Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakewest Rehabilitation And Skilled Care during CMS and state inspections, most recent first.
A resident with dementia, schizoaffective disorder, paranoid schizophrenia, psychosis, and documented homicidal ideations repeatedly refused psychotropic meds and exhibited escalating aggression, including pacing, yelling, and physical attacks. Over time, this resident slapped, punched, and verbally abused multiple other residents, including non‑verbal and highly dependent individuals, in locations such as the dining room and resident rooms. Facility records contained numerous internal investigations of resident‑to‑resident abuse, and nurse notes described episodes where the resident chased and struck staff and could not be redirected. Several residents reported being hit or threatened and stated they did not feel safe, and staff interviews confirmed the pattern of aggression and the facility’s difficulty managing the behavior, while the resident continued to have access to other residents.
A resident with dementia, psychotic disorders, and a documented history of aggression physically and verbally abused three other residents on multiple occasions, including striking non-verbal and ADL-dependent residents and entering another resident’s room to hit and verbally abuse her. Internal notes and investigation reports showed that leadership, including the Administrator and DON, were notified of these incidents, but there was no evidence that the required abuse reports were submitted to the state within the mandated timeframe. State reporting records contained no entries for these events, and one affected resident’s record lacked documentation or assessment of the alleged abuse, while another reported ongoing fear and continued unwanted room entry by the aggressor.
The facility failed to ensure call lights were accessible for four residents with conditions including muscle weakness, lack of coordination, paralysis, unsteadiness, and moderate cognitive impairment. Each resident’s comprehensive care plan included interventions related to using the call light, yet observations found call lights on the floor or hanging on lower bed rails, out of residents’ reach, while they were in bed and in need of assistance. Residents reported not knowing where their call lights were when they wanted help, and staff, including CNAs, an LVN, the Unit Manager, the ADON, and the DON, acknowledged that call lights should be within reach in accordance with facility policy requiring accessible call systems at bedside.
A resident with acute respiratory failure and intact cognition had physician orders for BiPAP therapy with supplemental O2 at bedtime, but the comprehensive care plan did not include any plan of care for BiPAP use. Review of records and staff interviews showed that the BiPAP device was coded and ordered, yet not incorporated into the care plan despite facility policy requiring all services identified in the comprehensive assessment to be care planned with measurable objectives and timeframes. Multiple staff, including the unit manager, ADON, MDS nurse, and DON, acknowledged that BiPAP use should have been care planned and described differing role expectations for who was responsible for updating the care plan.
A resident with acute respiratory failure, receiving BiPAP with supplemental O2 and scheduled Ipratropium-Albuterol nebulizer treatments, was found with both the BiPAP and nebulizer masks left unbagged on a nightstand when not in use. An LVN, the unit manager, ADON, and DON all acknowledged that respiratory delivery devices should be bagged when not in use to avoid infection, and the facility’s oxygen administration policy required keeping such devices covered in an antimicrobial bag, which was not done.
Failure to Provide Nail Care and Hygiene Assistance: Several residents who depended on staff for ADLs were observed with long, dirty, or untrimmed fingernails. A resident with CVA and hemiplegia, a resident with dementia and aphasia, a resident with moderate cognitive impairment, a resident with dementia and schizophrenia, and a resident with contractures all stated they wanted their nails trimmed or cleaned, and surveyors observed that staff had not provided the needed nail care.
Failure to provide ROM and contracture management: Multiple residents with CVA-related hemiplegia/hemiparesis and limited ROM were observed with contracted hands/wrists and no OT or restorative services in the look-back period. Care plans lacked specific interventions for the contractures, and residents reported not receiving therapy, exercises, or splints despite OT assessments noting benefit from therapy and resting hand or palm guards.
Staff failed to follow infection control practices during resident care and laundry handling. A resident with a Foley, wound, and recent kidney infection was provided incontinence and wound care without gowns, with missed hand hygiene and glove changes, and similar lapses occurred during incontinence care for another resident. An LPN also used improper technique during fingerstick blood sugar testing and insulin administration, an agency LVN did not wear a gown for G-tube medication administration, and residents’ clothing was stored with clean linens and left in open, unlabeled bags in the laundry room.
A resident with intact cognition and a history of major depressive disorder and generalized anxiety disorder reported receiving Amazon packages that had already been opened. The Business Office Manager stated she routinely opened and retained residents’ bank and insurance mail instead of giving it to them, and opened all mail for cognitively impaired residents, including personal cards and gift cards. The Receptionist reported that she brought resident packages to the assigned nurse, who would feel soft packages and open boxed packages to check contents before allowing delivery. The DON stated nursing was not responsible for handling resident mail and was unaware of any policy requiring such checks, while the Administrator stated residents’ mail and packages should not be opened before delivery, although the facility’s communication policy did not address residents’ rights to receive closed mail.
Care plans for two residents did not include contracture-related interventions. One resident with CVA and hemiplegia had a left wrist contracture, limited use of the hand, and a therapy recommendation for a resting hand splint, but the care plan only addressed CVA and fall risk. Another resident with cervical spinal stenosis and COPD had contractures of the right arm, left hand, and shoulder, yet the care plan did not include interventions for those contractures despite OT findings and a splint recommendation.
Missed wound care and no new order for reopened wound: Two residents with lower-extremity wounds did not receive ordered treatment or timely physician follow-up. One resident with bilateral venous ulcers missed scheduled dressing changes when the wound nurse was absent and floor nurses did not complete the care. Another resident on hospice had a left shin wound reopen, but staff did not obtain a new MD order or start treatment, and the wound remained without dressing.
Delayed Follow-Up for Prescribed Eyeglasses: A resident with CKD, dementia, MDD, and adult failure to thrive had an eye exam that recommended new bifocals and full-time glasses use, but the glasses were not obtained for several months. The resident said he had been waiting a long time and could not see well during that period. The SW stated she only followed up after the resident asked for his glasses, the DON said the need had fallen through the cracks, and the Administrator said the expected follow-up was 3-4 weeks, not 6 months.
Inadequate Perineal and Catheter Care: Staff failed to provide correct peri-care for a male resident who was incontinent and needed substantial to max assist, and failed to provide proper catheter/perineal care for a female resident with a Foley and a recent kidney infection. During observation, a CNA did not clean the penile shaft, pubic area, or scrotum correctly, and another CNA did not separate the labia or wipe the catheter tubing from the insertion site downward as required by facility policy.
Failure to provide specialized rehab services for a resident with CVA, L hemiparesis, and wheelchair dependence. PT documented significant functional impairments and a need for skilled PT to improve bed mobility and wheelchair propulsion, but the resident reported no therapy since admission. Nursing staff said no exercises were provided, and the rehab director stated therapy was not provided because insurance did not approve it.
The facility did not coordinate assessments with the PASRR program and failed to refer a resident for necessary services, resulting in noncompliance with assessment and referral requirements.
A resident with multiple complex medical conditions was found with several pills left unattended on her tray table after a medication pass. The medication aide did not observe the resident taking all her prescribed medications and left the room, contrary to facility policy requiring direct observation. This resulted in medications being left unsecured and unconsumed in the resident's room.
