Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Kruse Village Senior Living Community during CMS and state inspections, most recent first.
Improper glove use and hand hygiene were observed in the kitchen when a Dietary Aide handled a disinfectant rag, wrote on paper, moved food containers, and handled spice containers without changing gloves. The aide later stated the rag was contaminated and that she should have removed her gloves, washed her hands, and put on new gloves after touching contaminated items. The Admin stated gloves and handwashing were expected after contact with contaminated items, while the Dietary Mgr disputed that gloves had to be changed unless food was directly touched.
Care Plan Did Not Include Pacemaker and Transmitter: A resident with a pacemaker, atrial fibrillation, and heart failure had a quarterly MDS showing moderately impaired cognition, but the comprehensive care plan did not reflect the pacemaker or pacemaker transmitter. The MDS Coordinator acknowledged the omission, and the DON and Administrator stated the pacemaker-related needs were expected to be care planned and revised as needed.
A resident with a pacemaker, AFib, and CHF had an unplugged pacemaker monitor found on the floor of her room while she was away. The DON stated the monitor should be plugged in at all times and that residents with pacemakers needed to be transmitted via monitor, but staff did not know why it was unplugged and had not reported any related concerns to the PCP.
Unsecured Suprapubic Catheter: A resident with a suprapubic catheter was observed without the catheter secured to his body as ordered in the care plan and physician orders. The resident had diagnoses including CKD, neurogenic bladder, and incomplete paraplegia, and staff confirmed the catheter should have been anchored; the DON stated the unsecured catheter could pull, irritate the stoma, erode the site, and cause infection.
An unlocked medication cart was observed on a hall near a resident room, with no staff nearby at the time. A med aide stated she forgot to lock the cart, and an LVN and the DON confirmed carts were to be locked whenever medications were not being dispensed. The cart contained multiple physician-prescribed medications, and the facility policy required med carts to be locked when unattended.
Three residents with severe cognitive impairment and dependence on staff for ADLs were observed with soiled clothing, unkempt appearance, and unmet hygiene needs, despite staff training and facility policies requiring regular assistance and monitoring.
The facility did not provide group or individualized activities on weekends, instead relying on uncommunicated 'activity pacts' that residents and staff were unaware of or did not understand. Multiple residents reported boredom, lack of engagement, and not being consulted about their preferences, while staff interviews revealed confusion and lack of coordination regarding activity programming.
Two residents did not receive their physician-ordered medications due to failures in ensuring medication availability and administration. In both cases, a medication aide did not administer the required medications during the scheduled pass, either because the medications were not in stock or were overlooked, and did not promptly notify nursing staff. Documentation on the MARs indicated the medications were not given, with no explanation in the nurses' notes.
Surveyors found that the medication error rate exceeded 5% when two residents did not receive their physician-ordered medications, including calcium, gabapentin, and a probiotic, due to unavailability and omission by a medication aide. The aide did not notify nursing staff when medications were missing, and required documentation was incomplete.
Kitchen staff failed to follow hand hygiene and glove use protocols during food preparation, including puréeing food and baking, by not washing hands or wearing gloves after touching potentially contaminated surfaces and their own clothing, despite facility policies and staff training requirements.
A resident with a Stage III pressure ulcer did not receive wound care in accordance with infection control protocols when an LVN left a clean field unattended, allowed the wound to be recontaminated by skin folds without recleaning, and returned used supplies to the treatment cart. Both the LVN and DON confirmed these actions were not consistent with facility policy and could result in cross-contamination.
A resident with a urinary catheter was transported to and from the rehabilitation area with her catheter bag uncovered, exposing the contents to other residents. The staff member assisting did not check or report the uncovered bag, and interviews confirmed that all catheter bags were expected to be covered to protect resident dignity. Facility policies required care that maintains dignity and respect, but these were not followed in this instance.
A nurse failed to maintain a clean wound care field and used improper technique while treating a resident with a Stage III pressure ulcer, including leaving the clean field unattended, allowing skin folds to recontaminate the wound, and returning used supplies to the treatment cart, contrary to facility policy.
Two residents with indwelling catheters were found with their catheter bags and tubing on the floor, including one instance where a bag leaked after being run over by a bedside table and another where a resident's uncovered catheter bag and kinked tubing dragged on the floor during wheelchair transport. Staff interviews confirmed knowledge of proper catheter care, but the facility did not ensure compliance with policies requiring catheter bags to be covered, kept off the floor, and tubing to be free of kinks.
