speech therapy discharge summary and physician's orders indicating the resident could consume a regular diet and whole medications, the care plan still required crushed medications and thickened liquids. This discrepancy led to confusion during medication administration, as observed when a medication aide attempted to administer crushed medications and thickened fluids, which the resident refused, stating they had been on a regular diet for a year. Additionally, a resident's care plan inaccurately documented their code status and medical needs. Although the resident and their family had decided on a DNR status, the care plan still listed them as full code. Furthermore, the care plan incorrectly included a colostomy, which the resident did not have. Interviews with staff revealed a lack of communication and updates to the care plans, contributing to these inaccuracies and potential risks to resident care.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications, as observed in two medication carts and two residents' rooms. On the 200-unit, seven out of eleven insulin pens lacked pharmacy labels, and the medication cart was left unlocked with medications unattended. LVN A explained that insulin pens were delivered in a multi-count box with a label, but individual pens were not labeled, leading staff to write residents' names on the caps. MA D also left the cart unlocked with medications on top while washing hands, acknowledging the oversight. On the 400-unit, MA U left the medication cart unlocked and unattended with a bottle of medication on the counter. The DON confirmed that insulin pens were not individually labeled and acknowledged the safety benefits of having pharmacy labels on each pen. The facility's policy requires all drugs to be stored in locked compartments, and the failure to do so was recognized as a safety hazard. Resident #72, with mild cognitive impairment, was found with medicated ointment at his bedside, which he applied himself, despite not being assessed for self-administration. Similarly, Resident #84, who was cognitively intact but had impaired safety awareness, had a bottle of cough syrup at his bedside without a current order. The DON stated that residents should not have medications at their bedside without proper assessment, as it could lead to negative interactions with prescribed medications.
Deficiency in Food and Nutrition Service Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service. Specifically, six dietary staff members, identified as DA K, DA L, DA M, DA N, DW P, and DA O, did not possess the required Texas Food Handler Certificate. This deficiency was identified through record review and interviews, where it was noted that the certificates for these staff members were not found among the facility's records. During an interview, a staff member stated that these individuals were only responsible for washing dishes and did not believe they needed a food handler certificate. The facility's policy requires that food and nutrition services staff be trained and possess the necessary certifications to perform their duties, which was not adhered to in this case.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas within the kitchen. During an observation, it was noted that the handwashing station in the kitchen was improperly equipped with hand sanitizer instead of hand soap, which is necessary for proper hand hygiene. This was acknowledged by the Dietary Supervisor (DS), who indicated that the sanitizer was mistakenly placed in the dispenser. Additionally, dish racks were found directly on the kitchen floor, and juice lines were observed resting on the floor, with fruit flies present in the area. The DS was unaware of the fruit flies and stated that the juice machine was not in use. Further observations revealed improper food storage practices. A crate of milk cartons was found on the floor of the walk-in cooler, and there were undated open packages of turkey and shredded cheese. The DS confirmed that food items should be dated upon opening. Additionally, a container of onions was undated, a rotten potato was found among other potatoes, and an open bag of grits was not properly sealed. A bottle of BBQ sauce, which required refrigeration after opening, was found expanded and not refrigerated. The DS acknowledged these issues and indicated that the sauce should have been discarded. The facility also failed to maintain cleanliness and proper procedures in other areas. A resident's lunch tray was observed uncovered on a hallway cart, which could affect the food's temperature and safety. The ice machine was found with black spots inside the cover, and there was no cleaning log available. The DS stated that the ice machine had been cleaned months ago and was recently repaired, but there was no record of its cleaning. These deficiencies in food storage, preparation, and equipment maintenance could potentially place residents at risk for foodborne illnesses.