A resident with multiple chronic conditions was readmitted after a hospital stay, but the facility failed to accurately transcribe and administer medication changes as ordered by the hospital. The resident received incorrect dosages and frequencies of several medications, and staff interviews revealed breakdowns in communication and adherence to procedures for updating and verifying medication orders.
Several residents at risk for pressure ulcers did not receive proper care when their pressure-relieving mattresses were either not functioning correctly or not set to the appropriate weight. Staff were observed to lack understanding of mattress settings, and required checks were not consistently performed, resulting in improper use of pressure reduction devices as ordered in care plans and physician directives.
Staff members, including a CNA, CMA, and housekeeper, entered a resident's room under contact isolation for suspected C. diff without wearing required PPE, despite posted signage and physician orders. The resident had a history of limb amputation and was awaiting C. diff test results. Staff interviews revealed gaps in awareness and understanding of infection control protocols, resulting in non-compliance with established precautions.
A resident with a history of limb amputation and respiratory risk factors did not receive appropriate respiratory care due to a malfunctioning oxygen concentrator that was not promptly identified or replaced by staff. Despite care plan and physician orders for oxygen therapy, the resident's equipment continuously signaled low oxygen and service needs, and staff failed to ensure the device was functioning as required by facility policy and manufacturer instructions.
The facility did not maintain an effective pest control program, resulting in ongoing issues with roaches and water bugs in resident rooms and bathrooms on one hall. Multiple residents and staff reported frequent sightings of pests, and surveyors observed live and dead bugs as well as structural openings that allowed pest entry. Facility records showed repeated pest incidents and treatments, but the problem persisted due to gaps in cleaning, maintenance, and pest control follow-up.
A CMA physically and verbally abused a male resident with multiple medical conditions by throwing water on him and using profanity during a confrontation over medication refusal. The resident, who was cognitively intact but unsteady, became upset and attempted to pursue the CMA, resulting in a chaotic scene that required staff and a family member to intervene. Witnesses confirmed the staff member's aggressive actions and the escalation of the incident.
The facility failed to maintain food safety standards by not sealing food items properly, not taking temperatures of certain foods before serving, and not ensuring staff wore effective hair restraints during meal service. These deficiencies were observed in the kitchen, with staff acknowledging the oversights and the potential risks of contamination.
The facility failed to provide adequate personal hygiene and ADL care for four residents, leading to issues such as untrimmed and dirty fingernails and missed showers. A resident with severe cognitive impairment had long, discolored nails, while another lacked tools to trim his own. A cognitively intact resident missed a scheduled shower due to a staff oversight, and another resident was found with suspected feces around his nails, with staff failing to report care refusals. These deficiencies highlight lapses in care delivery and communication.
The facility failed to ensure proper handling of medications on three medication carts, as medications in unsecure blister packs were found. Staff responsible for these carts did not identify broken blister seals during shift change counts, posing a risk for drug diversion. The ADON confirmed that broken blister pack medications should be discarded, but staff failed to adhere to this policy.
The facility failed to maintain infection control protocols, as a CNA did not perform hand hygiene between glove changes during incontinence care for a resident, and an LVN and another CNA did not wear appropriate PPE during wound care for a resident under enhanced barrier precautions. These lapses could expose residents to infections.
A resident with limited mobility and a history of diabetes and dementia did not receive consistent foot care, resulting in dry, flaky skin. Despite the facility's policy on maintaining foot health, staff interviews revealed that foot care was sporadic, with CNAs responsible for cleaning and moisturizing feet under nursing supervision. This deficiency highlights a lapse in adhering to professional standards of practice.
A resident with cognitive impairment and swallowing difficulties did not receive sufficient fluids, as staff failed to provide water until later in the day. The resident expressed thirst, and staff interviews confirmed the delay in water distribution, contrary to the facility's hydration policy.
The facility failed to serve a lunch meal at an appetizing temperature, with a cold hamburger and undercooked vegetables. Residents had previously complained about improperly cooked food. Dietary staff acknowledged the importance of checking food temperatures to prevent foodborne illness, and the Resident Council had noted concerns about food temperature.
A resident requiring oxygen therapy did not receive proper respiratory care due to the facility's failure to label and date the oxygen humidity bottle and nasal cannula. Despite having a care plan for shortness of breath, the equipment was found unlabeled during an observation. Interviews revealed that the facility's practice was to change and date supplies weekly, but this was not followed, leading to a deficiency in care.
The facility failed to implement its abuse prevention policy in two incidents involving residents. In one case, a CNA observed a male resident touching a female resident's shoulder, but no investigation or documentation followed. In another case, a CNA witnessed a male resident hitting another with a cane, yet no assessment or documentation was conducted. The facility's policy requires immediate reporting and investigation, which was not adhered to, potentially placing all residents at risk.
The facility failed to investigate two alleged abuse incidents involving residents, as required by its abuse policy. In one case, a CNA reported a resident touching another resident's shoulder, but no investigation or documentation followed. In another case, a CNA witnessed a resident hitting another resident with a cane, but again, no investigation or documentation occurred. The facility's policy mandates immediate investigation and documentation of such incidents, but these steps were not taken, potentially placing residents at risk.
Failure to Protect Residents From Ongoing Abuse by a Psychiatrically Unstable Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with a known history of severe psychiatric illness and aggressive behavior. The resident identified as the aggressor had diagnoses including dementia with psychotic disturbance, paranoid schizophrenia, schizoaffective disorder, psychosis, homicidal ideations, and insomnia. Her care plan and psychiatric assessments documented longstanding confrontational behavior, refusal of medications and lab work, auditory and visual hallucinations, delusions, and repeated episodes of physical and verbal aggression. Progress notes over an extended period described frequent medication refusals, pacing, verbal outbursts, and escalating agitation toward staff and other residents. The facility’s own electronic medical record contained at least nine internal investigation reports documenting separate incidents in which this resident physically or verbally abused other residents. These included slapping another resident’s hand when the other resident touched her belongings, hitting another resident’s arm with a closed fist, spitting on and hitting a resident in the face, slapping a resident’s face on another occasion, and striking a non-verbal resident on the shoulder. Additional reports showed that she hit a non-verbal, ADL‑dependent resident in the face, hit another resident on the arm while being verbally abusive, and on two separate dates hit another resident with a closed fist. Nurse notes and staff interviews further described episodes where she chased and struck staff members, yelled profanities, and could not be redirected, with police and EMS involvement on at least one occasion. Interviews with residents and staff confirmed that these aggressive behaviors were ongoing and that other residents were not adequately protected from abuse. One resident reported being punched in the arm in the dining room after telling the aggressive resident to stop pushing her wheelchair, and stated she did not feel safe around her. Another resident reported being awakened in her bedroom and hit in the chest with a closed fist while being told her family was going to hell and her children were stupid, and also stated she did not feel safe. Additional residents reported being slapped or verbally abused and threatened with physical violence, and several residents and staff stated they did not feel safe around the aggressive resident. Multiple staff, including the interim administrator, ADONs, corporate DON, social worker, and other personnel acknowledged the resident’s repeated aggressive episodes, the facility’s difficulty managing her behaviors, and that residents had a right to be free from abuse and to feel safe, yet the resident remained in the general population and continued to have access to and contact with other residents, resulting in repeated incidents of resident‑to‑resident abuse.
