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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lampasas Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Incomplete MDS Functional Assessment: A resident with malnutrition, HTN urgency, DM2 with hyperglycemia, and age-related debility had an MDS with dashes in multiple GG areas, including bathing, dressing, hygiene, rolling, tub/shower transfer, and car transfer. The care plan addressed some ADLs, but not all functional abilities, and staff said the assessment was not completed because the baseline care plan was unavailable, even though resident/RP interviews and other sources could have been used.
Baseline care plan not completed within required timeframe. A resident with severe protein calorie malnutrition, HTN urgency, DM2 with hyperglycemia, and age-related debility did not have a baseline care plan completed within 48 hours of admission. The CRS said she could not complete the MDS assessment because nursing had not completed the baseline care plan, and the DON confirmed the required assessment could not be located. The ADM stated it was facility policy for baseline care plans to be completed within 48 hours and that the DON was responsible for ensuring completion.
A resident with severe cognitive impairment, nonverbal status, bilateral ROM limitations, and total dependence for transfers was care planned for mechanical lift transfers requiring two staff. Despite this, a CNA who had been trained on mechanical lift use and signed in to recent in-services on safe transfers and two-person assistance used the lift alone to transfer the resident from bed to wheelchair, as later confirmed by AEM footage. The CNA reported acting alone because the family was repeatedly calling and pressuring staff through the monitoring system while other staff were unavailable, even though she knew two staff were required. The charge nurse later noticed the resident in the dining room and questioned how the transfer had occurred, knowing the CNA was the only staff on that hall and that signage on the lift directed staff to use two people.
A resident with multiple chronic conditions and intact cognition was ordered several oral medications, including an anticoagulant, anticonvulsant, muscle relaxant, beta-blocker, and antidepressant. A medication aide documented administration of these p.m. doses, but later that evening an LVN found the resident unresponsive, drooling, and with four pills on her face. Staff interviews confirmed that MAs and nurses were required by facility policy to observe residents swallow medications, yet the aide reported he verified ingestion only by talking with the resident afterward. The resident’s medications were not actually ingested despite being charted as given, demonstrating a failure to ensure proper oral medication administration and adherence to the facility’s medication administration policy.
PASARR Screening Did Not Reflect Mental Illness Diagnosis: A resident with diagnoses including bipolar disorder, schizoaffective disorder, and major depressive disorder had a PASARR Level I screening that marked mental illness as N/A. The resident also had severe cognitive impairment on MDS and a care plan addressing mood problems related to depression and schizoaffective disorder. The DON said the MDS nurse was responsible for PASARR accuracy, and an LVN described the facility’s process for identifying possible mental illness and notifying the local authority.
Hand Hygiene Not Maintained During Food Prep: A kitchen employee failed to sanitize her hands between tasks while preparing puree and taking food temperatures. The DON/designee stated staff were expected to wash hands or change gloves after each task and after touching items such as the refrigerator or garbage can, and that hand hygiene was required before and after handling food. Another kitchen employee stated he washed hands or changed gloves when preparing food or taking temperatures and cleaned the thermometer after each use.
Failure to Use EBP During Catheter Care: A resident with an indwelling urinary catheter had EBP ordered and signage/PPE available outside the room, but a CNA provided catheter care wearing gloves only and no gown. The CNA stated the gown was forgotten, and the DON confirmed EBP is expected for residents with urinary catheters and other medical devices.
A resident with heart failure and dementia had an active PRN Tramadol order and was coded on the MDS as receiving PRN pain medication, but her comprehensive care plan did not include any mention of pain, pain issues, or pain medication. Staff interviews revealed that RNs and other nurses are responsible for updating care plans, that PRN pain medications were not typically care-planned, and that there was no dedicated MDS coordinator at the time, with various staff assisting. The facility’s own comprehensive care-planning policy requires person-centered care plans that address all identified medical and psychosocial needs, but this requirement was not met for the resident’s pain management.
Two residents did not receive care in accordance with professional standards and their care plans, including a lack of timely post-surgical pain medication, delayed enteral feeding and hydration, and inadequate colostomy care for one resident, as well as failure to assess and document a significant injury of unknown origin for another. Documentation was incomplete or missing, and staff interviews revealed confusion and lack of communication regarding care needs and events.
A resident with multiple serious health conditions experienced critically low blood pressure readings that were not reported by a medication aide to the LVN as required by care protocols. The lack of timely notification and intervention resulted in the resident being found unresponsive, later diagnosed with sepsis and hypotension in the hospital, and subsequently passing away. Staff interviews confirmed the communication breakdown that led to the deficiency.
