Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Heritage House At Paris Rehab & Nursing during CMS and state inspections, most recent first.
Failure to Notify Physician of New Scrotal Wound: A resident with severe cognitive impairment, a Foley catheter, bowel incontinence, and existing skin issues developed a new open area on the scrotum. The Wound Care Treatment Nurse saw the area and notified hospice, but did not notify the physician and did not document the hospice call. The physician later stated he was not informed of the new wound until the next day, and the resident was observed with an open nickel-sized area on the scrotum.
A CNA observed a new open area on a resident’s scrotum but did not notify the nurse because powder and cream were already present. The resident had severe cognitive impairment, a urinary catheter, bowel incontinence, diabetes, and other skin issues, and the care plan and orders required staff to report new skin changes. The LPN said she was not notified, and the physician was not informed until the next morning, when he assessed the resident and diagnosed cellulitis with a pus-filled abscess.
A facility failed to keep 14 of 18 residents informed in advance of labs, x-rays, and doppler studies, and residents said they were startled when an outside lab tech entered rooms in the middle of the night. AR#1 reported concerns to the DON and Administrator that residents were not told about procedures or results, while the DON and an LPN stated they notified only the responsible party and not the residents themselves.
Menu Not Followed for Lunch Meal: The facility failed to follow the planned lunch menu when residents were served turkey and gravy, stuffing, green bean casserole, and chocolate pudding cake, but no dinner roll was provided. The Dietary Manager stated there were no rolls available and said a substitution should have been made to maintain the caloric content, while the DON said the delivery truck could not access the facility due to ice and snow. The ADM stated dietary staff were expected to follow the menu and recipes, and the facility policy required menu variations to be documented and reviewed by the Dietitian.
Failure to Respect Resident Privacy and Dignity During Room Entry: Staff entered resident rooms without waiting for permission after knocking, including while a resident was on the toilet, another was getting dressed, and during lunch tray delivery. An ADON also entered a room to open blinds without waiting for permission and left the door open. The DON and Administrator stated staff should wait to be welcomed in, and the facility's Dignity policy required care that promotes residents' well-being, self-worth, and self-esteem.
Incomplete care plans and unimplemented interventions were identified for three residents. One resident with bilateral LE limited ROM had no care plan for ROM needs, another resident with a high fall risk had a fall mat order and care plan intervention but the mat was found propped against the wall instead of beside the bed, and a third resident with a left knee contracture had a daily brace order but no care plan for the contracture or brace use. Interviews confirmed staff had not consistently carried out the ordered interventions.
Inaccurate MDS coding for high-risk medications was identified for a resident with CHF, anxiety, and dementia. The quarterly MDS showed no high-risk drug class use, but the MAR and orders showed daily sertraline, torsemide, and Seroquel, and the care plan also documented daily psychotropic and diuretic use. The MDS Coordinator stated these meds should have been coded to reflect a complete representation of the resident's care and said the miscoding was an oversight.
Failure to Provide Scheduled Bathing and Grooming Assistance: A dependent resident with Parkinson disease, CHF, stiff-man syndrome, HTN, and moderate cognitive impairment did not receive scheduled bathing and grooming assistance as planned. The resident reported waiting for a shower and wanting to be shaved, had facial hair growth, a musty odor, and stained linens; later he stated he did not receive a shower or linen change as expected. CNA staff acknowledged the shower and linen care were not completed as scheduled and one CNA admitted documenting the bath in error.
A resident with limited ROM to both lower extremities had no care plan or documented ROM exercises after therapy stopped, and she stated no one had exercised her legs since then. Another resident with a left knee contracture had a physician order for a daily knee brace to prevent worsening contracture, but the brace was found sitting in a chair beside his bed and there was no documentation that staff applied or removed it as ordered. Interviews confirmed the facility lacked a restorative nursing program and that the brace should have been applied daily.
A resident with myopathies, dementia, dysphagia, and heart disease had a physician order for PRN O2 at 2-4 L via NC for SOB, but staff did not have an oxygen sign posted outside the room when the resident was observed on O2 and when the concentrator was at bedside. The care plan did not reflect oxygen use, the MDS indicated no O2 use in the look-back period, and staff stated the sign is used to alert others that oxygen is in use.
A resident with PTSD, anxiety, depression, and a history of trauma had an inaccurate trauma screen that did not identify her trauma history, even though the resident said she had already told the facility about it and it still affected her sleep. The Social Worker, MDS Nurse, DON, and Administrator stated the trauma assessment should have reflected the history and that trauma-related triggers should have been included in the care plan, but they were not.
Unsecured wound care chemicals were found in a resident’s room in plain view and readily accessible. The resident had aphasia, HTN, a right foot amputation, and moderately impaired cognition with dementia noted in the care plan. An LVN, the DON, and the Administrator stated that Povidone-Iodine 10% Solution and .9% Sodium Chloride Irrigation Solution should be kept on the med/treatment cart and not left in resident rooms; the facility policy required all drugs and biologicals to be stored in locked compartments.
A facility failed to provide a resident with an ongoing program of activities tailored to her interests and well-being. The resident, diagnosed with vascular dementia, expressed a desire to be read to due to poor vision, but this preference was not fulfilled. The Activities Director acknowledged not reading to the resident and incorrectly completing the Activity Evaluation. The Administrator confirmed the importance of fulfilling the resident's preferences to maximize quality of life.
