Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maverick Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Feeding Residents While Standing Over Them: A CNA fed two residents at a dining room table while standing instead of sitting at eye level. One resident had severe dementia, malnutrition, and adult failure to thrive, and the other had severe dementia and required assistance with eating. The CNA said she should have been sitting, the ADON observed the same, and both stated standing over residents while they ate could affect dignity and comfort.
A nurse gave a resident the wrong strength of docusate and did not notify the MD, then failed to complete an ordered IV vancomycin dose after the IV became clogged and could not be reinserted. The resident, who had MRSA and surgical wounds, reported the events and the ADON and DON confirmed there was no documentation that the physician was contacted.
Dirty Ceiling Vents in Resident Rooms and Dining Area: Ceiling vents in 3 resident rooms and the dining room were observed with black residue and built-up lint around the edges. The ADON acknowledged the vents were dirty and did not know when they were last cleaned in the secured unit. A resident's family member reported the vents in the resident's room were full of lint and said she had raised the concern to the ADON, MS, DON, and ADM.
Failure to Resolve Family Grievances: A resident with severe dementia and a BIMS of 0 had repeated unexplained skin tears and an incident where a male resident was found in her bed in the secured unit. A family member reported concerns about staffing, supervision, and the resident’s injuries, but said ADM, DON, HR, and ADON did not answer her questions or listen to her. Grievance records did not show the family’s concerns were tracked as grievances, and the ADM and DON discussed the issues with the RP instead of the person who raised them.
Dirty Clothing Not Addressed for Resident Needing ADL Assistance: A resident with severe dementia, malnutrition, and failure to thrive required substantial to maximal help with dressing, yet was observed in the dining room wearing a sweatshirt with white debris covering the chest area. Staff did not notice the dirty clothing until it was pointed out, and the LVN and ADON acknowledged that staff should help keep residents clean and change dirty clothing.
A resident with dementia, Alzheimer’s disease, anxiety, severe cognitive impairment, and high fall risk was observed eating dinner in the secured unit with a large puddle of liquid under his chair. Staff were busy assisting others, and an LPN initially did not notice the spill, then covered it with a towel; the ADON also did not see it. Staff acknowledged the resident was unsteady and could slip and fall if he stepped on the liquid.
Incorrect Docusate Dose Administered: An RN gave a resident two 100 mg Docusate tablets instead of the ordered two 50 mg tablets for constipation. The resident questioned the pills after receiving them, and the RN admitted she did not check the order and grabbed the OTC bottle instead. The RN acknowledged the error but did not complete a med error report, and there was no documentation that the MD was notified.
A resident with no cognitive impairment had incomplete MAR and progress note documentation for multiple medication-related events. RN F gave the wrong strength of Senna-Docusate and did not complete a medication error report, failed to document why Vancomycin was not administered after IV access problems and unsuccessful reinsertion attempts, and an ADON did not document notifying the resident when Loratadine was changed from scheduled to PRN. The DON stated staff should complete SBARs and/or progress notes for treatment changes, but the record lacked those entries.
Dirty Dining Room Vents in Secured Unit: The facility failed to keep 3 dining room vents in the secured unit clean, as observation showed black residue and built-up lint around the vent edges. An ADON acknowledged the vents were dirty and said the MS followed a cleaning schedule, but did not know when the vents were last cleaned. A resident's family member reported the vents were especially dirty and said she had raised the concern to the ADON, MS, DON, and ADM, while the DON stated the MS was supposed to clean the vents after the concern was brought to leadership.
Improper Hot Food Holding Temperature: The facility failed to keep puree bread on the serving line at the required hot-holding temperature, with the item measured at 116 degrees. The cook stated hot items should be held at 145 degrees or above, while the DM stated hot foods should be held at 135 degrees and above for regulation and safety. The facility policy required hot foods to be served at 135 F or greater and held for less than one hour while maintaining that temperature.
Food storage practices were not followed in the kitchen when surveyors found unsealed cheese, cilantro, and pizza dough, an undated container of macaroni, and a spoiled tomato in storage areas. The DM stated opened items should be sealed and dated, pasta should be labeled when placed in a container, and spoiled produce should be discarded. The facility policy required opened and bulk items to be tightly covered, labeled, and dated.
A resident with DM, renal dialysis dependence, myopathy, and moderate cognitive impairment was found with his call light behind the nightstand and out of arm's reach. The resident said he never knows where his call light is, and the assigned LVN confirmed it was not accessible. The care plan did not address the call light, and the facility policy states the call light system should be accessible while the resident is in bed or other sleeping accommodations.
Failure to Refer Resident With New Mental Health Diagnosis for PASARR Review: The facility failed to refer a resident for level II resident review after a new serious mental health diagnosis was identified. The resident had type 2 DM with CKD, severely impaired cognition, and a diagnosis of major depressive disorder, recurrent severe without psychotic features. The MDS Case Manager stated form 1012 was not submitted and believed major depressive disorder did not trigger a PASARR positive, while the RDS nurse stated the form should have been completed so the physician could decide whether PASARR needed to be redone.
Care Plan Missing Isolation and Wound Precautions: A resident with C-diff, sepsis, pseudomonas, and a stage 2 pressure ulcer had a care plan that listed infection and skin integrity problems but did not include Contact Isolation, EBP for the wound, or PPE interventions. Records showed active isolation and wound treatment orders, and staff observed PPE supplies outside the room without the required isolation or EBP signage.
