Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
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 Magnolia Place Health Care during CMS and state inspections, most recent first.
Incomplete DNR Forms for Two Residents: The facility failed to ensure valid advance directives were completed for two residents with DNR status. One resident with severe cognitive impairment had an OOH-DNR form missing the gender designation, and another resident with dementia, HF, and kidney disease had a DNR form that did not identify whether the signature in Section B was the legal guardian, MPOA agent, or proxy. The SW and DON both confirmed the forms were incomplete.
Care plans were not revised to reflect current resident conditions for three residents with g-tubes. One resident’s g-tube, tube feedings, meds via g-tube, and EBP had been discontinued, but the care plan still listed them. Two other residents’ care plans addressed tube feeding and HOB elevation, but did not include that they put the HOB flat during feeding. Staff and the DON stated the care plans should reflect the residents’ current condition.
Incorrect Dishwasher Sanitizer Test Strips Used: Dietary staff used the wrong chlorine test strips to check the dishwasher sanitizer concentration, and the strips did not measure low enough to verify the manufacturer-required 50 ppm final-rinse level for the dish machine. Observation and record review showed staff documented sanitizer readings with the incorrect strips, and interviews confirmed the strips were intended for the 3-compartment sink rather than the dishwasher.
Bathroom toilet seat left in disrepair. A room bathroom toilet seat was observed with a complete split, peeling paint, and a hole exposing the wood frame, with brown buildup inside the damaged area on one observation. Staff interviews showed the housekeeper, maintenance supervisor, and maintenance worker were not aware of the issue through the maintenance log, and the repair was not documented in the log binder as required by facility policy.
A resident with a G-tube, dysphagia, and a history of stroke received water flushes incorrectly when an LPN pushed 60 mL through the tube with a syringe and plunger instead of allowing it to flow by gravity. The LPN said she knew the flush should have been given by gravity and was nervous, then administered the medication and remaining flush by gravity. The DON and Administrator stated nurses were responsible for proper G-tube medication administration and that staff had been educated on the procedure.
The facility did not ensure that the Administrator, DON, and IP received training on Enhanced Barrier Precautions (EBP) or implemented EBP for residents with chronic wounds or indwelling medical devices during high-contact care activities. Observations and staff interviews confirmed a lack of EBP signage, PPE setup, and staff awareness of updated requirements, resulting in noncompliance with infection control standards.
The facility did not provide required training on Enhanced Barrier Precautions (EBP) to most staff, including the Administrator, DON, ADON/IP, LVNs, and CNAs. Staff were unable to accurately describe or implement EBP during resident care, and leadership had not received or provided updated infection control training prior to surveyor intervention. This resulted in staff not following EBP protocols, such as using gowns during high-contact care for residents with medical devices.
Two residents were administered antipsychotic and antidepressant medications without completed informed consent forms, as required by facility policy. Documentation was missing key information and signatures from both the prescriber and the resident or their representative, and facility leadership was unaware of the incomplete consent process.
Multiple residents with wounds or indwelling medical devices did not have Enhanced Barrier Precautions signage or PPE available, and staff did not consistently wear gowns or follow EBP protocols during high-contact care activities. Staff interviews revealed confusion and lack of training regarding EBP, and care plans and physician orders did not include EBP instructions, resulting in repeated failures to follow infection control policies.
Two residents with mental health diagnoses did not receive accurate PASRR Level 1 screenings, resulting in errors such as unverified primary diagnoses and incorrect documentation of intended length of stay. These inaccuracies occurred despite facility policy requiring proper assessment and coordination for individuals with MI, DD, or ID.
A resident with major depressive disorder, bipolar disorder, and adjustment insomnia was prescribed Seroquel (an antipsychotic) for multiple diagnoses without a clearly documented appropriate indication. The DON was unaware of the multiple diagnoses listed for the medication, and facility policy requiring specific, documented indications for psychotropic drug use was not followed.
A resident with chronic hepatic failure and cirrhosis was found to have over-the-counter medications, including cough drops, Neosporin, and hydrocortisone cream, stored at the bedside without a physician's order, care plan, or self-administration assessment. Facility staff and the DON confirmed that policy requires orders and assessments for bedside medication storage, but these were not in place, and the medications remained accessible over several days.