The facility failed to provide palatable, attractive, and properly cooked meals at a safe temperature for several residents during a lunch meal. Residents reported issues such as bad taste, improper cooking, and cold food. The dietary manager did not taste the meal on the day of the survey, and despite previous in-services on recipe adherence, complaints persisted. The administrator acknowledged receiving complaints but could not recall the last in-service on menu adherence.
The facility failed to maintain effective infection control practices, as observed in the care of three residents. A resident received improper incontinent care, with staff using the same wipe multiple times and neglecting hand hygiene. Another resident's bathroom contained bagged, dirty briefs, creating an unsanitary environment. Additionally, a third resident did not receive proper catheter care, and staff failed to follow enhanced barrier precautions. These deficiencies highlight significant lapses in infection control measures.
A resident with impaired vision did not receive proper meal setup assistance during lunch, as the Treatment Nurse failed to remove the meal from the tray or uncover the plate. The resident's care plan required supervision and setup for eating, but the nurse was unaware of the resident's vision issues and uncertain about meal service protocols. The DON and Administrator confirmed that staff should assist with meal setup to meet residents' nutritional needs.
A resident reported missing pink pants to a laundry aide, but no grievance was filed, and the resident was not informed of any progress. The Environmental Services Manager was unaware of the issue, and the Administrator confirmed a grievance should have been filed. The facility's grievance policy was not followed, leading to a deficiency in addressing resident concerns.
A resident with severe cognitive impairment and multiple medical conditions did not receive adequate nail care, as black material was observed under her fingernails over three consecutive days. Despite the care plan requiring regular nail maintenance, staff interviews confirmed that CNAs were responsible for this task, yet it was not performed, posing a risk of infection.
A resident with an indwelling urinary catheter did not receive proper catheter care, as observed when a CNA failed to clean the right peri area and catheter tubing. The resident, who had severe cognitive impairment and required full assistance, was seen holding her catheter tubing, which was not promptly addressed. Interviews with facility staff confirmed the expectation for thorough cleaning to prevent infections, but the observed care did not meet these standards.
A facility failed to document an oxygen order for a resident with vascular dementia and shortness of breath, despite the resident being placed on oxygen by a hospice nurse due to low saturation levels. The lack of documentation and communication between hospice and facility staff led to the absence of a formal order, risking the resident's respiratory care.
The facility failed to provide trauma-informed care for two residents with histories of trauma. One resident's trauma history was not documented or addressed in her care plan, while another resident's PTSD triggers were not identified. The facility's policy on trauma-informed care was not followed, potentially leading to severe psychological distress for the residents.
Two residents in the facility were administered blood pressure medications outside of the ordered parameters, leading to significant medication errors. One resident received Metoprolol and Hydralazine despite a diastolic blood pressure below the threshold, while another was given Hydralazine with a systolic blood pressure below the specified limit. The staff involved acknowledged the errors, and the facility's policy required adherence to physician orders to prevent adverse effects.
A medication cart in the 100 Hall was left unlocked and unattended by an LVN while she went to the restroom, posing risks of unauthorized access to medications. The cart was later locked by ADON N, who acknowledged the associated risks. Interviews with staff, including the DON and Administrator, confirmed the responsibility of charge nurses to ensure carts are locked when unattended, as per facility policy.
The facility failed to comply with food safety standards, as dietary staff did not label and date all food items and failed to dispose of expired items in the kitchen's refrigerator and freezer. Observations revealed expired catfish and celery, and unlabeled tomato juice. The Dietary Manager and Administrator were unaware of these issues, despite policies requiring proper labeling and disposal of expired food.
A facility failed to ensure proper antibiotic stewardship for a resident prescribed Doxycycline for cellulitis without documented signs or symptoms of infection. Despite awareness from the ADON and DON, the facility relied on doctor's orders without meeting criteria for antibiotic use. The facility's policy emphasized the importance of an antibiotic stewardship program, but implementation was lacking.
A resident with dementia and other conditions was roughly handled by a CNA during incontinent care, causing fear and a sense of unsafety. The incident was reported by the resident and his family, with video evidence provided. Despite this, the facility's administration failed to view the videos and did not adequately investigate the abuse allegations.
A facility failed to report an allegation of abuse involving a resident to the appropriate authorities within the required timeframe. The incident involved a CNA providing rough care to a resident with dementia and other conditions, causing fear and discomfort. Despite a family member's report and video evidence, the facility did not report the incident to the HHSC. Interviews revealed that the care was aggressive, but the facility did not follow its policy on reporting and investigating abuse.
A CNA failed to follow proper infection control procedures during incontinent care for a resident, including not changing gloves or performing hand hygiene after removing a soiled brief. The resident, with multiple health conditions, was at risk due to these actions. The DON and Administrator acknowledged the failure to adhere to infection control policies.
Failure to Notify Physician of New Scrotal Wound
Penalty
Summary
The facility failed to ensure that the Wound Care Treatment Nurse notified the physician when Resident #3 was noted to have a new open wound on the right side of his scrotum. Resident #3 was an older male with diagnoses including venous insufficiency, hypertension, neuromuscular dysfunction of the bladder, diabetes mellitus, benign prostatic hyperplasia, an indwelling urethral catheter, and existing pressure ulcers/skin injuries. His MDS indicated he was severely cognitively impaired, incontinent of bowel, had a urinary catheter, and was dependent for several activities of daily living. Resident #3’s care plan directed weekly skin checks and to report any new skin conditions to the physician. The order summary also directed head-to-toe skin assessments and to notify the physician with any changes in skin integrity. On 02/02/2026, the Wound Care Treatment Nurse documented a new open area to the right posterior lower leg and noted hospice physician notification, but she later stated that during wound care she also saw an area on the penis that looked slightly ulcerated. She said she called the hospice nurse and did not document it, and she did not notify the physician because she had notified hospice. On 02/03/2026, Resident #3 was observed to have an open area approximately the size of a nickel on the right side of the scrotum, with no bandage in place. CNA G stated the nickel-sized open area had been present the day before. Hospice documentation referenced redness to the penis at the Foley insertion site, but did not indicate notification of the new open area on the scrotum. The physician later stated he was not notified on 02/02/2026 of any new wound development involving the penis/scrotum area and expected the facility to notify him so care could be coordinated. The DON stated the facility notified hospice and assumed hospice had been notified of the wound, and the Administrator stated staff were expected to document and report changes in condition timely to the physician and family when appropriate.