Oxygen Concentrator Filter Not Kept Clean: A resident with a tracheostomy, severe cognitive impairment, and respiratory failure with hypoxia received oxygen via trach collar mask at 2 L/min, but the concentrator’s left-side foam filter was observed covered with dust and air particles while the right-side filter was clean. The DON confirmed the dirty filter and stated there was no guideline or process for checking and cleaning oxygen concentrator filters.
Unlabeled, Undated Food Stored in Resident Refrigerator: Surveyors found an opened pint of ice cream in a resident’s personal refrigerator that was unlabeled and undated on multiple observations. An LVN confirmed the item was present, and the DON stated perishable food in residents’ refrigerators should be labeled and dated, with night shift nurses responsible for oversight. The facility policy required food brought in by family or visitors to be labeled with contents and dated, and discarded if not consumed within 3 days.
Missing EBP and Isolation Signage for Residents With Wounds and C-Diff: Two residents with wounds were observed without required EBP signage, and one resident with C-Diff also lacked Contact Isolation signage despite active isolation orders and wound treatment. Staff confirmed the residents should have had the signs posted, and the DON stated the yellow door sign was considered enough even though PPE and isolation precautions were required.
A medication cart assigned to an LVN was left unattended and unlocked while the nurse stored enteral feeding formula in a resident pantry, leaving the cart out of her line of sight. Facility policy and interviews with the administrator and DON confirmed that medication carts are required to be locked when not directly attended.
Surveyors found that food items stored in the resident pantry refrigerator, including berries, desserts, a half sandwich, and a cookie, were not labeled or dated as required by facility policy. Staff interviews confirmed that daily inspections to ensure proper labeling and dating were not conducted, and partially eaten food was present in the refrigerator.
A resident with multiple medical conditions was inadequately supervised and improperly secured in a transport van, leading to a fall and fractures. The incident occurred when the van driver braked suddenly, and the resident, who was not properly secured, fell forward in her wheelchair. The facility acknowledged the improper securing of the resident, which resulted in the accident.
The facility's kitchen failed to store and label food according to professional standards, as observed with three unlabeled and undated packets of bread in the freezer, one of which had a torn plastic bag. The Kitchen Supervisor and Registered Dietitian acknowledged the oversight, which could risk foodborne illness, contrary to the facility's food storage policy.
A facility failed to maintain proper infection control practices, as a CNA did not fully sanitize her hands during incontinent care for a resident with severe cognitive impairment. Additionally, two CNAs did not wear gowns while providing care to another resident on Enhanced Barrier Precautions, despite clear instructions. These actions were contrary to the facility's infection control policies, potentially risking resident safety.
A resident's privacy was compromised when CNAs failed to fully close the privacy curtain during incontinent care, exposing the resident to view. Despite having received training on resident rights, the CNAs acknowledged the oversight. The DON confirmed the importance of privacy but noted the absence of a specific policy on curtain closure.
The facility failed to ensure accurate MDS assessments for two residents. One resident was incorrectly documented as receiving an anticoagulant instead of antiplatelet medications, while another resident's tobacco use was inaccurately recorded as non-use. These errors were confirmed by facility staff, who acknowledged the inaccuracies and the potential impact on resident care.
A facility failed to refer a resident for a Level II PASARR review after a new diagnosis of schizoaffective disorder-bipolar type. Despite the resident's significant change in mental status and prescription of Zyprexa, the facility did not initiate a re-evaluation. Interviews revealed a lack of policy and awareness regarding PASARR re-evaluation, with MDS nurses acknowledging the oversight.
A facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and multiple medical conditions, who was always incontinent of bowel. The care plan only addressed bladder incontinence, despite the need for substantial assistance with daily activities. Staff interviews confirmed the absence of a bowel incontinence care plan, and the facility lacked a specific policy for care plans, potentially risking skin breakdown due to inadequate care.
A resident with severe cognitive impairment and multiple medical conditions was receiving enteral feeding at a rate lower than prescribed by the physician. The facility failed to adjust the feeding rate from 55 ml/hour to 60 ml/hour as ordered, which was confirmed through staff interviews and observations. This oversight could result in inadequate caloric intake for the resident.
A resident with severe cognitive impairment and multiple health conditions did not receive appropriate respiratory care due to the facility's failure to replace nebulizer equipment weekly as required. The equipment was found with a date indicating it had not been changed for several weeks, posing a risk of respiratory infection. Staff interviews confirmed the oversight and acknowledged the potential harm.
A resident did not have advance directives documented in the admission agreement or electronic medical record from admission to discharge. The facility's staff failed to complete the necessary documentation and discussions regarding the resident's advance directives, as required by the facility's policy.
