Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mesa Springs Healthcare Center during CMS and state inspections, most recent first.
A resident with hemiplegia, ataxic gait, and cognitive communication deficit, who uses a wheelchair for ambulation, was transported in the facility van without being buckled in by the van driver. When the driver stopped suddenly, the resident fell from the wheelchair onto the van floor, later reporting generalized body pain and receiving pain medication after nursing assessment. Other residents reported always being buckled in during van transport. The facility’s abuse/neglect policy defines neglect and requires reporting allegations to state agencies within specified timeframes, but the Administrator did not report this incident externally, believing it was not neglect, and the transportation policy did not address securing residents in the van.
Failure to Submit PBJ Staffing Data: The facility failed to electronically submit complete and accurate PBJ staffing data to CMS for a quarter after a payroll vendor system upgrade delayed review and validation of the file. The PBJ was submitted late, an error code was not identified by the contracted service, and CMS rejected the entire file.
Improper Storage of Respiratory Equipment: Three residents receiving respiratory care had respiratory equipment left open to air or on the floor/bedside when not in use. One resident used continuous O2 via NC for hypoxic respiratory failure, another had asthma and COPD with continuous O2, and a third received nebulized Budesonide for asthma and COPD. Staff interviews confirmed NCs and nebulizer masks should be stored in plastic bags when not in use, but the facility policy did not address this storage practice.
Failure to Obtain Informed Consent for Bed Rails: The facility did not review the risks and benefits of bed rails with the resident or representative and did not obtain informed consent before bed rails were installed for three residents. One cognitively intact resident with stroke-related weakness, one resident with dementia and severe cognitive impairment, and one resident with a BKA all had bed rails or mobility bars in place, but records and staff interviews showed missing or delayed consents and no clear evidence that the required information was provided before installation.
Food was served below required temperatures when a meal cart was observed leaving the kitchen and sample trays were later tested with hot items ranging from 111 F to 130 F, below the facility’s 145 F serving standard. In a resident group meeting, 6 of 12 residents said meals were cold in their rooms and not appealing, and dietary staff confirmed they were responsible for monitoring serving temperatures while the cook was responsible for ensuring hot foods were 145 F and above.
Kitchen staff failed to date covered milk, fruit, and gelatin items in the refrigerator, left vanilla pudding cups on the pantry floor, and allowed the steam table to remain dirty with food particles and brown debris. Staff interviews confirmed that dietary aides were responsible for dating trays, all staff were responsible for keeping food off the floor, and cooks were responsible for cleaning the steam table; the facility policy required equipment to be cleaned and sanitized before use and food to be stored above floor level.
Care plans for two residents did not include bed rail use despite Bed Rail Safety Evaluations showing IDT recommendation for the rails. One resident had hemiplegia after CVA with intact cognition and used quarter rails to help with turning in bed, while the other had dementia with severe cognitive impairment and also had a quarter rail in place. Staff interviews showed they relied mainly on physician orders and acknowledged the bed rails were not added to the care plans.
A CNA had no documented dementia management training upon hire or while working at the facility, and there was also no evidence of required abuse, neglect, and exploitation education or reporting training. The ADMN and HR both acknowledged the missing training records, with HR stating the CNA’s CBT training may have been missed and the ADMN confirming she could not find proof the training had been completed.
Failure to provide QAPI training to a CNA: Record review showed CNA F had no evidence of completing required QAPI education upon hire or while employed. The ADMN said staff were expected to receive appropriate training and that she could not find documentation of CNA F’s in-service or CBT completion, while HR confirmed there was no evidence of QAPI training and said the missed training may have been overlooked when the CNA was rehired.
Missing Compliance and Ethics Training for CNA. The facility failed to include compliance and ethics training in its program and failed to ensure a CNA received required training upon hire. Record review showed the CNA had no evidence of completing the CBT or any in-service on compliance and ethics, and both the ADMN and HR confirmed there was no documentation of the training. The 2025 facility assessment listed staff training topics but did not mention compliance and ethics.
A resident with multiple medical conditions had a family member report concerns of neglect and dissatisfaction with care provided by an LVN, including allegations that wound care was not performed as ordered. Despite these concerns being communicated to facility leadership, no grievance form was completed and no investigation was initiated, contrary to facility policy requiring immediate documentation and investigation of grievances.
A facility did not follow its policy to investigate and report an allegation of neglect after a family member accused an LVN of failing to provide proper wound care to a resident with multiple medical conditions. Although the concern was communicated to facility leadership, it was not treated as a reportable allegation, and no investigation or state notification occurred as required.