The facility failed to provide a safe, clean, and homelike environment for several residents, with observations revealing a lack of top sheets on beds and clean towels in the rehabilitation unit. Staff interviews indicated issues with the laundry process and inadequate stocking of linen carts, leading to ongoing shortages.
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for three residents. Medications were administered without appropriate diagnoses, and blood pressure medications were not held when vital signs were outside the prescribed parameters, potentially placing residents at risk of complications.
The facility failed to employ sufficient staff with the appropriate competencies and skill sets for the food and nutrition service. The designated Dietary Supervisor did not have the required certification, placing residents at risk for foodborne illness and unmet nutritional needs. The facility had been attempting to hire a certified dietary manager or have staff become certified since February 2023.
The facility failed to ensure that a dietary aide had a current Food Handler's Certificate while working in the kitchen. The aide was unaware of the expiration, and the Administrator confirmed that the facility lacked a certified dietary manager responsible for monitoring certifications.
A resident with dysphagia was served thin liquids instead of the prescribed nectar thickened liquids during breakfast. Despite the dietary card indicating the need for thickened liquids, the resident received thin coffee and juice, which was confirmed by the ADON as inconsistent with the physician's orders and care plan.
The facility failed to provide prescribed therapeutic diets to two residents, resulting in them not receiving their health shakes with lunch. This oversight was confirmed by both residents and staff, and was only corrected after surveyor intervention.
Improper glove use and hand hygiene in kitchen food handling
Penalty
Summary
The facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety in one kitchen. During an observation in the kitchen, Dietary Aide C was seen wearing gloves while obtaining a disinfectant rag from a disinfectant water container, cleaning the food prep area, placing the rag back into the disinfectant container, and then reaching for an ink pen to write on small pieces of paper without changing gloves. She then continued wearing the same gloves while placing food in a silver container with aluminum foil on top and moving the container from the food prep area to a rolling kitchen utility cart. Dietary Aide C also continued with the same gloves while handling two large spice containers. One spice container lid was loose, and she touched the top of the spice container with her right middle and ring fingers while placing the top on the container. She then carried the spice containers to another area of the kitchen and placed them on a shelf. After these tasks, she removed her gloves and washed her hands, then put on new gloves. During interview, she stated she did not change her gloves when she used the disinfectant rag, that she touched the food containers and moved them, and that the disinfectant rag was considered contaminated. She also stated she had been in-serviced on hand hygiene but did not recall the date. The Administrator stated gloves were expected to be changed and hands washed anytime staff touched contaminated items, and that the disinfectant rag and ink pen were considered contaminated. The Dietary Manager stated that if staff did not directly touch food, gloves were not required to be changed, but also acknowledged that Dietary Aide C touched the disinfectant rag, food containers, and spice containers. The record also showed orientation training on sanitation tasks, including prevention of cross contamination, hand hygiene, use of gloves, and sanitation buckets, as well as an in-service stating gloves should be removed and hands washed after each task. The facility policy and Texas Food Establishment Rules required hand hygiene before working with exposed food, after handling soiled equipment or utensils, during food preparation as needed to prevent cross contamination, before donning gloves, and after activities that contaminate the hands.
Care Plan Did Not Include Pacemaker and Transmitter
Penalty
Summary
The facility failed to ensure the comprehensive care plan for Resident #41 included measurable objectives and time frames to meet her medical, nursing, and psychosocial needs identified in the comprehensive assessment. Record review showed Resident #41 was a [AGE]-year-old female admitted and readmitted with diagnoses including presence of a cardiac pacemaker, chronic atrial fibrillation, biventricular heart failure, and acute on chronic combined systolic and diastolic congestive heart failure. Her quarterly MDS reflected a BIMS score of 8, indicating moderately impaired cognition, and also identified a diagnosis of presence of cardiac pacemaker and heart failure. Review of the comprehensive care plan dated 04/08/2026 showed it did not reflect that Resident #41 had a pacemaker or a pacemaker transmitter. During interview, the MDS Coordinator stated the resident had both a pacemaker and a pacemaker transmitter and acknowledged they were not documented on the care plan, stating she missed documenting it. The DON stated the pacemaker and transmitter were expected to be care planned, and the Administrator stated that if anything changed, including resident preferences, the care plan was expected to be revised and that any health issue documented on the MDS was expected to be care planned.