Feeding Residents While Standing Over Them
Penalty
Summary
The facility failed to treat two residents with respect and dignity during the dinner meal when CNA E fed both residents while standing at the dining room table instead of sitting at their eye level. Resident #1 had diagnoses including severe unspecified dementia with behavioral disturbance, protein-calorie malnutrition, and adult failure to thrive, and his care plan stated he required supervision with set up by staff to eat. Resident #2 had diagnoses including severe unspecified dementia with anxiety and other persistent mood disorders, and her care plan stated she required limited assistance to eat; her MDS showed a BIMS score of 3 of 15, reflecting severe cognitive impairment, and she was on a mechanically altered diet. During observation in the secured unit, CNA E was seen feeding Resident #1 and Resident #2 while standing. Both residents looked up at her as she fed them. CNA E stated she should have been sitting but had no chair when she began feeding them, and she said she had given her chair to one of the residents. An empty chair was observed at another dining room table, and CNA E said she had not seen it. She acknowledged she should be sitting while feeding the residents so she could be at their eye level and stated standing might cause them to feel overwhelmed and uncomfortable. The ADON, who was in charge of the secured unit, also observed CNA E standing while feeding the residents and stated she knew better and should sit while feeding them. He stated standing over residents while they ate might make them feel inferior and uncomfortable. An LVN stated staff should be at the resident's level and that standing could affect dignity and make a resident feel uncomfortable or vulnerable.
Failure to Notify Physician of Medication Error and Missed IV Antibiotic Dose
Penalty
Summary
The facility failed to immediately inform the resident, consult the resident’s physician, and notify the resident representative when there was a significant change in the resident’s condition for one resident reviewed. Resident #5 was admitted with orthopedic aftercare and injuries from a motor vehicle collision, had a BIMS score of 15, and was her own responsible party. Her care plan addressed constipation related to decreased mobility and pain, and her active orders included Senna-Docusate 8.6-50 mg, 2 tablets twice daily, and IV Vancomycin for MRSA to surgical wounds on the right ankle. RN F administered two 100 mg tablets of Docusate instead of the ordered two 50 mg tablets. Resident #5 stated she questioned the medication after receiving it and later confirmed the bottle contained 100 mg tablets. RN F acknowledged she did not look at the order, grabbed the OTC bottle, believed it was a PRN dose, and did not call the physician after the medication error. ADON G stated the event was a medication error that required physician notification and found no documentation that the doctor was contacted. RN F also failed to complete the ordered IV Vancomycin dose when the resident reported the IV was not dripping normally and the access was clogged. RN F attempted to reinsert the IV twice without success, then left without arranging further assistance or notifying the physician. RN F stated she did not call the doctor, and ADON G confirmed there was no documentation that the physician was contacted. The DON stated she was not notified of either incident and that both required the charge nurse to contact the physician and report the change in condition.
Dirty Ceiling Vents in Resident Rooms and Dining Area
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in 3 of 26 rooms, including rooms 203, 213, and 215, because the ceiling vents in those rooms were observed with black residue on the outside and built-up lint around the edging. During the tour of the secured unit, the same condition was also observed on 3 vents in the dining room. The ADON acknowledged the vents were dirty and stated he understood the MS cleaned vents on a schedule according to the maintenance application, but he did not know when the vents in the secured unit were last cleaned. A resident's family member reported that she visited Resident #3 multiple times a week and noticed the vents in the resident's room were full of lint. She stated she believed this could get Resident #3 sick as well as other residents in the secured unit, and said she reported the concern to the ADON, MS, DON, and ADM. The DON stated the MS was supposed to clean the vents in the secured unit during March 2026 after the concern was brought to her and the ADM's attention. The facility's undated General Housekeeping policy stated the facility provides sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner and to keep the facility free from accumulations of dirt, rubbish, dust, and hazards.
Failure to Resolve Family Grievances
Penalty
Summary
The facility failed to ensure a resident’s right to voice grievances was honored and failed to make prompt efforts to resolve grievances for a resident with severe cognitive impairment. Resident #3 had diagnoses including Alzheimer’s disease and severe dementia, and her quarterly MDS showed a BIMS score of 0, reflecting severe cognitive impairment. Her care plan identified her as needing placement in the cognitive impairment unit due to poor safety awareness and high elopement risk, with an intervention to maintain a routine for bathing, dressing, and eating. The resident experienced multiple skin tears and other injuries during her stay, and the incident log documented several events involving unexplained skin tears to her legs, arms, foot, and shin. The record also documented an incident in which a male resident was found lying in Resident #3’s bed in her room in the secured unit. A family member stated she observed on camera that the male resident entered the room, lay in bed with Resident #3 for about 30 minutes, and lightly tapped her arm, chest area over her gown, and hair. The family member also reported concerns about lack of supervision, lack of night checks, staffing concerns, and staff experience in the secured unit. A letter from the family member, submitted to the corporate office, listed concerns about repeated skin tears, inadequate staffing, lack of rounding, and the male resident entering Resident #3’s room and lying in her bed on more than one occasion. The facility grievance records from October 2025 through June 2026 did not show grievances related to that letter. The family member stated she tried to raise her concerns with administrative staff, including the ADM, DON, HR, and ADON, but said she was not listened to and did not receive answers. The DON and ADM stated they discussed the concerns with the resident’s responsible party rather than with the family member who submitted the concerns, even though they acknowledged that their usual process was to address the grievance with the person who reported it.