Failure to Timely Report Resident-on-Resident Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to immediately report multiple allegations of resident-on-resident physical and verbal abuse to the Texas Health and Human Services Commission (THHSC) as required. A cognitively impaired female resident with dementia with psychotic disturbance, homicidal ideations, paranoid schizophrenia, schizoaffective disorder, psychosis, and insomnia had a care plan documenting a history of physical aggression toward staff and residents, use of objects (such as scissors and metal utensils) to harm others, delirium with reports that “the devil” tells her to do things, resistance to care, and aggressive behavior problems including striking other residents. Despite this known history and care plan problem list, the facility did not ensure that alleged abuse incidents involving this resident and three other residents were reported to the State Survey Agency within the mandated timeframe. Progress notes and internal investigation reports documented three separate incidents in which this resident physically and verbally abused other residents. On one occasion, the ADON witnessed the resident hit a non-verbal resident on the left shoulder while passing outside the dining room; the aggressor resident became verbally aggressive when questioned and refused assessment. On another occasion, the same resident was documented as physically aggressive toward another non-verbal, ADL-dependent resident, striking her in the face and making her cry. On a later date, progress notes indicated the resident became verbally hostile toward staff and then hit another resident; an internal investigation report stated this resident was hit on the arm and verbally abused. For the first two incidents, the Administrator and DON were notified, and for the third incident, the DON was notified. Despite internal documentation and leadership notification, there was no evidence that these allegations of abuse were reported to THHSC Complaint and Incident Intake (CII) as required by Provider Letter PL 2024-14, which mandates reporting abuse or neglect immediately, but not later than two hours after the incident occurs or is suspected. Review of the state’s TULIP system showed no reports filed for these residents during the relevant months. The Interim Administrator later stated he did not know why the abuse incidents were not reported to THHSC and acknowledged that the risk of not reporting abuse is that the abuse will continue happening. Additionally, one of the abused residents’ progress notes lacked documentation or assessment that she had been hit, and another abused resident reported that the aggressor resident continued to enter her room and that she did not feel safe around her.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call light systems were accessible to four residents reviewed for resident rights. For a female resident with muscle weakness, moderate cognitive impairment, and identified as a fall risk, the comprehensive care plan required that her call light be within reach. On observation, she was lying in bed with her call light found on the floor under the bed, contrary to her care plan and the facility’s call light accessibility policy. A second female resident with a history of stroke and paralysis of the left side, who had intact cognition and required assistance with self-care and mobility, had a care plan intervention to encourage use of the call light. During observation, she was in bed with her call light hanging on the lower portion of the left side rail, out of her reach, and she stated she was trying to get staff to help reposition her but did not know where her call light was. A male resident with lack of coordination, muscle weakness, unsteadiness on his feet, moderate cognitive impairment, and requiring assistance with self-care and mobility also had a care plan intervention to encourage use of the call light. He was observed in bed with his call light hanging on the lower portion of the left side rail, out of reach, and he stated he did not know where his call light was and wanted it to contact staff. Another male resident with lack of coordination, muscle weakness, moderate cognitive impairment, and a need for assistance with personal care and mobility had a care plan intervention to encourage use of the call light. He was observed lying in bed, stating he did not know where his call light was, and the call touch pad was found on the floor out of his reach. Multiple staff members, including CNAs, an LVN, the Unit Manager, the ADON, and the DON, acknowledged during interviews that call lights should be within reach of residents and that it was everyone’s responsibility to ensure this, and the facility’s written policy specified that the call system must be accessible to residents while in bed or other sleeping accommodations.
Failure to Care Plan BiPAP Use for Resident With Acute Respiratory Failure
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident using a BiPAP device. Record review showed that a male resident with a diagnosis of acute respiratory failure was admitted to the facility and had an intact cognitive status per a Quarterly MDS Assessment. The resident’s physician orders, dated after admission, specified BiPAP settings of 20/8 with 2L O2 at bedtime. However, review of the resident’s Comprehensive Care Plan revealed no care plan addressing the use of the BiPAP device, despite the resident’s respiratory diagnosis and active treatment order. During interviews, multiple staff members acknowledged that the resident’s BiPAP use should have been included in the care plan. The Unit Manager stated the BiPAP should have been care planned but reported she was not responsible for updating care plans. The ADON stated that the MDS nurse, ADON, DON, and Treatment Nurse updated care plans and confirmed that BiPAP use should be care planned so treatment could be monitored. The MDS nurse acknowledged that since the device was coded on her end, she should have updated the care plan and noted that failure to do so could place the resident in respiratory distress. The DON stated that BiPAP use should be care planned as a special device and explained that if the resident arrived with the device, the MDS nurse should update the care plan, and if new orders were obtained in-house, it was the responsibility of the DON and ADON. The facility’s written policy on Comprehensive Care Plans required inclusion of measurable objectives and timeframes for all services identified in the comprehensive assessment, which was not followed in this case.
Improper Storage of Respiratory Masks for Resident on BiPAP and Nebulizer
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice and its own policy for a resident requiring BiPAP and nebulizer treatments. The resident was an adult male with a diagnosis of acute respiratory failure, admitted in February and assessed as cognitively intact on a recent Quarterly MDS, with an active diagnosis of acute respiratory failure. Physician orders in early March included BiPAP settings of 20/8 with 2L O2 at bedtime and Ipratropium-Albuterol inhalation solution every six hours. On the morning of 03/05/26, a surveyor observed the resident’s BiPAP mask and nebulizer mask lying unbagged on top of the nightstand when not in use. When shown the equipment, an LVN stated the masks should be bagged when not in use to avoid infection. The Unit Manager, ADON, and DON each acknowledged in separate interviews that the masks should have been bagged when not in use to avoid infections and that staff, including charge nurses and department heads, were responsible for ensuring respiratory delivery devices were bagged and dated. The facility’s written Oxygen Administration policy, revised 01/2025, specified that oxygen delivery devices are to be kept covered in an antimicrobial bag when not in use, which was not followed in this instance.