A resident with chronic conditions and dependent on personal hygiene assistance did not receive necessary nail care, resulting in long, jagged, and sharp toenails. The care plan lacked documentation for nail care maintenance, and interviews revealed that nail care was expected during showers but was not properly planned or documented. The facility did not have a specific policy for activities of daily living, contributing to the deficiency.
The facility failed to store and label food items properly, as observed during a kitchen tour. Expired items, such as frozen chicken patties and pineapple slices, were found in the freezer, and a bag of French fries was punctured. Interviews with the Dietary Manager and Director of Nutrition confirmed labeling errors and the presence of expired items, which could lead to foodborne illness. Facility policies and FDA guidelines emphasize proper labeling and storage to prevent contamination.
A resident with arm fractures was not treated with dignity during meal assistance. An RN stood over the resident while feeding her and left before completing the task, resulting in the resident's meal becoming cold. A CNA later provided proper assistance by sitting at eye level. The facility's policy and guidelines emphasize the importance of maintaining resident dignity.
A resident with multiple fractures was unable to reach her call light, leaving her unable to call for assistance due to limited arm mobility. The call light was found on the floor, out of reach, and the resident expressed feeling vulnerable. A CNA later repositioned the call light to be accessible. Interviews with the DON and ADM confirmed the expectation for call lights to be within reach, but the facility lacked a formal policy, relying on in-service training instead.
A facility failed to include a resident's DNR status in their care plan, despite a physician's order indicating this status. The resident, with COPD and moderate cognitive impairment, had a care plan that did not reflect their Advance Directive, potentially leading to improper care. Interviews with the DON and ADM confirmed the oversight and the importance of accurate care plans.
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The lack of a baseline care plan was due to a computer error and a failure to complete an initial evaluation upon the resident's admission, leading to a gap in the resident's care.
Incomplete MDS Functional Assessment
Penalty
Summary
The facility failed to ensure that the comprehensive assessment accurately reflected Resident #1’s current functional status. Resident #1 was an [AGE]-year-old male with diagnoses including unspecified severe protein calorie malnutrition, hypertensive urgency, type 2 diabetes mellitus with hyperglycemia, and age-related physical debility. The admission MDS assessment dated [DATE] contained dashes in multiple Section GG functional areas, including shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, tub/shower transfer, and car transfer. The resident’s comprehensive care plan, initiated on 4/24/26 and last revised 06/17/26, identified an ADL self-care performance deficit and included interventions for bathing, bed mobility, eating, and discussion with the resident/family/POA about concerns related to loss of independence and decline in function. However, the care plan did not reflect other functional abilities such as personal hygiene, shower transfers, or dressing assistance required. The MDS assessment was signed by CRS A, who stated she assisted with completion of MDS assessments and used information from nursing, therapy, the resident, or family, but said she could not complete Resident #1’s assessment because the baseline care plan had not been completed by nursing staff. During interview, CRS A stated that resident or RP interviews were also sufficient to determine certain functional abilities, but those interviews were not attempted. The DON stated it was her expectation that MDS assessments be accurate and complete and acknowledged that the MDS guides care and affects the plan of care. The ADM stated there should be no errors on the MDS, that it should be completed within the required timeframe, and that information could be obtained from the IDT, hospital records, updated documents, the face sheet, hospice, or resident/RP interviews. The facility policy stated the comprehensive assessment would include physical and mental functional status and that the results are used to develop, review, and revise the resident’s comprehensive plan of care; the CMS RAI Manual stated dash use should be rare and that Section GG coding is based on the resident’s usual performance during the assessment period.
Baseline Care Plan Not Completed Within Required Timeframe
Penalty
Summary
Failure to develop and implement a baseline care plan within 48 hours of admission was identified for one resident. The resident was an older male with diagnoses including unspecified severe protein calorie malnutrition, hypertensive urgency, type 2 diabetes mellitus with hyperglycemia, and age-related physical debility. Record review showed the resident’s comprehensive care plan was initiated later and last revised on 06/17/26, but there was no available baseline care plan completed within 48 hours of the resident’s most recent admission on [DATE]. During interview, the CRS stated she assists with MDS completion and gathers information from nursing, therapy, the resident, or family members, but she was unable to complete the resident’s MDS assessment because the baseline care plan had not been completed by nursing staff. The DON stated she could not locate the required assessment and confirmed the baseline care plan was not completed. The ADM stated it was her expectation and policy that baseline care plans be completed within 48 hours of admission and that it was the DON’s responsibility to ensure completion.