The facility failed to employ a qualified dietary manager, as the acting Dietary Supervisor lacked certification. Despite efforts to hire a certified dietary manager since April, the position remained unfilled. The facility's policy required a certified dietary manager, which was not met, leading to a deficiency in the food and nutrition service.
The facility's kitchen failed to maintain sanitary conditions by not properly labeling and dating food items in refrigerators, including avocados, sippy cups, orange slices, ham, and cucumbers. The acting dietary supervisor admitted to lapses in labeling, and the administrator confirmed the expectation for proper food storage. This failure could lead to expired foods being served, risking foodborne illness.
The facility failed to comply with regulations by not employing or contracting a Social Worker (SW) as required. The Administrator confirmed the absence of a SW after the previous one quit a month ago, and they were actively searching for a replacement. The facility's policy and Texas Administrative Code require employing a SW to meet residents' needs.
The facility did not ensure that QAPI training was completed for all 17 staff members reviewed, including the Administrator, DON, and various LVNs and CNAs. Interviews revealed that the computer-based training system failed to trigger required training modules, leading to a systemic issue in the training process.
The facility did not ensure compliance and ethics training was completed for 17 staff members, including the Administrator, DON, and various LVNs and CNAs. Record reviews showed none had completed the required training, and interviews revealed a failure in the computer-based training system. The facility's policy mandates training completion as a condition of employment.
The facility failed to provide required training for contracted staff, including a dietician, PT, OT, and ST, and did not maintain training records. Interviews with HR, DON, Administrator, and ADON revealed a lack of awareness and implementation of training protocols for these staff members, despite a policy requiring compliance with training programs.
The facility failed to ensure that 11 out of 17 employees received mandatory training in effective communications, including during orientation and annually. Interviews revealed issues with the computer-based training system, which did not trigger the required trainings. This deficiency could place residents at risk of miscommunication and social isolation.
The facility failed to ensure staff completed training on resident rights and facility responsibilities during orientation and annually. Two employees did not complete the training during orientation, and three others, including the DON, did not complete it annually. A computer-based training system issue contributed to this deficiency.
The facility failed to ensure required training on Abuse, Neglect, and Exploitation (ANE) and dementia management for staff. An LVN did not complete ANE and dementia training during orientation, and the DON did not receive annual ANE training. A computer issue failed to trigger necessary trainings, potentially risking resident care.
The facility failed to ensure infection prevention and control training was completed for an LVN during orientation and for an MD annually. The DON and Administrator expected all required trainings to be completed, but a computer-based training issue prevented this. The facility's policy mandates compliance with training programs.
The facility failed to ensure CNAs completed required trainings in ANE and dementia management, with two CNAs not completing these trainings as mandated. CNA N did not complete the trainings during orientation, and CNA K did not complete them annually. The DON and Administrator expected these trainings to be completed, but a computer-based training system issue prevented the necessary alerts.
The facility did not ensure behavioral health training was completed for several staff members during orientation and annually, potentially risking resident care. Interviews revealed a computer system issue that failed to trigger required trainings, despite policy mandates.
A facility failed to accurately document a resident's use of oxygen therapy in her MDS assessment, despite her COPD diagnosis and continuous oxygen order. Staff interviews revealed the omission was an oversight, lacking a backup system for accuracy checks, potentially affecting facility revenue. The facility's policy and assessment manual require documentation of such treatments, underscoring the deficiency.
Incomplete DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure the right to formulate an advance directive was provided for 2 of 6 residents reviewed for resident rights. Resident #12 was an older male admitted with senile degeneration of the brain and had a DNR order, a care plan for DNR status, and a significant change MDS showing severe cognitive impairment with a BIMS of 7 out of 15. His OOH-DNR form contained his name, date of birth, and gender section, but the gender was not marked, and one of the witnesses on the form was the SW. During observation, he was in bed in his room and was difficult to understand when asked questions. Resident #18 was an older female admitted with dementia disease, heart failure, and kidney disease, and her record showed an advance directive of DO NOT RESUSCITATE. Her quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment. Her care plan included DNR status and interventions for no CPR in the event of death and to obtain a written DNR, and her order summary listed DNR orders. However, her DNR form did not identify whether the signature in Section B belonged to the legal guardian, agent in a medical power of attorney, or proxy in a directive. The SW stated that both DNR forms were not complete and that if a DNR form was not completed correctly with accurate dates, signatures, and checked boxes, it would be invalid. The SW said it was her responsibility to ensure DNR forms were completed accurately and acknowledged that a resident's wishes may not have been followed if the advance directive was not completed. The DON confirmed there were no additional advance directives or DNRs for either resident, verified that both current DNR forms were not completed, and stated that if the forms were incomplete staff would be required to initiate CPR, which would go against the resident's expressed wishes.