Failure to Provide Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary ADL assistance to maintain good grooming and personal hygiene for five residents who were dependent on staff for nail care. The deficiency involved Residents #17, #57, #63, #66, and #89, whose fingernails were observed to be long, untrimmed, and in some cases dirty or discolored. The report states that the facility failed to ensure Residents #17, #57, and #63 had trimmed fingernails, and failed to ensure Residents #89 and #66 had cleaned and trimmed fingernails. Resident #17 was cognitively intact but required substantial to maximum assistance for personal hygiene, toileting, bathing, and dressing, and had left-sided hemiplegia after a CVA. During observation, he was lying in bed with both hands' nails about 1/2 inch long and stated they needed to be trimmed badly and that no one had offered to trim them. The DON later observed that his nails definitely needed trimming and stated staff saw him daily and should have noticed them. Resident #57 had moderate cognitive impairment, aphasia, dementia, and one-sided functional limitation; he required supervision for personal hygiene. He was observed with long nails on both hands measuring about 0.5 to 0.7 inch, and he stated he wanted them trimmed and that staff had not offered nail care. His nails were later clipped. Resident #63 had moderate cognitive impairment and required substantial assistance for personal hygiene. She was observed with nails extending about 0.3 to 0.5 inch from the nail bed and stated she wanted them clipped. Resident #66 had intact cognition but needed set-up for personal hygiene and had dementia and schizophrenia; he was observed with long, discolored, dirty nails with black discoloration beneath the nail bed and stated he wanted them trimmed and cleaned. Resident #89 was dependent for personal hygiene, toileting, bathing, eating, and dressing, had contractures and limited range of motion, and was observed with thick buildup of dead, scaly skin on both hands and under the nails, with jagged, brown-tinged nails. He stated they had not been trimmed in a while and needed cleaning. Staff and management stated that CNAs and nurses were responsible for nail care, with nurses responsible for diabetic residents, and that nail care should be offered on shower days and as needed; however, the observations showed these residents had not received the needed nail care at the time of survey.
Failure to Provide ROM and Contracture Management
Penalty
Summary
The facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for four residents reviewed for quality of care. The deficiency involved Resident #17, Resident #8, Resident #89, and Resident #3, all of whom had diagnoses and assessments showing hemiplegia, hemiparesis, or other functional limitations affecting upper and/or lower extremities. The report states that these residents had not received occupational therapy or restorative nursing services during the 7-day look-back period on their MDS assessments, and their care plans did not contain interventions addressing the contractures or ROM limitations identified. Resident #17, a cognitively intact male with a history of CVA and hemiplegia, had left-sided functional ROM limitation and no OT or restorative services in the look-back period. His care plan referenced CVA with left-sided hemiparesis and risk for falls, contractures, and decreased overall wellbeing, but listed only therapy to evaluate and screen as ordered and as needed, with no contracture interventions. He was observed lying in bed with his left wrist turned downward approximately 90 degrees and unable to straighten it. He stated he had been trying to get a splint for months and did not want the wrist to worsen. OT later assessed him and stated he would benefit from therapy and a resting hand splint. Resident #8, also cognitively intact with CVA and hemiplegia, had functional ROM limitation on one side and no OT or restorative services in the look-back period. His care plan addressed CVA with interventions to keep positioning devices on and areas dry and clean to maintain proper alignment, but did not include interventions for his hand contracture. He was observed with his left hand curled into a fist and unable to straighten his fingers or open his hand. He stated he had never had a splint or brace and needed one. OT stated his left hand was flaccid and would benefit from a resting palm guard for comfort and positioning. Resident #89, a dependent male with spinal stenosis and COPD, had functional ROM limitation in both upper extremities and one lower extremity, with no OT or restorative services in the look-back period. His care plan noted unsafe and poor quality in ROM related to medically complex conditions, but did not address contractures to his right arm and left hand. He was observed with his right arm drawn up to his neck and his left hand contracted, and he stated he needed something done for his right hand and had not had any exercise for his left hand. OT assessed him and stated he would benefit from therapy and a resting hand splint. Resident #3, a female with CVA, hemiplegia, and hemiparesis, had upper and lower extremity impairment on one side and used a walker. Her PT evaluation described left-sided hemiparesis, inability to grip with the left hand, impaired motor control, trunk control, postural control, activity tolerance, strength, balance, and coordination, and identified risk for contractures and further decline without skilled therapeutic interventions. Her care plan stated she was at risk for falls, contractures, and overall wellbeing decrease, but the only intervention listed was therapy to evaluate and screen as ordered and as needed. She told staff she had been at the facility for therapy and had not had any therapy since admission and had not been assisted with exercises. The DON stated nursing had not been given instruction on splint placement for other residents, and the Director of Rehab stated the residents had been screened and identified as needing splints, but therapy had not provided services for Resident #3 because therapy had not been approved by insurance and she had not had therapy in the last year.
Infection Control Failures During Resident Care and Linen Handling
Penalty
Summary
The facility failed to establish and maintain an Infection Prevention and Control Program during multiple observed care events involving residents with wounds, urinary catheters, a G-tube, and incontinence care. Resident #98 was readmitted with a kidney infection, had a Foley catheter, and had open areas including a stage 3 pressure ulcer. During incontinence care and wound care, CNA D and LVN E did not use Enhanced Barrier Precautions, and staff were observed without gowns while providing care. LVN E also did not perform hand hygiene after glove changes during wound care and returned supplies to the treatment cart after taking them into the resident’s room. On a later observation, CNA B and CNA C again provided incontinence care to Resident #98 without gowns, without hand hygiene before entering or leaving the room, and without changing gloves when moving from dirty to clean tasks. Resident #17, who was frequently incontinent of bowel and bladder and had diagnoses including diabetes, CVA, and hemiplegia, was observed receiving incontinence care from CNA C without hand hygiene before care and without glove changes when moving from cleaning the dirty perineal area to placing a clean brief. CNA B entered the room and assisted with repositioning without performing hand hygiene, and both CNAs left the room without hand hygiene. Resident #68 was observed during fingerstick blood sugar testing and insulin administration, during which LVN E used the same gloves for the fingerstick and insulin administration, placed the glucometer, used lancet, test strip, insulin pen, and unused supplies together on a tray, and returned items to the medication cart after they had been in the resident’s room. The glucometer was wiped but not allowed to air dry before being placed back in the cart. Resident #12, who had a G-tube and was on Enhanced Barrier Precautions, was observed receiving G-tube medication administration by an agency LVN who sanitized hands and donned gloves but did not wear a gown. The facility also failed to maintain proper linen and laundry handling. In the linen closet on Hall 100, six items of residents’ clothing were stored with clean linens. In the laundry room, two open large plastic bags of residents’ clothing were observed on the floor without labels. The Housekeeping Supervisor and Laundry Staff stated residents’ clothing should not be stored with clean linens, and dirty clothing bags should be closed and labeled with the resident’s name. The facility’s infection preventionist and DON stated residents with wounds, urinary catheters, or G-tubes were to be on Enhanced Barrier Precautions, and that staff were expected to change gloves, perform hand hygiene, and keep clean and soiled items separated.