Unplugged Pacemaker Monitor Not in Use
Penalty
Summary
The facility failed to ensure that Resident #41’s pacemaker was being transmitted in accordance with her orders and care needs. Resident #41 was admitted and readmitted with diagnoses including presence of a cardiac pacemaker, chronic atrial fibrillation, biventricular heart failure, and acute on chronic combined systolic and diastolic congestive heart failure. Her quarterly MDS reflected a BIMS score of 8, indicating moderately impaired cognition. Her comprehensive care plan dated 04/08/2026 did not reflect that she had a pacemaker or a pacemaker transmitter. On 05/05/2026, surveyors observed an unplugged pacemaker monitor on the floor of Resident #41’s room while she was not present. During interview, the DON stated the pacemaker monitor was expected to be plugged in at all times and that any resident with a pacemaker needed to be transmitted via monitor, but she did not know why it was unplugged and had not been informed of any issues. The PCP stated he had not received any change of condition reports from nursing staff. An LVN stated he did not recall whether the monitor was unplugged when he entered the room. Later interviews documented that the monitor transmitted when tested and that the cardiology office reported no concerns, but the initial observation remained that the monitor was unplugged and not in use as expected.
Unsecured Suprapubic Catheter
Penalty
Summary
The facility failed to ensure a resident with an indwelling suprapubic catheter received appropriate treatment and services to prevent urinary tract infections when the catheter was not secured to the resident’s body as ordered. Resident #5 was an adult male with diagnoses including chronic kidney disease, neuromuscular dysfunction of the bladder, and incomplete paraplegia. His annual MDS reflected a BIMS score of 15 and dependence on staff for showers, toileting hygiene, lower body dressing, and transfers. His care plan identified a potential for complications with bowel and bladder related to his current medical and physical status, and it directed staff to keep the catheter bag and tubing below bladder level and ensure the anchor was in place. The physician’s orders and MAR directed catheter care every shift and PRN, including use of a catheter anchor and checking placement every shift. During observation, Resident #5 was seen with a suprapubic catheter, but it was not secured. An LVN stated the catheter should have been secured and acknowledged she observed it was not secured. The DON stated staff were expected to follow the physician’s orders and care plan and that if the catheter was not anchored, the suprapubic catheter could be pulled, irritate the stoma, erode the stoma site from tubing contact, and cause an infection. The facility’s catheter care policy stated catheters may be anchored or stabilized to prevent tension and recommended anchoring on the abdomen in men.
Unlocked Medication Cart Left Unsecured
Penalty
Summary
Medication Cart #1 on the 400 hall was observed at 7:42 a.m. with the locking mechanism protruding outward, indicating the cart was unlocked. The cart was located near room 404, and there was no staff in the hallway or at the nurses’ desk near the entrance to the 400 hall at the time of the observation. The door to the room was closed, and Med-Aide B exited the room a few minutes later. During interview, Med-Aide B stated she forgot to lock the medication cart and said all medication carts were to be locked except when a nurse was obtaining medications. She stated the cart contained all types of physician-prescribed medications except narcotics. LVN D stated the cart was to always be locked when not in use, and the DON stated the expectation was for all medication carts to be locked when not administering medications. The facility policy also required locked med carts and rooms, with med carts locked when unattended.
Failure to Provide Adequate ADL Assistance and Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. Observations and interviews revealed that one resident was found wearing a soiled and stained top, another had soiled pants and unwanted facial hair, and a third had crumbs on her blanket, unwanted facial hair, and a brown substance under her fingernails. These findings were corroborated by direct observation and interviews with staff, who confirmed their responsibility for ensuring residents were clean and well-groomed. Record reviews indicated that all three residents had significant cognitive impairments and required extensive or maximal assistance with ADLs, including personal hygiene, dressing, and grooming. Care plans for each resident documented their dependence on staff for these tasks and outlined interventions to address their deficits. Despite these documented needs and interventions, the residents were observed in unclean and unkempt conditions during the survey. Interviews with CNAs, the DON, and the administrator confirmed that staff had received training on ADL care and were aware of facility policies requiring regular checks and assistance with hygiene and grooming. Staff acknowledged the importance of maintaining residents' cleanliness and dignity but were unable to explain why the affected residents were left in dirty clothing and with unmet hygiene needs. The facility's policy stated that residents unable to perform ADLs should receive necessary services to maintain good nutrition, grooming, and personal hygiene.
