Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Hansford County Hospital District Dba Lakeridge Nu during CMS and state inspections, most recent first.
Failure to Provide Timely Hygiene and Incontinence Care: A resident with severe cognitive deficits, dementia, a urinary ostomy, and bowel incontinence was found by family with dried feces on her body and later with urine-soaked sheets and clothing. Records showed limited documented toileting hygiene and elimination care, and staff interviews indicated rounding and incontinence checks were not consistently completed as expected.
Medication pass documentation was not completed in the EMAR as medications were administered. An LVN used a handwritten medication log to guide the pass, compared it to medication blister packs, administered meds to residents, and then marked the paper log afterward. The DON stated staff were expected to use the tablet on the med cart and document in real time, and that handwritten logs and post-documenting were not supposed to be used.
An LVN failed to sanitize hands before and after medication administration for multiple residents during med pass, including when giving eye drops and crushed meds mixed in jelly. The LVN said she forgot to do hand hygiene between residents and was unsure of the med pass policy, while the DON stated staff were expected to perform hand hygiene before and after each resident and wear gloves for eye drop administration.
An LVN failed to treat a resident with dignity by repeatedly telling him to go to his room or outside and smoke when he asked for meds or tried to speak with staff and visitors. The resident, who had multiple serious diagnoses and intact cognition on MDS, reported that the LVN skipped his room during med pass and gave his meds last, and another resident said the LVN seemed to have a grudge against him. The DON stated the redirection was not appropriate and the facility policy required residents to be treated with kindness, respect, and dignity.
Unlocked Medication Cart Left Unattended: A charge nurse left the Station 1 med cart unattended with the lock popped out while she assisted with a resident transfer. The cart was observed in the hallway on two occasions, and a resident and family member approached it while it was unsecured. When the surveyor checked the cart, all drawers opened and meds and supplies were visible inside; the nurse stated she had been trained that the cart and keys were to remain secured.
A nurse cart on Hall 2 was observed unlocked and unattended twice while no residents or staff were present. An LVN confirmed wound care supplies were available in the cart and said she did not know why it was unlocked, though she had been trained to lock medication and nursing carts when not in use. The DON and ADM stated the carts should be locked when not in use, and the facility policy required drugs and biologicals to be stored in locked compartments and unattended unlocked carts not be left open.
A resident with epilepsy, TBI, and seizures had physician-ordered monthly Dilantin and Keppra levels due on the 21st of each month, but no lab results were found for two consecutive months. The DON confirmed the lab did not draw the tests, and leadership stated they were responsible for ensuring ordered labs were completed, while the ADON said she had not been trained to ensure completion of lab orders.
A resident with peripheral vascular disease, insomnia, and an acute URI had an order and care plan for EBP due to wound care and non-intact skin, but observations found no PPE box and no EBP signage posted outside the room. The resident said staff sometimes wore a gown and sometimes did not, and staff stated the signs were supposed to be taped on doors but could fall off. The ADM, DON, and LVN all acknowledged responsibility for ensuring the signs were in place, and facility policy and CDC guidance required clear signage outside the room indicating the precautions and PPE.
A CNA failed to change gloves and perform hand hygiene when moving from dirty to clean tasks during incontinence care for three male residents with incontinence and complex medical histories. Despite initial handwashing and glove use, the CNA did not follow infection control protocols as required by facility policy, a fact confirmed by interviews with the DON and Administrator.
A facility failed to report alleged abuse and neglect involving three residents to the appropriate authorities. The incidents included a resident being force-fed, another being transferred roughly, and a third receiving improper perineal care. Despite being reported by a student CNA, the facility's administration did not report these allegations to the Health and Human Services Commission (HHSC) as required by their abuse policy.
The facility's call light system was found to be malfunctioning, affecting 15 residents, including those with diabetes and COPD. The system failed to alert staff at the nurse's station, leading to delayed assistance. Staff interviews confirmed the issue persisted for months, with maintenance requests unaddressed, compromising resident safety.