Dirty Clothing Not Addressed for Resident Needing ADL Assistance
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received the necessary assistance to maintain good nutrition, grooming, and personal and oral hygiene. Resident #1 had diagnoses including severe dementia with behavioral disturbance, protein-calorie malnutrition, and adult failure to thrive. His care plan identified an ADL self-care performance deficit related to arthritis and shortness of breath and stated he required limited staff assistance with dressing. His MDS assessment showed a BIMS score of 3 out of 15 and that he required substantial to maximal assistance with upper and lower body dressing. During observation, Resident #1 was sitting in the dining room wearing a black sweatshirt with multiple white speckled debris covering the chest area. He was leaning to the right and did not respond to attempted interview questions. The LVN stated she did not know what was on his shirt and later said staff should change a resident’s shirt when it was dirty. A CNA later approached the resident, asked if he wanted his shirt changed, and he nodded yes. The ADON stated he saw the front of the shirt was full of white residue only after it was pointed out and said CNAs should help residents maintain good hygiene by ensuring they were clean. The facility policy stated care and services would be provided for bathing, dressing, grooming, and oral care.
Puddle of Liquid Left Under Resident’s Chair in Dining Area
Penalty
Summary
The facility failed to keep the resident environment free of an accident hazard when nursing staff did not promptly clean up a large puddle of liquid on the floor underneath a resident’s chair during dinner. The resident had diagnoses including dementia with severe behavioral disturbance, Alzheimer’s disease with late onset, and anxiety disorder. His care plan identified him as at high risk for falls due to an unsteady gait, history of falls, poor safety awareness, and episodes of hypotension, and his MDS showed a BIMS score of 3 out of 10, reflecting severe cognitive impairment. During observation in the secured unit dining room, the resident was sitting at a table eating dinner while a large puddle of liquid was visible under his chair and staff were busy assisting other residents. An LVN stated she did not initially see the puddle, went to get a towel, and placed it over the liquid, and acknowledged the resident could slip and fall if he stepped on it. The ADON stated he did not see the spill, confirmed the resident ambulated and was not steady, and stated the resident could slip and fall if he stood up and stepped on the water. The LVN later stated the spill was not urine and that it was the responsibility of nursing staff to ensure the resident environment was free of accident hazards.
Incorrect Docusate Dose Administered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident when RN F administered the wrong dose of Senna-Docusate to Resident #5. The resident was admitted with diagnoses including encounter for other orthopedic aftercare and driver injured in collision with unspecified motor vehicles in traffic accident, subsequent encounter. Her physician’s order required Senna-Docusate Sodium 8.6-50 mg, 2 tablets by mouth twice a day for constipation, and her quarterly MDS showed a BIMS score of 15 out of 15. Her care plan identified constipation related to decreased mobility and pain, with an intervention to monitor, document, and report signs and symptoms of complications related to constipation. Record review and interviews showed that on 10/20/25, Resident #5 received two 100 mg Docusate tablets instead of the ordered two 50 mg tablets. Resident #5 stated she questioned the pills after receiving them and later confirmed the bottle contained 100 mg tablets, telling RN F she was supposed to receive 50 mg tablets. RN F stated she did not look at the order and instead grabbed the OTC bottle of Docusate, thinking the resident was asking for a PRN dose and not knowing it was scheduled. RN F acknowledged the wrong milligrams constituted a medication error but did not complete a medication error report. ADON G stated the incident should have been documented as a medication error, with physician notification and a progress note, and record review showed no medication error report and no documentation that the doctor was called.
Incomplete Documentation of Medication Error, IV Antibiotic Interruption, and Allergy Medication Change
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident who had been admitted with orthopedic aftercare needs and injuries from a motor vehicle collision and later discharged from the facility. The resident’s record showed active orders for Senna-Docusate for constipation, Vancomycin IV for MRSA to surgical wounds on the right ankle and foot, and Loratadine for seasonal allergies. Her BIMS score was 15 out of 15, indicating no cognitive impairment, and her care plan included interventions for constipation, wound infection, and seasonal allergies. Record review and interviews showed that nursing staff did not document a medication error when RN F administered two 100 mg tablets of Senna-Docusate instead of two 50 mg tablets. RN F acknowledged that giving the wrong milligrams was a medication error but stated she did not complete a medication error report. ADON G also stated the incident would require a medication error report and a progress note, and confirmed that neither was completed in the resident’s electronic record. The resident stated she questioned the pills after receiving them and later confirmed the tablets were 100 mg, not the 50 mg tablets she had been receiving. The record also showed that Vancomycin doses were coded as held or other on two occasions, but the progress notes did not explain why the resident did not receive the medication. RN F stated she had difficulty with the IV access, made two unsuccessful attempts to reinsert the IV into the back of the resident’s right hand, and did not complete a progress note or SBAR for the incident. In addition, ADON D stated he notified the resident when Loratadine was changed from scheduled to PRN administration, but he did not document a progress note about that discussion. The DON stated nursing staff should complete an SBAR and/or progress note for changes in a resident’s treatment, but no policy was provided.
Dirty Dining Room Vents in Secured Unit
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 1 dining room in the secured unit because the vents were not cleaned and had excess lint. During observation, residents were seen walking in the hallway and some were sitting in the dining room, and a later tour of the secured unit with the ADON revealed 3 vents in the dining room with black residue on the outside and built-up lint around the edging of the vents. The ADON stated the dirty vents could cause residents to develop a respiratory infection and get sick, and also stated he knew the MS cleaned vents on a schedule according to the maintenance application but did not know when the vents in the secured unit were last cleaned. A resident's family member reported visiting the resident multiple times a week and said the dining room vents were especially dirty and covered with lint. The family member stated she had reported the concern to the ADON, MS, DON, and ADM, and said the administrative staff did not listen to her. The DON stated the MS was supposed to clean the vents in the secured unit during March 2026 when the concern was brought to her and the ADM's attention, and also stated the family member had complained about the dirty vents. The facility policy stated housekeeping and maintenance personnel were to maintain the facility in a safe, clean, orderly, and attractive manner and keep it free from accumulations of dirt, rubbish, dust, and hazards.