The facility failed to remove expired medications and supplies from the medication room and treatment cart, including a vancomycin IV bag, lancets, IV start kits, lubricating jelly, Anasept gel, and packing iodoform strips. Staff interviews revealed a lack of awareness and responsibility for checking and removing expired items, despite existing policies. This oversight could impact the therapeutic benefits for residents.
Expired COVID and influenza testing kits were found in the medication room, posing a risk of inaccurate results. Staff interviews revealed a lack of awareness and oversight in managing expired supplies, with the DON and ADON expressing expectations for expired goods to be destroyed.
The facility failed to properly store, label, and cover food in accordance with professional standards, as observed in their kitchen operations. Unsealed and unlabeled food items were found in refrigerators and the freezer, and desserts were transported uncovered, posing a risk of cross-contamination. The Dietary Manager acknowledged these issues, and the Interim Administrator emphasized the importance of following food safety policies.
The facility failed to implement its policy on food storage for residents, leading to expired goods and inadequate temperature monitoring in personal refrigerators for three residents. A resident's refrigerator contained expired whip cream and Ranch dressing, while another's had expired cultured buttermilk without a thermometer. A third resident's refrigerator lacked a temperature log and thermometer. Staff interviews revealed confusion over monitoring responsibilities, with the Director of Maintenance unaware of the need for thermometers.
The facility failed to maintain an effective infection prevention and control program, as two staff members did not adhere to proper PPE protocols. A CMA entered a COVID-positive resident's room without a face shield and mishandled contaminated materials, while another CMA improperly cleaned a face shield. The DON acknowledged staff training on PPE but noted non-compliance with protocols.
A resident's grievance about roommate incompatibility was not properly addressed by the facility. The grievance was verbally reported to an RN, who placed it on the DON's desk, but it was never received or logged. The SW was aware of the concern but did not document it as a formal grievance. The facility's grievance policy was not followed, leading to a deficiency in addressing resident concerns.
The facility failed to conduct PASRR evaluations for two residents with serious mental disorders, including major depressive disorder and schizoaffective disorder. Despite the facility's policy requiring PASRR evaluations upon admission, these residents were not referred for necessary evaluations, potentially affecting their access to specialized services. Staff interviews revealed issues with adherence to policy and staff turnover as contributing factors.
A resident with severe cognitive impairment and a history of falls had a care plan requiring his wheelchair to be placed at his bedside to prevent falls. However, the wheelchair was found in the bathroom, contrary to the care plan, due to staff misunderstanding. The resident's family raised concerns, and the DON acknowledged the error, attributing it to miscommunication.
A facility failed to change a resident's oxygen tubing weekly as per physician's orders, risking respiratory complications. The resident, with severe cognitive impairment and multiple health issues, was found with tubing unchanged since 01/06. The DON confirmed the oversight, attributing it to a lapse in protocol adherence, despite random checks by nursing leadership.
A treatment cart containing medications and medical supplies was left unlocked and unattended at a nurses' station, with residents present in the area. RN G admitted to forgetting to lock the cart due to being in a hurry, and the DON confirmed that the expectation was for all carts to be locked when not in use.
The facility failed to ensure privacy for two residents, leading to deficiencies in maintaining dignity. One resident was left uncovered during care without a privacy curtain, while another lacked a privacy curtain in her room. Staff interviews confirmed these oversights, which violated the facility's policy on resident rights.
A resident reported being verbally abused by her roommate, but the facility failed to conduct a thorough investigation. Despite staff witnessing the abuse and reporting it, the administrator did not fully investigate, mistaking the issue for a family dispute. The facility's policy requires immediate protection and thorough investigation of abuse allegations, which was not followed in this case.
A resident with Alzheimer's and dementia experienced a fall resulting in a forehead laceration requiring emergency treatment. The facility failed to update the resident's care plan to address the fall, despite having a policy for comprehensive person-centered care planning. Interviews revealed that the incident was not flagged for care planning during morning meetings, leading to a lapse in updating the care plan.