Care Plans Not Updated to Reflect Current Tube Feeding Status and HOB Interventions
Penalty
Summary
The facility failed to review and revise comprehensive care plans by the interdisciplinary team after assessments so they reflected residents’ current conditions for 3 of 6 residents reviewed. Resident #12 had physician orders showing his gastrostomy tube was discontinued, along with tube feedings, medications by g-tube, and EBP. His significant change MDS indicated he had a feeding tube while a resident and received 51% or more of total calories through the feeding tube. However, the care plan dated 04/01/26 still identified tube feedings and EBP, and during observation there was no EBP on the door and no feeding pump in the room. Resident #23 had diagnoses including gastrostomy tube and a quarterly MDS showing he had a feeding tube while a resident and received 51% or more of total calories through the feeding tube. His care plan identified g-tube feeding with interventions to keep the HOB elevated at least 30 degrees at all times, but it did not address the resident putting the HOB down flat. During observation, the resident was in bed with the HOB elevated and g-tube feeding infusing through the g-tube. Resident #30 also had diagnoses including gastrostomy tube and a quarterly MDS showing he had a feeding tube while a resident and received 51% or more of total calories through the feeding tube. His care plan identified tube feeding with interventions to keep the HOB elevated at least 30 degrees at all times, but it did not address the resident putting the HOB down flat. During observation, the resident was in bed with the HOB lying flat while the feeding pump was on and administering g-tube feeding. Staff stated the residents were known to put the HOB down when they wanted it down, and the MDS nurse and DON stated the care plans should reflect the residents’ current condition.
Incorrect Dishwasher Sanitizer Test Strips Used
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an observation on 07/27/2026, a Dishwasher Aide demonstrated testing the dishwasher sanitizer concentration by placing a chemical test strip in the rinse water during the dishwasher's rinse cycle, and the strip read 100 parts per million (ppm). The observation showed the facility was not using the appropriate chlorine test strips to verify the dishwasher's final-rinse sanitizer concentration, and the available strips did not measure chlorine concentrations as low as the manufacturer-required 50 ppm for the American Dish dishwasher model AF-3D. Record review showed staff had documented sanitizer concentrations using the incorrect test strips, so the logs did not provide evidence that the dishwasher's final-rinse chlorine concentration had been maintained at the required 50 ppm. Interviews with the DM and Dishwasher Aide confirmed the strips in use were intended for the three-compartment sink rather than the dishwasher, and the DM stated the sanitation company was responsible for ordering the strips. The facility policy required the commercial dishwasher to consistently achieve the required sanitizing temperature or chemical sanitizer concentration and for sanitization levels to be checked and documented at the beginning of each dietary shift and when needed after maintenance or performance concerns.
Bathroom Toilet Seat Left in Disrepair
Penalty
Summary
The facility failed to ensure room [ROOM NUMBER] was maintained in a safe, clean, comfortable, and homelike condition when the bathroom toilet seat was observed with a complete split, torn and peeling paint, and a hole exposing the brown wood frame. On one observation, the hole was described as approximately 4 inches wide and 0.5 inches long, with a brown substance buildup inside the hole; on a later observation, the toilet seat was again noted to have a complete split, torn and peeling paint, and a hole exposing the wood. During interview, the housekeeper said she had already cleaned the room and was not aware of the toilet seat condition, though she also stated she had notified maintenance face to face about the toilet. The maintenance supervisor and maintenance worker said they were not aware of the repair need and that it had not been logged in the maintenance binder. Record review of maintenance logs from 02/01/2026 through 07/29/2026 did not show the toilet seat had been reported for repair, and the facility policy required maintenance concerns to be reported, documented, and repaired in a timely manner.