Failure to Implement Food Storage Policy in Resident Rooms
Penalty
Summary
The facility failed to implement a policy regarding the use and storage of foods brought to residents by family and other visitors, leading to unsafe and unsanitary conditions. Specifically, Resident #70's personal refrigerator contained spoiled food, including lunch meat with green spots, and lacked a temperature log. The resident reported that staff did not assist in discarding food items or checking the refrigerator. Similarly, Resident #31's refrigerator contained expired food, such as a hard sandwich and a meatball with green spots, and had an incomplete temperature log. The staff did not consistently monitor or document the refrigerator temperatures, as evidenced by the blank entries in the log. Interviews with staff revealed inconsistencies in the monitoring of personal refrigerators. A CNA mentioned that sometimes they checked the refrigerators, but residents occasionally refused assistance. An LVN stated that the night shift was responsible for checking the refrigerators but admitted to not verifying if this was done. The facility's policy, dated 2013, required staff to monitor food safety in personal refrigeration units and educate individuals on safe food handling. However, the policy was not effectively enacted, as demonstrated by the lack of regular checks and documentation, potentially placing residents at risk of foodborne illness.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies in hand hygiene and personal protective equipment (PPE) use. Licensed Vocational Nurse (LVN) A did not perform proper hand hygiene while administering medications to three residents. LVN A was observed preparing and administering insulin and obtaining blood samples without washing or sanitizing hands between residents, despite having received recent in-service training on infection control practices. Another deficiency was observed with LVN J, who failed to wear a gown while administering medication via a peg tube to a resident with enhanced barrier precautions (EBP) orders. LVN J also did not change gloves after handling medication supplies, which could lead to cross-contamination. LVN J admitted to being unsure about the resident's EBP status and acknowledged the importance of changing gloves to prevent infection. Additionally, the facility did not ensure that a resident's indwelling urinary catheter bag was kept off the floor, as required by infection control guidelines. The catheter bag was observed on the floor, which was identified as a potential source of infection. Staff interviews confirmed that the catheter bag should not be on the floor to prevent urinary tract infections, and it was the responsibility of the aides and nurses to ensure proper care.
Inoperable Laundry Equipment Affects Resident Services
Penalty
Summary
The facility failed to maintain essential laundry equipment in safe operating condition, affecting the laundry department's ability to meet the needs of its residents. Specifically, only one of two washing machines and one of two dryers were operable, which led to frequent breakdowns and a backlog in laundry services. This issue was highlighted during a Resident Council meeting where residents expressed concerns about the laundry delays. The Laundry Assistant Manager confirmed that the equipment had been inoperable since she started working at the facility a year ago and that the issue had been reported to upper management. Despite a repair company's visit, the washer was deemed too old to repair, and the dryer required frequent repairs. The Administrator, who had been employed since May 2024, acknowledged awareness of the issue and stated that the corporate office was informed and bids for new units were being sought. The Maintenance Director, employed since January 2025, confirmed the equipment's inoperability and mentioned switching to a new repair vendor. The facility lacked a policy for maintaining essential equipment for resident care, as confirmed by the Administrator. The ongoing equipment issues could potentially place residents at risk of unmet needs due to the inability to maintain timely laundry services.
Deficiency in Staff Training on Resident Rights and Facility Responsibilities
Penalty
Summary
The facility failed to provide the required education on the rights of the residents and the responsibilities of the facility to properly care for its residents. This deficiency was identified for nine out of sixteen employees reviewed for training, including CNAs, LVNs, an RN, and a social worker. The personnel records of these employees showed no evidence of training on resident rights and facility responsibilities, despite their hire dates ranging from 2014 to 2023. The lack of documented training suggests a systemic issue in the facility's training program. Interviews with the HR Personnel and the Director of Nursing (DON) revealed gaps in the training process. The HR Personnel indicated that she was only responsible for initial orientation training, while ongoing training was managed by the DON or Administrator. The DON stated that she conducted weekly meetings or in-services based on issues that needed addressing, but there was no set curriculum or guidelines followed. This ad-hoc approach to training may have contributed to the oversight in providing essential education on resident rights and facility responsibilities.
Inadequate Infection Control Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on infection prevention and control standards, policies, and procedures for seven staff members, including DS, ACT D, LVN FF, LVN GG, RN HH, LVN JJ, and SW. A review of personnel records revealed that these staff members, hired between 2014 and 2024, did not receive education on infection control topics as part of their annual training in-services. This lack of training was confirmed during interviews with the HR Personnel and the Director of Nursing (DON). The HR Personnel indicated that she was only responsible for initial orientation training, while all other training was managed by the DON or Administrator. The DON stated that she conducted weekly meetings or in-services based on issues that needed addressing, without following a set curriculum or guidelines. This approach resulted in the omission of infection prevention and control training for the staff members reviewed, potentially placing residents at risk of illness due to insufficient staff training.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide mandatory behavioral health training for 15 out of 16 employees reviewed, including MDS, CNAs, MAs, LVNs, RNs, and a social worker. The personnel records of these employees, with hire dates ranging from 2014 to 2024, showed no evidence of behavioral health training. This lack of training was identified through interviews and record reviews, indicating a systemic issue in ensuring staff received the necessary training to care for residents with behavioral health needs. During interviews, the HR Personnel stated that she was only responsible for initial orientation training, while ongoing training was the responsibility of the Director of Nursing (DON) or the Administrator. The DON mentioned conducting weekly meetings or inservices based on issues that needed addressing but admitted there was no set curriculum or guidelines followed for these trainings. This lack of structured training could potentially place residents at risk of being cared for by untrained staff.