Failure to Report Van Transport Incident as Potential Neglect
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse and neglect policies by not reporting an incident of potential neglect to the state agency within the required timeframe. A female resident with hemiplegia affecting the right dominant side, ataxic gait, and a cognitive communication deficit, who required a wheelchair for ambulation and had a BIMS score of 99 (unable to assess cognitive impairment), was being transported back from a dental appointment in the facility van. During this transport, the van driver failed to buckle the resident into her wheelchair. When the van stopped suddenly, the resident fell out of her wheelchair and onto the floor near the driver’s seat. Nursing documentation showed that on the date of the incident, the van driver reported that the resident had fallen from her wheelchair and rolled over near the driver’s seat and that she did not have a seat belt on at the time the van stopped. A nurse assessed the resident upon return to the facility; the resident complained of generalized body pain but had no documented injuries and received pain medication, which was recorded on the Medication Administration Record. In an interview, the resident confirmed she had not been buckled in, that the driver had to stop suddenly, and that she fell onto the floor of the van. She stated that the driver assessed her, helped her back into the wheelchair, and then secured her with a strap, and she reported that she had always been buckled in on prior trips. Interviews with other sampled residents who used the van indicated they reported always being buckled in during van rides. The facility’s abuse prevention policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and stated that allegations of abuse or neglect would be reported outside the facility to appropriate state or federal agencies within applicable timeframes. The Administrator acknowledged that an internal investigation determined the van driver had failed to buckle the resident in but stated she did not report the event to the state because she did not consider it neglect. The facility’s transportation policy for diagnostic appointments did not address the requirement to buckle or secure residents while using the van.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for FY Quarter 4 2025, based on payroll and other verifiable and auditable data in the required uniform format. Review of the Staffing Data Report showed the facility triggered for Failed to Submit Data for the quarter, and the PBJ nurse staffing levels for October 1 through December 31, 2025 reflected reported hours for total nurse, RN, LVN, nurse aide, and PT staffing, but the submission was not accepted by CMS. During interview, the ADMN stated the facility had upgraded its payroll vendor system in January and February 2026, which caused an unanticipated delay in reviewing and validating the information for submission. She stated the PBJ was submitted after 5:00 p.m. on February 13, 2026, but an error code was not identified by the contracted service, and the issue was not discovered until after the submission error occurred. Record review of the facility's Process Improvement Plan for F851 stated the PBJ file failed to submit successfully before the deadline due to an inadvertent coding error following a system upgrade, causing CMS to reject the entire file.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment was properly stored when not in use for three residents receiving respiratory care. Resident #19 had a history of hypoxic respiratory failure and was ordered oxygen at 2-4 liters per minute via nasal cannula to keep oxygen above 90 percent. Resident #24 had diagnoses of asthma and COPD and was ordered continuous oxygen at 2 liters per minute via nasal cannula. Resident #31 had asthma and COPD and was ordered Budesonide inhalation suspension twice daily for asthma and COPD. On observation, Resident #24's nasal cannula was found left open to air and on the floor in an empty room. Resident #31's nebulizer mask was observed on the nightstand, open to air and uncovered; the resident stated the staff had administered her medication that morning and that the mask was usually stored in a plastic bag. Resident #19's nasal cannula was observed left on the bed in an empty room. During interviews, CNA H stated nasal cannulas and nebulizer masks should be stored in plastic bags when not in use to prevent contamination and that all staff were responsible for proper storage. RN I stated the items needed to be stored in a bag when not in use and should be discarded if not stored properly. The DON also stated oxygen tubing and masks were to be stored in a bag when not in use and that not storing them in bags was an infection control issue. Review of the facility's undated Oxygen Administration policy did not address storage of oxygen tubing or nebulizer masks when not in use.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to review the risks and benefits of bed rails with residents or their representatives and failed to obtain informed consent before bed rails were installed for 3 of 5 residents reviewed. The deficiency involved Resident #2, Resident #3, and Resident #6, all of whom had bed rails or mobility bars on their beds and were identified in the record review as having bed rail safety evaluations completed by the interdisciplinary team. Resident #2 was a cognitively intact female with hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and dependence for much of bed mobility and transfers. Her record reflected a bed rail safety evaluation stating that bed rails were recommended and that resident education and informed consent should be confirmed before installation. During observation, she had quarter rails on both sides of the bed and stated she used them to help with turning, but she could not state the risks of having the rails. The record did not show a physician order for the bed rail, and staff interviews reflected uncertainty about when the rails were placed and who obtained the consent. Resident #3 was a female with dementia, severe cognitive impairment, muscle weakness, need for assistance with personal care, and unsteadiness on feet. Her record also reflected a bed rail safety evaluation recommending bed rails and stating that resident education and informed consent should be obtained before installation. During observation, she had a quarter rail on the right side of the bed. Her representative stated he had no concerns about her care, did not know when the bed rails were placed, and could not remember whether he had signed a consent for the rail. Resident #6 was a cognitively intact male with a right below-knee amputation and neuropathy who required assistance with bed mobility and transfers. His physician order allowed mobility bars to aid turning and repositioning in bed, and his bed rail safety evaluation recommended bed rails and stated that informed consent should be confirmed before installation. The record showed that the bed side rail consent was signed 17 days after the safety evaluation and 23 days after the physician order. During observation, he had a side rail on the right side of the bed and stated he used it to help get out of bed and move while in bed. Interviews with nursing staff and the DON showed that the facility did not have the consent in the chart for Resident #2 or Resident #3 prior to 03/18/2026 and that the consent for Resident #6 should have been obtained sooner.