The facility failed to provide a private space for Resident Council meetings, affecting 13 residents. Meetings were held in a communal area with frequent interruptions, compromising privacy. Despite the Activity Director raising concerns with the Administrator, no changes were made to ensure privacy, violating the facility's policy.
The facility failed to maintain a safe environment, with several rooms having protruding electrical outlets, one with exposed wires. A resident with severe cognitive impairment was at risk due to these hazards. Staff were unaware of the issues, and no maintenance orders were recorded. The absence of the Maintenance Supervisor and insufficient rounds by the Administrator contributed to the oversight, leading to an Immediate Jeopardy finding.
A facility failed to provide proper respiratory care for three residents requiring oxygen therapy, as their oxygen tubing was found on the floor or improperly stored, contrary to facility policy. The residents, who had various medical conditions, were observed without storage bags for their oxygen tubing, leading to potential contamination risks. Staff interviews confirmed the policy requirement for storing tubing in plastic bags, but the facility administration was unaware of the issue, indicating a lapse in policy adherence and staff training.
The facility failed to provide palatable and appetizing food across three food forms during a lunch meal. Residents reported the food as bland and unappealing, with issues noted in the Spanish rice and beans. The Dietary Manager acknowledged the lack of seasoning and was unaware of resident complaints, while the ADM recognized the risk of weight loss if food was not appealing.
The facility was found to have deficiencies in food storage and kitchen sanitation, including unclean refrigerator handles, improperly stored cupcake pans, and unsealed food items. The Dietary Manager and a Dietary Aide acknowledged these issues, which were not in line with the facility's policies on maintaining clean and sanitary conditions.
The facility failed to ensure safe storage of residents' food in personal refrigerators, lacking temperature logs and thermometers, with undated perishable items observed. Interviews revealed a lack of clarity on monitoring responsibilities, posing potential health risks to residents.
A resident with intact cognition requested a copy of a grievance they filed, but the facility failed to provide it, contrary to their policy. The Social Worker and Administrator were unaware of the policy requirement, leading to a violation of the resident's rights.
The facility failed to properly store medications, resulting in loose pills found in two medication carts. Observations revealed loose pills in carts at Stations 1 and 2, which were subsequently destroyed. Staff interviews indicated that carts should be checked daily, but the deficiency was due to inconsistent adherence to this policy.
A facility failed to maintain proper infection control practices during wound care for two residents. An LVN did not perform hand hygiene between glove changes or after completing wound care, contrary to facility policy. The residents involved had multiple health conditions and were at risk for pressure ulcers. Interviews with the ADM and DON revealed they were unaware of these lapses, despite the facility's policy emphasizing hand hygiene to prevent infections.
The facility failed to maintain an effective pest control program, resulting in a roach infestation in a resident room on the East Hall corridor. Observations revealed roaches in the room, with gaps in cabinetry providing harborage. Residents reported seeing roaches in various areas, and the Maintenance Supervisor acknowledged the issue, citing food and poor cleaning as contributing factors. Despite multiple treatments, the roach problem persisted, indicating a deficiency in the facility's pest control efforts.
Failure to Provide Timely Hygiene and Incontinence Care
Penalty
Summary
The facility failed to ensure a resident who was dependent for personal hygiene, toileting, and bathing received needed ADL care and was kept clean of bowel movement and urine. The resident had severe cognitive deficits, dementia, muscle weakness, a urinary ostomy, and was always incontinent of bowel. Her care plan noted that she continuously removed clothes and her urostomy bag, and later documented that she removed feces from her brief, smeared it, and became agitated and physically aggressive when staff attempted redirection. On 5/10/2026, the resident’s family found her with dried feces on her hands, vaginal area, buttocks, body, bed rails, and clothing. A nurse later documented that the resident had feces all over her body and bed rails and that she was given a bed bath, cleaned, had her nails cleaned, and her clothes changed. The record showed toileting hygiene was documented at 4:16 a.m. and a large bowel movement at 4:18 a.m., but there were no further documented toileting hygiene tasks before the family found her soiled around 7:00 a.m. There were no progress notes showing that she had refused care before that time. On 5/11/2026, the resident’s family again found her in bed with urine on the sheets and clothing that appeared dry and stained. The video showed the family stating the room smelled like urine and that the resident appeared to have been sitting in urine for quite a while. The record did not show documented toileting hygiene or bowel and bladder elimination for that day, and there were no documented refusals before 3:30 p.m. Staff interviews described routine rounding every two hours, but multiple staff members stated they had not checked the resident as often as expected, and one CNA stated she had only rounded at 7:30 a.m. and 2:00 p.m. on that shift.