Failure to Provide Ongoing Activities Program on Weekends
Penalty
Summary
The facility failed to provide an ongoing activities program that met the interests and supported the physical, mental, and psychosocial well-being of each resident, particularly on weekends during the months of February and March 2025. Review of participation records and activity calendars showed that group activities did not occur on weekends, and the only activity listed was an 'activity pact,' which consisted of coloring pages and puzzles left for residents to do in their rooms. This was not considered a group activity, and there was no evidence that residents were informed about or offered these materials. Multiple residents reported not being interviewed about their activity preferences, not receiving activity items, and experiencing boredom and sadness due to the lack of engagement on weekends. Observations on the rehabilitation unit revealed residents sitting idly in common areas, some appearing to be asleep or expressing feelings of boredom and sadness. One resident was observed wandering and required redirection by staff, while another was found in his room with no stimulation or activity items, expressing feelings of sadness and a desire to be busy. Interviews with residents confirmed that they were not aware of the activity programs, had not been offered activity items, and had not been consulted about their interests or preferences. Residents expressed a desire for more group activities and involvement in decisions about activities. Staff interviews indicated a lack of communication and understanding regarding the activity program, especially the 'activity pact.' The Activity Director acknowledged being the only activity staff member and found it difficult to provide activities for all residents. Other staff, including nurses and CNAs, were not informed about residents' activity preferences or the nature of the weekend activities. The facility's policies required an ongoing, individualized activity program based on resident assessments and preferences, but these were not implemented as required, resulting in residents not receiving adequate activities to support their well-being.
Failure to Ensure Availability and Administration of Physician-Ordered Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring that physician-ordered medications were available and administered as prescribed. For one resident, who had a history of lumbar vertebra fracture, vitamin D deficiency, and low back pain, the physician had ordered calcium and gabapentin. On the day of observation, these medications were not included in the resident's prepared medications. The medication aide reported that the calcium was not in stock and was unsure about the gabapentin, which was not found on the cart. The aide did not report the missing medications to the nurse at the time, and documentation on the medication administration record (MAR) indicated the medications were not given, with no corresponding entry in the nurses' notes. Another resident, diagnosed with enterocolitis due to clostridium difficile and constipation, had a physician order for a probiotic (saccharomyces boulardii). During the medication pass, this medication was also not administered. The medication aide stated that the probiotic was missed during the pass and, upon review, acknowledged it should have been given. The MAR reflected the medication was not administered, and there was no documentation in the nurses' notes regarding its omission. Observations and interviews confirmed that the medication aide did not ensure all ordered medications were available and administered, and did not promptly notify nursing staff when medications were missing or unavailable. The facility's policy requires timely ordering, obtaining, and administration of medications as prescribed, but these procedures were not followed in these instances, resulting in missed doses for both residents.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Unavailable Medications
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, resulting in an observed error rate of 11.54% during a medication administration review. Specifically, three errors were identified out of 26 opportunities, involving two residents and one medication aide. The errors were related to the unavailability and omission of physician-ordered medications during the medication pass. One resident, a cognitively intact female with a history of lumbar vertebra fracture, vitamin D deficiency, and low back pain, did not receive her prescribed calcium and gabapentin. The medication aide did not administer these medications because the calcium was not in stock and the gabapentin was not found on the cart, and she did not report the missing medications to the nurse at the time. Documentation on the medication administration record indicated the medications were not given, and there was no corresponding entry in the nurses' notes. Another resident, a cognitively intact male with enterocolitis due to clostridium difficile and constipation, did not receive his ordered probiotic, saccharomyces boulardii, during the morning medication pass. The medication aide omitted the medication and later acknowledged the oversight after reviewing the orders. The medication was also not in stock at the time. In both cases, the facility's policy required staff to ensure medications were available and to notify nursing staff if medications were missing, but these procedures were not followed.