Improper G-Tube Flush Administration
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received enteral care and medication administration according to the ordered procedure. Resident #23 was a male admitted with diagnoses including transient ischemic attack, cerebral infarction, encounter for attention to gastrostomy, and dysphagia. His quarterly MDS indicated a BIMS score of 9 and that he had a feeding tube. His order summary directed staff to flush the gastrostomy tube with 60 mL of water before and after medication and feeding, and 10 mL between medications. His care plan identified the gastrostomy tube as related to altered nutrition risk and directed staff to assist with tube feeding and water flushes and to follow physician orders. During observation of medication administration, LVN D checked tube placement and pushed 60 mL of water through the resident’s gastrostomy tube slowly with a syringe and plunger instead of administering the water by gravity. LVN D stated she should have inserted the water by gravity, said she had been educated to give medication and water by gravity, and said she was nervous. She then administered the medication by gravity and followed with 60 mL of water by gravity. The DON and Administrator stated the nurse was responsible for giving gastrostomy tube medication properly and that all nurses had been educated on proper gastrostomy tube medication administration. The facility policy stated medications via G-tube should be allowed to flow by gravity or gently administered with an enteral syringe and that medication should never be forced through the tube.
Failure to Train Staff and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that the Administrator, Director of Nursing (DON), and Infection Preventionist (IP) received training on Enhanced Barrier Precautions (EBP) as required by updated CMS and CDC guidance. Observations conducted over several days revealed that there was no EBP signage or personal protective equipment (PPE) set up outside or inside any resident rooms. Interviews with the ADON/IP and DON confirmed that they were not familiar with EBP, had not received training on the updated requirements, and were unaware of recent changes or provider letters regarding EBP implementation. The Administrator also indicated only a brief awareness of EBP and was not fully informed about the regulatory requirements. Record review indicated that the facility had residents with chronic wounds and indwelling medical devices, such as g-tubes and foley catheters, who were not placed on EBP during high-contact care activities. The lack of EBP implementation was confirmed through staff interviews and direct observation, with no evidence of EBP being practiced for any residents, regardless of their multidrug-resistant organism status. The facility's failure to train key staff and implement EBP protocols resulted in noncompliance with current infection control standards.
Failure to Provide Mandatory EBP Training for Staff
Penalty
Summary
The facility failed to ensure that mandatory training on infection prevention and control, specifically Enhanced Barrier Precautions (EBP), was provided to 11 of 12 employees reviewed, including both new and existing staff such as the Administrator, DON, ADON/IP, LVNs, and CNAs. Record review indicated that education on EBP was only conducted after surveyor intervention, and prior to this, staff had not received adequate training on the facility's written standards, policies, and procedures for EBP. The facility's policy required implementation of EBP for residents with certain conditions, such as wounds or indwelling medical devices, but staff were not familiar with these requirements before the surveyor's involvement. Observations and interviews revealed that staff members, including CNAs and LVNs, were unable to accurately describe EBP or differentiate it from other types of precautions, such as Transmission-Based Precautions (TBP) or standard precautions. During incontinent care for a resident with a g-tube, CNAs donned gloves but did not use gowns as required by EBP, and there was no signage indicating EBP in the resident's room. Multiple staff members expressed uncertainty about what EBP entailed, when it should be used, and whether they had received training on it. Some staff confused EBP with the use of barrier creams or standard infection control practices, and several stated they were unsure if any residents were currently on EBP. Interviews with facility leadership, including the ADON/IP and DON, confirmed that they had not been trained on EBP prior to the survey and were unaware of recent updates or changes in infection control guidelines. The ADON/IP stated she relied on the DON and Administrator for updates, while the DON reported difficulty accessing training opportunities and was unable to articulate expectations related to EBP. The Administrator acknowledged responsibility for infection control education but indicated that staff were only educated on EBP after surveyor intervention. The lack of staff training on EBP and the facility's failure to implement its own policy placed residents at risk of illness due to inadequate infection control practices.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent prior to the administration of psychotropic medications. Specifically, for two residents reviewed, required consent forms for antipsychotic and antidepressant medications were either incomplete or missing at the time the medications were administered. Documentation for both residents lacked necessary information and signatures from the prescribing practitioner and the resident or their representative. One resident, an older female with diagnoses including major depressive disorder, bipolar disorder, and adjustment insomnia, was administered Seroquel and Cymbalta without completed consent forms. The forms for both medications were missing critical information such as the prescriber's details, clinical indications, and signatures from both the prescriber and the resident or representative. The resident's care plan indicated use of high-risk drugs and risk for side effects, but the required informed consent process was not documented. Another resident, also an older female with major depressive disorder and severely impaired cognition, received Seroquel without a completed consent form. The form lacked the resident or representative's acknowledgment and signature. Interviews with facility leadership revealed a lack of awareness regarding the incomplete consent forms, and the facility's policy required that residents or their representatives be informed of the risks, benefits, and alternatives to psychotropic medications prior to administration, with documentation of this process.