Medication Pass Documentation Not Completed in EMAR
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and that maintained records of receipt and disposition of drugs in sufficient detail for accurate reconciliation. During a nighttime medication pass, an LVN did not document medications in the EMAR immediately after administration and instead used a handwritten medication log as the reference for passing medications to residents. Record review showed the handwritten medication log listed residents' names, room numbers, and abbreviated medication names, but did not include the physician, time, or dosage amount for each medication. Some medication names were crossed out in black ink. During observation, the LVN used this handwritten log while comparing it to medication blister packs on the cart, popped the pills into cups, gave them to residents, and then crossed out the medications on the handwritten log after administration. The LVN stated she had written the medications down from the desktop computer because she could not access the EMAR on the tablet attached to the medication cart. The LVN stated she was responsible for the Station 1 medication cart and that she documented the medications on the desktop computer after completing the medication pass. She also stated she was not sure of the policy requirements for passing and documenting medications and had not been told anything about writing her own medication pass log. The DON stated staff were expected to use the tablet on the medication cart, document medications in real time in the EMAR as they were administered, and not use handwritten medication pass logs or post-document after the pass was completed.
Hand Hygiene Not Performed During Medication Pass
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five residents and one staff member reviewed for infection control. During an observation of medication pass on 4/30/26, LVN A prepared and administered medications to Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 without sanitizing her hands before or after each resident’s medication administration. During the same medication pass observation, LVN A administered oral medications and one drop of eye medication in each eye to Resident #4. She held Resident #4’s top eyelids open with her bare hand and did not sanitize her hands before or after the medication administration, and she did not wear gloves. LVN A then prepared crushed medications mixed in jelly for Resident #5 and administered them into the resident’s mouth with a wooden spoon without sanitizing her hands before or after the administration. During interview, LVN A stated she was the charge nurse on Station 1 and said she was trained to sanitize her hands between each resident even if she had no physical contact with them, but she did not do so every time because she forgot. She stated she was not sure of the policy requirements for passing medications and acknowledged that not sanitizing between residents created a risk of cross contamination and could spread germs to residents and get them sick. The DON stated staff were expected to sanitize before and after passing medications to each resident and to wear gloves when administering eye drops, and she was not aware staff were not doing hand hygiene during eye drop administration and between medication passes.
Dismissive responses and medication pass concerns
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when an LVN repeatedly responded to his requests in a dismissive manner and directed him to go to his room or go outside and smoke. The resident was a male with diagnoses including acute respiratory failure with hypoxia, chronic pain due to trauma, major depressive disorder, COPD, anoxic brain damage, seizures, dysphagia, muscle weakness, muscle spasm, cognitive communication deficit, dysarthria, anarthria, and myoclonus. His annual MDS showed a BIMS score of 13, indicating intact cognition. He submitted a grievance stating the night nurse treated him like a kid and gave his medications last. The resident stated the LVN parked the medication cart in a way that blocked him from getting by in his wheelchair, and when he asked her to move it, she became upset and told him to go outside and smoke. He also stated that when he approached the nurse's station to ask for his medication, she told him to go to his room or go smoke, and that she often told him to wait and would have things ready when he returned. He reported that she skipped his room during medication pass and gave him his medications last between 8:00 PM and 10:00 PM. Another resident stated she believed the LVN did not like him and had told him to wait when he asked for medications and a shower. During observation, the LVN was seen passing medications when the resident approached his doorway and asked for PRN pain medication; she told him she would look into it and told him to go back into his room and watch television. The LVN acknowledged telling him to go to his room so he could relax while she checked whether the medication was due, and she also acknowledged telling him to move away from a staff member and family member eating in the dining room and to go to his room or outside and smoke. The DON stated that sending the resident to his room or to smoke was not the appropriate way to redirect him and that it was not appropriate to redirect a resident from talking to staff eating in the dining room. The facility policy stated employees shall treat all residents with kindness, respect, and dignity, and that medication administration times are determined by resident need and benefit, not staff convenience.