Food Served Below Required Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures. During an observation on 03/17/26 at 12:10 PM, the meal cart for the 100-hall left the kitchen and the last tray was delivered to a resident room at 12:23 PM. When sample trays were tested at 12:25 PM, all meal entrees were below the facility’s serving temperature standard, including the mechanical, regular, and puree diets. The tested items included Steak Fritters, [NAME] Beans, Red Potatoes, and Mashed Potatoes, with temperatures ranging from 111 F to 130 F. During a confidential resident group meeting on 03/18/26 at 9:30 AM, 6 of 12 residents reported dissatisfaction with the meals and stated the food was cold when received in their rooms and the appearance was not appealing. They also stated these concerns had been reported to staff before. In interviews on 03/19/26, Dietary staff and the Dietary Manager stated meal serving temperatures were to be at least 145 F, that they monitored temperatures before serving, and that the cook was responsible for ensuring food temperatures were 145 F and above. Record review of the facility’s Infection Control Policy/Procedure stated that hot foods must be kept at 140 F or above.
Kitchen Food Storage, Dating, and Sanitation Lapses
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 the initial kitchen observation on 03/17/26, surveyors found a serving tray with multiple cups of milk covered with plastic wrapping, three small bowls of served fruit covered with plastic wrapping, and a cup of gelatin in the walk-in refrigerator that were not dated. The same observation also identified two boxes of vanilla pudding cups on the floor in the walk-in pantry. Later that morning, the steam table was observed with food particles and brown debris in the metal compartments in the water of the steam table. In interview, Dietary Aide G stated the dietary staff were responsible for dating trays with food and drinks, that all staff were responsible for keeping food items off the floor, and that the steam table was to be cleaned and maintained by the cook. She also stated the dishwasher and the [NAME] were responsible for monitoring sanitation levels before washing dishes, and that improper sanitation could result in dishes and utensils not being cleaned or sanitized correctly. The Assistant Dietary Manager stated the dietary aides who prepped trays with drinks and food were responsible for dating them and that the trays should have a 3-day date. She stated the vanilla pudding cups were not to be on the floor and that all staff were responsible for removing food items from the floor. She also stated the steam table was to be clean before and after meals and that dirty water or food particles in it should be cleaned and changed. The Dietary Manager stated dietary aides were responsible for dating trays, all kitchen staff were responsible for storing food off the floor, cooks were responsible for cleaning the steam table, and all staff were responsible for monitoring dishwasher chemical levels. The facility policy stated all equipment must be cleaned and sanitized before use, food must be stored above floor level and away from the wall, and work areas, floors, and dietary equipment must be kept as clean as possible throughout the work day.
Care Plans Missing Bed Rail Interventions for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for 2 of 16 residents reviewed for care plans. Resident #2 was an [AGE]-year-old female with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and muscle weakness. Her quarterly MDS dated 03/04/2026 showed a BIMS score of 14, indicating intact cognition, and she required a helper to do more than half of the effort for bed mobility and transferring from bed to chair. Her comprehensive care plan reviewed on 03/17/2026 did not include evidence that she utilized a bed rail, and her physician orders also did not reflect a bed rail order. Resident #2’s medical record included a Bed Rail Safety Evaluation dated 03/11/2026 that stated the IDT recommended a bed rail and directed staff to proceed with resident education regarding risks and benefits and to confirm informed consent before installation. During observation and interview on 03/17/2026, Resident #2 was lying in bed with quarter rails on both sides and stated she used the rails to help with turning in bed and wanted to continue having them on her bed. Despite this, the care plan did not reflect the bed rail use. Resident #3 was an [AGE]-year-old female admitted with diagnoses including dementia, muscle weakness, need for assistance with personal care, and unsteadiness on feet. Her quarterly MDS dated 01/26/2026 showed a BIMS score of 0, indicating severe cognitive impairment, and she required assistance for bed mobility and was dependent on a helper for transferring from bed to chair. Her comprehensive care plan reviewed on 03/17/2026 did not include evidence that she utilized a bed rail, and her physician orders also did not reflect a bed rail order. Her record contained a Bed Rail Safety Evaluation dated 03/12/2026 stating the IDT recommended a bed rail and that resident education and informed consent should be obtained before installation. During observation on 03/17/2026, Resident #3 was lying in bed with a quarter rail on the right side.
