Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Convalescent Center during CMS and state inspections, most recent first.
Failure to reasonably accommodate a resident’s brief size needs was cited when a cognitively intact, incontinent resident with multiple chronic conditions was provided 3X briefs even though she stated she needed 5X briefs. CNAs reported the briefs were too tight and uncomfortable, staff said they had asked management to order larger briefs, and the DON/ADON stated they had not obtained them, with the ADM saying no such size existed despite an online observation showing 4-5XL adult briefs.
A resident council grievance about bed sheets not being changed was not addressed for multiple residents. Five anonymous residents reported that sheets were not being changed weekly during showers, with one new admit stating her sheets had only been changed once since admission and another stating she had to make her own bed after receiving clean sheets. Staff interviews showed the AD, DON, and ADON were aware of the grievance process, but the concern was not clearly followed through, and no grievance was found in the record for the issue.
Kitchen Food Storage and Labeling Deficiency: Surveyors found multiple freezer, pantry, and refrigerator items that were unlabeled, undated, improperly stored, or expired, including deli meat, frozen foods, juice boxes, and dry mixes. Staff and the RD stated that all kitchen staff were responsible for labeling and dating food, and the facility policy required food to be dated when received and when opened.
Improperly Completed DNR Advance Directive: A resident with dementia and severe cognitive impairment was listed as DNR, but the DNR form in the chart was not properly completed because the two witnesses signed before the MPOA signed. An LPN reviewing the record stated the form was not legitimate, and the DON confirmed the witness signatures and MPOA signature sequence on the DNR document.
Soiled and Blood-Stained Linens Left in Resident Rooms: Two residents were observed with unclean bed linens left in place, and one room also contained a bloody tissue on the windowsill and another on the floor. One resident with intact cognition had repeated observations of a bottom sheet with greenish and tan splotches, while another resident with intact cognition had a bottom sheet stained with blood from an arm wound that remained in the same condition across multiple checks. Staff interviews confirmed that CNAs, nurses, and sometimes housekeeping were responsible for changing sheets and cleaning rooms when linens were soiled or bloody.
Incomplete Care Plans for Oxygen Therapy and Facial Lesion: The facility failed to include a resident’s oxygen therapy and another resident’s facial lesion in their care plans. One resident had severe cognitive impairment, SOB, intermittent O2 use, and was observed on NC O2, yet the care plan did not address O2 therapy. Another resident with severe cognitive impairment had a cancerous, ulcerated facial lesion documented in the MDS, progress notes, and observations, but the care plan did not include the lesion.
Unsafe Items Left in Resident Room: A resident with cognitive communication deficit, COPD, and dependence for most ADLs had a tube of medicated ointment and a can of sanitizing spray on bedside tables in her room, despite facility staff stating these items were not allowed in resident rooms. The resident said she used the ointment on her bottom and sprayed the aerosol in the air when the room smelled bad. The items’ labels warned to keep them out of reach of children and identified the spray as a compressed gas under pressure.
A resident with dementia, AFib, and severe cognitive impairment was observed receiving O2 by nasal cannula even though the chart lacked a clear oxygen order and the MAR had no documentation of oxygen therapy. The resident said she used oxygen when needed and had been using it for a while. An LVN could not find an order and stated oxygen without an order was a medication error, while the DON acknowledged the resident did not have an oxygen order in the chart.
Surveyors found multiple instances of improperly stored, unlabeled, and undated food items in the kitchen, freezer, and walk-in refrigerator. Staff interviews revealed inconsistent understanding and implementation of food labeling and dating procedures, despite prior in-service training and a documented policy. These failures could result in serving out-of-date or contaminated food to residents.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A nurse was observed on video removing and consuming narcotic medications from multiple residents' medication supplies. One resident, who was alert and aware of his medication schedule, reported not receiving his prescribed pain medication from the nurse, despite documentation indicating it was given. Staff interviews and narcotic log reviews revealed frequent medication wastage and missing second signatures, with the nurse as the sole signatory. The issue was discovered after a resident's complaint and subsequent video review, leading to a police report and a positive drug test for the nurse.