Failure to Address Resident Grievance on Missing Personal Property
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal, as evidenced by the case of a resident who reported missing personal property, including two laptops, a wallet, DVDs, and food items. The resident, who had intact cognition and expressed a desire to stay in the facility long-term, reported the missing items after being temporarily relocated due to a bed bug infestation in his room. Despite filing a grievance, the facility did not fully investigate or resolve the issue, leaving sections of the grievance report incomplete and failing to assist the resident in replacing his identification and bank card. Interviews with staff revealed inconsistencies and a lack of proper documentation regarding the resident's personal belongings. The facility's staff, including the LVN, QA, and DON, acknowledged the absence of an inventory sheet for the resident, which is typically completed upon admission and updated as necessary. The social worker admitted to not completing an inventory sheet after the grievance was filed and did not assist the resident in replacing his missing identification and bank card. The administrator and other staff members expressed skepticism about the resident's claims, citing a lack of evidence and changing accounts of the number of missing laptops. The facility's grievance policy requires thorough investigation and documentation of grievances, but this was not adhered to in the resident's case. The administrator did not report the missing items to the state agency, as she did not believe it constituted misappropriation of property. The facility's failure to properly investigate and address the resident's grievance, as well as the lack of assistance in replacing essential personal items, highlights a deficiency in honoring residents' rights to voice grievances and have them resolved promptly and effectively.
Failure to Protect Resident's Belongings During Room Transfer
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when he was forced to leave his room due to a bed bug infestation. Upon returning, the resident discovered that his wallet, DVDs, snacks, and two laptops were missing. The resident, who has multiple sclerosis and an intact cognition for daily decision-making, reported the missing items to the facility and filed a police report. However, the facility did not find or replace the missing items. Interviews with staff revealed that there was no inventory sheet for the resident, which is typically completed upon admission. The staff, including the LVN, QA, and DON, were unaware of the resident's belongings, and no inventory sheet was found for the resident. The social worker did not complete an inventory sheet after the grievance was filed and did not assist the resident in replacing his ID or bank card, which were in the missing wallet. The facility's grievance report was incomplete, with blank sections for investigation findings and expected results. The administrator did not report the incident to the state agency, as she did not believe it constituted misappropriation since the resident did not explicitly state the items were stolen. The facility's policies on grievances and abuse investigation require reporting and investigating alleged violations, but these procedures were not followed in this case.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged violation involving the misappropriation of property for a resident who claimed his wallet, DVDs, snacks, and two laptops were missing. The resident, who had intact cognition for daily decision-making, reported the missing items to the facility and filed a police report. However, the facility did not report the incident to the state agency as required by their policy. The grievance report completed by the social worker was incomplete, with missing investigation findings and unresolved follow-up actions. Interviews with staff revealed inconsistencies in the handling of the resident's belongings and the inventory process. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledged the absence of an inventory sheet for the resident, which is typically completed upon admission. The social worker admitted to not completing an inventory sheet after the grievance was filed and did not verify the resident's receipts for the missing items. The Administrator and staff expressed doubts about the number of laptops the resident owned and the circumstances under which they went missing. The facility's policy required all alleged violations of neglect, abuse, and misappropriation of property to be reported and investigated under state law. Despite this, the Administrator did not report the incident to the state agency, believing it was not misappropriation since the resident did not explicitly state the items were stolen. The Administrator also noted the resident's changing accounts of the missing items and planned to have him seen by psychiatric services. The facility's failure to report the incident and properly document the grievance process highlights a deficiency in adhering to regulatory requirements for reporting and investigating alleged violations.
