Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of Haltom during CMS and state inspections, most recent first.
Surveyors found that the facility failed to develop and implement comprehensive, person-centered care plans that incorporated ordered respiratory treatments and equipment care for three residents. One resident with obstructive sleep apnea had MD orders detailing BIPAP settings and cleaning, but the care plan only addressed assistance with applying and removing the mask and did not include BIPAP use, storage, or cleaning, and the mask and hose were observed with a greasy, cloudy film on the nightstand. A second resident with COPD and multiple fractures had MD orders for continuous oxygen and scheduled changes and labeling of oxygen tubing and humidifier bottles, but the care plan did not address tubing change frequency or labeling, and the resident was observed wearing an undated nasal cannula. A third resident with obstructive sleep apnea and asthma had MD orders for BIPAP and respiratory monitoring, yet the care plan only addressed hypertension and omitted BIPAP use, storage, and cleaning. The DON and Administrator acknowledged responsibilities for care plan accuracy but did not explain why these respiratory treatments and tasks were not reflected in the care plans, despite a facility policy requiring timely, interdisciplinary, person-centered care plan updates.
The facility failed to follow physician orders, care plans, and internal policy for cleaning, storing, changing, and labeling respiratory equipment for three residents requiring BIPAP and oxygen therapy. One resident’s BIPAP mask for sleep apnea was left unbagged on a nightstand with visible greasy buildup after staff removed it, contrary to expectations for cleaning and storage. Another resident on continuous oxygen via nasal cannula had oxygen tubing and a humidifier bottle that were not changed or dated as ordered, and the resident reported the tubing had not been changed since admission. A third resident using BIPAP for sleep apnea had a mask stored unbagged in a drawer with visible oil and moisture buildup, and her care plan did not address BIPAP use, cleaning, or storage, despite staff and DON stating that masks should be cleaned and bagged and oxygen equipment changed and dated at least weekly and as needed.
An LVN observed a male resident with a history of wandering and visual impairment in the bed area of a female roommate during night rounds, after which the roommate loudly alleged that her roommate had been molested. The alleged victim, an older female with multiple comorbidities and moderately impaired cognition requiring extensive ADL assistance, was found asleep with undisturbed covers, and the LVN performed only a general visual check without a full head-to-toe assessment. Despite being trained on abuse reporting and facility policy requiring immediate notification of suspected abuse, the LVN did not report the allegation to the Administrator or DON during the night and instead only noted it on a pad, believing abuse had not occurred. The Administrator did not learn of the allegation until late the following morning when the roommate reported it directly, resulting in a failure to report the alleged abuse within the required two-hour timeframe.
Incomplete Enteral Feeding Orders and MAR Documentation: A resident with a PEG tube, severe cognitive impairment, diabetes, malnutrition, and dysphagia received continuous Glucerna 1.5 feedings, but the MAR did not document any scheduled down time and the physician orders did not include the 2-hour daily interruption that staff were using. RN and leadership staff acknowledged the resident was disconnected from the pump each morning, yet the order details were not reflected in the charting.
Expired Zinc Left in Medication Cart: Surveyors found one bottle of zinc 50 mg with an expired date still stored in the Hall B med cart. MA A confirmed it had expired and said she had checked the cart but missed it. The ADON and DON stated staff were expected to review med carts daily for expired meds, and the facility policy required expired meds to be separated until destroyed or returned.
Missing Hospice Order and Coordination of Care: A resident receiving hospice services had no physician order for hospice in the chart, even though the MDS noted hospice care and the care plan referenced a terminal prognosis and coordination with the hospice team. An LVN and the DON both stated the order should have been present so staff would be aware of the resident’s hospice status and communicate with the hospice agency; the DON also noted the missing order could affect palliative care.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities, as required by regulations.
A resident with intact cognition and multiple diagnoses reported that a CNA asked for and received money, leading to an incomplete investigation by the facility. The facility did not document interviews with other staff or residents, nor did it provide evidence of a thorough investigation as required by policy.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Observations and record reviews showed lapses in assessment, monitoring, and intervention for pressure ulcer management.
Two residents with cognitive impairment and existing pressure ulcers were not consistently provided with pressure-relieving devices or repositioned as required by their care plans and facility policy. Observations showed both residents lying on their backs without support, despite orders and staff knowledge that repositioning and use of wedges were necessary to prevent further skin breakdown.