Failure to Protect Resident Privacy and Rights Related to Mail and Packages
Penalty
Summary
The facility failed to ensure residents’ rights to send and receive unopened mail and packages, including privacy of such communications, for one resident reviewed for resident rights. Resident #65, a cognitively intact [AGE]-year-old female with major depressive disorder and generalized anxiety disorder, reported that her Amazon packages had been received already opened, with the most recent occurrence around December 2025. Her face sheet and MDS showed an original admission in 2021, a recent readmission in 2025, and a BIMs score of 15, indicating intact cognition. The Business Office Manager stated that when resident mail was received, it was passed out to residents, but she routinely opened mail related to medical insurance claims and bank statements for all residents, scanned it, and filed it in residents’ electronic and physical files instead of giving it to them. She also reported opening all mail for cognitively impaired residents, including birthday cards and gift cards, before giving it to them, and acknowledged that she was unaware of the policy on delivering packages. The Receptionist reported that she received Amazon packages and other mail at the front desk and, before delivering packages to residents, showed them to the assigned nurse; if the package was a soft envelope, the nurse would feel it to determine if it could be given, and if it was a box, the nurse would open it to check for medications or items the resident could not have before delivery. The DON stated nursing was not responsible for resident mail or packages and was unaware of any policy requiring nursing to check them, and acknowledged that staff opening residents’ mail and packages affected residents’ privacy rights. The Administrator stated that mail should be sorted and given to residents unopened, including Amazon packages, and that there was no reason for staff to open residents’ mail, but the facility’s written communication policy did not address residents’ rights to receive closed mail.
Care plans omitted contracture interventions for two residents
Penalty
Summary
The facility failed to ensure the comprehensive care plan included services to meet the needs of two residents with contractures and to maintain or improve range of motion. For Resident #17, the quarterly MDS reflected intact cognition, substantial to maximum assistance with personal care, bowel and bladder incontinence, and functional limitations in range of motion on one side related to diabetes, CVA, and hemiplegia. His care plan addressed CVA and fall risk, but it did not include his left wrist contracture or interventions to prevent further decline, even though the record showed he had not received OT or restorative nursing services in the look-back period. Record review showed a skilled therapy referral for Resident #17 initiated by the Director of Rehab for a hand contracture, with a recommendation for a left resting hand splint to be worn for a maximum of 4 hours and during breakfast and lunch to support self-feeding. During observation, he was lying in bed with limited use of his left hand and his wrist turned downward about 90 degrees, and he stated he had been trying to get a splint for months and did not want the wrist to get worse. OT later assessed him and stated he would benefit from therapy to improve flexibility and decrease pain and from a resting hand splint. For Resident #89, the quarterly MDS reflected intact cognition, dependence on staff for personal care and eating, bowel and bladder incontinence, and functional limitations in range of motion of both upper extremities and one lower extremity related to cervical spinal stenosis and COPD. His care plan noted assistance with self-care and mobility, but it did not include interventions for contractures of the right arm, left hand, or shoulder. A skilled therapy referral also recommended a left resting hand splint for use during meals. During observation, he was lying in bed being fed lunch, with his right arm drawn up to his neck and his left hand contracted; he stated he wanted something done for his right hand to improve independence and said he had not had exercise for his left hand. OT assessed his left hand, right hand, and right arm and stated he would benefit from therapy to improve flexibility and decrease pain and from a resting hand splint.
Missed wound care and failure to obtain orders for reopened wound
Penalty
Summary
The facility failed to provide ordered wound care for a resident with bilateral lower-extremity wounds. Resident #39 was a cognitively intact female with diagnoses including stroke, anemia, hypertension, hyperlipidemia, hemiplegia, and chronic venous hypertension with ulcers of the lower extremities. Her care plan and physician orders directed wound cleansing and dressing changes to the right posterior calf and left lateral leg on a Monday/Wednesday/Friday schedule. The treatment administration record showed no wound treatment documented on 01/09/2026 for either wound, and the resident stated the dressings had last been changed on 01/07/2026. Staff interviews showed that the wound care nurse was not in the facility and that the floor nurses were aware the resident needed wound care, but the treatment was not completed. The weekend supervisor stated she was responsible for wound care on weekends and was not aware the treatment had been missed until the surveyor brought it to her attention. The charge nurse on the day shift stated she was busy with other residents and did not complete the wound care, and the oncoming nurse on the evening shift stated she also did not complete it after being told it was pending. The overnight nurse stated she was informed the wound care was not done but was also unable to complete it. The DON stated the floor nurses should have provided the ordered wound care when the wound care nurse was absent and should have notified the physician to obtain a PRN order. The facility also failed to address a reopened wound for another resident and did not obtain a physician order for treatment. Resident #48 was a cognitively intact male on hospice with diagnoses including stroke, cancer, hypertension, and respiratory failure. His care plan addressed a skin tear/potential for skin tear of the left lower lateral leg related to severe edema and directed treatment per facility protocol if a skin tear occurred. A hospice nurse observed that a previously healed left shin/anterior wound had reopened and informed facility staff, but the wound care nurse was not in the facility and no wound care order was in place. The treatment record showed no new orders or wound care for the reopened wound, and the resident later stated the wound was red and had no dressing. Staff interviews confirmed that the reopened wound was not treated and that a physician order was not obtained when the wound was identified.
Delayed Follow-Up for Prescribed Eyeglasses
Penalty
Summary
The facility failed to ensure that Resident #55 received timely follow-up for prescribed eyeglasses after an eye exam was completed. Resident #55 was a [AGE]-year-old male admitted on 3/7/22 with diagnoses including Chronic Kidney Disease, Unspecified Dementia, Major Depressive Disorder, and Adult Failure to Thrive. His quarterly MDS dated 12/24/25 showed a BIMS score of 15, indicating intact cognition. The eye exam summary dated 7/17/25 documented cataracts in both eyes, hyperopic astigmatism, and presbyopia, with new bifocals recommended and glasses required for full-time use for distance and reading, to be delivered upon approval. Record review and interviews showed that the resident had an eye refraction on 7/7/25 and was still waiting for his glasses months later. On 1/12/26, the resident stated he had gone to the optometrist a while ago and had not gotten his glasses, and he had been waiting for several months for them to arrive. The Social Worker stated on 1/13/26 that she had only recently followed up after the resident asked for his glasses, that she did not know what attempts the previous social worker had made, and that she delivered the glasses after receiving them in the mail that day. The DON stated the need for glasses had fallen through the cracks with the previous social worker, and the Administrator stated the expected follow-up for pending glasses was 3-4 weeks, not 6 months. The facility policy stated staff should refer vision needs to Social Services, and the social worker/social service designee was responsible for assisting with appointments and arranging transportation.
Inadequate Perineal and Catheter Care
Penalty
Summary
The facility failed to ensure appropriate perineal care for a male resident who was frequently incontinent of bowel and bladder and required substantial to maximum assistance with toileting and personal hygiene. The resident had diagnoses including diabetes, CVA, and hemiplegia, and his quarterly MDS reflected intact cognition with a BIMS score of 15. During an observation, CNA C provided incontinence care but wiped the penis and scrotum toward the anal area, then cleaned the anal area outward, and placed a clean brief without cleaning the pubic area, penile shaft, or scrotum. During interview, CNA C stated she thought she had performed peri-care correctly because she wiped from front to back, but she did not know she was supposed to hold the penis and wipe the penile shaft toward the scrotum. She also stated she did not clean the pubic area. Her skills checklist reflected competency in infection control, peri-care, and catheter care. The facility policy for male perineal care required cleansing the tip of the penis, the shaft using downward strokes toward the scrotum, and cleaning the scrotum and anal area with separate wipes. The facility also failed to ensure appropriate catheter and perineal care for a female resident who was always incontinent of bowel and bladder and had a Foley catheter. Her diagnoses included Parkinson’s disease, dementia, and diabetes, and her admission note stated she had been readmitted for a kidney infection and had a light pink Foley drainage. During observation, CNA B wiped across the pubic area and down each side of the groin but did not separate the labia or wipe down the middle, and did not clean the catheter tubing from the insertion site downward. CNA B stated she knew she did not go down the middle or wipe down the catheter tube and identified the risk as urinary tract infections. The facility policy for catheter care required separating the labia and wiping the catheter from the insertion site downward.