Failure to Follow Hand Hygiene and Glove Use During Food Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff followed professional standards for food safety and sanitation during food preparation. On one occasion, a staff member checked the temperature of baked chicken, rice, and beans while wearing an oven mitt, then proceeded to purée beans without washing her hands or donning gloves. She touched the inside of the grinder blade, the grinder lid, and rested her hands on the countertop during the process, all without hand hygiene or glove use. Later, the same staff member washed her hands before puréeing chicken but then touched her shirt, pants, pocket, oven mitt, inside of the chicken pan, kitchen counter, and a meal cart with dirty dishes, again without washing her hands or wearing gloves before continuing food preparation. Another staff member was observed preparing cake batter without wearing gloves. She acknowledged her training in hand hygiene and glove use, stating she knew to wash hands before and after tasks and to wear gloves when in direct contact with food. Despite this, she did not wear gloves while handling the cake ingredients. Interviews with the Registered Dietitian, Culinary Director, DON, and Administrator confirmed that the facility's expectation and policy required staff to wash hands and wear gloves during food preparation, especially after touching potentially contaminated surfaces or their own clothing. A review of the facility's in-service training records revealed that kitchen staff had not received training on hand hygiene and glove usage prior to the survey. Facility policies outlined the necessity of hand washing before food preparation, after touching contaminated surfaces, and the use of single-use gloves to prevent bare hand contact with food. The policies also specified that gloves must be changed and hands washed after touching soiled items or surfaces. These documented practices were not followed by the staff during the observed food preparation activities.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with a Stage III pressure ulcer. During wound care, an LVN prepared a clean field by placing a new package of 4x4s, wound cleanser, and gloves on a surface, but then left the field unattended to wash her hands, creating an opportunity for contamination. The LVN then performed wound care by cleansing the resident's sacral pressure ulcer, but allowed the skin folds to fall back over the cleaned wound, resulting in recontamination. Without recleaning the wound, the LVN applied the dressing. After the procedure, the LVN returned the used supplies, including the package of 4x4s, wound cleanser, and gloves, to her treatment cart, despite these items having been inside the resident's room and thus considered contaminated. Interviews with the LVN and the DON confirmed that these actions were not in accordance with facility policy or standard infection control practices. The LVN acknowledged that the clean field should not have been left unattended, that supplies brought into the resident's room should not be returned to the cart for use on other residents, and that the wound should have been recleaned after being recontaminated by the skin folds. The DON also stated that these practices could lead to cross-contamination and infection, and that staff are expected to use wound cleansing techniques that prevent recontamination.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag During Transport
Penalty
Summary
A deficiency occurred when a resident with a urinary catheter was transported by a Physical Therapist Assistant from her room to the rehabilitation area and back with her catheter bag uncovered. The resident required assistance with multiple activities of daily living and was not cognitively impaired, communicating without difficulty. The resident's care plan and physician orders specified the use of a catheter and outlined care requirements, but did not specifically address covering the catheter bag during transport. During the observed transport, the catheter bag was left uncovered in a public area where other residents were present. The Physical Therapist Assistant did not check to ensure the catheter bag was covered, nor did she report the issue to nursing staff or attempt to find a cover. Interviews with staff, including RNs, CNAs, and therapy leadership, confirmed that all catheter bags were expected to be covered to maintain resident dignity and prevent embarrassment for both the resident and others. Staff also stated that all personnel, including therapy staff, were expected to report any catheter-related concerns to nursing. A fellow resident expressed discomfort at seeing another person's urine, stating it made her feel sick. Facility policies on dignity and resident rights emphasized the importance of maintaining each resident's dignity and providing care in a manner that enhances quality of life. The failure to cover the catheter bag during transport was identified as a violation of these policies and resident rights.
Failure to Maintain Proper Wound Care Technique and Prevent Cross-Contamination
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow standard precautions and proper wound care techniques during the treatment of a resident with a Stage III pressure ulcer on her sacrum. The LVN prepared a clean field for wound care but left it unattended while going down the hall to wash her hands, potentially exposing the field to contamination. During the wound care procedure, the LVN cleansed the resident's pressure ulcer but allowed the skin folds to fall back over the wound, resulting in recontamination. The LVN then applied the dressing without recleaning the wound. Additionally, the LVN returned used supplies, including a package of 4x4s, wound cleanser, and gloves, to the treatment cart after they had been brought into the resident's room, which is against facility policy due to the risk of cross-contamination. The resident involved was an elderly female with dementia, a history of transient cerebral ischemic attack, and colon cancer, who was assessed as having severe cognitive impairment and at risk for pressure ulcers. Documentation indicated she had a Stage III pressure ulcer to her sacrum. The facility's policy required that any items brought into a resident's room be cleaned before leaving or disposed of, and that clean technique be maintained to prevent contamination. Both the LVN and the Director of Nursing acknowledged that the actions taken during the wound care did not meet these standards.