Two residents requiring enhanced barrier precautions due to wounds and skin breakdown did not have appropriate signage or PPE available in or outside their rooms. Staff were observed preparing to provide care without PPE until prompted, and interviews revealed inconsistent maintenance of infection control measures following room changes, despite active orders and facility policy.
A resident with severe cognitive impairment and left-sided paralysis was found by a family member to have significant bruising on the forearm, which was reported to the DON and an RN. Despite facility policy requiring immediate reporting of injuries of unknown origin, the injury was not documented or reported to the administrator or state authorities as required. Staff attributed the injury to combative behavior, and no timely investigation or notification occurred, resulting in a failure to follow abuse and neglect policies.
A resident with severe cognitive impairment and left-sided paralysis was found with a significant bruise of unknown origin on the left forearm. The family reported the injury to the DON and an RN, but the incident was not reported to the state or the administrator as required by policy. Staff interviews indicated uncertainty about the cause, and the DON determined the injury was not suspicious for abuse, so no report was made. The facility failed to follow required procedures for reporting alleged violations, including injuries of unknown source.
Two residents did not receive adequate supervision or proper assistive device use to prevent accidents. One resident with severe cognitive impairment and a history of falls was left unattended after requesting to be put to bed, resulting in an unwitnessed fall and injury. In another case, a resident with hemiplegia and total dependence for transfers was moved using a mechanical lift by only one staff member on two occasions, contrary to policy requiring two staff for such transfers.
A resident with severe cognitive impairment and left-sided paralysis developed a significant bruise on the left forearm, which was reported by a family member to the DON and an RN. Despite this, there was no documentation in the EHR, no progress notes, and no assessment of the bruise, even though x-rays were ordered. Staff interviews confirmed that required documentation and incident reporting were not completed, contrary to facility policy.
A facility failed to provide appropriate post-dialysis care for a resident with end-stage renal disease, as evidenced by missing documentation of vital signs and incomplete dialysis communication forms. Despite staff awareness and training, the necessary monitoring and documentation were not consistently performed, potentially placing the resident at risk of complications.
The facility failed to ensure proper pharmaceutical services, with deficiencies in medication management across multiple carts and storage areas. Insulin pens on two medication carts were not labeled with opening dates, and expired medications were found on two other carts. Additionally, a discrepancy in the reconciliation of a resident's morphine solution was discovered, with the narcotic log showing more than what was actually present. These oversights were acknowledged by the staff responsible for medication management.
A resident's privacy was compromised during IV medication administration when RN A failed to close the door or pull the privacy curtain, leaving the resident exposed. The resident was cognitively intact and receiving treatment for a skin infection. RN A admitted to forgetting to provide privacy due to nervousness, and the DON confirmed the expectation for staff to ensure privacy during care.
A facility failed to label IV medication bags with the date, time, and nurse's initials, risking medication errors for a resident. Despite training, staff oversight led to unlabeled bags, as confirmed by observations and interviews with nursing staff and the DON.
A facility failed to maintain infection control when a CNA entered a COVID-positive resident's room without wearing an N95 mask or eye protection, despite clear signage and available PPE. The resident, with severe cognitive impairment, was under contact and droplet precautions. Interviews with staff confirmed the expectation for PPE compliance, and the CNA had missed recent infection control training.
A resident's DNR order was found invalid due to improper dating, with mismatched signature dates between the resident and the physician. This discrepancy led to conflicting code status information in the resident's care plan and face sheet, potentially risking the resident's end-of-life wishes. The Social Worker and MDS Coordinator acknowledged the issue, and the DON confirmed the invalidity of the document.