Improper Solo Use of Mechanical Lift for Dependent Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance devices during transfers for a dependent resident who required a mechanical lift with two-person assistance. The resident was an elderly female with non-traumatic brain dysfunction, malnutrition, anxiety, depression, joint stiffness, adhesive capsulitis of the shoulder, and senile degeneration of the brain. She had impaired range of motion in both upper and lower extremities, used a wheelchair, and was dependent on staff for eating, toileting, and all transfers and bed mobility. Her mental status assessment showed short- and long-term memory problems and severely impaired cognitive skills for daily tasks, and she was rarely or never understood, with nonverbal status and impaired communication noted in her care plan. The resident’s comprehensive care plan identified her as at risk for falls and specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date in question, audio electronic monitoring (AEM) footage showed a CNA operating a mechanical lift alone to transfer the resident from bed to wheelchair, with no additional staff present throughout the transfer. The resident’s responsible party later stated they believed two people were supposed to transfer the resident with the mechanical lift and expressed fear that the resident could be dropped if only one person performed the transfer. Interviews revealed that the CNA had been employed at the facility for two months and had received facility training on proper mechanical lift use, including the requirement for two operators. She acknowledged knowing that two people were needed to operate the lift safely and stated she performed the solo transfer because the resident’s family was calling the nurse’s station, insisting the resident be gotten out of bed, while the other CNA was not yet on shift and the nurse was busy. She reported feeling nervous due to frequent calls and threats from the family communicated through the AEM. The MDS nurse, who was charge nurse that day, later observed the resident in the dining room and questioned how she had been transferred there, knowing that the CNA was the only staff on that hall at the time and that there was a sign on the mechanical lift instructing staff to use two people.
Failure to Ensure Resident Ingested Ordered Oral Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate administration of routine medications and to observe that a resident successfully ingested ordered oral medications. The resident had multiple significant medical diagnoses, including a displaced bimalleolar fracture of the right lower leg, lack of coordination, need for assistance with personal care, muscle wasting and atrophy, unsteadiness on feet, epilepsy, dementia, hypertension, chronic congestive heart failure, and chronic kidney disease. Her MDS showed she was cognitively intact with a BIMS score of 15/15 and she had no signs or symptoms of swallowing disorders. Physician orders included Apixaban, Levetiracetam, Methocarbamol, Metoprolol Tartrate, and Sertraline, all to be given orally on specific schedules. Record review of the MAR/TAR for the month showed that the medication aide documented that he orally administered Sertraline 50 mg, Apixaban 5 mg, Levetiracetam 500 mg, Metoprolol Tartrate 25 mg, and Methocarbamol 500 mg to the resident on the evening in question. However, a progress note later that evening documented that during shift change the resident was found not responding, with drool and her p.m. medications on her face. The LVN who assessed the resident noted that the resident would start to answer questions but was unable to complete her thoughts, and that four medications were observed on the resident’s face. The DON subsequently identified the medications on the resident’s face and provided them to EMS, although staff interviewed could not clearly state which specific medications were present, only that one may have been Metoprolol and another a blue pill. Multiple staff interviews confirmed that facility policy and practice required MAs and nurses to observe residents take their medications and ensure they were successfully swallowed, consistent with the written medication administration policy that includes a checklist item to observe the resident take medications. Staff, including LVNs, the MA, the ADM, the ADON, and the Regional Nurse, all stated that MAs and nurses were responsible for administering medications according to physician orders and observing residents orally take them. The MA reported that he verified residents took their medications by talking to them after administration, and stated he had observed this resident take her medications by talking to her after giving them. Despite this, the resident was later found with four medications on her face, indicating that the medications documented as administered were not actually ingested, constituting a failure to provide and accurately administer routine medications as ordered and to follow the facility’s own medication administration guidelines.
PASARR Screening Did Not Reflect Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure the PASARR Level I screening accurately reflected Resident #1’s status. Resident #1’s record showed diagnoses including bipolar disorder, schizoaffective disorder, bipolar type, bipolar disorder with manic episode, and major depressive disorder. However, the PASARR Level I Screening dated 10/08/2019 marked Section C Mental Illness as N/A, indicating that Resident #1 did not have a mental illness. The resident’s quarterly MDS dated 12/12/2025 showed a BIMS score of 02, severe cognitive impairment, and dependence on staff for toileting and bathing with substantial to maximal assistance needed for personal hygiene. The resident’s care plan dated 03/07/25 identified a mood problem related to depression and schizoaffective disorder, bipolar type, with interventions for monitoring and reporting mood patterns and signs of self-harm risk. During interview, the DON stated the MDS nurse was responsible for ensuring PASARR accuracy and described the facility’s process for identifying residents with possible mental illness, intellectual disability, or related conditions. LVN A stated the facility reviewed hospital paperwork, completed form 1012 when a diagnosis was present, and used the electronic system to notify the local authority, but she denied that Resident #1 had a newly evident or possible condition after admission.