Failure to Provide Ordered Rehabilitative Therapy
Penalty
Summary
The facility failed to provide specialized rehabilitative services for one resident with a history of CVA, left hemiparesis, wheelchair dependence, and assistance needs for multiple ADLs. The resident’s comprehensive care plan identified her as at risk for falls, contractures, and decline in overall wellbeing, and included therapy to evaluate and screen as ordered and as needed. Her physician records showed no active orders for restorative therapy or therapy at the time of review. A PT evaluation completed after the resident’s readmission documented left-sided hemiparesis, impaired motor control, trunk and postural control, reduced activity tolerance, generalized weakness, impaired sitting balance, and limited coordination, with a plan of treatment focused on restoration. The evaluation stated she would highly benefit from PT to address these impairments and improve bed mobility, out-of-bed frequency, and manual wheelchair propulsion. The evaluation also noted that without skilled therapeutic interventions, the resident was at risk for DVT, falls, immobility, further decline in function, depression, dehydration, limited out-of-bed activity, muscle atrophy, pressure sores, decreased skin integrity, contractures, and compromised general health. Despite repeated provider progress notes stating to continue PT and a later note referencing PT evaluation, the resident reported she had not had any therapy since admission and wanted to walk again and be more independent. Nursing staff stated therapy had not provided exercises, and the rehab director stated the resident had been evaluated by therapy but the evaluation was not approved by insurance, so she was not in therapy. The rehab director also stated the resident had not had therapy in the last year due to insurance non-approval, and the administrator stated that if therapy was denied or there was no payor source, they were to be notified so the resident’s needs could be addressed.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements.
Medications Left Unsecured and Unconsumed in Resident Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access, as required by professional standards. During observation, a resident was found in her room with two cups containing a total of seven pills left on her tray table, along with a nutritional supplement. The resident stated that staff usually waited with her to ensure she swallowed her medication, but on this occasion, the medication aide left the pills and supplement in the room and departed. The medications had been left there since the morning, and the resident was unsure of what all the pills were. Record review showed that the resident had multiple diagnoses, including paraplegia, diabetes, osteomyelitis, cognitive communication deficit, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, pruritis, and hypertension. The medication administration record indicated that all morning medications were marked as given by the medication aide. Interviews with the DON and the medication aide confirmed that the aide did not observe the resident taking all her medications, contrary to facility policy, which requires direct observation of medication consumption. This lapse resulted in medications being left unsecured and unconsumed in the resident's room.
Failure to Accurately Transcribe and Administer Medications After Hospital Readmission
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not correctly transcribing medication changes for a resident who was readmitted after a hospital stay. Upon the resident's return, the admitting nurse was responsible for entering the new medication orders into the electronic medical record (EMR) and ensuring they matched the hospital discharge instructions. However, the review of records showed discrepancies between the hospital discharge orders and the facility's active physician orders and medication administration records (MAR). Specifically, the dosages and administration frequencies for medications such as Bisacodyl, Buspirone, and Hydroxyzine were not accurately transcribed, resulting in the resident receiving incorrect medication regimens for an extended period. The resident involved had a history of chronic obstructive pulmonary disease with acute exacerbation, respiratory failure with hypoxia, constipation, pain, insomnia, and anxiety disorder. The resident was cognitively intact and able to communicate concerns about the medication regimen, reporting that the volume and timing of medications made him excessively sleepy and affected his ability to function. The MAR indicated that medications were administered as transcribed by the facility, not as ordered by the hospital, and there was no documentation of changes to the medication regimen following the resident's readmission. Interviews with staff revealed gaps in communication and process adherence. The admitting nurse who transcribed the orders was no longer employed at the facility, and the ADON described issues with providing an updated medication list to the hospital due to a malfunctioning fax machine. The hospital pharmacist reported recurring problems with obtaining accurate and current medication lists from the facility, leading to delays and potential complications in patient care. Facility policies required clarification and accurate transcription of new medication orders, but these procedures were not followed in this instance.
Failure to Ensure Proper Use and Function of Pressure-Relieving Mattresses
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent the development and worsening of pressure ulcers for four out of five residents reviewed. Observations and record reviews revealed that pressure-relieving mattresses were not functioning properly or were not set to the correct weight settings for several residents at risk for pressure ulcers. Specifically, one resident's pressure-relieving mattress was found to be beeping and set to static mode, which staff acknowledged would prevent the mattress from circulating air as intended. Staff interviews indicated a lack of understanding regarding the operation and significance of the mattress settings. For three other residents, the pressure-relieving mattresses were not set to the correct weight according to the residents' actual weights. In one case, a mattress was set to a weight significantly lower than the resident's actual weight, while in another, the setting was much higher than the resident's weight. Staff interviews revealed that some nurses were unaware of the correct settings or had not checked the beds since returning from leave. Additionally, one resident reported discomfort and feeling a hole in the bed, further indicating improper mattress function or settings. Record reviews showed that physician orders and care plans required the use of pressure-relieving mattresses and regular checks for proper functioning. However, these orders were not consistently followed, as evidenced by the incorrect mattress settings and lack of staff knowledge. The facility's own policy emphasized the importance of pressure reduction surfaces and regular monitoring, but these standards were not met for the residents reviewed.
Failure to Enforce Contact Isolation Precautions for Resident with Suspected C. diff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident who was under contact isolation precautions due to suspected Clostridioides difficile (C. diff) infection. Despite clear signage and physician orders requiring the use of personal protective equipment (PPE) such as gowns and gloves before entering the resident's room, multiple staff members—including a Certified Medication Aide (CMA), a Certified Nursing Assistant (CNA), and a housekeeper—entered the room without donning the required PPE. Observations showed that the CNA entered the room to address the resident's concerns about lunch, the CMA entered to deliver medication, and the housekeeper entered to clean the room while the resident was at dialysis, all without using PPE. Staff interviews revealed a lack of awareness or understanding of the isolation requirements, with one CNA stating she was unaware of the need for PPE due to just returning from vacation and not being informed, and the housekeeper believing PPE was unnecessary if the resident was not present. The resident involved was a male with a history of limb amputation and tobacco use, who had been tested for C. diff with results pending at the time of the observations. The care plan included interventions for respiratory symptoms and the use of oxygen, and the resident had a moderate level of cognition. Facility policy required the use of PPE for contact precautions, and staff interviews confirmed that all staff were expected to follow infection control protocols. However, the observed failures to comply with these protocols placed residents at risk for cross-contamination and the potential spread of infection.