Improper Hot Food Holding Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen observed. During an observation on 12/11/2025 at 11:45 a.m., the cook took the temperature of the bread puree on the serving line and it measured 116 degrees. During interviews later that day, the cook stated hot items should be held at 145 degrees or above and that items not meeting holding temperatures could be reheated in the microwave; the cook also stated the lower temperature could increase the risk of bacteria in the food. The DM stated hot items should be held at 135 degrees and above for regulation and safety and that foods not meeting the appropriate holding temperatures could be reheated in the oven or microwave. The DON stated on 12/12/2025 that there had not been any foodborne illness outbreaks in the facility this year. The facility's policy, Food Holding and Service, revised 06/01/2019, stated hot foods should be served at 135 F or greater and held for less than one hour while maintaining the required temperatures.
Food items were left unsealed, undated, and spoiled in kitchen storage areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during a kitchen observation. In the kitchen refrigerator, surveyors observed an unsealed cheese bag dated 12/4/2025, an unsealed cilantro bag dated 12/5/2025, and a tomato that appeared spoiled. In the kitchen freezer, an unsealed pizza dough bag dated 10/26/2025 was observed. In the kitchen pantry, surveyors observed an undated container of macaroni pasta. During interview, the DM stated that once items were opened, they were to be placed in a Ziploc bag, sealed, dated, and stored. The DM also stated that when pasta is received, it is poured into a container and labeled with a date, that tomatoes should be red and fresh, and that the tomato found was not. The DM stated that if produce goes bad while at the facility it is thrown away, and that other foods can come in contact with unsealed foods and affect food safety. Record review of the facility's Food Storage policy stated that opened and bulk items must be stored in tightly covered containers, all containers must be labeled and dated, refrigerated foods must be dated, labeled, and tightly sealed, and frozen foods must be stored in moisture-proof wrap or containers that are labeled and dated.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that Resident #1 had the call light within reach. Resident #1 was a male admitted on 11/19/25 with diagnoses including diabetes mellitus, dependence on renal dialysis, and myopathy. His admission MDS assessment showed a BIMS score of 09, indicating moderate cognitive impairment. His care plan dated 12/09/25 did not address the call light. During observation and interview on 12/9/25 at 10:10 AM, Resident #1's call light was found behind the nightstand and out of arm's reach. Resident #1 stated he never knows where his call light is and hopes and prays someone will come and check on him today. The assigned LVN confirmed the call light was behind the nightstand and stated she did not know how it got there, but would place it within reach at once. The DON later stated that call light accessibility is important and that charge nurses monitor this task during daily morning rounds, with the ADON overseeing the process. The facility policy stated that the call light system will be accessible to residents while in bed or other sleeping accommodations within the resident's room.
Failure to Refer Resident With New Mental Health Diagnosis for PASARR Review
Penalty
Summary
The facility failed to refer all level II residents and residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review after a significant change in status assessment. For Resident #68, the MDS Case Manager did not refer the resident for a level II resident review when a new serious mental health diagnosis was identified. Resident #68 was a [AGE]-year-old male admitted with type 2 diabetes mellitus with diabetic chronic kidney disease, and the MDS showed a BIMS score of 4 out of 15, indicating severely impaired cognition for daily decision-making. Record review showed Resident #68 had a diagnosis of major depressive disorder, recurrent severe without psychotic features, with an onset date of 10/27/2025, and the history and physical note also documented that diagnosis. During interviews, the MDS Case Manager stated they reviewed PASARR documents on admission and believed major depressive disorder did not trigger a PASARR positive, and stated that when a resident has a new MI diagnosis they need to complete and submit form 1012 to the physician. The MDS Case Manager also stated the DON was responsible for informing MDS of residents with newly diagnosed MI or IDD. The RDS nurse stated form 1012 should have been completed and submitted for Resident #68 so the physician could decide whether PASARR needed to be redone. The DON stated the MDS Case Manager was responsible for PASARR for residents and was not sure of the process for notifying MDS of new MI or IDD diagnoses.