Failure to Integrate Respiratory Treatments and Equipment Care Into Comprehensive Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for residents receiving respiratory treatments and equipment. For three residents reviewed, the care plans did not fully address their respiratory therapy needs as reflected in physician orders and actual use of equipment. The facility’s own policy required timely, person-centered comprehensive care plans that are reviewed and revised by an interdisciplinary team when resident conditions or treatments change. For one resident with obstructive sleep apnea and a BIMS score indicating moderate cognitive impairment, the MDS documented respiratory therapy and active diagnoses including obstructive sleep apnea. The care plan noted altered respiratory status related to sleep apnea and included a goal that the resident would have no signs or symptoms of poor oxygen absorption, with an intervention to assist with putting on and taking off the BIPAP mask at bedtime and in the morning. However, the care plan did not address BIPAP use, storage, or cleaning, despite MD orders specifying BIPAP settings, use while sleeping or napping, and detailed cleaning instructions for the mask and reservoir. During observation, the resident’s BIPAP mask and hose were seen on the nightstand with a small greasy and cloudy film from daily facial use, and the resident stated staff had removed the mask that morning. For a second resident with COPD, multiple fractures, and a BIMS score indicating moderate cognitive impairment, the MDS and MD orders documented continuous oxygen via nasal cannula and specific orders to change oxygen tubing, nebulizer circuit, and humidifier bottle on a set schedule, with labeling when changed and as needed when soiled. The admission care plan addressed COPD with respiratory failure, included a goal for optimal breathing patterns, and listed interventions such as elevating the head of bed and monitoring for signs and symptoms of respiratory infection and acute respiratory insufficiency, as well as documenting oxygen settings. The care plan did not address the frequency of oxygen tubing changes or labeling, even though MD orders required these tasks. During observation, the resident was seen in bed wearing an undated nasal cannula and denied concerns with the oxygen machines. For a third resident with intact cognition, obstructive sleep apnea, and asthma, the MDS documented use of a wheelchair and walker and dependence on staff for several ADLs. The care plan addressed hypertension, including administration of antihypertensive medications, monitoring for side effects, and obtaining blood pressure readings prior to medication administration. Section O of the MDS reflected special treatments and procedures, and MD orders included monitoring for shortness of breath when lying flat, PRN nebulized albuterol for shortness of breath and wheezing, and an order for BIPAP with specified settings to be applied upon availability. The resident’s care plan did not address BIPAP use, storage, or cleaning. In interviews, the DON stated clinical staff were responsible for updating care plans and that the EMR provided prompts, and acknowledged that residents were receiving respiratory treatments per MD orders but did not explain why these treatments were not reflected in the care plans. The Administrator stated the DON was responsible for monitoring and ensuring resident care tasks were addressed and accurate, and that care plans address residents’ individual medical needs and treatments, but did not provide additional information regarding the non-compliance with care plans. The facility’s written policy on comprehensive care plans and revision, dated and reviewed as noted in the record, stated that the facility would ensure timeliness of each resident’s person-centered comprehensive care plan and that the plan would be reviewed and revised by an interdisciplinary team knowledgeable about the resident and their needs, with resident and representative involvement. The policy further stated that the facility should monitor residents over time to identify changes that may warrant updates to the care plan, and when such changes occur, the care plan should be reviewed and updated to reflect changes in care delivery, including adding interventions, updating goals or problem statements, or adding short-term problems, goals, and interventions. Despite this policy, the care plans for the three residents did not incorporate the specific respiratory treatments, equipment care, and related tasks ordered by physicians and documented in the medical record.
Failure to Clean, Store, Change, and Label Respiratory Equipment per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care consistent with professional standards, physician orders, and care plans for multiple residents using BIPAP and oxygen therapy. For one male resident with obstructive sleep apnea who required BIPAP while sleeping or napping, the care plan and physician orders directed staff to assist with applying and removing the BIPAP mask at bedtime and in the morning, to clean the mask with warm soapy water and air dry as needed, and to clean the reservoir weekly. During observation, his BIPAP mask was found lying unbagged on his nightstand among other personal items, with a greasy substance visible on the mask. The resident reported that staff had removed the mask that morning, placed it on the nightstand, and had not cleaned or bagged it, contrary to the facility’s BIPAP/CPAP administration policy and the infection control expectations described by nursing leadership. Another resident with COPD and multiple fractures required continuous oxygen at 4 L/min via nasal cannula, with a physician order to change the oxygen tubing, nebulizer circuit, and humidifier bottle weekly on the night shift, to label them when changed, and to change and label them every 24 hours as needed when visibly soiled. The resident’s care plan addressed oxygen use and monitoring for respiratory symptoms but did not address the frequency of oxygen tubing changes or labeling. Review of the treatment administration record showed that the oxygen tubing had not been changed on several consecutive days, and during observation the resident was wearing an undated nasal cannula and had an undated oxygen water bottle. The resident stated the tubing had not been changed since admission. Documentation later showed that an LPN changed the tubing and water that same day, but at the time of the initial observation the equipment was not dated as required by the physician order and facility practice. A third resident with obstructive sleep apnea and asthma had a physician order for BIPAP use with specified settings but no orders addressing cleaning frequency or storage of the BIPAP equipment. Her care plan did not address BIPAP use, storage, or cleaning. During observation, her BIPAP mask was found in the top drawer of her nightstand with visible oil buildup, moisture, and a cloudy appearance, and it was not stored in a bag. The resident reported she did not know when the mask was last cleaned and that she used it during naps and at night. Interviews with nursing staff and the DON confirmed that standard practice and protocol required BIPAP masks to be cleaned as needed, bagged when not in use, and oxygen equipment to be changed and dated at least weekly and as needed. These observations and record reviews showed that the facility did not follow its own BIPAP/CPAP administration policy, infection control practices, and physician orders for cleaning, storing, changing, and labeling respiratory equipment for these residents.
