Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Vista Inn Health Center during CMS and state inspections, most recent first.
Personal refrigerators in three residents’ rooms were not properly monitored or maintained. One resident with spina bifida, hydrocephalus, MDD, and an above-knee amputation had no thermometer or temp log, another resident with intracranial injury, chronic pain, osteoporosis, and a TBI history also had no thermometer or log, and a third resident with dementia, paraplegia, and other chronic conditions had an incomplete log, ice buildup, brown discoloration, an unknown brown substance, undated food, and a nutritional shake labeled for another resident. The DON and Administrator stated hallway champions should check the fridges and that each fridge should have a thermometer and temp log.
A facility failed to keep resident rooms free of accident hazards when scissors were left openly on a nightstand, mouthwash was kept in a shared room occupied by residents with cognitive impairment and unsafe behaviors, and mouthwash plus Tiger balm were found in another resident’s room. Staff and the DON stated these items should not have been accessible because of the residents’ conditions and the risk of improper use or access by others.
Controlled substance reconciliation logs were incomplete on two nurse/medication carts, with missing signatures and one signature entered before the next cart exchange. A third cart contained expired Naproxen 220 mg and five insulins past the opened-by expiration date. An LPN and the DON stated the logs should be signed at the time of the count and expired meds should not remain in the cart.
Food service sanitation standards were not followed in the warming kitchen during meal service. A Dietary Aide plated food without washing her hands, left and re-entered the area to get plates and bowls without washing her hands again, and a CNA entered without a hair net and got ice without washing her hands. Paper towels were also missing from the handwashing sink dispenser.
An LVN contaminated clean wound-care supplies after leaving a resident’s room, touching the sink faucet and door with bare hands, and handling tape before returning to dressing care. Staff also failed to keep two residents’ catheter bags off the floor or out of a trash can containing a dirty brief. In addition, an RN administered PEG/G-tube meds without a gown for a resident on EBP, and a medication aide used unsanitized scissors to open a new medication bottle.
A resident with an indwelling catheter, dementia, diabetes, obstructive and reflux uropathy, hyperlipidemia, and liver cirrhosis was observed with his catheter bag on the side of the bed facing the hallway and not placed in a privacy bag. A second observation found the room door open and the catheter bag still visible from the hallway. The ADON and DON stated the bag should not be visible and should be covered to preserve the resident’s dignity, and the care plan included keeping the catheter bag and tubing below the bladder and in a privacy bag.
Failure to maintain privacy during wound care: A cognitively intact resident with multiple pressure ulcers and other diagnoses received wound care while the shared bathroom door in her room was left open. An LVN and CNA provided care with the door open until an unknown person entered the bathroom, and both the LVN and DON stated the door should have been closed to protect the resident’s privacy and dignity.
MDS assessments for two residents did not accurately show hospice status. One resident with Alzheimer’s disease and severe malnutrition, and another resident with dementia, respiratory failure, and end-stage liver disease, both had quarterly MDSs that omitted hospice in Section O/K1 even though their care plans and records documented hospice services. The MDS D acknowledged the omissions.
PASRR screening was not accurately completed for a resident with PTSD. The record showed PTSD on the admission sheet and MDS, a BIMS score of 7, an active Depakote order for mood, and a care plan addressing trauma-related triggers and symptoms. The PASRR form left the mental illness question unanswered, and staff stated a Level 1 screening should have been done with a Level 2 eval by the Local Authority; the MDS LVN also said the facility had no PASRR policy and followed the HHSC website.
Failure to Develop Baseline Care Plan Within 48 Hours: A resident admitted with encephalopathy, DM2, dementia, disorientation, hyperlipidemia, alcoholic cirrhosis, and a cognitive communication deficit did not have a baseline care plan placed in the chart within 48 hours. The record showed an acknowledgement form, but the actual care plan was not in the medical record until later; the resident said the plan was taken back because he could not read it, the family contact said she did not receive it, and the DON and Administrator described the omission as a records error.
Undated Sterile Water on Oxygen Concentrator: A resident with COPD and severe cognitive impairment had an oxygen order and care plan for oxygen therapy, but staff observed a sterile water container attached to the oxygen concentrator with no date on it on two occasions. The CNA was unaware of the concentrator, the LVN said the sterile water should be dated by the nurse, and the DON confirmed dating was used to track how long it had been in the room and to reduce contamination concerns.