Failure to Report New Scrotal Wound
Penalty
Summary
The facility failed to ensure that a CNA notified the charge nurse of a new open wound on the right side of a resident’s scrotum. The resident was an older male with multiple diagnoses including venous insufficiency, hypertension, neurogenic bladder with an indwelling urinary catheter, diabetes mellitus, a pressure ulcer of the right heel, and a chronic ulcer of the back. His MDS assessment indicated severe cognitive impairment with a BIMS score of 03, bowel incontinence, urinary catheter use, dependence for several activities of daily living, and risk for pressure ulcers and skin injuries. The resident’s care plan directed weekly skin checks for redness, circulatory problems, breakdown, or other skin concerns and to report any new skin conditions to the physician. His order summary also required head-to-toe skin assessments and notification of the physician with any changes in skin integrity. On the weekend shift, a CNA observed an open area on the right side of the scrotum but did not report it to the nurse because powder and cream were present and he believed it had already been addressed. The CNA later stated he should have reported it to prevent further decline. During the same period, the LPN stated she had not been notified of any new areas of concern and had not noticed the open area during her shift. The wound care treatment nurse documented a new open area to the right posterior lower leg and later noted a referral for wound care, but the hospice progress notes did not show notification of the new scrotal wound. The physician stated he was not notified of the new wound until the following morning, when he assessed the resident and diagnosed cellulitis of the penis with a pus-filled abscess that had surfaced and opened. The DON and administrator stated they expected staff to document and report changes in condition timely, and the facility policy required immediate notification of significant changes in physical status.
Residents Not Kept Informed of Labs and Other Procedures
Penalty
Summary
The facility failed to keep 14 of 18 residents informed in advance of laboratory services and other medical procedures, including labs, x-rays, and doppler studies. Record review showed no documented resident concerns in Resident Council Minutes from September 2025 through December 2025, no related grievances in the grievance log from February 2025 through February 2026, and no in-services in the facility binder addressing informing residents about medical procedures, results, or entering rooms only after permission was given. The deficiency involved Anonymous Residents #1, AR#2, AR#4, AR#5, AR#7, AR#8, AR#9, AR#10, AR#11, AR#12, AR#14, AR#15, AR#16, and AR#17. During interview, AR#1 stated that he had raised concerns with the DON and Administrator that residents were not being informed before procedures such as labs and x-rays were performed, and that it startled residents when someone came into their rooms in the middle of the night to draw blood. AR#1 also stated residents were not being told the results of their procedures. Other affected residents stated they were not informed of lab draws, x-rays, or doppler studies before the outside individual arrived, and that this made them feel scared and uneasy. The DON stated she was not aware of the resident concerns and said routine labs were done without notifying residents or families because they were notified when the new order came in. An LPN stated she informed only the responsible party of new lab and x-ray orders and did not tell residents when they were due for labs. The Administrator stated he had spoken with one resident who was frightened by a stranger entering his room in the middle of the night because no one had explained how the lab worked in the facility.
Menu Not Followed for Lunch Meal
Penalty
Summary
The facility failed to follow the menu for the lunch meal on 02/02/2026. The planned menu for that meal listed roast breast of turkey and gravy, savory bread stuffing, green bean casserole, buttered dinner roll served with margarine, and chocolate pudding cake. During observation of the lunch meal at 12:15 p.m., residents were served turkey and gravy, bread stuffing, green bean casserole, and chocolate pudding cake, but they were not served a dinner roll. During interview, the Dietary Manager stated there were no rolls to serve with the lunch meal and said there should have been a substitution, such as a slice of bread, to keep the caloric content the same as the menu indicated. The DON later stated there were no rolls because the delivery truck was unable to get into the parking lot due to ice and snow the previous week. The ADM stated he expected dietary staff to follow the menu and recipes for the facility's meals and expected the Dietary Manager to ensure menus were printed for each meal. The facility policy stated any variation from the planned menu would be documented by the Dietary Services Manager and reviewed and signed by the Dietitian.
Failure to Respect Resident Privacy and Dignity During Room Entry
Penalty
Summary
The facility failed to treat residents with dignity and respect by not waiting for permission before entering resident rooms after knocking for 7 of 18 residents reviewed for resident rights. During interviews, AR #7 stated staff had entered her room while she was on the toilet with a lunch tray, and she said she was embarrassed. AR #13 stated staff knocked and entered while she was getting dressed to open her blinds, and she said she was fully capable of opening them herself when ready. AR #8 stated an ADON knocked, opened the door without waiting for permission, entered to open the blinds, and left the door open; AR #8 said the action was very disrespectful and that staff routinely burst into rooms without waiting for permission, especially during meal tray delivery. During observation on 02/02/2026 at 11:40 a.m., LVN C entered the rooms of AR #7, AR #10, AR #12, and AR #18 without waiting for permission while passing lunch trays. In interview, LVN C stated she knocked and announced the lunch tray before entering, but did not always wait for residents to respond because some were asleep and she needed to wake them to eat while the food was hot. She also stated she would not like someone delivering food to knock and come into her house. The ADON stated she had not realized she was walking into rooms without permission and said she knocks and opens blinds to bring in light, while the DON and Administrator stated they expected staff to wait to be welcomed in and not enter residents' rooms without permission. The facility policy titled Dignity stated each resident shall be cared for in a manner that promotes and enhances well-being, satisfaction with life, and self-worth and self-esteem.