Failure to Maintain Proper Catheter Care and Placement
Penalty
Summary
The facility failed to ensure proper care and management of indwelling urinary catheters for two residents, resulting in catheter bags and tubing being found on the floor. For one male resident with end stage congestive heart failure and renal insufficiency, observations revealed that his catheter bag and tubing were lying flat on the floor beside his bed, with the tubing crossing over the wheels of the bedside table. When the resident moved the table, it rolled on top of the full catheter bag, causing it to leak. Staff responses included picking up the bag, emptying it, and wiping it with a towel, but the bag had already been on the floor and was leaking urine. Interviews with staff confirmed that the catheter bag should not have been on the floor and that it was everyone's responsibility to check its placement when entering the room. A second resident, a female with urinary retention, neuromuscular bladder dysfunction, and cerebral infarction, was observed being transferred in a wheelchair by a Physical Therapy Assistant. During the transfer to and from the rehabilitation area, her uncovered catheter bag and tubing dragged on the floor, and the tubing was kinked. The Physical Therapy Assistant was unaware of the proper handling of the catheter bag and tubing and did not check or report the issue to nursing staff. Interviews with nursing and therapy staff confirmed that catheter bags and tubing should be kept off the floor, covered, and free of kinks, and that all staff, including therapy, were expected to report any issues to nursing. Review of facility policies indicated that catheter bags should be covered with privacy bags at all times, hooked to the bed frame when the resident is in bed, and never touch the floor. The policies also required that tubing be free from kinks. Despite these policies and staff training, the facility did not ensure compliance, resulting in catheter bags and tubing being on the floor for both residents, with one instance involving a leaking bag and another involving a kinked tube during transport.
Facility Fails to Provide Adequate Bed Linens and Towels
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for several residents, specifically in terms of bed linens and towels. Observations revealed that five residents' beds lacked top sheets, and the rehabilitation unit did not have clean towels and top sheets available. Interviews with staff indicated that the housekeeping department, operated by a third party, was unaware of the shortage of top sheets, and there were issues with the laundry process, including the return and washing of dirty linens. The Housekeeping Supervisor admitted to not knowing the exact number of sheets and towels needed and mentioned that the facility had been experiencing shortages for the past month or two. Resident #1, a female with moderate cognitive status, was observed without a top sheet on her bed. Similarly, Resident #2, with severe cognitive impairment, and Resident #3, with intact cognitive status, also lacked top sheets. Resident #4, with intact cognitive status and multiple diagnoses including dementia and diabetes, and Resident #5, with moderate cognitive impairment and Alzheimer's disease, were also found without top sheets. The facility's laundry room and rehabilitation unit were observed to be lacking clean towels and top sheets, with staff interviews confirming the ongoing shortages. The facility's staff, including the ADON, CNAs, and the Housekeeping Supervisor, provided various reasons for the shortages, such as issues with the laundry process, inadequate stocking of linen carts, and possible disposal of linens by aides. The Executive Director, who was unaware of the laundry issues, stated that the facility should have adequate linen supplies to meet residents' needs. The facility's policy on resident rights emphasized the importance of providing a safe, clean, and homelike environment, which was not being met due to the deficiencies observed.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for three residents reviewed. Resident #39 did not have appropriate indications for medications based on his diagnoses, and there were no parameters to hold his blood pressure medication. Additionally, the facility did not hold blood pressure medications for Residents #44 and #47 when their blood pressure or pulse was outside the parameters set by their physician. These failures could place residents at risk of complications related to receiving unnecessary medications. Resident #39, an elderly male with multiple diagnoses including atrial fibrillation, heart failure, and renal insufficiency, had orders for medications such as atorvastatin, potassium, and levothyroxine without appropriate diagnoses. The facility staff, including the admitting nurse and the Administrator, acknowledged that medications should be given appropriate diagnoses based on the resident's conditions. However, the necessary steps to ensure this were not taken, leading to the administration of medications without proper indications. For Resident #44, a female with hypertension, the facility failed to hold her blood pressure medications, amlodipine and metoprolol, when her blood pressure readings were below the set parameters. Similarly, Resident #47, a female with cardiomyopathy, received Toprol XL despite her blood pressure and pulse being outside the prescribed parameters. Interviews with the nursing staff and the Assistant Director of Nursing (ADON) confirmed that blood pressure medications should be held if the vital signs were outside the parameters, but this was not consistently documented or followed, leading to potential adverse consequences for the residents.