Missing Required Dementia and Abuse Training for CNA
Penalty
Summary
The facility failed to provide dementia management training for CNA F, a staff member reviewed for required education. Record review showed CNA F had a hire date of 12/30/2025, and HR records contained no evidence that she completed dementia management training upon hire or while working at the facility. The facility’s records also showed that CNA F had no documented training on abuse, neglect, and exploitation reporting, despite the facility assessment identifying these topics as required training for direct care staff and nurse aides. During interviews, the ADMN stated she expected staff to have appropriate training per regulations and acknowledged the facility did not have a training policy, relying instead on regulations for orientation and annual training. She stated she believed an in-service had been done but could not find CNA F’s signature, and the CBT program also showed no evidence of dementia management training for CNA F. HR stated she was responsible for ensuring staff completed CBT training, but she was new to the position and may have missed that CNA F had not completed the dementia care training. HR also stated there was no evidence CNA F had completed the training before her hire date because CNA F had quit and been rehired, and she confirmed there was no evidence CNA F had training on dementia care.
Failure to Provide QAPI Training to CNA
Penalty
Summary
Mandatory training on the facility’s QAPI program was not provided to all staff, as the facility failed to ensure CNA F completed QAPI education upon hire. Record review showed CNA F had a hire date of 12/30/2025, and the HR record contained no evidence that CNA F completed QAPI training either at hire or while working at the facility. The facility’s Facility Assessment identified QAPI as one of the training topics available for direct care staff, and the CBT program was listed as a resource for training and competency validation. During interview, the ADMN stated she expected staff to receive appropriate training per regulations and said the facility did not have a training policy, instead following regulations for orientation and annual training. She stated she believed an in-service had been done but could not find CNA F’s signature, and the CBT program also showed no evidence of QAPI training completion. The HR stated she was responsible for ensuring staff completed CBT training, acknowledged she had no evidence CNA F completed QAPI training, and said CNA F had previously quit and been rehired, which she believed may have contributed to the missed training.
Missing Compliance and Ethics Training for CNA
Penalty
Summary
The facility failed to include compliance and ethics training as part of its compliance and ethics program, including an effective way to communicate the program's standards, policies, and procedures through training or another practical method. The report states that the facility also failed to provide annual training for all new and existing staff for an organization operating 5 or more facilities, and this was identified for 1 of 18 staff reviewed, CNA F. Record review showed CNA F was hired on 12/30/2025 and had no evidence of completing compliance and ethics training upon hire or while working at the facility. During interviews, the ADMN stated she expected staff to receive appropriate training per regulations, said the facility did not have a training policy and relied on regulations for orientation and annual training, and confirmed she could not find CNA F's signature on any in-service record or evidence in the CBT program. The HR stated she was responsible for ensuring staff completed CBT training, was new to the position, and had no evidence that CNA F completed compliance and ethics training. The facility assessment for 2025 listed training topics for staff, including direct care staff, but did not mention compliance and ethics training.
Failure to Address Resident Grievance Regarding Nursing Care
Penalty
Summary
The facility failed to ensure that a resident's grievance regarding the care provided by an LVN was properly addressed according to its grievance policy. A resident with multiple complex medical conditions, including dementia, chronic kidney disease, pressure ulcer, and other comorbidities, had a family member who verbally reported concerns about neglect and dissatisfaction with the care provided by an LVN. The family member specifically requested that the LVN not provide care to her family member and expressed concerns that the LVN was responsible for the resident's wound and decline, alleging that dressing changes were not performed as ordered. Despite these concerns being reported to both the Marketer and the Administrator, no grievance form was completed, and no investigation was initiated by the facility. The Administrator stated she was unsure of the grievance policy and did not act because the family member mentioned contacting the State. The DON did not recall being informed of the concerns and did not believe the comments warranted an investigation. The facility's policy required that grievances be documented and investigated immediately, with written decisions provided if requested, but this process was not followed in this instance. Interviews with staff confirmed that the family member's concerns were communicated to facility leadership, but there was a lack of follow-through in initiating the grievance process. The facility's failure to document and investigate the grievance as required by policy resulted in the resident's complaint not being formally addressed, potentially leaving the concern unresolved.