Incomplete Care Plans and Unimplemented Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for three residents whose assessments and orders identified ongoing care needs. Resident #7, a female with Wernicke's encephalopathy, diabetes type II, chronic pain, severe cognitive impairment, and dependence for ADLs, had limited range of motion to both lower extremities, but her care plan dated 01/06/2026 did not include a plan for bilateral lower extremity ROM. During observation and interview, she was lying in bed and stated she had trouble moving her legs, could wiggle her toes but could not move her ankles or knees well, and said no one exercised her legs anymore since she was no longer in therapy. Resident #29, a female with bipolar disorder, major depression, anxiety, severe cognitive impairment, dependence for ADLs, and a history of two or more falls in the prior 90 days, had a care plan titled High Fall Risk that included a fall mat beside the bed. The physician order also directed that a fall mat be placed beside the bed when in bed. However, during observations on 02/03/2026, the fall mat was found propped against the wall across the room rather than in place beside the bed. The resident stated staff sometimes forgot to put the mat back down after mopping and explained she had the mat because she had fallen out of bed previously. Resident #67, a male with CVA, atrial fibrillation, and dementia, had a physician order dated 05/02/2025 to apply a knee brace to the left leg daily, remove it only during bathing or patient care, and reapply it after treatment to prevent progression of joint contracture due to flexor spasticity from an old CVA. His care plan dated 01/20/2026 did not include the left knee contracture or brace use. During interview, he stated staff used to put the brace on every day but had not done so in the last couple of months, and he could not recall it being applied since before Christmas. The MDS Coordinator stated care plans should include all items coded on the MDS and that leaving the contracture and brace off the care plan was an oversight. The DON and ADM stated staff were expected to follow the interventions and that not following them could worsen the resident's condition and decrease quality of life.
Inaccurate MDS Coding for High-Risk Medications
Penalty
Summary
An inaccurate MDS assessment was completed for Resident #17, a 72-year-old female admitted with CHF, anxiety, and dementia. Her quarterly MDS dated [DATE] documented a BIMS score of 09, indicating moderate cognitive impairment, and showed dependent-level assistance for bed mobility, transfer, and toileting. The MDS also indicated that she had not taken any high-risk drug class medications. Record review showed that Resident #17 had active orders for sertraline 100 mg once daily, torsemide 20 mg once daily, and Seroquel 25 mg twice daily, and the November 2025 MAR showed she received each of these medications daily. Her care plan also documented daily use of psychotropic medications, including antidepressants and antipsychotics, as well as daily diuretic use for CHF. During interview, the MDS Coordinator stated these medications should have been coded on the MDS to reflect a complete representation of the resident's care and acknowledged the miscoding was an oversight.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure a resident who was dependent for all ADLs received the necessary services to maintain grooming and personal hygiene. The resident was a male with Parkinson disease, congestive heart failure, stiff-man syndrome, hypertension, and moderate cognitive impairment with a BIMS score of 11. His care plan identified an ADL self-care performance deficit related to Parkinson disease with dyskinesia and directed that he was dependent with bathing and required a shower, shave, oral care, hair care, and nail care provided per schedule and when needed. Record review showed the resident was scheduled for showers on Monday, Wednesday, and Friday during the 6 AM to 6 PM shift. On 02/02/2026, the resident told the surveyor he was waiting for the aide because it was his shower day, had about one-half inch of facial hair growth, and said he would like to be shaved and showered. A musty odor was noted in the room, and the top linen sheet had several dark brown circular stains. On 02/03/2026, the resident was observed clean-shaven, but he stated he had been shaved that morning and was waiting to be taken for his shower. The musty odor remained, and the same stained top sheet was still present. On 02/04/2026, the resident stated he did not get a shower or have his linens changed the previous day, and the same stained sheet was still in place. During interviews, CNA H said she was the shower aide unless aides were short-handed and that Resident #2 should have received showers on Monday, Wednesday, and Friday. CNA G later stated she had not given the resident a bath or changed the linens on Monday or Tuesday, said she got busy and forgot with surveyors in the building, and admitted she documented on Monday that she gave the resident a bath by mistake. The DON and Administrator stated showers were to be provided as scheduled or as requested, and both emphasized the importance of bathing and personal hygiene for dignity, cleanliness, skin integrity, and infection control. The facility policy stated residents unable to carry out ADLs would receive the necessary services to maintain grooming and personal and oral hygiene.