In a LTC facility, Cooks C, D, and E failed to follow proper hand hygiene and glove use protocols while preparing food, leading to potential cross-contamination. Observations revealed that the cooks touched various kitchen surfaces and then handled food without changing gloves. The Dietary Manager acknowledged the lapses in procedure, despite having trained the staff in hand hygiene and glove use.
A facility failed to ensure proper hand hygiene and medication administration by RN J, compromising resident safety. RN J left medication carts unlocked and medications unattended, and did not perform hand hygiene when assisting with meals or breaking pills. Despite attending training, these deficiencies persisted, leading to RN J's termination.
The facility failed to properly store and label medications, leaving carts unlocked and medications unattended. Observations showed loose pills in a cart, insulin without an open date, and expired glucometer solutions. Medications were left on bedside tables for residents, with staff confirming this as a regular practice. Interviews with the DON and ADON noted potential negative outcomes, and facility policies on medication storage and administration were not adhered to.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to hand hygiene protocols. An RN assisted a resident with a meal and broke a pill without washing hands or using gloves. CNAs did not perform hand hygiene during incontinent care for two residents, increasing the risk of cross-contamination and infection.
A facility failed to provide a privacy bag for a resident's foley catheter, compromising her dignity and potentially leading to infection risks. The resident, who has no cognitive impairment and requires supervision, was observed without a privacy cover during incontinent care. Facility policies emphasize dignity and privacy, but the specific policy on incontinent care lacked guidance on privacy covers for catheters.
A facility failed to ensure the validity of a resident's DNR order due to the absence of a physician's signature date, potentially leading to treatment against the resident's wishes. The resident, who was moderately cognitively impaired and required maximal assistance, had multiple health conditions. Interviews with staff confirmed that the lack of a signature date made the DNR form void, and facility policies lacked guidance on necessary signatures.
A resident with peripheral vascular disease and bilateral below-knee amputations did not have updated wound care orders reflected in his care plan. The MDS LVN responsible for care plans acknowledged the oversight, which was confirmed by the DON and ADONs. This failure to update the care plan could lead to improper treatment documentation and potential negative outcomes for the resident.
A resident with a history of peripheral vascular disease and bilateral below-knee amputations did not receive wound care as ordered, risking poor healing and infection. Despite specific wound care instructions, the facility failed to provide care on at least two occasions, with no documentation of alternative care or appointments. Staff interviews revealed inconsistencies in documentation and responsibility for wound care, highlighting a deficiency in adhering to the care plan.
A facility failed to limit PRN orders for psychotropic medications to 14 days for a resident with anxiety disorder, as required by policy. Despite the resident's stable condition, the PRN order for Alprazolam was not reviewed or justified for continuation beyond the 14-day limit. Interviews with nursing staff revealed a lack of adherence to the policy, resulting in the deficiency.
The facility failed to maintain sanitary conditions in resident refrigerators, leading to the presence of expired and rotten food items. Two residents expressed concerns about the cleanliness of the refrigerators, which were found to contain improperly labeled and expired food, as well as unsanitary conditions. Staff interviews revealed confusion about who was responsible for cleaning the refrigerators, contributing to the deficiency.
A resident with multiple health conditions did not receive wound care and central line maintenance as ordered by physicians. Wound treatments for the resident's finger, amputation site, and sacral area were missed on several occasions. Additionally, central line dressing changes were not performed as scheduled, and there was no documentation of treatment refusals. Interviews with staff highlighted potential negative outcomes, and facility policies on catheter care and documentation were not followed.