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure the Station 1 medication cart was secured when unattended. On 4/30/26 at 8:14 PM, the Station 1 medication cart was observed in the Station 1 hallway with the lock popped out, unattended, and without staff present. LVN A was seen coming out of a resident room and approaching the cart. Later that evening at 8:33 PM, the Station 1 medication cart was again observed in the Station 1 hallway with the lock popped out and unattended. LVN A was in Resident room [ROOM NUMBER]-B assisting another staff member transfer a resident into bed with a mechanical lift. While the surveyor waited by the cart, Resident #2 and their family approached and stood next to it. LVN A then exited the room, approached the cart, moved it, and stated she was the charge nurse assigned to the cart and was in the middle of passing out medications when she went to help with the transfer. The surveyor pulled on all drawers and all opened; the drawer containing narcotic medications opened, though the lock box was secure. Various cards and bottles of medications and medical supplies were observed in the open drawers. LVN A stated she had been trained that medication carts were to always be locked and that the keys were to always be with her, and she acknowledged she forgot to lock the cart.
Unlocked Nurse Cart Left Unattended
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in a locked compartment for 1 of 2 nurse carts reviewed for medication storage. During observations on 03/03/26 at 9:38 AM and again at 12:15 PM, Nurse Cart A on Hall 2 was observed unlocked and unattended, with no residents or staff present at the cart. During the first observation, LVN A confirmed that wound care supplies were available in the cart by opening it and stated she did not know why it was unlocked. She also stated she had been trained to lock medication and nursing carts when not in use but could not remember when the last training occurred. During interviews, the DON stated she expected nursing carts to be locked when not in use and that the charge nurse was responsible for ensuring they were locked, but she did not know why Nurse Cart A was left unlocked or when staff were last trained on locking carts. The ADM stated the nursing carts should be locked when not in use and that the charge nurse or medication aide was responsible for locking the medication cart or nursing carts when not in use. Record review of the facility policy titled, Storage of Medications, revised November 2020, stated drugs and biologicals are to be stored in locked compartments and that compartments containing drugs and biologicals are locked when not in use; it also stated unlocked medication carts are not left unattended.
Missed Monthly Antiseizure Drug Lab Monitoring
Penalty
Summary
The facility failed to provide or obtain ordered laboratory services for Resident #8, a male resident with diagnoses including epilepsy, traumatic brain injury, and other seizures. The physician had ordered monthly Dilantin (Phenytoin) levels and monthly Keppra (Levetiracetam) levels to be drawn on the 21st of each month, but no laboratory results were found in the resident’s record for January 2026 or February 2026. Record review showed the laboratory orders were active in the resident’s order summary, but the clinical record did not contain results for the two months in question. During interview, the DON stated she was unable to locate the results and confirmed that the laboratory used by the facility did not draw the tests for those months. The DON stated she did not know why the tests were not drawn and said the facility was working on a system for ensuring laboratory orders were completed. The DON, ADON, and ADM each stated that nursing leadership was responsible for ensuring laboratory orders were completed as ordered by the physician. The ADON stated she was never trained to complete or ensure completion of laboratory orders and was not aware the tests were missed for Resident #8. The ADM stated he was not aware the laboratory results were not completed and confirmed the facility was working on a new monitoring system. The facility policy stated staff will process test requisitions and arrange for tests.