A resident with ESRD receiving hemodialysis three times weekly did not have consistent facility-dialysis center communication or documentation. Dialysis communication forms were repeatedly missing, incomplete, unsigned, or left blank, and some treatment days had no form or nursing note. An RN said she forgot to check the dialysis binder, and the DON said staff were expected to complete the pre- and post-assessments but the process had not been monitored. The resident also reported staff did not check her fistula, and weight documentation was inconsistent.
The facility failed to ensure drugs and biologicals were stored and labeled according to accepted professional principles for 1 of 7 medication carts reviewed. Two insulins in the 100/400 hall nurse cart had no opened date, and an LVN stated the opened date is needed to know when insulin expires. The DON stated staff were expected to check carts each shift for expired items, and the facility policy required prescription medication labels to include an expiration date.
Inaccurate hospice binder code status: A resident with Alzheimer's disease and severely impaired cognition had a documented DNR order in the care plan, order summary, and medical record, but the hospice binder incorrectly labeled the resident as full code. The Hospice TM, LVN, DON, and Administrator all discussed the mismatch, and the DON and Administrator stated there was no policy regarding hospice binders or clinical records.
Failure to Post Daily Nurse Staffing Information: The facility did not have nurse staffing hours posted in the clear case near the front entry, and the posting was observed empty when surveyed. The BOM stated this was where staffing hours were normally displayed, and the DON stated it was her responsibility to post the nurse staffing hours daily and that something should always be in the case. A facility Mandatory Posting document listed daily staffing by shift of licensed and unlicensed nursing staff.
During wound care for a resident with a stage IV pressure ulcer and skin tears on enhanced barrier precautions, an LVN and the DON failed to perform hand hygiene at required times. The DON touched non-sterile surfaces and then provided direct care without changing gloves or washing hands, while the LVN donned clean gloves after removing soiled ones without washing hands. Both staff acknowledged not following infection control protocols as per facility policy and training.
A resident with severe cognitive impairment and a history of falls was found with unexplained bruising to the right temple and left hand. Staff identified the injuries during shift change and notified the physician and nursing leadership, but failed to report the incident to the administrator and state authorities within the required two-hour timeframe, as mandated by facility policy and regulation. The delay in reporting was confirmed through staff interviews and record review.
Staff failed to consistently wear and properly remove PPE during wound care for three residents on enhanced barrier precautions, including a resident with diabetes and vascular disease and two residents with cognitive impairments. Observations revealed that staff did not don gloves or gowns as required and did not follow correct procedures for removing contaminated PPE, despite facility policy and CDC guidelines. Staff interviews confirmed lapses in infection control practices during resident care.
Two residents did not have their privacy and dignity maintained during wound care, as staff failed to close doors, blinds, or privacy curtains during procedures. One resident, who was cognitively intact, received care in a shared room without privacy measures, while another with severe cognitive impairment had wound care in a private room with the blinds left open. Staff interviews confirmed that privacy protocols were not consistently followed.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice care, but the care plan failed to include all ordered hospice diagnoses, resulting in a mismatch between the care plan and medical orders. The DON confirmed that the care plan should have matched the hospice order diagnoses, but it did not in this case.
A deficiency occurred when the Medical Records Director, under instruction from an administrator, used a physician's EMR credentials to electronically sign physician orders instead of the physician signing them personally. This practice went undetected for an extended period and was only discovered during an audit, with staff and the physician unaware that orders were being signed in this manner. The facility's policies and agreements required that only the physician sign their own orders and that credentials not be shared.
A facility failed to create and update a comprehensive care plan for a resident with Alzheimer's Disease who exhibited physical and verbal aggression, as well as other behavioral symptoms. Although staff recognized and managed these behaviors through redirection and monitoring, these interventions were not documented in the resident's care plan, contrary to facility policy and assessment findings.
A CNA failed to change soiled gloves and perform hand hygiene during incontinent care for a resident with chronic incontinence and multiple comorbidities. The CNA touched clean linens and a clean brief with contaminated gloves after providing perineal care, and the DON, who assisted, did not identify the lapse. Facility policy required glove changes and hand hygiene after such care, but these steps were not followed.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in a laceration that required six sutures. Although the incident was documented and family, hospice, and physician were notified, the facility administrator and DON did not report the serious injury of unknown source to HHSC as required by the facility's abuse and neglect policy.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in a forehead laceration that required six sutures. Although staff notified the family, hospice, and physician, the administrator did not report the incident to the State Survey Agency as required for injuries of unknown source or serious bodily injury. Staff interviews confirmed the lack of timely reporting, contrary to facility policy.