Failure to Provide Properly Sized Incontinence Briefs
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not met for one resident who was incontinent of bladder and frequently incontinent of bowel and who had diagnoses including chronic respiratory failure with hypoxia, depression, hypothyroidism, type 2 diabetes mellitus, morbid obesity, anxiety disorder, myopathy, hypertension, emphysema, and COPD. The resident’s quarterly MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and she required extensive assistance with mobility and transfers. Her care plan documented bladder incontinence with a goal of remaining free from skin breakdown due to incontinence and brief use, and noted that she preferred to wear 2 briefs and a protective pad for furniture. During observation, the resident stated she was wearing 3X briefs but needed 5X briefs, and that she had told CNAs not to fasten the sides because the 3X briefs were too tight and uncomfortable. She stated that management had previously said they were looking for 5X briefs, but she had not heard whether they were ordered. The supply closet on her hall contained 3X briefs as the largest size available. Staff interviews showed uncertainty and inconsistency about the resident’s brief size needs and whether larger briefs had been obtained; one RN was not sure if the facility had tried to get larger briefs, and CNAs stated they had asked administration to order bigger briefs but had not seen any 5X briefs for the resident. Additional interviews confirmed that staff believed the smaller briefs were uncomfortable for the resident, and one RN stated her bottom area could become aggravated because the briefs were too small. The ADON acknowledged that CNAs had asked her to order 5X briefs, but she did not order them and said the company website did not have that size. The ADM stated she had not ordered 5X briefs because no one made that large a size, despite an online observation showing adult briefs available in 4-5XL on Amazon. The resident stated she did not feel the facility tried to meet her needs in this regard and said management had talked to her only once about getting a larger brief.
Resident Council Grievances About Unchanged Bed Sheets Not Addressed
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly on grievances and recommendations concerning resident care and life in the facility for 5 of 7 anonymous residents. During a resident council meeting on 12/03/25, five attendees reported that their bed sheets were not being changed weekly during showers as expected. One resident stated she had been in the facility for one month and her sheets had only been changed one time since admission. Another resident stated a nurse brought clean sheets for her to put on herself and make her own bed. All five residents stated they had raised the concern at resident council meetings for the last couple of months and had not received any response from staff about how the issue was being addressed. Record review showed no grievance from June 2025 through December 2025 about sheets not being changed, although resident council minutes from 10/7/25 and 11/4/2025 documented that beds were not being made, with the AD present at those meetings. During interviews, the AD stated grievances were supposed to be reported to the SW and investigated, and that resident council issues were presented at morning meeting for department heads to address, but she was not sure what happened with the sheet issue after a resident told her on 12/2/25 that her sheets had not been changed in a month. The DON stated the protocol was for nurses to change bed sheets 3 times a week when residents received a shower, but she had not heard about the concern in morning meeting. The facility policy stated residents have the right to voice grievances and have the facility respond, and the resident council policy stated the facility would consider resident council views and act promptly on grievances and recommendations.
Kitchen Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation. During observation of the freezer, pantry, and walk-in refrigerator, surveyors found multiple food items that were not properly labeled or dated, including French fries, chicken nuggets, juice boxes, deli meat, a Ziploc bag containing an open cheese sauce mix bag, and a box of Jiffy corn bread mix stored in a Ziploc bag. The pantry also contained an opened pork roast gravy mix that was not in a sealed container. Surveyors also found expired food items in the pantry, including a bag of sloppy joe mix that expired in December 2024 and a box of Jiffy corn bread mix with an expiration date of 5/22/24. The DM discarded the expired sloppy joe mix during the observation. In interviews, kitchen staff and the DM stated that all staff were responsible for labeling and dating food, and the RD stated she trained staff on the facility's labeling and dating policy and conducted in-services based on that policy. The facility policy stated that all food must be dated when received, items removed from original packaging must be dated, and opened food items must be dated the day they are opened.
Improperly Completed DNR Advance Directive
Penalty
Summary
The facility failed to ensure that Resident #24 had a properly completed advance directive. Resident #24 was a female resident with diagnoses including dementia, Alzheimer’s disease, and renal insufficiency. Her record listed her as DNR, and her quarterly MDS showed a BIMS of 05, indicating severe cognitive impairment. Her care plan also identified that the resident and/or responsible family had a DNR order, and the clinical record contained an active DNR order and a DNR form signed by the resident’s MPOA. Record review showed the DNR form was not completed correctly because the two witnesses signed the form two days before the MPOA signed it. During interview, the nurse caring for Resident #24 reviewed the chart and stated the form was not legitimate and that if the DNR was not completed correctly, residents would not be coded correctly and their wishes might not be honored. The DON also reviewed the form and reported that the MPOA signed it and that the former social worker and current AD signed as witnesses. The facility policy stated it would honor advance directives developed in accordance with state law, and the Texas OOH-DNR order required two competent adult witnesses to sign and date the form.