Care Plan Missing Isolation and Wound Precautions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #83 that included measurable objectives and timeframes for her identified medical and nursing needs. Resident #83 was admitted with diagnoses including sepsis, C-diff, pseudomonas, major depressive disorder, anxiety, and a stage 2 pressure ulcer of the right buttock. Her quarterly MDS showed she could usually understand and be understood, had a BIMS score of 9, had a UTI in the last 30 days, and had active diagnoses of C-diff, sepsis, pseudomonas, and a pressure ulcer. The MDS also reflected isolation or quarantine for active infectious disease and substantial to maximal assistance with ADLs. Review of the comprehensive person-centered care plan dated 11/24/2025 showed a problem for gastrointestinal infection with an intervention to administer antibiotics per MD orders, and a problem for pressure ulcer with altered skin integrity. The care plan did not reflect Contact Isolation for the C-diff infection, did not include EBP for the infected wound that required treatment and a dressing, and did not reflect the use of PPE as an intervention. Active orders showed Contact Isolation for C-diff and a wound treatment order for the stage 2 right gluteus wound, along with oral vancomycin orders for C-diff. Lab results were positive for C-diff toxin, and a wound culture showed Pseudomonas aeruginosa growing in the wound. During observation, Resident #83 had a plastic bin outside her room containing paper gowns, gloves, and masks, but no Contact Isolation sign or EBP sign was seen. A yellow sign on the door stated to check with the nurse before entering the room. The DON and the MDS nurse both stated that the care plan needed to reflect the isolation requirements, the type of PPE required, and the EBP for the wound, and that the missing information could result in staff not knowing what care or precautions were required.
Oxygen Concentrator Filter Not Kept Clean
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident who required oxygen therapy via trach collar mask at 2 L/min. The resident had diagnoses including epilepsy, anoxic brain damage, respiratory failure with hypoxia, dementia, and quadriplegia. His quarterly MDS reflected that he rarely understood and was rarely understood, was not a candidate for BIMS, was severely cognitively impaired, was dependent on staff for ADLs, and was not interview-able. His care plan identified a tracheostomy and risk for hypoxia, with interventions to administer oxygen at 30 percent via collar mask oxygen and oxygen at 2 L/min, and the active order directed oxygen via trach collar mask at 2 L/min. During observation, the resident was lying in bed with humidified oxygen via trach collar and mask infusing, and the oxygen concentrator was set at 2 L/min. The black foam filter on the right side of the concentrator was clean, but the left-side filter was gray from dust and air particles; the surveyor was able to touch the filter and move the dust to reveal the black foam. A later observation showed the left filter remained covered with dust and air particles. The DON confirmed the dust and dirt particles on the filter and stated she thought the filters needed to be checked and cleaned once a week, but there were no guidelines or process for cleaning and checking oxygen concentrator filters.
Unlabeled, Undated Food Stored in Resident Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of residents’ food items in one personal refrigerator in resident room 301-B. During observation on 12/10/2025 at 9:05 a.m. and again on 12/11/2025 at 8:50 a.m., surveyors found an opened pint of ice cream in the refrigerator that was unlabeled and undated, even though it had an expiration date of 03/15/26. A further observation on 12/11/2025 at 12:54 p.m. showed the ice cream was still present in the refrigerator. During interview on 12/11/2025 at 2:00 p.m., an LVN confirmed that the refrigerator in resident room 301-B contained the opened ice cream pint with an expiration date of 3/15/2026 and that it was unlabeled and undated. During interview on 12/12/2025 at 9:30 a.m., the DON confirmed that perishable food in residents’ personal refrigerators should be labeled and dated to prevent residents from consuming spoiled food, and stated that night shift nurses were responsible for overseeing this and that it was not currently being monitored. Record review of the facility policy, Use and Storage of Food Brought in by Family or Visitors, dated 1/27/2023, stated that all food items prepared by family or visitors must be labeled with the contents and dated, and if not consumed by 3 days, facility staff will throw the food away.
Missing EBP and Isolation Signage for Residents With Wounds and C-Diff
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents who had wounds and, in one case, C-Diff. Resident #36 had a stage 2 buttock wound with treatment orders for cleansing, collagen powder, and a hydrocolloid dressing. Although staff stated that enhanced barrier precautions (EBP) signage was required for residents with open wounds and that the resident should have had EBP signage, observations on 12/11/2025 at 10:04 a.m. and again at 2:15 p.m. showed no EBP sign posted by the door. Resident #83 had diagnoses that included sepsis, C-Diff, pseudomonas aeruginosa, and a stage 2 pressure ulcer of the right buttock. Her records showed a positive C-Diff toxin result, contact isolation orders for C-Diff, and wound treatment orders for the right gluteus with a gauze dressing. Observations on 12/09/2025 and 12/10/2025 showed PPE supplies outside the room, but no Contact Isolation sign and no EBP sign were posted. A yellow sign on the door stated only, "Check with nurse before entering room." During interviews, the DON confirmed there was no EBP or Contact Isolation sign outside Resident #83's room and stated the yellow sign was thought to be enough for staff to go to the nurse and find out what the resident needed. The treatment nurse stated she knew the resident had C-Diff and a wound but did not notice that the signs were not placed. The LVN who readmitted the resident stated she knew the contact isolation order and wound treatment order were present and that signs should have been posted, but she did not know why they were not. Facility staff also stated they were responsible for posting EBP signage for residents with wounds and other conditions requiring precautions.
Medication Cart Left Unattended and Unlocked
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) left the 300-hall medication cart unattended and unlocked while she stored a bottle of enteral feeding formula in the facility's resident pantry. During this time, the cart was stationed at the end of the 300-hall and was not within the nurse's line of sight. Another LVN later locked the cart and confirmed it was assigned to the nurse who had left it unattended. Interviews with the administrator and DON confirmed that facility policy requires medication carts to be secured and locked when not directly attended, and a review of the facility's policy reiterated that medication carts must be locked at all times when out of the nurse's view.