Failure to Timely Report Alleged Sexual Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an alleged incident of abuse was reported immediately, and no later than two hours after the allegation was made. During the night shift at approximately 3:00 AM, an LVN observed a male resident in the room of two female residents. The LVN reported finding the male resident feeling around on one female resident’s bed as if trying to find his way back to bed, with the bathroom light on. This male resident had a history of wandering and visual impairment, and had previously wandered into other residents’ rooms. As the LVN and an aide escorted the male resident back to his room, the roommate followed and yelled that her roommate had been molested. The female resident who was the alleged victim was described in her records as an older adult with multiple medical conditions, including hypertension, acute embolism and thrombosis, acute respiratory failure, dysphasia, and reduced mobility. Her care plan reflected a BIMS score indicating moderately impaired cognition and a need for maximal assistance with most ADLs. When the LVN checked on her after the allegation, the resident was sound asleep with covers pulled up to her neck and undisturbed. The LVN did not complete a head-to-toe assessment at that time and only performed a general visual inspection, despite being aware of the allegation made by the roommate. The roommate, who also had moderately impaired cognition but required only setup or clean-up assistance with most ADLs, reported that the male resident had molested her roommate and later demonstrated to the Administrator that the male resident had been rubbing the alleged victim’s thigh and waist area. The LVN acknowledged that she had been trained on abuse and neglect reporting at the facility and knew the protocol, including the requirement to report allegations immediately. However, she did not notify the Administrator or DON of the allegation during the night shift and stated that it slipped her mind due to the busy shift and because she did not personally believe abuse had occurred based on her observations. She wrote the incident on a notepad but did not escalate it. The Administrator first learned of the allegation from the roommate around 11:00 AM, several hours after the alleged incident and the roommate’s initial statement to staff. The facility’s abuse policies required staff to report any suspected abuse to the Executive Director or DON and required covered individuals to immediately notify the Executive Director once they formed a reasonable suspicion that a crime had been committed, with subsequent reporting to law enforcement and the state survey agency within prescribed timeframes. The delay in reporting by the LVN, despite her training and the facility’s written policies, led to the cited deficiency for failure to report an alleged violation involving abuse within the required timeframe.
Incomplete Enteral Feeding Orders and MAR Documentation
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition had complete physician orders and MAR documentation for the resident’s tube feeding schedule. Resident #13 was a severely cognitively impaired female with diagnoses including diabetes mellitus, malnutrition, and dysphagia, and she received nutrition through a PEG tube. Her care plan identified the need for tube feeding and monitoring for complications, and physician orders directed continuous Glucerna 1.5 tube feeding at 55 mL/hour for 22 hours with water flushes every 4 hours, along with head-of-bed elevation and tube site care. Record review of the January 2026 MAR did not show any down time for the tube feedings. However, observations on 01/13/26, 01/14/26, and 01/15/26 from 10:00 AM to 12:00 PM showed the resident disconnected from the feeding pump, meaning the formula was not infusing during those periods. RN C stated the resident was disconnected at 10:00 AM and reconnected at 12:00 PM to give her a break from the machine and to aid digestion, but she could not locate an order documenting the 2-hour interruption or whether that time was intended for therapy or incontinent care. The ADON stated she knew the resident was disconnected for 2 hours each morning but did not see an order specifying the down time, and she said the MAR should alert staff to do so. The DON stated nurses were expected to record orders as they came in and follow them, and if orders did not indicate a down time, staff should contact the physician to complete the order. The facility’s enteral nutrition policy stated continuous enteral nutrition must be provided in accordance with physician orders and professional standards of practice.
Expired Zinc Left in Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs when one bottle of zinc 50 mg with an expiration date of 11/2025 remained in the Hall B medication cart. During observation of the Hall B MA cart, surveyors found the expired zinc still stored with active medications. MA A confirmed the zinc had expired in November 2025 and stated she had checked her cart for expired medications the previous week but did not see it. She also stated it was her medication cart and acknowledged the expired medication should have been removed. Interviews with the Facility Physician, ADON, and DON showed that staff expected medication carts to be reviewed regularly for expired medications, with the ADON stating nurses and medication aides should review carts daily and the DON stating staff should review all carts daily. The facility policy required expired medications to be stored separately until destroyed or returned to the pharmacy or supplier, and required regular inspection of nursing station storage areas for compliance. The ADON stated she had checked the cart last week but missed the expired zinc, and the DON stated the nursing team was responsible for ensuring there were no expired medications on the carts.