Failure to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a safe environment for Resident #47 by allowing an insulin needle to be left on her bedside table. Resident #47, a female with intact cognition and a history of type 2 diabetes mellitus, depression, hypothyroidism, and anxiety disorder, was observed with an unopened insulin pen needle on her dresser. The resident stated that staff had given her the needle, which she initially kept in her purse before placing it on the dresser. The Director of Nursing (DON) confirmed that residents require an assessment to self-administer medications and that all medications should be administered by staff. The presence of the needle without proper assessment and care planning posed a potential risk to the resident's safety. Additionally, the facility did not ensure a hazard-free environment for Resident #70, who had a power strip with a fan plugged into it in his room. Resident #70, a male with intact cognition and a history of hypertensive heart disease, edema, chronic obstructive pulmonary disease, obesity, repeated falls, bipolar II, insomnia, and generalized anxiety disorder, stated he used the fan due to room temperature issues. Despite the facility's policy prohibiting power strips, the resident continued to have one in his room, as confirmed by the Administrator. This oversight could lead to potential hazards and accidents, especially given the resident's history of falls.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure proper communication and coordination with the dialysis center for a resident requiring dialysis services. The resident, a male with chronic kidney disease stage 5 and type 2 diabetes, was admitted to the facility and required dialysis treatments on specific days. The facility's records indicated that the resident's dialysis communication sheets were incomplete or missing for several dates in February, which is crucial for maintaining continuity of care and monitoring the resident's condition. Observations and interviews revealed that the facility staff, including the LVN and CNA, were responsible for preparing and managing the dialysis communication sheets. However, there were multiple instances where the sheets were not filled out or returned from the dialysis center, and the facility did not have a policy in place to ensure the completion and return of these sheets. The Director of Nursing (DON) acknowledged the importance of these sheets for tracking the resident's health status and stated that it was the nurse's responsibility to follow up with the dialysis center if the sheets were not returned. The lack of a formal policy and procedure for managing dialysis communication sheets contributed to the deficiency. The DON and nursing staff were aware of the issue but did not consistently ensure that the communication sheets were completed and filed appropriately. This oversight could potentially affect the resident's care and treatment, as the dialysis communication sheets are essential for documenting vital signs, medication changes, and any health issues related to the dialysis treatment.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. For one resident, a medication aide prepared the medications, but a Licensed Vocational Nurse (LVN) administered them without verifying the medications. The LVN admitted to not knowing what medications were being given, which could result in incorrect medication administration. The Director of Nursing (DON) stated that while it is expected for the person who prepares the medication to administer it, it would be acceptable if a supervisor verified the medications before administration. In another case, an LVN did not administer the full prescribed dose of an arginine-based powder mixture to a resident with a PEG tube. The LVN discarded 15 mls of the mixture, believing it to be just water, despite it being part of the therapeutic dose. The DON confirmed that all of the mixed medicine should be administered for therapeutic effect. This oversight could compromise the resident's nutritional and wound management needs. The facility's policy on medication administration emphasizes that medications should be administered by the individual who prepared them and in accordance with prescribers' orders. The Texas Administrative Code also mandates that all medications be administered by the person who prepared them. These deficiencies highlight a failure to adhere to established protocols, potentially putting residents at risk for medication errors.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, specifically with Dumpster #1, which was observed to be open on multiple occasions. On two separate observations, the side door of the dumpster was found open, and trash, including a food wrapper, used gloves, and used masks, was found on the ground behind the dumpster. Interviews with staff revealed that the dumpster is shared with the entire facility, and sometimes others leave it open. The Director of Services (DS) acknowledged that the open dumpster and trash on the ground could attract animals and should not be there. The Maintenance Staff (MS) stated they were responsible for picking up trash outside the facility and had done so the day before. The Administrator confirmed that maintenance was responsible for picking up trash outside, but any staff could assist, and an in-service had been conducted to remind staff to keep the dumpster closed.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to potential risks in their care. For one resident, the facility did not update the physician's orders to reflect changes in the resident's diet and medication administration. Despite the resident being evaluated by a speech-language pathologist and deemed safe to consume whole medications and a regular diet, the care plan continued to indicate the need for crushed medications and a mechanically altered diet. This discrepancy was acknowledged by the Director of Nursing (DON), who admitted that care plans were not being updated promptly, which is crucial for guiding staff in providing appropriate care. Another resident's medical records were not updated to reflect their current Do Not Resuscitate (DNR) status. Although the resident's face sheet and discussions with the resident indicated a DNR status, the physician's orders and care plan still listed the resident as Full Code. This inconsistency was noted by the DON, who confirmed that the resident was currently DNR and on hospice care. The MDS Coordinator, responsible for updating care plans, admitted to being overwhelmed and acknowledged that many care plans were missing or incomplete, including the one for this resident. These deficiencies in maintaining accurate medical records could lead to improper care due to staff following outdated or incorrect care plans. The facility's failure to update care plans promptly and accurately reflects a systemic issue in managing resident information, as acknowledged by both the DON and the MDS Coordinator.