Hand Hygiene Not Maintained During Food Preparation
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food safety in the kitchen reviewed for sanitation. During an observation on 01/20/26 at 11:54 a.m., DC A did not sanitize her hands between tasks while preparing puree and taking temperatures of food items placed in the hot tray. The observation documented that she failed to wash her hands after each transition to a new task while handling food and checking temperatures. During interviews, DS A stated that kitchen staff were expected to wear hair nets throughout their time in the kitchen and to practice hand hygiene by washing hands or changing gloves after each task or after touching items such as the refrigerator or garbage can. DS A also stated that staff should wash or replace gloves after each food-related task and that failure to do so could result in foodborne illness and cross contamination. DC B stated that he always washed his hands or changed gloves when taking food temperatures or preparing food and cleaned the thermometer with a new alcohol swab after each use. DC A later stated that she washes her hands and changes gloves each time she starts something different in the kitchen and denied not practicing proper hand hygiene on 01/20/26.
Failure to Use Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one resident observed for infection prevention. Resident #12 was a [AGE] year-old man admitted on 04/23/2024 with diagnoses including heart failure, obstructive and reflux uropathy, and benign prostatic hyperplasia. His quarterly MDS showed a BIMS score of 15, indicating intact cognition, and record review showed he had an external catheter. Active orders dated 01/16/2026 included a urinary catheter with gravity drainage and Enhanced Barrier Precautions under special instructions, and the care plan identified an indwelling catheter with related catheter care interventions. During observation on 01/21/2026 at 10:38 AM, a sign for Enhanced Barrier Precautions was posted on the resident’s door and PPE was available outside the room. CNA A was observed putting on gloves but not wearing a gown while providing catheter care to the resident. When interviewed shortly afterward, CNA A stated, “I forgot to wear a gown,” and said EBP is required when performing direct care to a resident with conditions such as wounds or any opening to the body. The DON later stated that EBP is expected when a resident has an open wound or medical equipment such as a urinary catheter, and that failure to follow EBP could result in the spread of infection. The facility policy stated that EBP includes targeted gown and glove use during high-contact resident care activities and is indicated for residents with indwelling medical devices, including urinary catheters.
Failure to Include PRN Pain Management in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident’s identified pain management needs. An older female resident with diagnoses including heart failure and unspecified dementia was admitted and later readmitted to the facility. Her MDS, completed on 12/22/25, showed a BIMS score of 99, indicating the exam could not be completed, and documented that she received PRN pain medications. The resident’s order summary showed a PRN order for Tramadol 50 mg by mouth every 6 hours as needed for pain, with a start date of 12/01/25. However, review of the resident’s care plan, last revised on 11/10/25, revealed no mention of pain, pain-related issues, or pain medication, despite the active PRN Tramadol order and the MDS coding for PRN pain medication use. During interviews, the resident was unable to recall which medications she received and had difficulty answering questions. Multiple staff members, including an LPN, LVNs, the DON, a CNA, and the administrator, acknowledged that the resident’s pain and PRN Tramadol should have been included in the care plan and that nurses are responsible for updating care plans when there are changes. Staff also reported that PRN pain medications were not typically included in care plans and that there was no current MDS coordinator, with a corporate nurse assisting and LVN B having last assisted with MDS duties until 12/23/25. The facility’s undated policy on comprehensive care planning states that each resident will have a person-centered comprehensive care plan developed and implemented to meet medical, physical, mental, and psychosocial needs identified in the comprehensive assessment, but this was not followed for this resident’s pain management needs.