Missing Hospice Order and Coordination of Care
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services, and it failed to obtain the resident’s physician order for hospice services. Resident #13’s admission MDS, dated 10/30/25, identified her as an [AGE]-year-old female admitted on [DATE] with a BIMS score of 14, active diagnoses of Alzheimer’s Disease and malnutrition, and noted that she received hospice care while a resident. However, the physician’s orders reviewed on 01/14/26 did not include an order for hospice services. The resident’s care plan, revised 01/06/26, included a focus that she had a terminal prognosis and an intervention to work cooperatively with the hospice team to provide spiritual, emotional, intellectual, physical, and social needs. During observation and attempted interviews on 01/13/26 and 01/15/26, the resident was asleep in bed and did not rouse when spoken to and asked questions. An LVN stated the resident should have an order in the chart for hospice services and that the admitting nurse should have included it. The DON stated the resident should have had an order to be admitted to hospice in the chart, that the order was needed so staff would be aware she was receiving hospice services and could communicate with the hospice agency, and that the missing order could potentially cause an issue with her palliative care. The facility’s Hospice Coordination of Care policy stated the facility must ensure each resident’s written plan of care includes the most recent hospice plan of care and a description of services furnished by the LTC facility.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt notification and communication regarding an incident that required reporting, as well as the absence of documented follow-up with the appropriate external agencies. The report specifically notes the failure to meet regulatory requirements for reporting and investigation communication, but does not provide further details about the individuals involved or the nature of the incident.
Failure to Thoroughly Investigate Allegation of Exploitation
Penalty
Summary
The facility failed to provide evidence that all alleged violations related to abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident. Specifically, a certified nursing assistant (CNA) admitted to asking a resident, who had intact cognition and diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression, for $0.50 to buy a soda. The resident reported feeling compelled to give the money and subsequently informed the Administrator. The investigation conducted by the facility was limited to interviews with the resident and the CNA involved, with the CNA admitting to the request and receipt of money. There was no documentation of broader staff education or interviews, nor were other residents interviewed at the time of the incident. The facility's investigation report lacked evidence of comprehensive investigative steps, such as staff and resident interviews beyond those directly involved. The facility's policy required prompt and thorough investigation of all allegations of abuse, neglect, exploitation, or misappropriation, but the documentation did not demonstrate that these procedures were fully followed in this case.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in pressure ulcer management and prevention protocols. The report notes that the facility did not ensure consistent assessment, monitoring, or intervention for residents at risk for or with existing pressure ulcers.
Failure to Provide Pressure Relieving Devices and Repositioning for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that two residents at risk for pressure ulcers received care consistent with professional standards of practice to prevent the development and worsening of pressure ulcers. Both residents had significant medical histories, including cognitive impairment, immobility, and existing pressure ulcers upon admission. Despite care plans indicating the need for frequent repositioning and the use of pressure-relieving devices, observations revealed that both residents were found lying on their backs without any support or wedges in place, while the wedges intended for their use were observed on their dressers instead of being utilized. For one resident, documentation showed a history of non-compliance with offloading and repositioning, but education was provided and the resident verbalized understanding. The resident's care plan included frequent repositioning and the use of pressure-relieving devices, yet on observation, the resident was not positioned as required. The wound report indicated deterioration of a sacral ulcer, and the care plan emphasized the need for interventions to maintain skin integrity. Staff interviews confirmed that repositioning and the use of wedges were expected practices, but these were not consistently implemented. The second resident, who had multiple stage 2 and stage 4 pressure ulcers and severe cognitive impairment, was also observed lying on her back without support. Her care plan and medical orders required repositioning every two hours and the use of pressure-reducing devices. Staff interviews revealed that repositioning was sometimes delayed or omitted, particularly after bathing or in anticipation of wound care. The facility's policy required repositioning and the use of positioning devices to prevent pressure injuries, but these measures were not consistently followed, as evidenced by the observations and staff statements.