Failure to Investigate and Report Alleged Neglect
Penalty
Summary
The facility failed to implement and follow its written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for one resident. Specifically, the facility did not investigate or report an allegation of neglect to the Texas Health and Human Services Commission (HHSC) as required by its own policy. The incident involved a family member alleging that an LVN neglected a resident, but the facility did not initiate the mandated investigation or reporting process. The resident involved was an elderly female with multiple complex medical diagnoses, including dementia, chronic kidney disease, pressure ulcer, diabetes, Parkinson's disease, and heart failure. Her care plan and physician's orders required specific wound care interventions, which were documented as being performed as ordered. Despite this, the family member expressed concerns that the LVN did not perform dressing changes as required, leading to the resident's wound worsening and subsequent hospitalization. The family member communicated these concerns to the facility's Marketer, who then reported them to the Administrator. Interviews with facility staff revealed that the Administrator and DON were aware of the family member's dissatisfaction and anger, particularly toward the LVN, but did not interpret the complaint as an allegation of neglect or abuse. As a result, the required investigation and reporting to the State were not initiated. The facility's policy clearly defined neglect and outlined procedures for immediate reporting and investigation, but these procedures were not followed in this instance.
Expired Medications and Supplies Not Removed
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not removing expired medications and supplies from the medication room and treatment cart. During an observation, it was found that a vancomycin IV bag, lancets, IV start kits, lubricating jelly, Anasept gel, and packing iodoform strips were expired and had not been removed. These items were found in one medication room and one treatment cart, indicating a lapse in the facility's procedures for managing pharmaceutical supplies. Interviews with staff revealed a lack of awareness and responsibility regarding the removal of expired items. LVN H admitted to not being aware of the expired items on the treatment cart, as they were not used in recent treatments. LVN F acknowledged the presence of expired items in the medication room and expressed uncertainty about the potential risks of using such items. MA E, responsible for the medication room, was unaware of the need to check for expired supplies, despite being in charge for five months. The facility's policies on the disposal and storage of medications were not adhered to, as evidenced by the presence of expired items. The ADON and DON both stated that expired goods should be destroyed and not stored, and they acknowledged the oversight in the facility's procedures. The failure to remove expired medications and supplies could potentially impact the therapeutic benefits for residents, as noted by the DON.
Expired Testing Kits Found in Medication Room
Penalty
Summary
The facility failed to ensure the quality of laboratory services by not removing expired COVID and influenza testing kits from the medication room. During an observation, it was found that two boxes of COVID testing kits had expired on December 15, 2023, and one box along with four packages of influenza A & B tests had expired on November 30, 2024. These expired kits were still present in the medication room, which could lead to inaccurate testing results for residents. Interviews with staff revealed a lack of awareness and oversight regarding the management of expired supplies. LVN F acknowledged that expired tests should be disposed of and recognized the risk of inaccurate results from using expired kits. MA E, who was responsible for the medication room, admitted to not knowing she should check for expired supplies. The ADON and DON both expressed that their expectation was for expired goods to be destroyed and not stored in the medication room. The DON noted that the lead MA was responsible for weekly checks, and the failure to remove expired supplies was due to oversight.
Food Storage and Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During inspections, it was noted that food items in Refrigerator #1, Refrigerator #2, and the freezer were not properly sealed or labeled. Specifically, a bin of celery and a box of muffins in Refrigerator #1, a box of sausage in Refrigerator #2, and a box of cannoli in the freezer were all found unsealed and exposed to air. The Dietary Manager (DM) acknowledged these issues, stating that such products should be stored in sealed containers to prevent cross-contamination, which could lead to residents becoming ill. The DM also mentioned that continuous training is provided to staff on proper food storage practices. Additionally, during the transportation of food from the kitchen to resident areas, it was observed that cakes on hall carts were uncovered, which the DM admitted could lead to cross-contamination. The DM explained that the failure to cover the desserts was due to staff being in a hurry and mistakenly believing that covering the entire cart was sufficient. The Interim Administrator (ADMN) confirmed that staff should follow policies for dating and labeling food to prevent the risk of residents consuming expired or contaminated food. The Social Worker (SW) noted that all but one resident consumed food from the kitchen, highlighting the potential widespread impact of these deficiencies.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors, leading to unsafe and unsanitary conditions for three residents. Resident #36's personal refrigerator contained expired goods, such as whip cream and Ranch dressing, and lacked a consistent temperature log for the month. Resident #36 was unaware of the expired items due to difficulty reading small labels and requested assistance in disposing of them. Resident #65's personal refrigerator also contained expired goods, specifically cultured buttermilk, and lacked a thermometer to monitor the temperature. The temperature log on the refrigerator was incomplete, with no date or year, and Resident #65 was unaware of the expired items and relied on staff or visitors for assistance. A visitor removed the expired buttermilk to prevent accidental consumption. Resident #23's personal refrigerator did not have a thermometer and lacked a temperature log for the month. The refrigerator contained drinks and food items, including cake in a Styrofoam container. Interviews with facility staff revealed confusion about responsibility for monitoring personal refrigerators, with housekeeping and nursing staff providing conflicting information. The Director of Maintenance, who recently assumed the housekeeping supervisor role, was unaware of the need for thermometers in personal refrigerators.