Failure to Provide Timely Pain Management, Nutrition, and Injury Assessment
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive care plan, and resident choices for two residents. One resident, who had recently undergone digestive system surgery and had multiple complex diagnoses including sepsis, diabetes, and ulcerative colitis, was not provided with post-surgical pain medication for more than 48 hours after admission. Additionally, this resident did not receive enteral feeding or hydration for over 19 hours after admission, despite orders for continuous tube feeding and water flushes. The resident also did not receive appropriate colostomy/ileostomy care, resulting in fecal leakage and skin breakdown, and was ultimately transferred to an acute care hospital with a rash around the stoma. Documentation was lacking regarding the administration of pain medication and enteral feeding, and there was no evidence of timely reconciliation or implementation of physician orders. Another resident was not provided with proper care and assessment to identify an injury of unknown origin, which resulted in a large bruise across her chest and breasts. The injury was not promptly identified or reported by staff, and skin assessments failed to document the presence of new bruising. Interviews revealed inconsistencies in staff recollection of events and a lack of thorough skin assessments, with some staff only assessing visible areas and not the entire body. The resident's representative and hospice staff provided photographic evidence of extensive bruising, which was not documented in the facility's records. There was also confusion among staff regarding the use of mechanical lifts and the circumstances surrounding the injury. The facility's documentation practices did not reflect the care and treatment provided, and there were discrepancies in medication administration records and narcotic counts. Staff interviews indicated a lack of awareness and communication regarding the residents' conditions and care needs. The failures in care and documentation placed residents at risk for harm, including starvation, uncontrolled pain, and unidentified injuries.
Failure to Notify Nurse of Critically Low Blood Pressure Leads to Resident Death
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to notify a licensed vocational nurse (LVN) of a resident's significantly low blood pressure readings, which were far below the resident's baseline. The resident, an elderly female with a complex medical history including acute respiratory failure, hypertension, pneumonia, asthma, respiratory failure, and COPD, had a blood pressure reading of 86/54 and later 75/41. Despite holding the resident's blood pressure medication due to the low readings, the MA did not inform the LVN of these critical changes. The resident's care plan and physician orders required close monitoring of vital signs and immediate notification to the nurse practitioner (NP) or physician if there were significant changes, such as hypotension or symptoms like lethargy or confusion. The NP had specifically ordered that any change in blood pressure or symptoms should prompt sending the resident to the emergency room. However, the lack of communication from the MA to the LVN meant that the NP was not notified, and the resident did not receive timely medical intervention. As a result of this failure to follow professional standards of practice and the resident's care plan, the resident was eventually found unresponsive and was sent to the emergency room, where she was diagnosed with sepsis and hypotension. The resident died two days later in the hospital. Interviews with facility staff confirmed that the MA did not report the low blood pressure readings to the LVN, and the LVN stated she would have taken further action had she been informed.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide necessary nail care to a resident who was unable to perform activities of daily living independently. The resident, a female with chronic venous hypertension, muscle wasting, and dyspnea, was admitted to the facility with a vascular wound on her right shin and was dependent on personal hygiene assistance. Observations revealed that the resident's toenails were long, jagged, and sharp, indicating a lack of proper nail care. The care plan for the resident did not include documentation regarding nail care maintenance or any refusal of care for toenail care. Interviews with the Director of Nursing (DON) and the Administrator highlighted that nail trimming was expected to be performed by CNAs during showers, except for diabetic residents. The DON emphasized the importance of nail care to prevent skin tears and infections, while the Administrator acknowledged that nail care should be part of the care plan and documented if refused by the resident. However, the facility did not have a specific policy for activities of daily living, which contributed to the oversight in providing adequate nail care for the resident.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. In the reach-in freezer, two bags of frozen breaded chicken patties and a bag of frozen pineapple slices were found with expired dates. Additionally, a bag of frozen French fries was punctured, exposing its contents to open air. A container of corn flakes was also improperly labeled with an open date and use-by date. These observations were confirmed through interviews with the Dietary Manager (DM) and the Director of Nutrition (DTN), who acknowledged the labeling errors and the presence of expired items. Interviews with the DM and DTN revealed that the facility's expectations were not met regarding the labeling and storage of food items. The DM admitted that mislabeled or expired items should be discarded to prevent potential illness. The DTN emphasized that all items should be labeled with a received date, prepared date, and use-by date, and that no expired items should be present in storage. Both the DM and DTN recognized the risk of foodborne illness and contamination due to improper labeling and storage practices. The facility's policies on food storage and receiving, as well as the FDA Food Code, were reviewed and highlighted the need for proper labeling, dating, and storage to prevent cross-contamination and ensure food safety. The policies require that all food items be stored in a manner that ensures timely utilization based on the first-in-first-out (FIFO) inventory management principle. The failure to comply with these standards could lead to the serving of expired or contaminated food, posing a risk to resident health.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during meal assistance, which compromised the resident's quality of life. The resident, a female with fractures in both arms, was unable to feed herself and relied entirely on staff for assistance. During a lunch service, an RN was observed standing over the resident and leaning against her wheelchair while feeding her, which was acknowledged as a dignity issue by the RN. The RN left the resident after a few minutes without completing the meal assistance, leaving the resident's food to become cold. Approximately ten minutes later, a CNA noticed the cold meal and arranged for a warm meal to be provided. The CNA then assisted the resident by sitting at eye level, which was in line with the facility's expectations for maintaining resident dignity. The resident expressed that having someone stand over her while feeding did not make her feel good and noted that delays in receiving meal assistance had been a common occurrence since her admission. Interviews with the DON and ADM confirmed that staff are expected to sit with residents and provide undivided attention during meal assistance to uphold dignity. The facility's policy and the Texas Health and Human Services guidelines emphasize the right of residents to be treated with dignity and respect, which was not upheld in this instance.