Failure to Implement Enhanced Barrier Precautions and Infection Control Measures
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Multiple residents with conditions such as suprapubic catheters, gastrostomy tubes, foley catheters, and pressure ulcers did not have EBP signage posted outside their rooms, and personal protective equipment (PPE) was not set up or readily accessible prior to staff entering the rooms. Observations revealed that staff did not consistently wear gowns or follow EBP protocols during high-contact care activities, such as catheter care, wound care, medication administration via g-tube, and resident transfers. In several instances, staff only wore gloves and did not don gowns, even when their uniforms came into direct contact with residents or their bedding during care. Interviews with staff, including CNAs and LVNs, indicated a lack of understanding and training regarding EBP and the distinction between EBP and other types of precautions. Some staff believed EBP referred to the use of barrier creams or setting up towels, and were unsure about which resident care activities required EBP. Staff also reported not receiving recent or adequate training on EBP, and some were unaware of the updated CDC recommendations or facility policies regarding EBP. The infection preventionist and DON also demonstrated limited knowledge of EBP requirements and did not identify any residents as currently needing EBP, despite the presence of qualifying conditions among several residents. Record reviews further showed that care plans and physician orders for affected residents did not include instructions for EBP, and the facility's own policy on EBP was not being followed in practice. The lack of EBP implementation was observed across multiple days and for several residents, with repeated failures to post signage, provide PPE, and ensure staff compliance with gown use during high-contact care. These deficiencies were confirmed through direct observation, interviews with staff and residents, and review of facility documentation.
Deficient PASRR Screening and Evaluation for Residents with Mental Illness or Disability
Penalty
Summary
The facility failed to ensure that individuals identified with mental illness (MI), developmental disability (DD), or intellectual disability (ID) were properly evaluated for services, as required by the PASRR process, for two of five residents reviewed. For one resident, the PASRR Level 1 screening incorrectly listed dementia as the primary diagnosis without verification from a physician or supporting documentation, despite the resident having diagnoses of major depressive disorder and bipolar disorder and being prescribed antipsychotic and antidepressant medications. The MDS nurse admitted to not confirming the primary diagnosis with the physician and acknowledged the PASRR Level 1 was not accurate and needed to be redone. For another resident, the PASRR Level 1 form was incorrectly marked to indicate a short-term stay of less than 30 days, even though the resident was intended for long-term placement and had diagnoses including schizoaffective disorder and major depressive disorder, and was receiving antipsychotic medications. The MDS nurse responsible for the form was unsure why the error occurred and recognized that the mistake could have delayed services. The facility's policy requires accurate coordination with the PASRR program to ensure appropriate care and services for individuals with MI, DD, or ID, but this was not followed in these cases.
Failure to Ensure Appropriate Indication for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the use of Seroquel (an antipsychotic). Record review showed that the resident, an older female with diagnoses of major depressive disorder, bipolar disorder, and adjustment insomnia, had physician orders for Seroquel to treat all three conditions, as well as Cymbalta for major depressive disorder. The orders did not specify an appropriate diagnosis for the use of Seroquel, and the care plan identified her as being at high risk for side effects from both antidepressant and antipsychotic medications. The Minimum Data Set (MDS) confirmed the resident was taking both an antipsychotic and an antidepressant and had moderately impaired cognition. During interviews, the DON stated she was unaware that the resident had multiple diagnoses listed for Seroquel and acknowledged that a resident could receive a medication for the wrong indication. She explained that nurses are responsible for verifying the correct diagnosis with the physician, and that she and the ADONs conduct random chart reviews. The facility's policy on psychotropic medications requires that such drugs only be given when necessary to treat a specific, documented condition and that the medication's benefit be demonstrated through monitoring and documentation, which was not followed in this case.