Failure to Ensure Proper Functioning of Oxygen Concentrator for Resident Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to a resident requiring oxygen therapy. The resident, who had a history of limb amputation and tobacco use, was at risk for shortness of breath and chest pain, with care plan interventions including the application of oxygen as ordered and monitoring for effectiveness. Despite physician orders for oxygen administration via nasal cannula and non-rebreather mask as needed, the resident's oxygen concentrator was observed to be malfunctioning, with continuous beeping and warning lights indicating low oxygen concentration and a need for service. The resident reported that the machine had been malfunctioning since admission and that the beeping had become a persistent issue. Staff interviews revealed that the malfunctioning concentrator had not been previously reported or addressed, and the resident continued to rely on the faulty equipment for respiratory support. Observations confirmed that multiple concentrators in the facility were not functioning properly, requiring several attempts to find a working device for the resident. Facility policy and manufacturer guidelines specified the need for staff to verify proper functioning of oxygen concentrators and to place warning signs, but these procedures were not consistently followed, resulting in the resident not receiving respiratory care consistent with professional standards and the care plan.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, resulting in the presence of roaches and water bugs in resident rooms and bathrooms on Hall 100. Multiple residents reported seeing live roaches in their rooms and bathrooms, particularly at night, and expressed that the ongoing pest issue was bothersome. Staff interviews confirmed the presence of roaches and water bugs in resident rooms, closets, and bathrooms, and noted that the problem was ongoing and facility staff were aware of it. Observations by surveyors corroborated these reports, with live and dead bugs found in resident rooms, bathrooms, and glue traps, as well as structural issues such as a 1-inch opening in a floorboard where pests were seen entering. Housekeeping and maintenance staff indicated that pest sightings were documented and that pest control services were called, but there was a lack of clarity regarding the frequency and thoroughness of deep cleaning in affected rooms. The pest control representative confirmed recent treatment for roaches and water bugs, noting that pests were coming from drains and possibly from under commodes that were not properly sealed. However, the representative could not specify which rooms were treated, and facility records showed repeated pest sightings and treatments over several months, indicating a persistent issue. Review of facility logs and pest control documentation revealed ongoing reports of roaches and water bugs in various rooms, with service dates recorded for some but not all incidents. The facility's pest control policy required maintaining an effective program and a reporting system for issues between scheduled visits, but interviews and record reviews indicated gaps in implementation and follow-up. The deficiency was identified based on direct observations, resident and staff interviews, and review of facility records.
Failure to Protect Resident from Physical and Verbal Abuse by Staff
Penalty
Summary
A certified medication aide (CMA) engaged in physical and verbal abuse toward a male resident with a history of aphasia, dysarthria, hemiplegia, bipolar disorder, major depressive disorder, and unsteadiness on his feet. The incident occurred when the resident refused medication, leading to a confrontation in which the CMA threw a pitcher of water at the resident, causing him and his bed to become wet. Multiple witnesses, including staff and a family member, observed the CMA using profanity and antagonizing the resident, while the resident also used profanity and attempted to pursue the CMA despite being unsteady and falling during the altercation. The resident was cognitively intact, as indicated by a BIMS score of 15, and was generally independent in activities of daily living. During the incident, the resident became upset, attempted to go after the CMA, and was described as very unsteady on his feet, ultimately falling but getting back up. Staff and a family member intervened by trying to separate the two and placing a medication cart between them. The situation escalated with both parties yelling and using profane language, and the resident continued to pursue the CMA until additional staff arrived and the situation was brought under control. Interviews and documentation confirmed that the CMA was physically aggressive and abusive toward the resident, including the act of throwing water and engaging in a verbal altercation. The facility's investigation, as well as statements from staff and witnesses, corroborated the occurrence of both physical and verbal abuse by the CMA. The incident was self-reported by the facility, and the abuse was substantiated through interviews, record reviews, and direct observations of the aftermath, such as the resident and his bed being wet and the presence of water on the floor.
Food Safety and Hair Restraint Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. In the walk-in refrigerator, food items were not properly sealed, and some produce showed signs of expiration. Specifically, a container labeled 'Burger Toppings' was not sealed, and the lettuce inside was turning brown. Additionally, a bin of tomatoes contained several bruised items, and an open box of bacon was not sealed. The Dietary Manager acknowledged these issues and stated that the lettuce and tomatoes would be discarded, and the bacon would be sealed. During meal service, the facility did not take the temperatures of certain food items before serving them to residents. Hamburger patties, chicken nuggets, fries, ice cream, and gelatin dessert were served without temperature checks. Dietary staff admitted to not taking the temperatures, citing the need to serve food on time as a reason for the oversight. The Dietary Manager confirmed that the expectation was to take temperatures of all food items to ensure they were served at safe temperatures. Additionally, staff members did not wear effective hair restraints during meal service. Observations revealed that an LVN, a Dietary Aide, and a Dishwasher had hair not covered by hair restraints while handling food. Interviews with the staff confirmed that they were aware of the expectation to cover all hair to prevent contamination. The Dietary Manager acknowledged that some staff had not been in-serviced about effective hair restraints, which posed a risk of hair falling into food and drinks, potentially causing contamination.
Deficiency in Personal Hygiene and ADL Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Four residents were affected by this deficiency. Resident #69, a male with severe cognitive impairment, was observed with long, discolored fingernails with dark residue underneath, indicating a lack of personal hygiene care. Similarly, Resident #86, also with severe cognitive impairment, had chipped and untrimmed fingernails and expressed that he lacked the tools to trim them himself. The staff, including CNAs and LVNs, were responsible for nail care, but this was not adequately provided. Resident #47, who was cognitively intact but required assistance due to right-sided hemiplegia, did not receive a scheduled shower. The resident reported that he did not refuse the shower, contrary to what was documented by CNA L. The CNA did not return to provide the shower after initially lacking bed linens, leading to a missed care opportunity. This discrepancy between the resident's account and the staff's documentation highlights a failure in communication and care delivery. Resident #33, with moderate cognitive impairment and dependency on staff for self-care, was observed with a dark brown substance around his fingernail cuticles, suspected to be feces. Despite the resident's frequent refusals of care, the CNA did not report this to the charge nurse, as required by protocol. The Assistant Director of Nursing (ADON) acknowledged that nail care should be provided as needed, especially during shower times, and that refusals should be reported to the charge nurse. The facility's policy on activities of daily living emphasizes the importance of providing care for bathing, dressing, grooming, and oral care, which was not adhered to in these cases.