Failure to Provide Accessible Call Light System
Penalty
Summary
The facility failed to provide a reasonable accommodation for a resident, identified as Resident #143, by not equipping her with a device to call for staff assistance. The resident, who had been admitted to the facility with multiple fractures and osteoporosis, was observed in her room unable to reach her call light, which was on the floor. This left her unable to call for help due to her limited arm mobility from her fractures. The resident expressed feeling vulnerable and unable to perform tasks for herself, such as adjusting her arms or getting water, highlighting her dependency on staff for assistance. During an interview and observation, it was noted that the call light was a specialized pad that required gentle pressure to activate, but it was not within the resident's reach. A CNA later entered the room, addressed the resident's concerns, and repositioned the call light to be accessible by clipping it to the resident's shirt. The CNA acknowledged that the call light should have been within reach at all times and that the resident was fully dependent on staff for her needs. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed the expectation that call lights should be within reach and answered promptly. However, the facility lacked a formal call light policy, relying instead on an in-service training sheet outlining the requirements for call light systems. The deficiency in providing an accessible call light system could potentially lead to negative outcomes, such as falls, as the resident might attempt to reach the call light without assistance.
Failure to Reflect DNR Status in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which did not reflect the resident's Advance Directive status of Do Not Resuscitate (DNR). This deficiency was identified during a review of the resident's care plan, which was dated 10/18/2024, and did not include the DNR status despite the physician's order dated 10/17/2024 indicating the resident's DNR status. The resident, an elderly female with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), had a moderate cognitive impairment as reflected by a BIMS score of 10 on the Initial MDS assessment dated 10/08/2024. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the care plan should have included the resident's code status to ensure appropriate care. The DON acknowledged responsibility for completing MDS and care plan assessments following the resignation of the MDS Coordinator. Both the DON and ADM recognized that an inaccurate care plan could result in the resident not receiving proper care. The facility's policy and the Long-Term Care Facility Resident Assessment Instrument (RAI) manual emphasize the importance of a comprehensive care plan that includes measurable objectives and timeframes to meet the resident's needs.
Failure to Implement Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. This deficiency was identified during a review of the resident's records, which showed that no Minimum Data Set (MDS) was completed and no baseline care plan was created. The resident, a male with multiple diagnoses including irritant contact dermatitis, diabetes, depression, chronic obstructive pulmonary disease, bipolar disorder, and chronic thromboembolic pulmonary hypertension, was admitted and later discharged without a baseline care plan in place. Interviews with the Director of Nursing (DON), Administrator (ADM), and MDS Coordinator revealed that the lack of a baseline care plan was due to a computer error and a failure to complete an initial evaluation upon the resident's admission. The DON acknowledged the importance of a baseline care plan for identifying resident needs and guiding staff in providing appropriate care. The ADM and MDS Coordinator also recognized the significance of a care plan in ensuring that the resident receives necessary treatments and interventions. The facility's policy mandates the creation of a baseline care plan within 24 hours of admission, but this was not followed, leading to a gap in the resident's care. The absence of a baseline care plan could result in unmet needs and potential harm to the resident, as critical interventions and safety measures may be overlooked.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lampasas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caraday Of Lampasas | 0.8 mi | ★★★★★ | 6 | 0 |
| Lily Springs Rehabilitation And Healthcare Center | 1.4 mi | ★★★★★ | 5 | 0 |
| Copperas Cove Nursing & Rehabilitation | 17.1 mi | ★★★★★ | 12 | 0 |
| Hill Country Heights | 17.8 mi | ★★★★★ | 7 | 0 |
| Avir At Burnet | 21.9 mi | ★★★★★ | 5 | 0 |
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