Failure to Provide ROM Services and Ordered Brace Use
Penalty
Summary
The facility failed to ensure that residents with limited ROM received appropriate treatment and services to maintain or improve ROM and to prevent further decrease in ROM. One resident, a female admitted with Wernicke's encephalopathy, diabetes type II, and chronic pain, had limited ROM to both lower extremities and was dependent for ADLs including toileting, transfer, and bathing. Her quarterly MDS showed severe cognitive impairment, but her care plan did not address her limited ROM, and the January and February 2026 ADL sheets showed no ROM exercises being performed. During observation, she stated she had trouble moving her legs, could wiggle her toes, but could not move her ankles or knees well, and said therapy used to exercise her legs but had stopped, with no one exercising them since then. A second resident, a male admitted with CVA, atrial fibrillation, and dementia, had an order dated 05/02/2025 to apply a left knee brace daily and remove it only during bathing or patient care, then reapply it to prevent progression of joint contracture due to flexor spasticity from an old CVA. His records contained no order or documentation for brace application or removal, and his care plan did not address the left knee contracture or brace use. The brace was observed in a chair beside his bed under towels and a jacket during multiple observations, and the resident stated staff were supposed to put the brace on every day because his left knee had started to draw up since his stroke. During interviews, the resident said staff had not put the brace on in the last couple of months and that the last time he recalled a nurse applying it was before Christmas. The MDS Coordinator stated the facility did not have a restorative nursing program and that, unless a resident was on therapy services, the resident probably was not getting ROM exercises. She also stated the brace should have been applied daily by nursing and was unsure why it had not been worn, with no refusals reported. The DON stated the floor nurse and administrative nurses were responsible for ensuring staff were educated about interventions for all aspects of resident care, and the ADM stated staff were expected to follow physician and nursing recommendations and perform ROM exercises for residents with limited ROM.
Missing Oxygen Sign for Resident on PRN O2
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident #35. The resident was a male admitted with diagnoses including myopathies, dementia, dysphagia, and heart disease. His quarterly MDS dated 01/13/2026 indicated a BIMS score of 12, showing moderately impaired cognition, and that he required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. A physician order dated 02/01/2026 directed oxygen at 2-4 liters via nasal cannula as needed for shortness of breath, but the comprehensive care plan dated 02/04/2026 did not indicate oxygen usage, and the MDS indicated he was not receiving oxygen during the 7-day look-back period. During observations on 02/02/2026 at 08:26 a.m. and 4:00 p.m., Resident #35 had oxygen at 2 liters via nasal cannula, and no oxygen sign was noted outside his door. During an observation on 02/03/2026 at 4:00 p.m., the resident did not have oxygen on, the oxygen concentrator was at bedside, and no oxygen sign was noted outside the door. CNA G stated she was aware residents wore oxygen by the sign outside the door and said the charge nurse usually put up the oxygen sign for residents with oxygen. The ADON, DON, and Administrator each stated that residents who require oxygen should have an oxygen sign on the door for safety, and the ADON said she was not aware Resident #35 did not have the sign and that his decline had gone unnoticed.
Inaccurate trauma screening and missing trauma triggers in care plan
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma received culturally competent, trauma-informed care in accordance with professional standards of practice. Resident #9 had diagnoses including Alzheimer's disease, COPD, Type 2 diabetes, major depressive disorder, generalized anxiety disorder, and PTSD. The resident's MDS indicated she understood others, could make herself understood, had a BIMS score of 15, and required supervision or touching assistance with showering/bathing while using a wheelchair for mobility. Record review showed the resident's Comprehensive Trauma Screening, effective 09/30/2022, did not indicate a history of trauma on Section C Question B. However, during interview, the resident stated she had a history of trauma and preferred not to discuss it because she had already told the facility about those incidents and they sometimes still affected her sleep. The Social Worker stated she was not aware of the resident's trauma history and said the trauma assessment had not been completed by her because she started at the facility in April 2025. The Social Worker also stated the assessment should have been marked yes in Section C Question B based on Section 2, Question f, which was marked yes for having ever been sexually assaulted. The resident's care plan addressed mood alteration related to depression and anxiety, but it did not indicate a history of sexual trauma or include trauma-related triggers. The Social Worker, MDS Nurse, DON, and Administrator all stated that trauma and triggers should be identified and reflected in the care plan. The facility's Trauma Informed Care policy stated that triggers for residents with a history of trauma should be identified and added to the care plan, including individualized triggers such as lack of privacy, loud noises, bright lights, certain sights, sounds, smells, and physical touch.
Unsecured wound care chemicals found in resident room
Penalty
Summary
Drugs and biologicals were not stored in locked compartments for one resident reviewed, Resident #50. Resident #50’s record showed diagnoses including aphasia, hypertension, and amputation of the right foot, and the MDS indicated a BIMS score of 09 with moderately impaired cognition. A care plan revised on 12/30/25 documented impaired cognition and risk for further decline related to dementia. During observations on 2/2/26 and 2/3/26, Povidone-Iodine 10% Solution and .9% Sodium Chloride Irrigation Solution were found unsecured in Resident #50’s room and in plain view, readily accessible to anyone in the building. In interviews, an LVN stated residents are not allowed to keep medications in their rooms and that these treatment chemicals should have been kept on the medication cart or treatment cart. The DON stated wound care treatment chemicals should be kept in the treatment cart, and the Administrator stated they should not be left in plain sight in residents’ rooms. The facility policy stated all drugs and biologicals are to be stored in locked compartments.