Failure to Employ Qualified Dietary Manager
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility did not designate a person to serve as the dietary manager who met the required qualifications. The designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. This deficiency was identified during a review of the personnel file, which indicated no documentation of the Dietary Supervisor having completed the certified Dietary Manager course since her hire date in December 2016. Interviews with the Dietary Supervisor, HR staff, and the Administrator confirmed that the Dietary Supervisor had not completed or started the dietary manager classes and was working in the position temporarily until a certified dietary manager could be hired. The facility had been attempting to hire a certified dietary manager or have staff become certified since February 2023. The deficiency could place residents at risk for the spread of foodborne illness and not having their nutritional needs met. The Texas Food Establishment Rules require that at least one employee with supervisory and management responsibility in food preparation and service be a certified food protection manager. The facility's Food Service policy also mandates that a minimum of one person directly responsible for food preparation must successfully complete a state-approved food protection program. The Administrator acknowledged that the expectation was for the Dietary Manager to be certified to oversee dietary services, monitor staff's dietary certifications, and ensure diets were followed.
Failure to Maintain Current Food Handler Certification for Dietary Staff
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility did not ensure that Dietary Aide B had a current Food Handler's Certificate while working in the kitchen. Record review indicated that Dietary Aide B's certificate had expired, and during an interview, Dietary Aide B was unaware of the expiration. The Administrator confirmed that the Dietary Manager was responsible for monitoring the dietary staff and their certifications, but the facility did not have a certified dietary manager at the time. The Administrator acknowledged that current food handler certifications were required to prevent foodborne illness, as per the Texas Food Establishment Rules dated 2015.
Failure to Provide Thickened Liquids as Prescribed
Penalty
Summary
The facility failed to provide liquids consistent with the needs of a resident diagnosed with dysphagia. Specifically, the resident, who required nectar thickened liquids, was served thin coffee and juice during breakfast. This discrepancy was observed on the resident's tray, despite the dietary card indicating the need for nectar thickened liquids. The resident's care plan and physician orders both specified the requirement for thickened liquids to prevent choking or aspiration. During an interview, the Assistant Director of Nursing (ADON) confirmed that the resident's physician orders mandated a mechanical soft diet with nectar thickened liquids. The ADON emphasized that the consistency of the resident's liquids was crucial to prevent choking or aspiration. The facility's policy on consistency-altered diets, dated February 2021, also supported the need to adhere to prescribed dietary modifications to meet residents' dietary needs and ensure their health and safety.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that residents were provided with the therapeutic diets as prescribed by the attending physician. Specifically, two residents, Resident #18 and Resident #40, did not receive their health shakes with their lunch meals as ordered by their physicians. Resident #18, who has a history of vitamin deficiency and heart disease, was observed eating her lunch without the prescribed health shake. She confirmed in an interview that she did not receive her milkshake. Similarly, Resident #40, who has a history of stroke, dysphagia, and protein-calorie malnutrition, was also observed without her prescribed health shake during lunch. She could not recall if she had received it, and a CNA confirmed that the health shakes were not sent out with the lunch trays by the kitchen staff. The care plans and physician orders for both residents clearly indicated the need for health shakes with their meals to address their specific nutritional needs. The Director of Nursing (DON) acknowledged that the dietary staff had failed to include the health shakes with the lunch trays, and the oversight was only corrected after surveyor intervention. This lapse in providing the prescribed therapeutic diets could potentially place residents at risk for a decrease in calories and weight loss.
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 80 citations issued within 25 miles in the last 12 months — including the 8 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 Brenham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brenham Healthcare Center | 1.7 mi | ★★★★★ | 18 | 5 |
| High Hope Care Center Of Brenham | 1.9 mi | ★★★★★ | 9 | 0 |
| Brenham Nursing And Rehabilitation Center | 2.2 mi | ★★★★★ | 29 | 1 |
| Avir At Bellville | 15.5 mi | ★★★★★ | 11 | 0 |
| Golden Creek Healthcare And Rehabilitation Center | 23.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.