Soiled and Blood-Stained Linens Left in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents by leaving soiled bed linens in place and, for one resident, failing to remove a bloody tissue from the room. Resident #12, an older female with diagnoses including cognitive communication deficit, weakness, need for assistance with personal care, and muscle weakness, had intact cognition on her quarterly MDS and no care plan mention of refusing or resisting care. During multiple observations, her bottom sheet remained soiled with greenish and tan splotches in the same area near her left shoulder, and she stated staff changed her top sheet nearly every day but her bottom sheet every 4 days. Resident #78, an older male with weakness and need for assistance with personal care, also had intact cognition on his quarterly MDS and no care plan mention of refusing or resisting care. During repeated observations, his bottom sheet remained stained with blood in the same pattern on the upper right side of the bed, and a bloody tissue remained on his windowsill and another had been on the floor. He stated the blood was from his upper right arm and that his arm would not quit bleeding. The blood-stained sheet and bloody tissue were still present during later observations. Staff interviews showed that nurses, CNAs, and sometimes housekeeping were responsible for changing sheets and cleaning resident rooms, with sheets changed on shower days and when soiled or bloody. ADON B stated soiled or bloody sheets should be removed as soon as noticed, the mattress cleaned with disinfectant spray, and clean sheets applied. RN F stated she had seen blood on Resident #78's sheets and that he refused to have them changed, while other staff stated they would expect bloody tissues to be discarded and rooms cleaned when needed. Facility policies stated residents have the right to a dignified existence and to a clean, sanitary, orderly environment with clean bed and bath linens.
Incomplete Care Plans for Oxygen Therapy and Facial Lesion
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1 by omitting oxygen therapy from the care plan. Resident #1 was admitted with diagnoses including paroxysmal atrial fibrillation and generalized anxiety disorder, had a BIMS score of 5 indicating severely impaired cognition, and her MDS showed shortness of breath with exertion, at rest, and when lying flat, with intermittent oxygen therapy documented. Her care plan dated 08/28/25 addressed shortness of breath and difficulty breathing, but did not mention oxygen therapy, even though an order dated 12/04/25 specified oxygen via nasal cannula at 1-2 L as needed related to paroxysmal atrial fibrillation. Record review showed Resident #1 had multiple oxygen saturation entries and was observed receiving oxygen via nasal cannula at 2 L/min while lying in bed with the head of the bed elevated. During interview, the resident stated she wore oxygen when needed for trouble breathing. The LVN stated the resident received oxygen PRN for tachycardia, while the MDS LVN stated the resident was not on the care plan for oxygen because she was not receiving it anymore and acknowledged there was no documentation showing she was using oxygen at the time of the interview. The facility also failed to include Resident #24's facial lesion in her care plan. Resident #24 had diagnoses including Alzheimer's disease and acute kidney failure, a BIMS score of 5, and her MDS identified an open lesion other than ulcers, rashes, or cuts. Progress notes described a cancerous mass on the left side of her cheek, with a dark, ulcerated lesion about 1 cm in diameter, and later notes documented family discussion about the lesion and that treatment would not proceed. On observation, the resident had a large growth on her left cheek and later a large raised, rough, open area that she described as bad, getting bigger, and seeping. Her care plan completed 10/09/25 did not mention the lesion or sore, and the MDS LVN stated she did not know why it had not been included.
Unsafe Items Left in Resident Room
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for one resident. Resident #11, a [AGE]-year-old female admitted with diagnoses including cognitive communication deficit, COPD, and need for assistance with personal care, had a quarterly MDS showing a BIMS score of 13, dependence on staff for toileting, bathing, lower body dressing, footwear, and all mobility and transfers, and was always incontinent of urine and frequently incontinent of bowel. Her care plan did not mention self-administration of medication, and there was no order for the medicated ointment found in her room. During observation, a can of sanitizing spray was found on one bedside table and a tube of medicated ointment was found on the other bedside table in Resident #11’s room. The items remained in the room on a later observation when the resident was not present. When interviewed, the resident stated she used the medicated ointment on her bottom and used the sanitizing spray to spray in the air when it smelled like poop. The ADON, DON, and RN stated residents were not to have sanitizing spray in their rooms, and the DON stated residents were not to have sanitizing sprays or medicated creams in their rooms. Record review showed the sanitizing spray label warned it was hazardous to humans and domestic animals, advised avoiding contact with skin or clothing, and stated it should be stored in areas inaccessible to small children. The safety data sheet identified it as a compressed gas under pressure that may explode if heated. The medicated ointment label stated to keep it out of reach of children and to contact a physician or Poison Control Center in case of accidental ingestion. The facility’s admission packet listed medicated creams and aerosol cans as items not allowed in resident rooms, and the facility policy stated residents are provided a safe, homelike environment.