Unauthorized Bedside Storage of Medications Without Physician Order or Assessment
Penalty
Summary
A deficiency occurred when a resident was found to have over-the-counter medications, including Luden's cough drops, Neosporin ointment, and Equate hydrocortisone cream, stored at the bedside without a physician's order or care plan authorizing self-administration. The resident's medical record did not contain any orders for these medications, nor was there documentation of a self-administration medication assessment or a care plan addressing the storage or self-administration of medications. Multiple observations over several days confirmed that the medications remained accessible on the resident's bedside table while the resident was not present in the room and the door was open. Interviews with the resident revealed that he did not inform nursing staff about possessing the medications, stating he was capable of managing them himself. The responsible party for the resident admitted to bringing the medications into the facility and was unaware of the requirement to notify staff about over-the-counter medications. Nursing staff and the DON confirmed that facility policy requires a physician's order and a completed self-administration assessment before a resident may keep medications at the bedside, and that unauthorized medications should not be left in resident rooms. Review of facility policy indicated that all medications found at the bedside without authorization must be reported and returned to the responsible party, and that the care plan must reflect any arrangements for self-administration and storage. In this case, the facility failed to follow its own policy and federal regulations regarding medication storage, labeling, and resident self-administration, resulting in unauthorized medications being accessible in a resident's room.
Deficiency in Dietary Management Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility did not designate a qualified dietary manager, as the acting Dietary Supervisor lacked the necessary certification or any other qualifying credentials. This deficiency was identified during a review of the personnel file, which showed no documentation of the Dietary Supervisor having completed the certified Dietary Manager course. Interviews with the Dietary Supervisor, HR staff, and the Administrator confirmed that the Dietary Supervisor had not started the dietary manager classes and was temporarily filling the role until a certified dietary manager could be hired. The facility had been attempting to hire a certified dietary manager since April 2024, but had not succeeded by the time of the survey. The facility's policy required the employment of a full-time certified dietary manager, which was not met.
Improper Food Labeling and Storage in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. Specifically, food items in the refrigerators were not properly labeled with product and expiration dates. This included a browning avocado in a gallon-sized bag, sippy cups with a white substance, a container with orange slices, a piece of ham covered with foil, and a Styrofoam dish with sliced cucumbers, all of which were not labeled or dated. The acting dietary supervisor admitted to forgetting to label and date the sippy cups and was unsure about the dates for the cucumbers and orange slices, leading to their disposal. The supervisor acknowledged that all dietary staff were responsible for labeling and dating items to prevent serving old food to residents. The facility's administrator, who was temporarily overseeing the dietary staff, confirmed the expectation for proper food storage, including labeling and dating. The facility's policy from 2005 required refrigerated foods to be covered, labeled, and dated. Additionally, the 2022 Food Code mandates date marking for ready-to-eat, time/temperature control for safety food, to ensure food is consumed, sold, or discarded within a safe timeframe. The lack of proper labeling and dating could result in expired foods being served to residents, posing a risk for foodborne illness.
Failure to Employ Required Social Worker
Penalty
Summary
The facility's governing body failed to comply with applicable Federal, State, and local laws, regulations, and codes by not employing or contracting a Social Worker (SW) as required by state regulations. During an interview, the Administrator confirmed that the facility did not have a SW, as the previous SW had quit about a month prior, and they were actively searching for a replacement. A review of the facility's Social Services Policy indicated that the facility was supposed to employ a full or part-time SW. Additionally, the Texas Administrative Code 554.703 (a)(2) mandates that a facility with 120 beds or less must employ or contract with a qualified SW to provide social services adequately to meet the residents' needs.
Failure to Complete QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that Quality Assurance and Performance Improvement (QAPI) training was completed for all 17 employees reviewed, including the Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and various other staff members such as Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs). The lack of training was identified through interviews and record reviews, which revealed that none of the staff had completed the required QAPI training. This deficiency was noted across various roles, indicating a systemic issue in the training process. Interviews with the DON and Administrator highlighted that there was an expectation for all required trainings to be completed during orientation and annually. However, it was discovered that there was a problem with the computer-based training system, which failed to trigger the necessary training modules for staff. The facility's Staff Education policy mandates compliance with training programs as a condition of employment, yet this was not adhered to, potentially placing staff and residents at risk due to a lack of awareness of facility programs, implementation, and monitoring.