A resident with dementia, repeated falls, and a stage 4 pressure ulcer did not have her fall mat in place as specified in her care plan. The mat was found propped against a chair after being moved for a visitor and not returned, despite the care plan requiring its use to address fall risk and behaviors. Staff and family interviews confirmed the lapse, and facility policy mandates comprehensive care planning with measurable objectives.
A resident with a stage 4 sacral pressure ulcer and weighing 114 pounds was found to have an air mattress set to over 310 pounds, contrary to care plan and physician orders. The resident reported discomfort, and staff interviews confirmed the mattress should be set to the resident's weight, but there was no policy in place to ensure this adjustment.
A resident with diabetes and moderate cognitive impairment was found with nail clippers, posing a risk of self-injury. The facility failed to ensure the environment was free from hazards, as the resident's family often brought items, and there was no policy on accidents and hazards. The DON acknowledged the risk and the need for closer monitoring.
A resident with severe cognitive impairment and an indwelling urinary catheter received improper incontinent care, risking infection. CNAs used incorrect wiping techniques and reused wipes, contrary to facility policy. The DON confirmed the expected procedure was not followed, and one CNA had not received competency training.
A resident with severe cognitive impairment and functional limitations was observed using a left arm sling without a written physician's order. Despite hospice recommendations and staff observations, the facility failed to update the resident's medical records to reflect the continued use of the sling, as confirmed by interviews with facility staff.
The facility failed to maintain an effective infection control program, as evidenced by deficiencies in the care of two residents. A resident with a colostomy was not identified for Enhanced Barrier Precautions, and there was no signage indicating the need for such precautions. Additionally, two CNAs did not follow proper infection control practices during catheter and incontinent/peri care for another resident, failing to change gloves and perform hand hygiene appropriately. These lapses were confirmed by staff interviews and observations, highlighting significant gaps in the facility's infection control program.
A resident with dementia and other health conditions experienced a malfunctioning call light system, which did not alert staff when activated. The issue was confirmed by staff and later fixed by maintenance, but the delay in addressing the malfunction led to a deficiency in the facility's call system functionality.
A resident with severe dementia and a history of wandering eloped from the Memory Care wing by undoing a window lock and leaving the facility undetected. Despite having a care plan addressing his risk for wandering, the resident was not found until the next morning, indicating a lapse in supervision. The incident highlighted the need for improved safety measures and monitoring to prevent similar occurrences.
The facility failed to inform a resident and their responsible parties about the risks and benefits of the antipsychotic medication Lexapro, and did not obtain a signed consent for its use. The responsible parties were not notified of a dosage increase, leading to concerns about the resident's increased sleepiness and potential adverse reactions.
Personal Refrigerators Not Properly Monitored or Maintained
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for residents with personal refrigerators. During observations and record review, personal refrigerators in the rooms of three residents were found without proper monitoring or maintenance, including missing thermometers, missing or incomplete temperature logs, and spoiled or questionable food items stored inside. Resident #2, a female with diagnoses including sacral spina bifida with hydrocephalus, major depressive disorder, and an above-knee amputation, was observed with a personal refrigerator in her room that did not have a thermometer or a temperature log. Her MDS assessment indicated she was cognitively intact for daily decision making, and her care plan included assistance with ADLs and monitoring for cognitive changes. During the observation, she stated that no one from the facility had ever checked her refrigerator. Resident #72, a male with diagnoses including intracranial injury, major depressive disorder, chronic pain, osteoporosis, osteonecrosis, and a history of traumatic brain injury, also had a personal refrigerator in his room without a thermometer or temperature log. On follow-up observation, the same condition remained. He stated that staff had not told him he was responsible for cleaning out the refrigerator and that housekeeping had only wiped off the top of the refrigerator. Resident #89, a male with diagnoses including dementia with agitation, major depressive disorder, anxiety, insomnia, metabolic encephalopathy, paraplegia, mononeuropathy/polyneuropathy, chronic pain, and a history of spinal cord injury, had a personal refrigerator with an incomplete temperature log, ice buildup with brown discoloration in the freezer, a towel with an unknown brown substance in the bottom, multiple undated food items, and a nutritional shake labeled with another resident's name and dated 1/3/26 with instructions to keep frozen. He stated that staff and family had not assisted with cleaning out the refrigerator. The Administrator and DON stated that hallway champions should be checking residents' personal refrigerators, that each fridge should have a thermometer and temperature log, and that staff should have noticed the condition of Resident #89's refrigerator and assisted with it.