Oxygen Therapy Given Without a Documented Order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident #1. The resident was admitted with diagnoses including atrial fibrillation, dementia, generalized anxiety disorder, and seizures. Her admission MDS listed a BIMS of 5, indicating severe cognitive impairment, and noted that she was dependent on staff for most ADLs and was on oxygen therapy on admission and while a resident. However, the care plan dated 8/20/2025 contained no care plan for oxygen use, and the order summary printed 12/04/2025 showed only an order for oxygen via nasal cannula 1-2 L as needed, with no other oxygen therapy orders noted. Observation and record review showed the resident wearing oxygen via nasal cannula at 2 L/min while asleep in bed, and later with the oxygen concentrator beside her and tubing stored in a plastic bag. The resident stated she wore oxygen when needed and had been using it "a while." The MAR for August 2025 and December 2025 contained no documentation of oxygen therapy. During interview, the LVN could not find an order for oxygen therapy and stated the resident received oxygen PRN and could have it continuously if needed for tachycardia, while also stating that giving oxygen without an order was a medication error. The DON stated the facility was aware the resident did not have an order for oxygen therapy and that the nurse who took the order was responsible for writing it in the chart, but the nurse could not be determined because the resident had been on oxygen for a while.
Failure to Properly Store, Label, and Date Food Items in Kitchen and Refrigeration Areas
Penalty
Summary
Surveyors observed multiple instances of improper food storage, labeling, and dating in the facility's kitchen, freezer, and walk-in refrigerator. Items found included bags of unidentified food, opened and unlabeled freezer bags of French fries, hamburger patties, hashbrowns exposed to air, a half-eaten ice cream sandwich, and clear cups with an orange substance, all lacking labels or dates. In the walk-in refrigerator, there were sealed and opened containers of vegetable base, butter, bowls of water with celery and carrots, a bowl of whole onions, peppers, and tomatoes, and a box of cucumbers, none of which were labeled or dated. These observations were made during a kitchen sanitation review. Interviews with kitchen staff, the dietary manager (DM), and the administrator (ADM) revealed that all kitchen staff were responsible for labeling and dating food, but there was confusion regarding the existence and implementation of a formal policy. The ADM initially stated there was no policy for labeling and storage, while the registered dietitian (RD) indicated that in-service training and handouts on labeling and dating had been provided. Record review confirmed that a dietary in-service had been conducted, outlining procedures for proper food storage, labeling, and dating, but these procedures were not being consistently followed as evidenced by the observations.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information and proper record-keeping were not consistently followed. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Nurse Misappropriation of Resident Narcotics
Penalty
Summary
A nurse (LVN A) was observed and recorded on video taking narcotic medications from the medication cart, removing pills from multiple residents' bubble packs, and consuming them herself. The video evidence showed LVN A accessing the narcotic drawer, popping out approximately 14 pills from various residents' medications, and ingesting them. On another occasion, she was seen placing medications in her pocket and later consuming them. The identities of the specific residents whose medications were taken could not be determined from the video, but the actions were confirmed by direct observation and interviews. Resident interviews revealed that one resident, who was fully alert and oriented, reported not receiving scheduled hydrocodone doses from LVN A, despite the nurse documenting administration. This resident was able to accurately recall his medication regimen and noted improvement after LVN A's departure. Other residents did not report missing medications, but one mentioned a nurse offering pain medication that was not requested. Medication Administration Records (MARs) for the reviewed period did not show discrepancies, but staff interviews indicated frequent unexplained medication wastage and increased frequency of narcotic orders. Staff interviews and review of narcotic log books revealed that LVN A was the sole signatory for multiple instances of wasted, dropped, or refused narcotics, with no required second signature. Other nurses reported suspicions due to increased medication usage and missing doses, which were reported to the Director of Nursing. The facility administrator confirmed that the issue came to light after a resident complained of pain and a review of video footage was conducted. A police report was filed, and a drug test of LVN A was positive for multiple controlled substances.