Inadequate Infection Control Practices by Staff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two staff members, CMA J and CMA K, who did not adhere to proper PPE protocols. CMA J entered a COVID-positive resident's room without wearing a face shield, despite being aware of the requirement to do so. Additionally, CMA J dropped a glove on the floor and continued to assist the resident without replacing it, further compromising infection control measures. CMA J also failed to properly dispose of contaminated materials, placing a tray wrapped in a contaminated bag on the medication cart in the hallway. CMA K was observed carrying a face shield down the hallway to clean it with bleach wipes, instead of cleaning it immediately after exiting a resident's room. This action was contrary to infection control protocols, which require PPE to be cleaned or disposed of before leaving the room. The Director of Nursing acknowledged that staff had been trained on PPE usage but did not follow their training or the facility's policies, which contributed to the potential exposure of residents to COVID-19.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to ensure that residents had the right to voice grievances regarding their care and treatment, as well as other concerns related to their stay. This deficiency was identified for one resident, who was admitted with diagnoses including unspecified dementia, muscle weakness, anxiety disorder, and major depressive disorder. The resident's representative made a verbal grievance to an RN about the resident's incompatibility with her roommate, but the grievance was not properly investigated or resolved by the facility. The RN who received the grievance placed it on the DON's desk, but the DON stated she never received it. The grievance coordinator, who was a different administrator at the time, was not aware of the grievance, and the grievance was not logged in the facility's grievance log. The SW was aware of the concern about the roommate but did not document it as a formal grievance, as she did not receive a formal grievance form. The facility's grievance policy requires that grievances be logged and investigated, but this process was not followed in this case. The facility's grievance log for December did not contain any record of the grievance, and the last grievance listed was dated several days before the incident. The facility's policy outlines that the grievance official is responsible for overseeing the grievance process, but there was a lack of clarity and communication among staff regarding the handling of grievances. This failure to properly address and document the grievance could place residents at risk of not having their concerns heard and resolved.
Failure to Conduct PASRR Evaluations for Residents with Mental Illness
Penalty
Summary
The facility failed to refer two residents for a Pre-Admission Screening and Resident Review (PASRR) evaluation despite their diagnoses of serious mental disorders. Resident #27, a female with major depressive disorder and post-traumatic stress disorder, and Resident #29, a female with schizoaffective disorder, bipolar disorder, and major depressive disorder, were not referred for PASRR evaluations. This oversight was identified through interviews and record reviews, which revealed that neither resident had undergone the necessary PASRR evaluation, potentially impacting their access to specialized therapy and services. Interviews with facility staff, including the social worker and MDS coordinator, highlighted a lack of adherence to the facility's PASRR policy. The MDS coordinator acknowledged the absence of a PASRR evaluation for the residents and attributed it to staff turnover and the absence of a dedicated MDS coordinator at the facility. The facility's policy mandates PASRR evaluations upon admission and appropriate referrals for specialized services, but there was no evidence of such evaluations being conducted for the residents in question. The MDS coordinator also noted that the facility lacked policies for addressing suspected mental illness after admission.
Failure to Follow Care Plan for Wheelchair Placement
Penalty
Summary
The facility failed to adhere to the care plan for a resident with a history of falls and severe cognitive impairment. The resident, who was diagnosed with Alzheimer's disease, chronic kidney disease, and lack of coordination, had a care plan intervention that required his wheelchair to be placed at his bedside to reduce the risk of falls. However, during an observation, it was noted that the wheelchair was placed in the bathroom instead of at the bedside, contrary to the care plan. This misplacement was discovered by the resident's family, who expressed concern due to the resident's recent history of falls. Interviews with facility staff revealed a misunderstanding regarding the placement of the wheelchair. A CNA admitted to moving the wheelchair to the bathroom, believing it was necessary because the resident was COVID positive and weak, and she was unaware of the care plan requirement. The Director of Nursing acknowledged that the wheelchair should have been at the bedside as per the care plan and attributed the failure to miscommunication among staff. The facility's policy on fall prevention emphasizes the need to follow care plans to prevent falls, but this was not adhered to in this instance.