Failure to Complete Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that compliance and ethics training was completed for all 17 employees reviewed, including the Administrator, Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and various licensed vocational nurses (LVNs) and certified nursing assistants (CNAs). The record review of employee files revealed that none of these staff members had completed the required training. This lack of training was acknowledged by the DON, who stated that all training should be completed during orientation and annually as required. The Administrator also confirmed the expectation that all necessary training should be completed during orientation and on an annual basis. Interviews conducted with the DON and Administrator highlighted a failure in the computer-based training system, which did not trigger the required training for staff during orientation and annually. The facility's Staff Education policy, implemented in 2024, mandates that compliance with training programs is a condition of employment, requiring all employees to complete necessary training within designated time frames. The absence of completed training could potentially impact the quality of care provided to residents, as indicated by the DON.
Deficiency in Training for Contracted Staff
Penalty
Summary
The facility failed to ensure that individuals providing services under a contractual arrangement received training consistent with their expected roles. This deficiency was identified for four contracted staff members, including a dietician, physical therapist (PT), occupational therapist (OT), and speech therapist (ST). The facility did not maintain records of these trainings, which could potentially place residents at risk due to insufficiently trained staff. Interviews with facility personnel, including the Human Resources (HR) representative, Director of Nursing (DON), Administrator, and Assistant Director of Nursing (ADON), revealed a lack of awareness and implementation of training protocols for contracted staff. The HR representative was unaware of any training files for the dietician and therapy staff, while the DON and ADON confirmed that the facility did not provide training for contracted staff. The Administrator expressed an expectation that all required trainings should be completed during orientation and annually as required, but acknowledged that the impact of incomplete trainings would depend on the specific staff and trainings involved. A review of the facility's Staff Education policy indicated that compliance with training programs is a condition of employment, yet this policy was not effectively implemented for contracted staff.
Deficiency in Staff Training on Effective Communication
Penalty
Summary
The facility failed to ensure that employees received the required training in effective communications, which is mandatory for direct care staff members. This deficiency was identified for 11 out of 17 employees reviewed for training, including the Administrator, Assistant Administrator, LVN F, RN G, AD, MD, HS, CNA K, CNA L, CNA M, and CNA N. Specifically, the facility did not ensure that effective communication training was completed during orientation for LVN F, RN G, CNA L, CNA M, and CNA N. Additionally, the facility failed to ensure that the Administrator, Assistant Administrator, AD, MD, HS, and CNA K completed this training annually. Interviews with the Director of Nursing (DON) and the Administrator revealed that there was an expectation for all required trainings to be completed during orientation and annually. However, the DON indicated that there was an issue with the computer-based training system, which failed to trigger the required trainings for staff. The facility's Staff Education policy, implemented in 2024, mandates compliance with training programs as a condition of employment, yet the deficiency in training completion was evident. This lack of training could potentially place residents at risk of miscommunication and social isolation.
Deficiency in Staff Training on Resident Rights
Penalty
Summary
The facility failed to ensure that staff members were adequately trained on resident rights and facility responsibilities, as required during orientation and annually. Specifically, two employees, LVN F and CNA N, did not complete the necessary training during their orientation period. Additionally, three other staff members, including the Director of Nursing (DON), LVN D, and CNA K, did not complete their annual training on these critical topics. This lack of training was identified through a review of employee files, which showed gaps in compliance with the facility's training requirements. Interviews with the DON and the Administrator revealed that there was an expectation for all staff to complete the required training during orientation and annually. However, a computer-based training system issue was identified as a contributing factor, as it failed to trigger the necessary training alerts for staff. The facility's Staff Education policy mandates compliance with training programs as a condition of employment, yet these deficiencies in training completion could potentially affect residents by leaving them uninformed due to the staff's lack of training.