Improper Hand Hygiene in Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen where food storage, preparation, and distribution were taking place. Cooks C, D, and E did not perform hand hygiene appropriately while preparing food, which could lead to cross-contamination and pose a risk of food-borne illness to residents. During observations, Cook C was seen touching various kitchen surfaces and then handling food without changing gloves, despite acknowledging the mistake when questioned. Similarly, Cook E was observed preparing dessert cups and using her gloved hand to handle food after touching kitchen surfaces, without changing gloves. Cook E admitted to not realizing she had touched the food with her gloved hands and acknowledged the potential risk of contamination. Cook D also failed to change gloves after touching kitchen surfaces and used his fingers to push food onto plates, which he recognized as improper practice that could lead to food-borne illness. The Dietary Manager (DM) confirmed that she was responsible for training staff in hand hygiene and glove use, and acknowledged that Cooks C, D, and E did not follow proper procedures. The facility's policy on glove use emphasizes no bare hand contact with food and the necessity of washing hands before and after glove use to prevent cross-contamination. The DM stated that failure to change gloves and wash hands could contribute to food-borne illness, despite having trained the staff in these protocols.
Deficiencies in Medication Administration and Hand Hygiene
Penalty
Summary
The facility failed to ensure that RN J adhered to proper hand hygiene and medication administration protocols, which compromised resident safety and well-being. Observations revealed that RN J did not use proper hand hygiene when administering medications and assisting a resident with eating. Additionally, RN J left the medication cart unlocked and unattended, and medications were left on residents' bedside tables without supervision, increasing the risk of drug diversion and medication errors. During the survey, it was observed that RN J left a medication cup with several medications on Resident #57's bedside table, and the resident was unsure why this occurred. Another resident, Resident #10, had medications left on her breakfast tray, which she intended to take with her oatmeal. Interviews with staff confirmed that leaving medications unattended was a recurring issue with RN J and another nurse, posing a risk of other residents accessing the medications. Further observations showed RN J assisting an unidentified resident with their meal without performing hand hygiene, and breaking a pill for Resident #57 with bare hands, again without washing hands or wearing gloves. Interviews with facility administration and nursing leadership highlighted the potential negative outcomes of these practices, including medication errors and increased risk of infections. Despite attending in-service training on medication administration and infection control, RN J continued to demonstrate these deficiencies, leading to her termination.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and labeled according to professional principles. Observations revealed that the medication cart on Hall 100 was left unlocked and unattended, and there were loose pills found in the drawers of the cart. Additionally, insulin for a resident did not have an open date, which is required for proper tracking and disposal. Expired control solutions for glucometer calibration were also found in the Hall 400 medication cart. Medications were left unattended on bedside tables for several residents, which was confirmed by interviews with staff and residents. One resident reported that medications were left with her 60-75% of the time, and another resident mentioned that she could not take her medication with water and would mix it with oatmeal. A CNA confirmed that leaving medications unattended was a regular occurrence with certain nurses. Interviews with the DON and ADON highlighted the potential negative outcomes of these practices, such as drug diversion, overdose, and administration errors. The facility's policies on medication storage and administration were not followed, as evidenced by the presence of loose and expired medications, and the failure to lock medication carts when not in use.
Infection Control Deficiencies in Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed incidents involving staff members not adhering to proper hand hygiene protocols. RN J was observed assisting a resident with their midday meal without performing hand hygiene before, during, or after the assistance. Additionally, RN J broke a pill with her bare hands for another resident without using gloves or washing her hands. These actions were contrary to infection control practices and increased the risk of spreading infections among residents. Further observations revealed that CNAs H and I did not perform hand hygiene during incontinent care for two residents. CNA I failed to wash her hands when changing gloves during catheter care, and CNA H did not perform hand hygiene after changing soiled gloves while assisting with turning a resident. These lapses in hand hygiene were acknowledged by the staff during interviews, where they recognized the potential for cross-contamination and infection due to these practices. The facility's policy on incontinent care emphasized the importance of hand hygiene to prevent cross-contamination, which was not adhered to in these instances.