Missing EBP Signage for Resident Room
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents reviewed for infection control. Resident #41, a male with diagnoses including peripheral vascular disease, insomnia, and acute upper respiratory infection, had an order for Enhanced Barrier Precautions with daily wound care every shift and a care plan identifying EBP use due to indwelling and non-intact skin or when coming in contact with blood, body fluids, mucous membranes, or non-intact skin. His quarterly MDS showed a BIMS score of 15, indicating intact cognition. During observations, Resident #41's room had no PPE box outside the room and no signage on the door regarding EBP. A later observation again found no EBP signage on the door. During interview, the resident stated staff sometimes wore a gown when providing care and sometimes did not, and he did not know why. Staff interviews revealed that EBP signs were supposed to be taped on resident doors, but they sometimes fell off; the LVN stated everyone was responsible for ensuring the signs were on the doors, and the ADM stated he checked for the signs each morning and replaced them if needed. The DON stated she was responsible for replacing signs when they fell off and did not know why Resident #41 did not have a sign on his door. The facility policy and CDC guidance both reflected that clear signage should be posted outside the resident room indicating the precautions and required PPE.
Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during incontinence care for three residents. Observations revealed that CNA A did not change gloves or perform hand hygiene when transitioning from dirty to clean tasks during incontinence care procedures. This practice was observed during care for three male residents, all of whom had a history of bladder and/or bowel incontinence and various medical conditions, including cerebral palsy, schizoaffective disorder, atherosclerotic heart disease, dysphagia, aphasia, and anemia. During the observed care episodes, CNA A and CNA B initially washed their hands and donned clean gloves before starting incontinence care. However, CNA A proceeded to remove soiled briefs, cleanse the residents' groin and buttocks, and then immediately placed clean briefs and assisted with clothing adjustments without changing gloves or performing hand hygiene between dirty and clean tasks. This sequence was repeated for all three residents, despite the facility's infection control policy requiring glove changes and hand hygiene when moving from dirty to clean procedures. Interviews with CNA A, the DON, and the Administrator confirmed that CNA A had received training on proper glove use and hand hygiene but failed to follow protocol during the observed care. Both the DON and Administrator acknowledged the expectation for staff to change gloves and perform hand hygiene as per facility policy. The facility's infection control policy, last revised in October 2018, was reviewed and found to require these practices to prevent the transmission of infections.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, to the appropriate authorities within the required timeframe. Specifically, the allegations involved three residents who were reportedly mistreated by staff members. The allegations included a resident being fed forcibly, another being transferred roughly, and a third receiving improper perineal care. These incidents were reported by a student CNA, but the facility's administration did not report them to the Health and Human Services Commission (HHSC) as required by their abuse policy. Resident #1, a severely cognitively impaired female with dementia and anxiety, was allegedly force-fed by a CNA, causing her to choke. Despite the resident's inability to communicate effectively due to her condition, the incident was not documented in her progress notes, and no report was made to HHSC. Similarly, Resident #2, also severely cognitively impaired, was reportedly transferred roughly by a CNA, but this was not documented or reported. Resident #3, who required substantial assistance with toileting hygiene, was allegedly changed improperly, leading to discomfort and potential harm, yet this incident was also not reported to the authorities. Interviews with facility staff revealed a lack of clarity and communication regarding the reporting of these incidents. The ADM and DON were aware of the allegations but did not perceive them as abuse, leading to a failure to report to HHSC. The ADON and other staff members were trained on the facility's abuse policy, which mandates immediate reporting of such allegations, but the incidents were instead treated as grievances. This misinterpretation and failure to follow protocol could place residents at risk for continued abuse and neglect.
Deficient Call Light System in Facility
Penalty
Summary
The facility failed to maintain a fully functioning call light system for 15 of 74 residents, which is essential for residents to call for staff assistance. Observations and interviews revealed that the call lights in several rooms were either not working, not triggering a sound at the nurse's station, or triggering lights in incorrect rooms. This malfunctioning system was reported to have been an issue for approximately 4 to 6 months, with maintenance requests submitted but not resolved. Residents with significant medical conditions, such as diabetes, COPD, and cognitive impairments, were affected by this deficiency. For instance, a resident with diabetes reported that the call light system's unreliability left them without assistance during a critical drop in blood sugar levels. Another resident expressed concerns about being left unattended and without necessary assistance, which could exacerbate their medical conditions. Staff interviews confirmed the ongoing issues with the call light system, with some staff members indicating that they had to rely on frequent rounds to ensure residents' needs were met. The facility's policy requires that call systems be functional at all times and that calls for assistance be answered promptly, but these standards were not met, leading to potential risks for resident safety and well-being.