Failure to Maintain Enhanced Barrier Precautions and PPE Availability
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents who required enhanced barrier precautions due to wounds and skin breakdown. For one resident with multiple pressure ulcers, including stage 2 and stage 4 wounds, there was no enhanced barrier precaution signage or personal protective equipment (PPE) available outside or inside the resident's room following a room transfer. Staff were observed preparing to provide care without donning appropriate PPE until reminded by the wound care nurse, after which the necessary equipment was retrieved and signage was eventually posted. Another resident, who had a history of diabetes, neuropathy, limb amputations, and end-stage renal disease, also required enhanced barrier precautions for a skin opening and monitoring of a shunt/fistula site. However, PPE was not available inside or outside this resident's room as required by facility policy and physician orders. Interviews with staff and the infection preventionist revealed that the signage and PPE were not consistently maintained, particularly after room changes, and that there was confusion or lack of clarity regarding responsibility for ensuring these measures were in place. Record reviews confirmed that both residents had active orders for enhanced barrier precautions and that facility policy required PPE and signage for residents with wounds or indwelling devices. Despite in-service training and established policies, the facility did not consistently provide the necessary supplies or visual cues to support infection control practices, as evidenced by direct observations and staff interviews.
Failure to Implement Abuse and Neglect Reporting Policies
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, specifically in the case of one resident with severe cognitive impairment and left-sided paralysis following a stroke. The resident, who required moderate assistance for mobility and had a care plan for regular repositioning and ambulation, was found by a family member to have significant bruising on his left forearm. The family member reported the injury to the DON and an RN, but there was no documentation of progress notes or assessments on the day the bruise was discovered. Despite the facility's policy requiring immediate reporting of injuries of unknown origin to the administrator and state authorities, the injury was not reported as required. Interviews revealed that the DON and nursing staff were notified of the bruise but did not consider it suspicious for abuse, attributing it to the resident's combative behavior during showers. The administrator was not made aware of the injury until much later and only found an email about the incident days after it occurred. The DON and administrator both stated that the injury did not meet the criteria for reporting, and no investigation or timely notification to authorities was completed as outlined in facility policy. The lack of timely assessment, documentation, and reporting of the injury of unknown origin, as well as the failure to follow established abuse and neglect policies, constituted a deficiency. The facility's inaction in this case could have resulted in unaddressed abuse or neglect, as the required procedures for investigation and reporting were not followed for the resident with significant physical and cognitive limitations.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation was made, as required. Specifically, a resident with severe cognitive impairment and left-sided paralysis was found to have a significant bruise of unknown origin on his left forearm. The bruise was first noticed by a family member, who reported it to the DON and an RN, and followed up with an email, but did not receive a response. The family member also provided a photograph of the bruise, which was described as dark red/purple and extended from the mid-forearm to the elbow. Interviews with staff revealed that the nurse assigned to the resident could not recall the details of the incident, and the RN obtained an x-ray after being notified, which showed no acute fractures. The DON stated that after interviewing staff, it was determined the resident had been combative during showers and could move his left arm, suggesting the bruise may have resulted from this behavior. The DON did not consider the bruise suspicious for abuse and did not report it to the state, believing it did not meet the criteria for reporting. The Administrator confirmed he was not notified of the bruise until much later and, after reviewing the situation, agreed with the DON's assessment that it was not an injury of unknown origin requiring state notification. A review of the facility's policy indicated that all alleged violations, including injuries of unknown source, must be reported immediately to the administrator and appropriate authorities. However, there was no documentation of progress notes or assessments for the resident on the date the bruise was discovered, and the required reporting procedures were not followed. This failure to report the incident as required by policy and regulation constituted the deficiency.
Failure to Provide Adequate Supervision and Safe Transfer Practices
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for two residents. In the first case, a female resident with severe cognitive impairment, a history of falls, and multiple comorbidities including dementia, muscle weakness, and chronic kidney disease, requested to be put to bed. The assigned CNA acknowledged the request but left the room to obtain a mechanical lift and assistance. Due to a miscommunication regarding staff assignments, the resident was left unattended for an extended period. The resident attempted to self-transfer from her wheelchair to the bed, resulting in an unwitnessed fall. She was later found on the floor with a hematoma and two small lacerations on her head and was subsequently transferred to the hospital for evaluation. Interviews with staff revealed confusion over which CNA was responsible for the resident at the time of the incident. The CNA initially assigned to the resident believed she had been reassigned, while the other CNA was unaware of the resident's request to be put to bed. Neither CNA ensured the resident's request was fulfilled or communicated the need for assistance, leading to the resident being left unsupervised. Video footage and interviews confirmed the resident remained on the floor for approximately 23 minutes before staff responded. In the second case, a male resident with severe cognitive impairment, left-sided weakness following a stroke, and total dependence for transfers was transferred using a mechanical lift by a single CNA on two separate occasions. Facility policy and the resident's care plan required two staff members for mechanical lift transfers. Video footage confirmed that both a regular CNA and an agency CNA performed single-person mechanical lift transfers. Interviews with staff and the DON confirmed that this practice was not in accordance with facility policy and posed a safety risk to the resident.