Training Deficiency in ANE and Dementia Management
Penalty
Summary
The facility failed to ensure that employees received the required training on Abuse, Neglect, and Exploitation (ANE) and dementia management. Specifically, the Licensed Vocational Nurse (LVN F), who was hired on August 7, 2023, did not complete ANE and dementia management training during orientation. Additionally, the Director of Nursing (DON), hired on January 19, 2015, last completed ANE training on January 31, 2023, and did not receive the required annual training. The Health Services (HS) staff also did not complete the annual ANE training. Interviews with the DON and the Administrator revealed that there was an expectation for all nursing staff to complete the necessary trainings during orientation and annually. However, a computer-based training issue failed to trigger the required trainings for staff, leading to the deficiency. The lack of training could potentially place residents with dementia at risk of abuse, neglect, and exploitation, as well as result in poor quality of care by inadequately trained staff.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to ensure that its infection prevention and control program's standards, policies, and procedures were completed for two staff members, an LVN and an MD, as part of their training requirements. Specifically, the LVN, hired on 08/07/23, did not complete the infection prevention and control training during orientation. Additionally, the MD, hired on 07/01/04, did not complete the required annual infection prevention and control training. These lapses in training were identified through a review of employee files. Interviews with the Director of Nursing (DON) and the Administrator revealed that there was an expectation for all nursing staff to complete required trainings during orientation and annually. The DON acknowledged an issue with the computer-based training system, which failed to trigger the necessary training requirements for staff. The facility's Staff Education policy, implemented in 2024, mandates compliance with training programs as a condition of employment, yet these deficiencies in training completion were noted.
Failure to Complete Required CNA Trainings
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed required trainings in Abuse, Neglect, and Exploitation (ANE) and dementia management. Specifically, two CNAs, identified as CNA K and CNA N, did not complete these trainings as mandated. CNA N, who was hired on December 7, 2023, did not complete the ANE and dementia management trainings during their orientation period. Similarly, CNA K, hired on October 25, 2021, failed to complete the annual ANE and dementia management trainings. This oversight in training could potentially place residents with dementia at risk of receiving inadequate care. Interviews with the Director of Nursing (DON) and the Administrator revealed that there was an expectation for all nursing staff to complete required trainings during orientation and annually. The DON acknowledged a problem with the computer-based training system, which failed to trigger the necessary training alerts for staff. The facility's Staff Education policy, implemented in 2024, mandates compliance with training programs as a condition of employment, yet this policy was not adhered to in these instances.
Failure to Complete Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that behavioral health training was completed for 11 out of 17 employees reviewed for training. Specifically, the facility did not provide behavioral health training during orientation for several staff members, including an LVN, an RN, and multiple CNAs. Additionally, the facility did not ensure that the Administrator, Assistant Administrator, AD, MD, HS, and a CNA completed their required annual behavioral health training. This lack of training could potentially place residents with behavioral issues at risk of not receiving appropriate care. Interviews with the Director of Nursing (DON) and the Administrator revealed that there was an expectation for all required trainings to be completed during orientation and annually. However, a computer-based training system issue was identified, which failed to trigger the necessary training requirements for staff. The facility's Staff Education policy mandates compliance with training programs as a condition of employment, yet the deficiency in training completion was evident in the employee files reviewed.
Inaccurate Resident Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the resident assessment for a resident accurately reflected her status, specifically regarding the use of oxygen therapy. The resident, an elderly female with a diagnosis of Chronic Pulmonary Disease (COPD) and dependence on supplemental oxygen, was admitted to the facility with a physician's order for continuous oxygen therapy. Despite this, the quarterly Minimum Data Set (MDS) assessment did not indicate that she was receiving oxygen therapy, which was a significant oversight given her medical condition and treatment requirements. Interviews with facility staff, including the MDS nurse and the Director of Nursing (DON), revealed that the omission was due to an oversight and lack of a backup system to double-check the accuracy of MDS entries. The MDS nurse acknowledged the error and noted that it could affect the facility's revenue, while the DON emphasized the importance of accurate MDS documentation to reflect the residents' needs and conditions. The facility's policy and the Long-Term Care Facility Resident Assessment Instrument Manual both require that special treatments, such as oxygen therapy, be documented in the MDS, highlighting the deficiency in the facility's assessment process.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 40 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Liberty Health Care Center | 0.2 mi | ★★★★★ | 4 | 2 |
| Dayton Nursing And Rehabilitation | 5.7 mi | ★★★★★ | 1 | 0 |
| Focused Care At Burnet Bay | 23.2 mi | ★★★★★ | 6 | 0 |
| Focused Care At Allenbrook | 23.3 mi | ★★★★★ | 4 | 0 |
| Focused Care At Cedar Bayou | 23.4 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.