Lack of Privacy for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for the monthly Resident Council meetings, affecting 13 residents who attended these meetings. The meetings were held in the front lobby, a communal area with frequent interruptions from staff and visitors, which compromised the privacy of the discussions. Despite a sign indicating that a meeting was in progress, staff and visitors continued to enter and exit the area, leading to concerns among residents about the lack of privacy and potential staff retaliation. The Activity Director, responsible for organizing the meetings, acknowledged the issue and had raised concerns with the Administrator, who suggested using the physical therapy room for privacy. However, this change was not implemented. The facility's policy, revised in February 2021, states that the Resident Council should be provided with space, privacy, and support to conduct meetings, which was not adhered to in this instance.
Facility Fails to Address Electrical Hazards in Resident Rooms
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards, specifically concerning electrical outlets in resident rooms. Observations revealed that several rooms had electrical outlets protruding from the walls, with one room having exposed wires. This posed a significant risk to residents, particularly those with cognitive impairments or mobility issues. For instance, a resident with severe cognitive impairment and the ability to self-ambulate in a wheelchair was residing in a room with an electrical outlet hanging from the wall, exposing wires. Interviews with staff indicated a lack of awareness and communication regarding the maintenance issues. A Licensed Vocational Nurse (LVN) was unaware of the protruding outlets, and there were no work orders recorded for the necessary repairs in the maintenance log. Residents expressed concerns about the safety of using these outlets, but staff reassured them without addressing the underlying hazard. The Maintenance Supervisor was absent due to illness, and the Administrator admitted to not conducting sufficient rounds to identify and address these hazards. The deficiency was identified as an Immediate Jeopardy, indicating a severe risk to resident safety. The facility's failure to maintain a safe environment could lead to serious injury, including electrocution or fire. The Administrator acknowledged the oversight and the potential for harm, noting that residents often bumped into the outlets, which could have contributed to the damage. The facility's inaction and lack of proper maintenance protocols directly led to the hazardous conditions observed.
Removal Plan
- Room [ROOM NUMBER] hazard identified prompted immediate removal of residents and closure of room until electrician arrived. Electrician provided fix under the direction of corporate maintenance director.
- All outlets in the facility will be reviewed by the administrator under the direction of the corporate maintenance director. Any negative findings will be documented on the facility map with location identified with immediate correction for removal of hazard.
- RNC completed an in-service with the Administrator regarding accident and incident prevention policy and procedure with focus on hazards.
- RNC completed an in-service with all staff regarding policy and procedure for Accidents and Incidents. Any oncoming shifts will be in-serviced prior to the start of resident assignment until completion.
- An audit of the last 90 days entry log for the maintenance book was initiated by the administrator. Any identified issues will be notated for completion by the facility designee under the direction of the corporate maintenance director.