Failure to Label and Date Resident Food in Pantry Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an inspection of the resident pantry refrigerator, multiple food items including berries, desserts in foam containers, a half sandwich, and a cookie were found without any labels or dates. The refrigerator had signage instructing that all food should be labeled with the resident's name, room number, and date when placed into storage, and that unlabeled food would be disposed of. However, these instructions were not followed, as confirmed by staff interviews. Interviews with the Administrator and DON confirmed that the facility's expectation was for nursing staff to inspect the resident pantry refrigerator daily to ensure all food items were properly labeled and dated. The facility's policy required all resident food items to be labeled with the resident's name, the item, and a use-by date, and specified that partially eaten food should not be kept in the refrigerator. Despite these policies, the observed food items were not labeled or dated, and partially eaten food was present, indicating a failure to adhere to established food safety protocols.
Resident Injury Due to Inadequate Supervision During Transport
Penalty
Summary
The facility failed to ensure adequate supervision and proper securing of a resident during transportation, leading to an accident. On the specified date, a resident was not properly secured in the facility's transport van, resulting in a fall that caused fractures to the resident's fingers and elbow. The incident occurred when the van driver had to apply the brakes suddenly, causing the resident to fall forward in her wheelchair. The resident involved was an elderly female with multiple medical conditions, including metabolic encephalopathy, seizures, acute kidney failure, and dementia. She was dependent on others for transfers and transportation, and her medical records indicated a high risk for falls. At the time of the incident, the resident was being transported to a medical appointment, and it was noted that the seat belt was loose, contributing to the fall. Interviews and observations revealed inconsistencies in the van driver's account of the incident, initially stating that the resident was injured by the van door. However, further investigation indicated that the resident's injuries were likely due to improper securing of the seat belt and shoulder strap. The facility's maintenance supervisor and administrator acknowledged that the resident was not properly secured, which led to the accident.
Food Storage and Labeling Deficiency in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, specifically regarding the storage and labeling of food items. During an observation, it was noted that three packets of bread in the freezer were not labeled or dated, which is a requirement according to the facility's food storage policy. Additionally, one of the packets, containing French toasted bread, was found with a torn plastic bag, leaving the contents exposed. This oversight was acknowledged by the Kitchen Supervisor, who admitted to not knowing when the bread was opened and confirmed that the staff should have labeled and dated the packets and replaced the torn bag to prevent food contamination. Further interviews with the Kitchen Supervisor and the Registered Dietitian confirmed the lapse in following food safety protocols. The Registered Dietitian emphasized the importance of labeling, dating, and ensuring the integrity of food packaging to prevent potential foodborne illnesses. The facility's policy, revised in 2019, clearly outlines the necessity for storing food in moisture-proof wrap or containers that are labeled and dated, in compliance with state, federal, and US Food Codes and HACCP guidelines. The failure to comply with these standards could place residents at risk of foodborne illness.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and failure to use appropriate personal protective equipment (PPE) during resident care. Specifically, a Certified Nursing Assistant (CNA) did not properly sanitize her hands while providing incontinent care to a resident with severe cognitive impairment and a history of dementia, epilepsy, and traumatic brain injury. The CNA admitted to not rubbing the sanitizer between her fingers, which is a crucial step in ensuring complete hand hygiene. This oversight was confirmed by the Director of Nursing (DON), who acknowledged that improper hand hygiene could lead to cross-contamination and pose an infection risk to residents. In another instance, two CNAs failed to wear gowns while providing incontinent care to a resident on Enhanced Barrier Precautions (EBP) due to Alzheimer's disease and other medical conditions. Despite a clear sign on the resident's door indicating the need for gown and gloves during high-contact care activities, the CNAs only wore gloves. They later acknowledged their mistake, attributing it to nervousness, and recognized that their failure to wear gowns could potentially lead to infections for the resident. The DON confirmed that wearing gowns was necessary for such high-contact activities under EBP to prevent the transmission of multiple-resistant organisms. The facility's policies on hand hygiene and enhanced barrier precautions were not adhered to during these incidents. The hand hygiene policy required thorough sanitization of all hand surfaces, including fingers, while the EBP policy mandated gown and glove use during high-contact care activities. These lapses in following established protocols highlight deficiencies in the facility's infection control practices, potentially compromising resident safety.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during the provision of incontinent care. Specifically, two CNAs did not completely close the privacy curtain while attending to a resident, who was severely cognitively impaired and required extensive assistance with activities of daily living. This oversight exposed the resident to view from the room's door, compromising her privacy. The resident's roommate was present in the room during this incident. Interviews with the CNAs confirmed that the privacy curtain was not fully closed, although they acknowledged it should have been. Both CNAs had received training on resident rights within the year. The Director of Nursing also confirmed that privacy should be maintained during care and that the staff had been trained on resident rights. However, it was noted that the facility did not have a specific policy regarding the closure of privacy curtains during care.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care documentation. For one resident, the quarterly Minimum Data Set (MDS) inaccurately recorded the resident as receiving an anticoagulant medication. The resident was actually receiving two antiplatelet medications, Clopidogrel and Aspirin, which were incorrectly coded as an anticoagulant. The MDS Coordinator confirmed the error, acknowledging a lack of understanding regarding the classification of these medications. Another resident's annual MDS inaccurately reflected that the resident did not use tobacco, despite evidence to the contrary. The resident was documented as a smoker in the comprehensive care plan and was observed smoking at the facility. The MDS nurse admitted the mistake, recognizing that the resident's tobacco use should have been accurately recorded in the MDS. This error was acknowledged during interviews with the resident and facility staff. The facility did not have a specific policy regarding MDS accuracy, relying instead on the CMS MDS 3.0 Manual. The inaccuracies in the MDS assessments could potentially lead to inadequate care and services for the residents involved, as the assessments did not accurately reflect their current health conditions and medication use.