Failure to Provide Resident-Specific Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests and well-being of a resident diagnosed with vascular dementia and shortness of breath. The resident, who had cognitive impairments and was at risk for isolation, was supposed to participate in activities of choice 1-3 times weekly. However, the facility did not ensure that the resident's Activities Evaluation was accurately completed, and no in-room activities were documented for August, September, and October 2024. The resident expressed a desire to be read to, as she could no longer see the books, but this preference was not fulfilled. The Activities Director, who started in August 2024, acknowledged that she had not read to the resident and had incorrectly filled out the Activity Evaluation, assuming the resident read on her own. The Administrator confirmed that if the resident liked to be read to, it should have been done, and the Activities Director was responsible for ensuring activities and assessments were completed. The facility's policy emphasized the importance of recreational services in enhancing residents' quality of life, but the lack of adherence to this policy led to the deficiency.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for eight residents during a lunch meal. Residents reported that the food tasted bad, was not cooked properly, and was served cold. Specific complaints included food being consistently bad, meals being improperly prepared, and a lack of variety. One resident mentioned receiving food items they could not eat, such as rice and corn, and another noted that the dinner roll was raw inside. These issues were observed during a lunch meal where the dietary manager and surveyors noted deficiencies in the taste and appearance of the food. The dietary manager, who has been employed at the facility for several years, admitted to not tasting the lunch meal on the day of the survey due to being occupied with other kitchen duties. The dietary staff had completed in-services on following recipes earlier in the year, but the exact timing was unclear. The dietary manager handled food complaints by communicating with residents and allowing families to make food choices for residents who frequently complained. Despite these efforts, the issues persisted, as evidenced by the residents' complaints and the surveyors' observations. The administrator, who has been in the role for 14 months, stated that he oversees the dietary manager and occasionally orders test trays from the kitchen. He acknowledged receiving food complaints and mentioned that the dietary manager would address these by speaking with residents. However, the administrator could not recall when the last in-service on following the menu was conducted. The facility's policy on menus and nutritional adequacy, revised in 2012, indicates that menus are planned to meet average resident nutritional needs, yet the observed deficiencies suggest a failure to adhere to this policy.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident #2, the facility did not ensure proper incontinent care was provided. During an observation, LVN E and CNA F were seen using the same wipe multiple times to clean the resident's peri area, which is against infection control practices. Additionally, they failed to perform hand hygiene between glove changes, which is crucial to prevent cross-contamination. Both LVN E and CNA F acknowledged their lapses in following proper procedures during interviews. Resident #53's care was also compromised due to the presence of bagged, dirty briefs left in her bathroom, which emitted a strong urine odor. This oversight was attributed to the CNAs being too busy to remove the waste, as stated by CNA F. The resident expressed discomfort and dissatisfaction with the situation, indicating that her complaints to the nursing staff were not addressed. This neglect in maintaining a sanitary environment poses a risk of infection and affects the resident's quality of life. For Resident #72, the facility failed to provide adequate catheter care and adhere to enhanced barrier precautions. CNA H did not clean the resident's right peri area or the catheter tubing, and she touched the resident's sheets without gloves, which is against the enhanced barrier precautions protocol. The ADON and DON confirmed the importance of proper catheter care and the need to follow infection control practices to prevent urinary tract infections and other complications. These deficiencies highlight significant lapses in the facility's infection control measures, potentially endangering residents' health.
Failure to Accommodate Resident's Meal Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as Resident #76, during a lunch meal service. The Treatment Nurse served the resident her lunch but did not remove the meal from the tray or uncover the plate, leaving it on the warmer with a lid. This oversight occurred despite the resident's impaired vision and her care plan indicating a need for supervision and setup for eating. The resident expressed difficulty seeing her meal due to blindness in one eye, and another resident had to assist by removing the lid and positioning the plate for her. Interviews revealed that the Treatment Nurse was unfamiliar with the resident's vision issues and was uncertain about the protocol for uncovering meals. The nurse admitted to being new and under the impression that plates should not be uncovered, although she acknowledged the importance of assisting residents with meal setup. The Director of Nursing (DON) and the Administrator both stated that staff are expected to set up meal trays and provide necessary assistance to ensure residents' nutritional needs are met. The facility's policy on resident rights emphasizes the right to reasonable accommodation of needs and preferences, which was not upheld in this instance.
Failure to Address Resident Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident who was missing a pair of pink pants from the laundry. The resident, who had intact cognition and was dependent on staff for dressing and personal hygiene, reported the missing pants to a laundry aide. The laundry aide acknowledged the report but did not file a grievance or inform the resident of any progress toward resolution. The aide mentioned notifying the Environmental Services Manager, who was responsible for filing grievances, but the manager was unaware of the issue and had not taken any action. Interviews with the Environmental Services Manager and the Administrator revealed a lack of communication and follow-through in the grievance process. The Environmental Services Manager stated that grievances should be filed to ensure lost items are recovered, but was not informed of the missing pants. The Administrator confirmed that a grievance should have been filed and that any staff member could initiate the process. The facility's grievance policy emphasized the importance of addressing resident concerns promptly, but this was not adhered to in this case.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was unable to perform activities of daily living independently. The resident, a female with severe cognitive impairment and multiple medical conditions including lung cancer and chronic respiratory failure, required assistance from two persons for dressing, bathing, and personal hygiene. Despite the care plan indicating the need for regular nail care, observations on three consecutive days revealed black material under the resident's fingernails, indicating a lack of proper hygiene maintenance. Interviews with facility staff, including a CNA and the DON, confirmed that it was the responsibility of CNAs to ensure residents' fingernails were clean, particularly during showers. The CNA acknowledged the importance of keeping fingernails clean to prevent bacterial infections, especially since the resident had a habit of putting her hands in her mouth. The DON and the Administrator both recognized the risk of infection and the need for maintaining the resident's dignity through proper hygiene, yet the deficiency persisted over the observed period.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident who was incontinent of the bladder and had an indwelling urinary catheter. During an observation, CNA H did not clean the resident's right peri area or the foley catheter tubing while providing incontinent care. The resident, who had a severely impaired cognition and was dependent on staff for all activities of daily living, was observed holding her catheter tubing, which was not addressed promptly by the CNAs. This oversight in care could lead to potential risks such as urinary tract infections and injury. The resident's care plan indicated the need for catheter care every shift and highlighted the risk of urinary tract infections and injury. The care plan also required enhanced barrier precautions during high-contact resident care activities. Despite these guidelines, the CNAs did not adhere to the proper catheter care procedures, as evidenced by the incomplete cleaning of the peri area and catheter tubing. Interviews with the ADON and DON revealed that the CNAs were expected to clean both sides of the peri area and the catheter tubing to prevent infections and skin breakdown. The facility's policy on urinary catheter management emphasized the importance of proper catheter care to prevent complications. However, the CNAs did not follow these protocols during the observed care, leading to the identified deficiency.