Medication Handling Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, as evidenced by the improper handling of medications on three medication carts. Specifically, medications in unsecure blister packs were found on the Nurses Cart Hall 300, Med Aide Cart Hall 300/400, and Nurses Cart Hall 400. LVN D, responsible for Nurses Cart Hall 300, was unaware of when or how the blister pack seals for controlled medications were broken, posing a risk for drug diversion. Similarly, MA E, responsible for Med Aide Cart Hall 300/400, and LVN F, responsible for Nurses Cart Hall 400, also failed to identify broken blister seals during their shift change counts, despite being responsible for checking these packs. Interviews with the staff revealed a lack of awareness and adherence to the facility's policy regarding the handling of medications with broken seals. The Assistant Director of Nursing (ADON) confirmed that broken blister pack medications should be discarded to prevent drug diversion and infection control issues. The facility's policy mandates that the pharmacy and medication rooms be routinely inspected for discontinued, outdated, or defective medications, yet the staff failed to comply with these procedures, leading to the observed deficiencies.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two separate incidents involving residents. In the first incident, a Certified Nursing Assistant (CNA) did not perform hand hygiene between glove changes while providing incontinence care to a resident with severe cognitive impairment and incontinence issues. The CNA acknowledged the lapse in protocol, which could expose the resident to infections. In the second incident, a Licensed Vocational Nurse (LVN) and another CNA did not wear the appropriate personal protective equipment (PPE) while performing wound care on a resident under enhanced barrier precautions due to a pressure ulcer. The LVN, who was new to the facility, admitted to not noticing the precautionary signage, while the CNA misunderstood the signage's applicability. Both staff members recognized the risk of infection due to their actions.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident #40, who was observed to have dry, flaky skin on her feet. This deficiency was identified through observation, interview, and record review. Resident #40, a cognitively intact female with a BIMS score of 15, required extensive assistance for activities of daily living (ADLs) due to limited mobility. Her medical history included hypertension, diabetes mellitus, and non-Alzheimer's dementia. Despite these needs, the resident reported receiving bed baths only three times a week, with foot cleaning and lotion application occurring sporadically. During an observation, a CNA acknowledged the need to clean and moisturize the resident's feet, recognizing the potential for infection and skin breakdown. Interviews with facility staff, including an LVN and the ADON, revealed that it was the CNAs' responsibility to provide foot care, with oversight from nursing staff. The facility's policy on skin integrity and foot care, revised in February 2023, emphasized the importance of maintaining good foot health. However, the lack of consistent foot care for Resident #40 indicated a failure to adhere to this policy, placing residents at risk for skin issues and infections.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to ensure that a resident was offered sufficient fluid intake to maintain proper hydration. This deficiency was identified for a resident who was moderately cognitively impaired and required set-up assistance with eating. The resident, who was on hospice services and had a mechanically altered diet due to a swallowing disorder, expressed thirst and reported not receiving water from the staff during the morning shift. The resident's care plan included encouragement of dietary and fluid intake, but the staff did not provide water until later in the day. Interviews with facility staff revealed that the CNAs did not have time to pass out water before breakfast, and water was only provided right before lunch. The staff acknowledged the risk of dehydration and increased confusion due to insufficient fluid intake. The facility's policy on hydration emphasized offering sufficient fluids to maintain proper hydration and health, but this was not adhered to in the case of the resident, leading to the identified deficiency.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food at an appetizing temperature and palatable texture during a lunch meal, specifically serving a cold hamburger and undercooked vegetables. This issue was identified through observation, interviews, and record reviews. During a confidential group interview, residents expressed concerns about food not being cooked properly, with instances of overcooking. Observations revealed that the 400 hall trays were the last to be served, and a test tray showed that the vegetable medley was hard and undercooked, while the hamburger was cold. Interviews with dietary staff highlighted the importance of checking food temperatures to ensure they are at least 165°F to prevent foodborne illness. The Dietary Manager acknowledged that the vegetables should not be hard, as this could make them difficult for residents to chew and potentially lead to illness. The Resident Council Minutes also reflected dietary concerns about food temperature. The facility's policy on date marking for food safety was reviewed, indicating procedures for checking and discarding expired food items, but it did not address the specific issue of serving food at the correct temperature.
Failure to Label and Date Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as evidenced by the lack of labeling and dating on the oxygen humidity bottle and nasal cannula. The resident, a female with intact cognition, was readmitted to the facility with diagnoses including anemia, cirrhosis, hepatic failure, and septicemia. Her care plan indicated resistance to care related to shortness of breath, with orders for oxygen therapy as needed. However, during an observation, it was noted that the oxygen equipment was not labeled or dated, which could increase the risk of respiratory infection. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the facility's practice was to change and date oxygen supplies weekly, but this was not done in this instance. The DON acknowledged the oversight and stated that the nighttime nursing staff was responsible for this task. The facility's policy on oxygen administration, revised in October 2023, requires adherence to professional standards of practice, but there was no specific policy for labeling and dating oxygen equipment. This lapse in procedure was identified as a deficiency in the facility's care practices.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement and follow its abuse, neglect, and exploitation policy, resulting in two incidents involving residents. In the first incident, a CNA observed a male resident touching a female resident's shoulder in a manner that made the CNA uncomfortable, given the male resident's history of inappropriate behavior. Despite reporting the incident to an LVN and the Administrator, no documentation or investigation was conducted, and the Administrator was unaware of the incident until informed by the CNA the following day. The Administrator and DON did not follow the facility's policy to ensure resident safety and investigate the situation. In the second incident, a CNA witnessed a male resident hitting another male resident on the head with a cane. The CNA intervened and reported the incident to the ADONs and the Administrator, but no documentation or investigation followed. The Administrator and DON were aware of the incident but did not assess the residents for harm or document the event, as they did not believe physical contact occurred. The facility's policy was not implemented to ensure resident safety or investigate the incident. Both incidents highlight the facility's failure to adhere to its abuse prevention policy, which requires immediate reporting, investigation, and documentation of any allegations or suspicions of abuse. The lack of action and documentation in these cases could place all residents at risk for abuse and psychosocial harm, as the facility did not ensure the safety and protection of its residents during and after the incidents.
Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to investigate alleged or suspected abuse involving two residents, which could potentially place all residents at risk for abuse and psychosocial harm. In the first incident, a CNA observed a resident touching another resident's shoulder in a manner that made the CNA uncomfortable due to the resident's history of inappropriate behavior. Despite reporting the incident to an LVN and the Administrator, no investigation was conducted, and there was no documentation of the incident in the residents' progress notes. The Administrator and DON were unaware of the incident until it was reported the following day, and they did not follow the facility's abuse policy to ensure resident safety. In the second incident, a CNA witnessed a resident hitting another resident on the head with a cane. The CNA intervened and reported the incident to the ADONs and the Administrator, but again, no investigation was conducted, and there was no documentation of the incident. The Administrator and DON were present during the incident but did not assess the residents or document any findings. The facility's abuse policy was not implemented, and the residents were not assessed for harm. The facility's policy requires immediate investigation of all alleged abuse, neglect, or exploitation, with thorough documentation and reporting. However, in both incidents, the facility failed to follow its policy, resulting in a lack of investigation and documentation. The Regional Nurse confirmed that the facility did not adhere to its abuse policy, as there was no investigation or documentation of the incidents, and the residents were not assessed for harm.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,606 citations issued within 25 miles in the last 12 months — including the 33 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Renaissance At Kessler Park | 2.3 mi | ★★★★★ | 6 | 0 |
| Forest Park Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 16 | 1 |
| Ventana By Buckner | 4 mi | ★★★★★ | 3 | 0 |
| Traymore Nursing Center | 4.4 mi | ★★★★★ | 2 | 0 |
| Avir At Dallas | 4.8 mi | ★★★★★ | 1 | 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 October 2026) and official state health department websites.