Failure to Document Bruise and Incident in Resident's Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when a significant bruise was discovered on the resident's left forearm. The bruise was first noticed by a family member, who reported it to the DON and an RN. Despite this notification, there was no documentation in the resident's electronic health record (EHR) regarding the bruise, no progress notes, and no assessment completed on the date the bruise was identified. The family member also followed up with an email to the DON, but did not receive a response, and a photograph of the bruise was taken the following day. The resident involved was a male with a history of muscle weakness, dysphagia, osteoarthritis, vascular dementia, and hemiplegia following a stroke, resulting in severe cognitive impairment and left-sided paralysis. The care plan indicated the need for regular repositioning and ambulation assistance. Despite these vulnerabilities, the clinical record did not reflect the presence of the bruise, the incident, or any related assessments or notifications, even though x-rays were ordered and completed, showing no acute fractures or dislocations. Interviews with staff confirmed that the nurse assigned to the resident failed to document the bruise, complete an incident report, or record notifications to the family and physician. The DON acknowledged that her expectations for documentation were not met, and the administrator confirmed that there was no documentation regarding the bruise in the resident's chart. The facility's own policy required documentation of any change in condition, including skin injuries, but this was not followed in this instance.
Failure to Ensure Post-Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate post-dialysis care, consistent with professional standards and the resident's care plan. The resident, a male with end-stage renal disease and severely impaired cognition, was admitted to the facility and required hemodialysis. The care plan specified that the resident should have no signs of complications from dialysis, and the facility was responsible for sending and obtaining completed dialysis communication sheets from the dialysis center. The facility did not complete post-dialysis assessments for the resident, as evidenced by missing documentation of post-dialysis vital signs and incomplete dialysis communication forms. The resident's electronic health records lacked nursing documentation regarding post-dialysis vital signs, and several dialysis communication forms were missing for multiple dates across August, September, and October. Interviews with staff revealed that they were aware of the requirement to complete these forms and monitor the resident's dialysis access site, but the forms were not consistently filled out or collected. The Director of Nursing and other staff acknowledged the importance of these forms for monitoring vital signs and ensuring communication between the dialysis center and the facility. Despite training sessions conducted on the dialysis communication form, the facility failed to ensure that the necessary post-dialysis monitoring and documentation were consistently performed, potentially placing the resident at risk of complications such as low blood pressure, infection, and bleeding.
Deficiencies in Medication Management and Reconciliation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by several deficiencies in medication management across multiple medication carts and storage areas. Specifically, insulin pens on Hall E and Hall F medication carts were found to be opened and used without being labeled with opening dates. This oversight was acknowledged by RN N, who admitted that it was the responsibility of all nurses to date insulin upon opening to ensure its efficacy within the 28-day usage period. LVN K also confirmed that it was her duty to check the medication carts for proper labeling, but she had not done so since the previous day. Additionally, expired medications were discovered on the Hall A and Hall D medication carts, including calcium, sodium carbonate, and nitroglycerin, all past their expiration dates. LVN D admitted to not checking the carts for expired medications, which was part of her responsibilities. RN H, who was also responsible for checking these carts, acknowledged missing the expired medications during her last check. The Director of Nursing (DON) confirmed that it was her responsibility to oversee the removal of expired medications and that her managers were delegated to check the carts, but the last check was not thorough enough. Furthermore, a discrepancy was found in the reconciliation of a resident's morphine solution after the resident's death. The narcotic log indicated 20 ml remaining, while the actual bottle contained only 18 ml. The DON admitted to not verifying the narcotic count upon receiving it for destruction, relying instead on the nurse manager's signature. RN H, who cleared the carts of narcotics, also failed to confirm the count accurately. This discrepancy was reported to the police, and the facility began an investigation into the matter.