Unsafe Items Left Accessible in Resident Rooms
Penalty
Summary
The facility failed to keep the resident environment free of accident hazards for three residents. During observation, a pair of full-size scissors was found sitting in an opened container on a resident’s nightstand. The resident had diagnoses including cancer and epilepsy, had a BIMS score of 13, and was receiving levetiracetam for seizures. The resident’s care plan included seizure disorder, impaired visual function, and ADL self-care performance deficit. RN and DON interviews stated scissors should not be left in the room because they are sharp objects and could harm the resident, and the admission agreement stated scissors or knives should be stored so they are not readily available to other residents. The facility also failed to keep mouthwash out of a shared room occupied by two residents. One resident had diagnoses including unspecified dementia, mild, with anxiety, depression, anxiety disorder, gait and mobility abnormalities, and a history of TIA. Her care plan identified impaired cognitive function/dementia and included interventions for consistent supervision and maintaining a safe environment. The roommate had vascular dementia, moderate, with mood disturbance, depression, anxiety disorder, insomnia, and cerebral infarction. Her care plan documented physically abusive behaviors, including slashing her abdomen with a butter knife, and included use of plastic silverware for safety. Despite these conditions, a bottle of mouthwash was observed on the first resident’s nightstand in the shared room, and the resident identified it as her mouthwash. The DON stated residents were not allowed to keep mouthwash in their rooms because of their mental state and possible improper use. The facility also failed to keep mouthwash and Tiger balm out of another resident’s room. That resident had unspecified dementia with severe cognitive impairment, with a BIMS score of 5, and her care plan included assistance with personal hygiene. On two observations, mouthwash and Tiger balm were found in her cabinet drawer with labels stating to keep out of reach of children. The resident stated she used the Tiger balm on her legs and had kept both items in her room. Staff interviews stated residents in the memory care unit should not have mouthwash or Tiger balm in their possession, that mouth hygiene products were kept in a locked closet, and that residents could wander into each other’s rooms. The DON stated residents could not have medications, mouthwash, or products labeled keep out of reach of children in their rooms.
Missing Controlled Substance Signatures and Expired Medications in Medication Carts
Penalty
Summary
Pharmaceutical services were not provided in a manner that ensured accurate dispensing and administering of medications for 3 of 7 carts reviewed, including the 700/800 hall nurse cart, the 700/800 hall medication cart, and the 100/400 nurse cart. During observation of the 700/800 hall nurse cart, four signatures were missing from the controlled medication reconciliation log used to audit controlled substance counts during shift change. During observation of the 700/800 hall medication cart, four signatures were missing from the controlled medication reconciliation log, and one signature had been entered in advance of the next cart exchange. Staff interviewed stated that signatures should not be missing or completed in advance and that the count should be documented at the time it is performed. The DON also stated that the logs should not have missing signatures or be signed before the medication count, and that the count should be documented at the time of the inventory. The 100/400 hall nurse cart contained a bottle of Naproxen 220 mg with a manufacturer expiration date of 5/2025, and five insulins that were outside of the 28-day opened-by expiration date. An LVN stated that expired insulins and other medications should not be in the cart because they might not be effective or safe. The DON stated there should not be expired medications in the medication carts and that expired medications should not be administered to residents because the resident might not get the full dose or full potency of the medication. Facility policy stated controlled medications require special handling and record keeping, and medication labels must include an expiration date.
Food Service Sanitation Lapses in Warming Kitchen
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the warming kitchen on the secure unit during meal service. A Dietary Aide was observed plating food from the steam table without washing her hands. She then returned to the main kitchen to obtain more plates and later to retrieve more bowls, and upon returning to the warming kitchen she did not wash her hands before continuing to plate food. During the same meal service, a CNA entered the warming kitchen without a hair net and did not wash her hands before going to the ice machine to fill a glass with ice. It was also observed that there were no paper towels in the dispenser above the handwashing sink in the warming kitchen. When interviewed, the Dietary Manager stated that no one should enter the area during meal service without a hair net and that the Dietary Aide and CNA should have washed their hands before serving food or getting ice.