Failure to Document Oxygen Order for Resident
Penalty
Summary
The facility failed to ensure that respiratory care was provided consistent with professional standards of practice for a resident requiring oxygen therapy. The resident, an elderly female with vascular dementia and shortness of breath, was observed without an active order for oxygen despite having been placed on oxygen by a hospice nurse due to low oxygen saturation levels. The resident's care plan and MDS assessment did not reflect the use of oxygen, and there was a lack of documentation in the facility's records to support the administration of oxygen. Interviews with facility staff and hospice personnel revealed a breakdown in communication and documentation regarding the resident's need for oxygen. The hospice nurse had given a verbal order for oxygen, but it was not properly documented or communicated to the facility staff, leading to the absence of a formal order in the resident's records. This oversight was acknowledged by the facility's nursing staff and the Director of Nursing, who emphasized the importance of having a documented order to ensure the resident received the necessary care and to prevent potential respiratory complications.
Failure to Provide Trauma-Informed Care for Residents
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents, both of whom had histories of trauma. Resident #46, a female with major depressive disorder, generalized anxiety disorder, and mild cognitive impairment, did not have an accurate trauma screen identifying possible triggers despite having a history of trauma. Her care plan did not reflect her trauma history, and the current social worker was unaware of her past trauma. Interviews revealed that Resident #46 had communicated her traumatic experiences to staff, but this information was not documented or addressed in her care plan. Resident #15, diagnosed with bipolar disorder, PTSD, and generalized anxiety disorder, also did not have her PTSD triggers identified in her care plan. The social worker was unsure who was responsible for updating PTSD triggers and had not conducted a trauma assessment for Resident #15. Despite being seen by psychiatric services, the lack of identified triggers in her care plan meant that appropriate care could not be provided to mitigate potential re-traumatization. The facility's policy on trauma-informed care, which mandates the identification of triggers and the inclusion of trigger-specific interventions in care plans, was not followed. This oversight in both residents' cases could lead to severe psychological distress due to re-traumatization, as the facility did not adequately account for their trauma histories and preferences in their care plans.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. Resident #15, a female with a history of hypertension and other mental health conditions, was administered Metoprolol and Hydralazine despite her diastolic blood pressure being below the ordered parameters. On a specific date, her blood pressure was recorded as 143/55, yet she received both medications, which were supposed to be held if the diastolic blood pressure was less than 60. The medication aide responsible for administering the medication acknowledged the error and mentioned that she was not allowed to contact the doctor when the blood pressure was out of parameter, although she was supposed to notify the charge nurse. Resident #68, a male with chronic heart failure and pulmonary hypertension, was also administered Hydralazine when his blood pressure was outside the ordered parameters. His blood pressure was recorded as 99/60, and the medication was given despite instructions to hold it if the systolic blood pressure was less than 100. The LVN involved stated that she did not administer the medication on that day, but acknowledged the importance of adhering to the parameters to prevent adverse effects. Interviews with the Director of Nursing (DON) and the Administrator revealed that it was the responsibility of the nurse or medication aide to contact the doctor if a resident's blood pressure was out of the specified parameters. The facility's policy required medications to be administered according to physician orders, and the failure to adhere to these orders could result in significant risks to the residents. The DON and Administrator emphasized the importance of following the physician's orders and the potential consequences of administering medication outside of the prescribed parameters.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by their policy. This deficiency was observed when a medication cart in the 100 Hall was left unlocked and unattended by LVN M while she went to the restroom. The cart was parked beside the centralized nursing station, and this oversight was noticed during an observation. ADON N later locked the cart and acknowledged the risks associated with leaving it unlocked, including potential theft of medications, poisoning, and overdose. Interviews with staff revealed that LVN P accidentally left the cart unattended after being stopped by someone with a question. Both the DON and the Administrator confirmed that it was the responsibility of the charge nurses to ensure the carts were locked when unattended. They acknowledged the risks posed by this failure, such as unauthorized access to medications by residents, staff, or visitors, which could lead to poisoning, needle sticks, or misuse of medications. The facility's policy on medication storage emphasized the importance of locking all drugs and biologicals and restricting access to authorized personnel only.