Improper Storage of Oxygen Tubing in LTC Facility
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required oxygen therapy, as observed during a survey. The deficiency was identified through observations, interviews, and record reviews, which revealed that the facility did not adhere to its policy for the proper storage of oxygen tubing. Specifically, the oxygen tubing for the residents was found on the floor or improperly stored, which could lead to contamination and infection. The residents involved had various medical conditions, including Chronic Obstructive Pulmonary Disease, heart disease, and diabetes, and required oxygen therapy as part of their treatment. Resident #50, a cognitively intact female, was observed with her oxygen tubing on the floor, and she reported that staff usually changed the tubing but did not provide a storage bag. Similarly, Resident #68, who had moderate cognitive impairment, was found with his oxygen tubing on the floor, and he was unaware of where to store it. Resident #35, also cognitively intact, had his oxygen tubing from a portable tank on the floor and stated that staff did not always provide a storage bag. These observations were consistent across multiple days, indicating a systemic issue with the facility's adherence to its policy. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), confirmed that oxygen tubing should be stored in plastic bags when not in use to prevent contamination. However, they acknowledged that bags were not consistently available in resident rooms. The facility's administration, including the Administrator (ADM) and Director of Nursing (DON), were unaware of the issue and reiterated the policy that oxygen tubing should be stored properly to prevent infection. The facility's policy, revised in 2011, clearly stated that oxygen cannulae and tubing should be kept in a plastic bag when not in use, highlighting a failure in policy implementation and staff training.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide food that was palatable and at a safe, appetizing temperature for three different food forms (Regular, Mechanical Soft, and Pureed) during a lunch meal observation. During confidential interviews, five out of fourteen residents expressed concerns about the palatability of the food, stating it did not taste good, was bland, and lacked flavor. One resident questioned the cooking skills of the staff, while another described the food as very bland. A test tray evaluation revealed that the Spanish rice was bland and lacked taste, and the beans were thick and dry across all food forms. The Dietary Manager (DM) acknowledged the issues with the Spanish rice and beans, noting that the rice was pre-seasoned and cooked without additional seasoning, and the beans were prepared by simply adding water. The DM stated that she was unaware of any resident complaints and mentioned that salt and pepper packets were provided for additional seasoning. The Assistant Dietary Manager (ADM) indicated that the dietary staff were responsible for food palatability and acknowledged the risk of weight loss if residents did not find the food appetizing. The facility's policy emphasized the importance of nutrition and providing a menu that meets residents' preferences, but the observed deficiencies suggest a failure to adhere to this policy.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. The deficiencies included unclean refrigerator handles with dry, sticky substances, improper storage of a cupcake pan, and improperly sealed food items in the pantry and refrigerator. Specifically, a bag of enriched farina hot cereal was not fully sealed, and a bag of shredded lettuce was also found not fully sealed in the refrigerator. These observations were confirmed through interviews with the Dietary Manager (DM) and a Dietary Aide, who acknowledged the improper storage and cleanliness issues. The DM admitted to not knowing why the refrigerator handles were unclean and confirmed that the refrigerators are cleaned weekly. The DM also acknowledged that food should be stored fully sealed and that the cupcake pan should be stored upside down. The Dietary Aide confirmed that all foods should be stored fully sealed to prevent cross-contamination. The facility's policies on food storage and kitchen sanitation, which were reviewed, emphasize maintaining clean and sanitary conditions, but the observed practices did not align with these guidelines.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of residents' food items in four personal refrigerators. Observations revealed that none of the refrigerators had up-to-date temperature logs or thermometers inside, and they contained undated perishable food items. Specific items noted included creamy spinach dip, cheese, iced tea, potato salad, pimiento cheese, soda, cranberry juice, Jello, pickles, and a partially eaten burrito. These deficiencies were observed across multiple rooms, indicating a systemic issue with monitoring and maintaining food safety standards. Interviews with the Administrator (ADM) and Director of Nursing (DON) revealed a lack of awareness and clarity regarding the responsibility for monitoring personal refrigerator temperatures. The ADM stated that the maintenance supervisor, who was no longer employed, was previously responsible for this task. The DON was unsure of the policy and assumed it was housekeeping's responsibility. Both acknowledged the potential health risks to residents from improper temperature monitoring, such as foodborne illnesses and bacterial infections. The facility's policy required that refrigerators have working thermometers, temperatures be monitored, and food items be properly dated and stored, which was not adhered to in this case.