Failure to Provide Privacy for Foley Catheter
Penalty
Summary
The facility failed to ensure the dignity and respect of a resident by not providing a privacy bag for her foley catheter. This deficiency was identified during an observation of the resident receiving incontinent care from two CNAs, where it was noted that the foley catheter bag was not covered. The absence of a privacy bag for the catheter was acknowledged by the ADON and DON, who both recognized the potential for humiliation and infection risks due to the bag potentially touching the ground or being pulled. The resident involved is a woman with a BIMS score indicating no cognitive impairment, and she requires supervision and touch assistance. Her medical history includes type 2 diabetes, mild cognitive impairment, pancreatic tumors, and other significant health issues. The facility's policies on resident rights and dignity emphasize treating residents with respect and maintaining their privacy, but the policy on incontinent care did not mention the use of privacy covers for foley catheter bags.
Failure to Ensure Validity of Advance Directives
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advance directive, specifically for one resident who had a Do Not Resuscitate (DNR) order in her clinical record without a physician's signature date. This oversight was identified during a review of the clinical records and interviews with facility staff. The resident in question was an elderly female with multiple health conditions, including chronic obstructive pulmonary disease, sleep apnea, and heart failure, and was moderately cognitively impaired, requiring maximal assistance with most activities. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the absence of a physician's signature date on the DNR form rendered it invalid, meaning the resident would be treated as a full code in the event of a medical emergency, contrary to her wishes. The facility's policy documents did not provide clear guidance on the necessary signatures or dates required for the validity of advance directives, contributing to the deficiency.
Failure to Update Resident's Care Plan with New Wound Care Orders
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #50, which included updating wound care orders. Resident #50, a male with peripheral vascular disease, type 2 diabetes, and bilateral below-knee amputations, had a wound treatment order for his left leg amputation site that was not updated in his care plan. The wound treatment order, which started on 08/21/24, was not reflected in the care plan, which still contained outdated orders from 07/18/24 to 08/21/24. During observations and interviews, Resident #50 expressed that staff did not change his bandage as often as ordered. The MDS LVN, responsible for updating care plans, acknowledged that the new wound care orders were overlooked and not documented in the care plan. This oversight was confirmed during interviews with the Director of Nursing (DON) and Assistant Directors of Nursing (ADONs), who noted that not updating the care plan could lead to improper treatment documentation and potential negative outcomes for the resident. The facility's policy on comprehensive person-centered care plans, dated December 2016, requires that care plans include measurable objectives and timetables to meet residents' needs and be revised as residents' conditions change. The failure to update Resident #50's care plan with the new wound care orders was a deviation from this policy, potentially affecting the resident's healing process and increasing the risk of further injury or infection.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care for a resident, identified as Resident #50, as ordered, which could place the resident at risk of poor healing, worsening infection, and increased pain. Resident #50, a male with a history of peripheral vascular disease, type 2 diabetes, and bilateral below-knee amputations, was admitted to the facility with specific wound care orders for his left leg amputation site. These orders included soaking the wound with a cleanser, applying gauze and antibiotic cream, and securing the dressing with specific materials. However, the facility did not adhere to these orders on at least two occasions, as documented in the Treatment Administration Record (TAR) for September 2024. Interviews and observations revealed that the resident did not receive wound care on the specified dates, and there was no documentation of any appointments that might have justified the missed care. The Director of Nursing (DON) and other staff members acknowledged that the charge nurses were responsible for wound care, but due to the resident's behavior, the Assistant Director of Nursing (ADON) had taken over his care for a period. Despite this arrangement, the wound care was not performed as ordered, and there was no documentation to support any alternative care or reasons for the missed treatments. The facility's policy on charting and documentation requires that all services provided to residents, including treatments, be documented in the medical record. However, there was a lack of documentation regarding the resident's appointments or any alternative wound care provided. Interviews with staff, including the DON, ADON, and Licensed Vocational Nurses (LVNs), highlighted inconsistencies in the documentation process and a failure to ensure that the resident received the necessary wound care as per the care plan.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days for a resident, which is a requirement to prevent potential oversedation and dependency. The resident, an elderly female with diagnoses including type 2 diabetes, depression, and anxiety disorder, was admitted to the facility with a PRN order for Alprazolam, an antianxiety medication. The order, which started in November of the previous year, was not discontinued or reviewed for necessity beyond the 14-day limit, as required by facility policy and federal regulations. The resident's care plan and medical records indicated that she was receiving antianxiety medication as needed, with no documented physician's note justifying the continuation of the PRN order beyond 14 days. Despite multiple physician notes over several months indicating that the resident's anxiety disorder was stable, there was no mention of the PRN order's duration or necessity. The resident's medication administration records showed frequent use of the PRN medication over several months, yet there was no documented rationale for extending the PRN order. Interviews with the facility's Director of Nursing (DON) and Assistant Directors of Nursing (ADONs) revealed a lack of awareness and adherence to the policy requiring PRN orders for psychotropic drugs to be limited to 14 days unless a physician documented the need for an extension. The facility's policy, dated from 2017, clearly stated the requirement for PRN orders to be limited and the necessity for physician documentation if an extension was warranted. However, this policy was not followed, leading to the deficiency identified during the survey.