Failure to Refer Resident for PASARR Re-evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR review after a new diagnosis of schizoaffective disorder-bipolar type was made. The resident, a male with a history of cirrhosis of the liver, hypertension, atherosclerotic heart disease, and schizoaffective disorder-bipolar type, was admitted from an acute hospital with a negative PASARR Level I evaluation. Despite the new diagnosis and the prescription of antipsychotic medication Zyprexa, the facility did not initiate a re-evaluation for PASARR, which is required when there is a significant change in a resident's mental status. Interviews with the Director of Nursing (DON) and MDS nurses revealed a lack of awareness and policy regarding PASARR re-evaluation. The MDS nurses, who were relatively new to their roles, acknowledged the oversight but were unsure why the referral was not made. The DON confirmed that the facility did not have a policy for PASARR re-evaluation and was following CMS regulations. This oversight could potentially result in the resident not receiving necessary mental health services.
Failure to Implement Comprehensive Care Plan for Bowel Incontinence
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and multiple medical conditions, including dementia, major depressive disorder, hypertension, muscle wasting, and chronic kidney disease. The resident, who was always incontinent of both bladder and bowel, did not have a care plan addressing bowel incontinence, despite the requirement for substantial assistance with daily activities and hygiene. The care plan only addressed bladder incontinence, with interventions such as cleaning the peri-area after each episode and encouraging fluid intake. Interviews with facility staff, including a CNA and the MDS Coordinator, confirmed the resident's bowel incontinence and the absence of a corresponding care plan. The MDS Coordinator, who was recently hired, was unaware of why the bowel incontinence care plan was missing. The Director of Nursing revealed that the facility did not have a specific policy regarding care plans and was following CMS regulations. The lack of a care plan for bowel incontinence could potentially lead to skin breakdown due to inadequate care.
Failure to Follow Physician's Order for Enteral Feeding Rate
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was provided with the appropriate treatment and services as prescribed by the physician. Specifically, the resident, who was a female with severe cognitive impairment and multiple medical conditions including dementia, dysphagia, and type 2 diabetes, was receiving Glucerna at a rate of 55 ml/hour via a gastrostomy tube. However, the physician's order, dated four days prior, specified that the resident should receive Glucerna at a rate of 60 ml/hour for 18 hours a day. The discrepancy was observed during a survey, and it was confirmed through interviews with the nursing staff and the Director of Nursing (DON) that the physician's order was not followed. The Licensed Vocational Nurse (LVN) acknowledged the error, stating that the nurse forgot to adjust the rate to 60 ml/hour as per the updated physician's order. The facility's policy on medication administration, which includes tube feeding, mandates that medications and feedings are administered as ordered by the physician. This oversight could potentially lead to the resident not receiving the necessary caloric intake, as noted by the DON.
Failure to Maintain Nebulizer Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in maintaining the cleanliness and timely replacement of nebulizer equipment. The resident, an elderly female with severe cognitive impairment and multiple health conditions including Alzheimer's disease, hypertension, and cardiac arrhythmia, was observed to have a nebulizer mask and tubing that were not replaced as per facility policy. The equipment was found covered in a plastic bag with a date indicating it had not been changed since July, despite the policy requiring weekly changes. Interviews with facility staff, including an LVN and the DON, confirmed that the nebulizer equipment should have been changed weekly to prevent potential respiratory infections. The staff acknowledged the oversight and the risk it posed to the resident's health. The facility's policy on nebulizer use clearly stated that equipment should be labeled with the setup date and changed after seven days of use, which was not adhered to in this case.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to ensure that residents have the right to formulate an advance directive and determine their choice to receive or not receive CPR. Specifically, a resident did not have advance directives documented in the admission agreement or electronic medical record from the date of admission to discharge. The resident was admitted with a diagnosis of Alzheimer's Disease and had an order for Full Code status, but no advanced directive care planning was scheduled with the resident's representative. The resident's representative did not sign the facility admission agreement that discusses advanced directives prior to or after the resident's admission to the facility. Interviews with the Admissions Director, Social Worker, and Director of Nursing (DON) revealed that the admissions packet, which includes advanced directives, was not completed prior to or during the resident's stay. The Social Worker was on vacation during the resident's admission, and the MDS Nurse, who had just started, did not address advanced directives. The facility's policy requires the admission agreement to be completed within 24 to 48 hours of admission, but this was not adhered to in this case. The facility's advanced directives care planning policy emphasizes the importance of documenting whether a resident has executed an Advance Directive, but this was not done for the resident in question.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Eagle Pass
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Hacienda De Paz Rehabilitation And Care Center | 0.3 mi | ★★★★★ | 14 | 0 |
| Eagle Pass Nursing And Rehabilitation | 1.3 mi | ★★★★★ | 0 | 0 |
| Whispering Springs Rehabilitation And Healthcare C | 38.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Maverick Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.