Failure to Provide Grievance Copy to Resident
Penalty
Summary
The facility failed to honor a resident's right to receive a copy of a grievance they filed, as outlined in the facility's grievance policy. Resident #51, who has an intact cognitive status with a BIMS score of thirteen, requested a copy of their grievance from the Social Worker. The Social Worker, after consulting with the Administrator, informed the resident that they would not receive a copy. This decision was contrary to the facility's policy, which mandates that a written summary of the grievance report be provided to the resident. Interviews with the Social Worker and the Administrator revealed a lack of awareness and adherence to the facility's grievance policy. The Social Worker was initially unsure of the policy details, and the Administrator admitted to not realizing the requirement to provide a copy of the grievance to the resident. Both acknowledged that not providing a copy could negatively impact the resident's perception of their grievances being addressed, thus impeding on resident rights. The facility's policy clearly states that a written summary of the grievance findings should be provided to the resident, which was not done in this case.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals in two medication carts, leading to the presence of loose pills. During an observation of the medication cart at Station 1, three loose pills were found, identified as Carbidopa/Levodopa, Carbamazepine, and Xarelto. Similarly, the medication cart at Station 2 contained five loose pills, identified as Levothyroxine, Ondansetron HCl, Gabapentin, and Eliquis. The loose medications were destroyed by the staff, and it was noted that the presence of loose pills could result in residents missing their prescribed doses. Interviews with the medication aides and nursing administration revealed that the carts were supposed to be checked daily for loose or expired medications, and monthly audits were conducted by a pharmacy consultant. However, the staff was unaware of the loose medications until the survey. The facility's policy required that all drugs and biologicals be stored in their original packaging and that the nursing staff maintain medication storage areas in a clean and safe manner. The deficiency was attributed to a lack of adherence to these policies, as the staff did not consistently check the carts for loose medications before their shifts.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of LVN A during wound care procedures for two residents. LVN A did not perform hand hygiene between glove changes while providing wound care to a resident's right lower leg and another resident's left heel. Additionally, LVN A did not sanitize her hands after completing the wound care for the first resident. These actions were observed during wound care sessions and were confirmed by LVN A during an interview. The first resident, a male with multiple diagnoses including senile degeneration of the brain, dysphagia, and chronic obstructive pulmonary disease, was receiving daily wound care for a right lower leg wound. The second resident, a female with multiple sclerosis and other conditions, was receiving daily wound care for a left heel wound. Both residents were at risk for developing pressure ulcers, as indicated in their comprehensive care plans. Despite the facility's policy requiring hand hygiene before and after glove changes and after touching a resident, LVN A failed to adhere to these protocols. Interviews with the ADM and DON revealed that they were unaware of the lapses in hand hygiene by LVN A. Both acknowledged the facility's policy on hand hygiene and the importance of following it to prevent infection and cross-contamination. The facility's policy, revised in October 2023, emphasizes hand hygiene as the primary means to prevent healthcare-associated infections, specifying that hand hygiene should be performed immediately before and after resident contact, between glove changes, and after glove removal.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in one of the resident rooms on the East Hall corridor. Observations revealed roaches crawling on the walls and floor, with gaps in the hand sink cabinetry and adjacent wall area providing harborage for pests. The room was cluttered, with extra mattresses stacked on a vacant bed, and the area was dark, which may have contributed to the pest issue. Interviews with residents indicated that roach activity had been observed in various areas of the facility, including bathrooms, closets, and bed areas. The Maintenance Supervisor acknowledged the pest problem, stating that the facility had been sprayed twice in the last month, but roaches continued to be an issue. He noted that food and poor cleaning practices could have contributed to the increase in roach activity. The Maintenance Supervisor also mentioned that he relied on staff reports and his own observations to monitor pest activity, checking for roaches about once a week. Despite these efforts, the roach problem persisted, particularly in the East corridor. The facility's pest control records showed multiple treatments for various types of roaches and other pests over several months. However, the treatments appeared to be insufficient in controlling the roach population, as evidenced by the ongoing observations of live roaches. The facility's policy on pest control, which emphasized maintaining a pest-free environment, was not effectively implemented, leading to the deficiency noted in the report.
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What surveyors actually found near you
We read the 139 citations issued within 25 miles in the last 12 months — including the 14 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.
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Nursing homes near Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Lubbock | 1.8 mi | ★★★★★ | 17 | 3 |
| Crown Point Health Suites | 2.3 mi | ★★★★★ | 7 | 0 |
| Avir At Heritage Oaks | 2.7 mi | ★★★★★ | 16 | 0 |
| Mesquite Post Acute Care | 3 mi | ★★★★★ | 11 | 0 |
| Mi Casita Nursing And Rehabilitation Center | 3.1 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.