Unsanitary Conditions in Resident Refrigerators
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by the condition of the resident refrigerators. Observations revealed that the refrigerators contained expired and rotten food items, which were not removed, posing a risk of foodborne illness to the residents. The refrigerators were also found to be in an unsanitary condition, with smears and sticky patches on the surfaces, and ice crystals forming on improperly stored food items. Resident #18, a male with diagnoses including congestive heart failure, mild intellectual disabilities, and type 2 diabetes, expressed concern about the cleanliness of the refrigerator near the entrance. Similarly, Resident #60, who has acute respiratory failure with hypoxia and cognitive communication deficit, noted the poor condition of the common fridge for residents. Both residents' observations were corroborated by the surveyors' findings, which included improperly labeled and expired food items, as well as unsanitary conditions in the refrigerators. Interviews with facility staff revealed confusion regarding the responsibility for cleaning the refrigerators. While some staff members believed it was the responsibility of housekeeping, others thought it was the duty of the CNAs or nursing staff. This lack of clarity contributed to the failure to maintain the refrigerators in a sanitary condition, as evidenced by the presence of expired and rotten food items. The facility's policies on food safety and storage were not adhered to, resulting in a breach of the residents' right to a safe, clean, and comfortable living environment.
Deficiencies in Wound Care and Central Line Maintenance
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident, leading to deficiencies in wound care and central line maintenance. The resident, a male with multiple health conditions including peripheral vascular disease, diabetes, and amputations, did not receive wound care as ordered by the physician. Specifically, wound treatments for the resident's right 4th finger, left below-knee amputation, and sacral area were not performed on several specified dates, despite physician orders for regular care. Additionally, the resident's central line maintenance was not conducted as required. The central line dressing was not changed as per the schedule, and there was a lack of documentation indicating that the resident refused any treatments. Interviews with staff, including an LVN and the DON, highlighted the potential negative outcomes of not following physician orders, such as infection and discomfort for the resident. The LVN acknowledged the importance of documentation, yet there were gaps in the records. The facility's policies on intravenous catheter care and documentation were not adhered to, as evidenced by the lack of recorded interventions and observations related to the resident's care. The facility's guidelines required documentation of the appearance of the catheter site, interventions performed, and any unusual findings, none of which were consistently recorded. This lack of adherence to policy and physician orders resulted in the identified deficiencies in the resident's care.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 79 citations issued within 25 miles in the last 12 months — including the 6 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windflower Health Center | 0.1 mi | ★★★★★ | 1 | 0 |
| Amarillo Medical Lodge | 0.2 mi | ★★★★★ | 4 | 0 |
| Amarillo Center For Skilled Care | 0.7 mi | ★★★★★ | 8 | 0 |
| Landmark Of Amarillo Rehabilitation And Nursing | 0.8 mi | ★★★★★ | 16 | 1 |
| Kirkland Court Health And Rehabilitation Center | 0.9 mi | ★★★★★ | 8 | 3 |
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.