Failure to Change Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not changing the oxygen tubing weekly as per the physician's order. Resident #12, a male with severe cognitive impairment and multiple health conditions including Alzheimer's disease, chronic kidney disease, heart disease, and a history of COVID-19, was observed with oxygen tubing that had not been changed since 01/06, despite the requirement for weekly changes. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the tubing should have been changed every Sunday night shift. The DON stated that the responsibility for changing the oxygen tubing lay with the Sunday night shift nurse, and that random checks were conducted by the DON and the Assistant Director of Nursing (ADON) to ensure compliance. However, the failure to change the tubing was attributed to oversight, which could potentially lead to respiratory complications or infections for residents using oxygen. The facility's policy, dated 05/2007, also stipulated that oxygen tubing should be replaced weekly, underscoring the lapse in adherence to established protocols.
Failure to Secure Treatment Cart with Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with a treatment cart left unlocked and unattended at the nurses' station. This cart contained various medications and medical supplies, including insulin pens, needles, lancets, inhalers, and other prescription medications. During an observation, it was noted that the treatment cart was left unsecured with residents present in the area, posing a risk of unauthorized access to the medications. RN G, who was responsible for the treatment cart, admitted to leaving it unlocked due to being in a hurry to get to the dining room. The Director of Nursing (DON) confirmed that the expectation was for all medication and treatment carts to be locked when not in use, and acknowledged that carelessness led to the failure of securing the cart. The facility's policy mandates that only authorized personnel have access to medications, and that medication carts should be locked or attended by authorized individuals.
Privacy Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure personal privacy for two residents, leading to deficiencies in maintaining dignity and respect. For one resident, CNAs A and B did not provide full privacy during incontinent care, as observed on video. The resident was left uncovered and undressed while waiting for RN C, and the privacy curtain was not pulled, even though the door was shut. This oversight allowed the resident to be visible from the hallway when the door was opened. Interviews with the CNAs and RN C confirmed that the privacy curtain was not used, despite the resident being unclothed. Another resident did not have a privacy curtain installed in her room, as observed during a facility visit. The resident confirmed the absence of a privacy curtain, although her roommate had one. RN C acknowledged that all rooms should have privacy curtains and was unsure why this particular room lacked one. The facility's policy on resident rights emphasizes the importance of privacy and dignity, which was not upheld in these instances.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident. The incident involved a resident who reported being verbally abused by her roommate, which was not properly investigated by the facility. The resident, who was mildly cognitively impaired, expressed that her roommate was verbally abusive daily, calling her names and making fun of her. Despite the resident's distress, the facility did not have evidence of a thorough investigation into the allegations. Interviews with staff revealed that a CNA overheard the verbal abuse and reported it to the charge nurse, who then contacted the administrator. However, the administrator did not conduct a full investigation, mistakenly believing the issue was between the resident and a family member rather than between the two residents. The administrator acknowledged that a more thorough investigation should have been conducted, which would have led to better room placement for the residents involved. The facility's policy on abuse prevention requires immediate steps to protect residents and a prompt, thorough investigation of any allegations. However, in this case, the facility did not comply with its policy, as the investigation was not completed, and the resident continued to experience verbal abuse. This failure to investigate thoroughly could place residents at risk of further abuse.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident following a fall incident, which was identified during a comprehensive assessment. The resident, a female with Alzheimer's Disease, muscle weakness, unspecified lack of coordination, and dementia, experienced a fall on April 29, 2024, resulting in a forehead laceration that required emergency treatment. Despite the incident, the resident's care plan, dated June 25, 2024, did not address the fall, indicating a lapse in updating the care plan to reflect the resident's current needs. Interviews with facility staff revealed that the normal process involves updating care plans during morning meetings when changes in a resident's condition occur. However, the fall incident involving the resident was not flagged for care planning, leading to a failure in updating the care plan. The facility's policy requires the interdisciplinary team to develop comprehensive person-centered care plans that include measurable objectives and timeframes, but this was not adhered to in this case, as the resident's fall was not incorporated into her care plan.
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.
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What surveyors actually found near you
We read the 124 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Abilene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesley Court Health Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Windcrest Health & Rehabilitation | 2.3 mi | ★★★★★ | 11 | 0 |
| Wisteria Place | 3.4 mi | ★★★★★ | 5 | 1 |
| Willowcreek Rehab And Nursing | 5.5 mi | ★★★★★ | 9 | 0 |
| Brightpointe At Lytle Lake | 6.8 mi | ★★★★★ | 10 | 2 |
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 July 2026) and official state health department websites.