Failure to Ensure Resident Privacy During IV Medication Administration
Penalty
Summary
The facility failed to respect a resident's right to personal privacy during medical treatment. Specifically, RN A did not provide full privacy for a resident during intravenous medication administration. The resident, a cognitively intact male with a BIMS score of 15, was receiving IV medications related to a skin infection in the groin area. During the procedure, RN A did not close the door or pull the privacy curtain, leaving the resident exposed to anyone passing by. RN A acknowledged her failure to provide privacy, attributing it to nervousness due to the presence of surveyors. The Director of Nursing (DON) confirmed that staff are expected to ensure privacy by closing doors, blinds, and curtains, and covering residents during care. The facility's Resident Rights policy emphasizes the right to personal privacy, which includes medical treatment and personal care, although it does not require a private room for each resident.
Failure to Label IV Medication Bags
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, as observed during a survey. Specifically, the IV medication bags for a resident were not labeled with the date, time, and initials of the administering nurse, which is a requirement to ensure proper medication administration. This oversight was noted during multiple observations, where the resident's IV bags were found unlabeled, potentially leading to medication errors such as missed doses or overdoses. Interviews with nursing staff revealed that the failure to label the IV bags was due to oversight and time constraints, despite the staff being aware of the labeling requirements. The Director of Nursing (DON) confirmed that staff were expected to label IV bags and tubing to prevent medication errors and infections. The facility had conducted training on IV administration, emphasizing the importance of labeling, but the practice was not consistently followed, as evidenced by the observations and staff interviews.
Infection Control Breach Due to PPE Non-Compliance
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of CNA E, who did not adhere to the required personal protective equipment (PPE) protocols when entering the room of a COVID-positive resident. On the observed date, CNA E entered the room of a resident who was under contact and droplet precautions without wearing an N95 mask or eye protection, despite the clear signage and availability of PPE outside the resident's door. This oversight occurred while CNA E was assisting with housekeeping duties, and she admitted to being unaware of the resident's isolation status. The resident in question, a female with severe cognitive impairment, was admitted to the facility with a displaced fracture and other health issues. Her care plan included enhanced barrier precautions due to surgical incisions, and she was under specific COVID-19 precautions as per physician orders. The facility had clear protocols in place, including signs indicating the necessary PPE for staff entering the room, which CNA E failed to follow. Interviews with facility staff, including the Administrator, DON, and Infection Preventionist, confirmed that the expectation was for all staff to don appropriate PPE before entering rooms of residents with COVID-19. The facility had conducted an in-service training on infection control just two days prior to the incident, which CNA E did not attend. The facility's policy on PPE usage for SARS-COV-2 was also reviewed, highlighting the requirement for respirators and eye protection when caring for COVID-19 positive residents.
Invalid DNR Order Due to Improper Dating
Penalty
Summary
The facility failed to ensure the validity of a resident's Out-of-Hospital Do Not Resuscitate (OOHDNR) order, which was not properly dated by both the resident and the physician at the time of signing. This discrepancy rendered the document invalid, potentially placing the resident at risk of having their end-of-life wishes dishonored. The resident, who was an elderly female with moderate cognitive impairment and multiple diagnoses including Non-Alzheimer's Dementia and Schizophrenia, had conflicting information regarding her code status in her care plan and face sheet. The issue was identified during a review of the resident's records, which showed that the care plan indicated a Full Code status, while the face sheet and order summary reported a DNR status. The Social Worker and MDS Coordinator both acknowledged the inconsistency and the invalidity of the DNR due to the mismatched dates of signatures. The Social Worker noted that the nurses were responsible for updating the system to reflect the resident's code status, and the failure to do so could result in the resident's choices not being honored in critical situations. The Director of Nursing (DON) and the Administrator were informed of the discrepancy, and both confirmed that the DNR was invalid because it was not signed on the same date by all parties. The DON noted that the form appeared to have been altered, with someone other than the resident possibly printing the resident's name and date. The facility's policy on advance directives emphasized the residents' right to self-determination regarding their medical care, highlighting the importance of accurate and up-to-date documentation.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 995 citations issued within 25 miles in the last 12 months — including the 42 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Richland Hills Rehabilitation And Healthcare Cente | 2.1 mi | ★★★★★ | 13 | 0 |
| Avir At Richland Hills | 2.5 mi | ★★★★★ | 6 | 0 |
| Glenview Wellness & Rehabilitation | 3.6 mi | ★★★★★ | 18 | 0 |
| Park View Care Center | 3.7 mi | ★★★★★ | 24 | 0 |
| North Pointe Nursing And Rehabilitation | 4.6 mi | ★★★★★ | 1 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.