Failure to Provide Privacy Curtain for Resident
Penalty
Summary
The facility failed to ensure full visual privacy for a resident, identified as Resident #66, by not providing a privacy curtain in his room. This deficiency was observed during a survey where it was noted that Resident #66, a male with multiple medical conditions including cerebral infarction, pressure ulcers, and encephalopathy, did not have a privacy curtain in his room. The resident was primarily bedbound and required assistance for all activities of daily living and mobility tasks. During an observation, it was found that the privacy curtain had fallen off a long time ago and was never replaced, as confirmed by the resident's roommate. Interviews conducted during the survey revealed that the Licensed Vocational Nurse (LVN) was unaware of the missing privacy curtain until it was brought to her attention, at which point she planned to inform maintenance. The Maintenance Manager (MM) also stated he was not aware of the missing curtain until the day of the interview and mentioned the need to order a new one. The Administrator acknowledged the absence of the privacy curtain and had already moved the resident to a room with a curtain, recognizing the importance of privacy and dignity for residents. The facility's policy on Resident Rights emphasized the importance of treating residents with respect and dignity, including ensuring their privacy and confidentiality.
Infection Control Breach by CNAs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of three CNAs who did not adhere to proper infection control protocols while providing peri care to two residents. CNA A, CNA B, and CNA C were observed handling clean items with dirty gloves, which could lead to the transmission of infections. Specifically, CNA A did not change gloves after touching a soiled brief and continued to handle clean items and surfaces, including a new brief, a cupboard, and a resident's sneakers, without changing gloves or sanitizing hands. CNA B also failed to change gloves during peri care, handling a new brief and other clean items with soiled gloves. She did not wash her hands before donning gloves and continued to use the same gloves throughout the care process, potentially spreading germs. Similarly, CNA C did not wash or sanitize her hands before starting peri care and used the same gloves to handle both soiled and clean items, only changing gloves after applying a new brief. The facility's Director of Nursing acknowledged the breach in infection control protocols, noting that the CNAs involved had a limited understanding of proper practices. The facility's policy on standard precautions clearly outlines the necessity of hand hygiene and changing gloves to prevent cross-contamination, but these guidelines were not followed by the staff involved in the incidents.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, specifically in the storage of nasal cannulas and tubing when not in use. The resident, a female with a history of hypertension and shortness of breath, had active orders for oxygen therapy at 2 liters by nasal cannula continuously. However, observations revealed that the nasal cannula and tubing were improperly stored, hanging over a wheelchair handle instead of being placed in a protective bag as per the facility's policy. Interviews with various staff members, including CNAs, a PRN nurse, and the ADM, indicated a lack of awareness and adherence to the proper storage procedures for oxygen equipment. While some staff members acknowledged the importance of storing the equipment in a bag to prevent infection, none noticed the improper storage in the resident's room. The facility's policy, revised in November 2011, clearly stated that oxygen cannulas and tubing should be kept in a plastic bag when not in use to prevent infection. The deficiency was further highlighted by the DON and ADON, who confirmed that staff were in-serviced on oxygen storage weekly and that improper storage could lead to infection control issues. Despite these measures, the staff failed to notice and correct the improper storage of the resident's oxygen equipment, potentially placing the resident at risk of cross-contamination and illness.
Failure to Provide Adequate Pain Management for Resident with Cancer
Penalty
Summary
The facility failed to provide adequate pain management for a resident diagnosed with malignant cancer, resulting in chronic pain. Despite having orders for methadone and hydromorphone, the medications were frequently unavailable, leading to numerous instances where the resident did not receive the prescribed pain relief. The resident, who had a BIMS score indicating no cognitive impairment, reported severe pain over several days, which was documented in her care plan and medical records. The resident's medical history included malignant neoplasm of peripheral nerves and autonomic nervous system, adrenocortical insufficiency, and chronic pain. Hospital records indicated that the resident had been experiencing worsening pain and swelling in her lower extremity, which was later found to be due to a broken femur. Despite this, the facility repeatedly failed to administer the prescribed pain medications, as documented in the medication administration records, which showed numerous instances of medications being unavailable. Interviews with staff, including the DON and LVN, revealed that the facility was aware of the resident's chronic pain and the importance of administering her pain medications. However, due to issues with obtaining the prescriptions, the resident often went without her necessary pain relief, leading to significant distress and pain. The resident herself reported being in constant pain and having to call EMS due to the severity of her condition, highlighting the facility's failure to meet her pain management needs.
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 332 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gracy Woods Ii Living Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Avir At Park Bend | 0.4 mi | ★★★★★ | 8 | 0 |
| Windsor Nursing And Rehabilitation Center Of Duval | 2.7 mi | ★★★★★ | 1 | 0 |
| Legend Oaks Healthcare And Rehabilitation - North | 3 mi | ★★★★★ | 11 | 2 |
| Sage Park Austin | 4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.