Failure to Adhere to Food Safety Standards in Dietary Services
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen's dietary services. The survey revealed that the dietary staff did not label and date all food items, and they also failed to dispose of expired food items in the refrigerator and freezer. These lapses were identified during observations in the kitchen's walk-in freezer and refrigerator, where expired items such as a zip lock bag of frozen catfish and a container of celery were found, along with a container of tomato juice that was not labeled or dated. Interviews with the Dietary Manager and the Administrator highlighted a lack of awareness and oversight regarding the expired and unlabeled food items. The Dietary Manager, who had been employed at the facility for several years, admitted to conducting daily walk-throughs but failed to notice the issues identified by the surveyor. The Administrator, who had been in the role for 14 months, stated that he conducted weekly walk-throughs but had not done so in the week of the survey. Both acknowledged the importance of labeling, dating, and discarding expired food to prevent potential foodborne illnesses among residents. The facility's policy on food storage and the FDA Food Code were reviewed, indicating requirements for labeling, dating, and discarding expired food items. The policy emphasized the need for proper sealing, labeling, and rotation of food items, while the FDA Food Code outlined specific labeling requirements for food packaged in a food establishment. Despite these guidelines, the facility's failure to comply with these standards was evident in the survey findings, posing a risk of food contamination and illness to residents.
Failure in Antibiotic Stewardship and Documentation
Penalty
Summary
The facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy for a resident reviewed for antibiotic use. The resident, an elderly female with dementia and anxiety, was prescribed Doxycycline Monohydrate for cellulitis in the left lower extremity. However, there was no documented evidence of signs or symptoms of infection to support the use of the antibiotic. The facility's records, including the Revised McGeer Criteria for Infection Surveillance Checklist, indicated that the resident did not meet the criteria for antibiotic use for cellulitis, soft tissue, or wound infection. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed awareness of the issue but a reliance on following doctor's orders despite the lack of documented criteria. The ADON, who was responsible for infection control, acknowledged the absence of proper documentation and education regarding antibiotic use. The facility's policy on infection prevention and control emphasized the importance of an antibiotic stewardship program, yet the implementation and adherence to this policy were lacking, as evidenced by the failure to document necessary signs and symptoms for antibiotic administration.
Rough Handling of Resident During Incontinent Care
Penalty
Summary
The facility failed to protect a resident from abuse when a Certified Nursing Assistant (CNA) roughly provided incontinent care. The incident involved a male resident with a history of dementia, congestive heart failure, Parkinson's disease, and other conditions that required assistance with daily activities. During the care, the CNA used excessive force to roll the resident onto his side, causing his legs to come off the bed swiftly. This rough handling was observed in a video and reported by the resident and his family member. The resident expressed feeling scared and unsafe due to the rough care provided by the CNA. The family member of the resident reported the incident to the facility's Assistant Director of Nursing (ADON) and Director of Nursing (DON), providing video evidence of the rough handling. However, the facility's administration, including the DON and ADON, claimed they were unable to view the videos due to technical issues. Despite the family member's attempts to show the videos in person, the facility's leadership declined the offer. Interviews with other staff members, including another CNA present during the incident, confirmed the rough handling of the resident. The facility's staffing coordinator and ADON, upon viewing the video with the state surveyor, identified the actions as aggressive and uncalled for. The facility's policy on abuse and neglect emphasizes the importance of protecting residents from harm and conducting timely investigations, which was not adequately followed in this case.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the appropriate authorities within the required timeframe. The incident involved a certified nursing assistant (CNA) who was observed providing rough and aggressive care to a resident during incontinent care. The resident, who had a history of dementia, congestive heart failure, Parkinson's disease, and other conditions, was handled in a manner that caused fear and discomfort. Despite the family member's report and video evidence of the incident, the facility did not report the allegation to the Health and Human Services Commission (HHSC) as required. The resident's family member reported the incident to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), providing video evidence of the rough handling. However, the facility's administration, including the Administrator, DON, and ADON, failed to view the videos or take appropriate action to report the incident. The family member's attempts to show the videos in person were declined, and the facility did not conduct a proper investigation or report the incident to the state agency. Interviews with staff members revealed that the CNA involved in the incident had been identified and that the care provided was considered aggressive and rough. Despite this, the facility did not follow its policy on reporting and investigating allegations of abuse. The Administrator, who was responsible for reporting such incidents, acknowledged the failure to report and investigate the allegation, which could have prevented further harm to the resident.
Inadequate Infection Control During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during the provision of incontinent care to a resident. CNA A did not change her gloves or perform hand hygiene after removing the resident's soiled brief, and she improperly disposed of the soiled brief by throwing it across the room. These actions were observed in a video dated 06/07/2024, which showed CNA A continuing to touch the resident and other surfaces with contaminated gloves, thereby increasing the risk of cross-contamination and infection. The resident involved was an elderly male with multiple diagnoses, including dementia, congestive heart failure, Parkinson's disease, and hypertension. His comprehensive care plan indicated a need for assistance with activities of daily living and emphasized maintaining his dignity by ensuring he was clean and well-groomed. Despite this, the care provided by CNA A did not adhere to the facility's infection control policies, as she failed to perform proper hand hygiene and glove changes during the care process. Interviews with CNA A, the DON, and the Administrator confirmed that the infection control procedures were not followed. CNA A acknowledged the incorrect practices and identified the risk of infection due to improper cleaning and handling of soiled materials. The DON, who is responsible for infection control, and the Administrator both recognized the failure to adhere to the facility's policies, which are designed to prevent the transmission of communicable diseases and infections.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 45 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Paris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legend Healthcare And Rehabilitation - Paris | 2.9 mi | ★★★★★ | 14 | 0 |
| Stillhouse Rehabilitation And Healthcare Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Brentwood Terrace Healthcare And Rehabilitation | 3 mi | ★★★★★ | 3 | 0 |
| Avir At Paris | 3.3 mi | ★★★★★ | 5 | 0 |
| Homestead Of Hugo | 22.7 mi | ★★★★★ | 4 | 1 |
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.