Infection Control Failures During Wound Care, Catheter Care, EBP, and Medication Pass
Penalty
Summary
The facility failed to maintain infection prevention and control practices during wound care for a resident with multiple pressure ulcers and a history of cellulitis, neuromuscular bladder dysfunction, and left above-knee amputation. During wound care, an LVN left the room to retrieve tape, returned, washed his hands, touched the sink faucet and the resident room door with bare hands, then handled the tape with bare hands after another staff member handed it to him. He placed the tape on the bedside table with other clean supplies, washed his hands again, and later used the tape to secure the resident’s dressings. During the same care, he also closed the shared bathroom door with a gloved hand before continuing the dressing application. The DON stated the nurse should not touch clean supplies after contaminating his hands because the supplies were no longer as clean as possible to prevent infections. The facility also failed to maintain catheter care for two residents with indwelling urinary catheters. One resident with severe cognitive impairment and an indwelling Foley catheter had the catheter bag inside a trash can that contained a dirty brief. The LVN stated the resident had placed the catheter in the trash can on his own and acknowledged that the used brief could cause cross contamination. Another resident with severe cognitive impairment and a suprapubic catheter had the catheter bag touching the floor during observation. The LVN stated the bag should not be touching the floor because it could cause cross contamination. The DON stated catheter bags should not touch the floor and that a basin could be used to keep the bag from resting on the floor. The facility further failed to follow enhanced barrier precautions and medication pass infection control practices. An RN administered medications through a resident’s PEG/G tube while wearing gloves but not a gown, even though the resident’s care plan required gloves and gown for high-contact activities and the resident had enhanced barrier precautions due to an indwelling medical device. The RN stated he should have worn a gown and that not doing so could cause infection. In another observation, a medication aide used scissors taken from an opened bag on top of the medication cart to open the foil on a new bottle of lactulose without sanitizing the scissors first. The aide stated the scissors should have been sanitized before use because they could cause infection if not sanitized, and the DON stated the scissors should have been sanitized to keep the medication as clean as possible and avoid contamination.
Catheter Bag Left Visible From Hallway
Penalty
Summary
The facility failed to treat Resident #64 with dignity and respect when his catheter bag was left visible from the hallway and was not placed in a privacy bag. Resident #64 was admitted with diagnoses including type 2 diabetes mellitus, obstructive and reflux uropathy, hyperlipidemia, dementia, and liver cirrhosis. His MDS assessment documented that his memory was OK and that he was independent in making decisions regarding tasks of daily life, and the assessment also noted the use of an indwelling catheter. Resident #64 had an active order for Foley catheter care every shift, and his care plan included interventions to position the catheter bag and tubing below the level of the bladder and in a privacy bag. During observation, the resident was seen in his room with the catheter bag on the side of the bed facing the hallway and not inside a privacy bag. On a second observation, the room door was open and the catheter bag remained uncovered and visible from the hallway. The ADON and DON both stated that the catheter bag should not be visible from the hallway and should be covered with a privacy bag to preserve the resident's dignity. The facility policy on Residents Rights stated that the resident has a right to personal privacy and confidentiality, including personal privacy in accommodations and medical treatment.
Failure to Maintain Privacy During Wound Care
Penalty
Summary
The facility failed to respect Resident #2’s right to confidentiality and privacy during wound care when the shared bathroom door in the resident’s room was left open. Resident #2 was a fully cognitively intact female with diagnoses including sacral spina bifida with hydrocephalus, stage 4 pressure ulcers, cellulitis, neuromuscular dysfunction of the bladder, and an acquired absence of the left leg above the knee. Her care plan included physician-ordered wound treatments for the sacrum, right toe, and right knee, along with monitoring and assistance with repositioning and skin care. During an observation, LVN E and CNA F prepared and provided wound care to Resident #2’s bottom while she was lying in bed facing the bathroom door area. The bathroom door remained open for the duration of the observation until an unknown person entered the shared bathroom, at which point LVN E closed the door. In interview, LVN E stated the bathroom door should have been closed during wound care and said he did not know it was a shared bathroom. The DON also stated the bathroom door should have been closed during wound care to provide privacy for the resident. The facility policy on Resident Rights states residents have a right to dignity and personal privacy, including privacy in medical treatment and personal care.
MDS Assessments Failed to Reflect Hospice Services
Penalty
Summary
The facility failed to ensure that the MDS assessments accurately reflected hospice status for 2 residents. Resident #88, a female with diagnoses including Alzheimer's disease, severe protein calorie malnutrition, bipolar disorder, and unspecified anxiety disorder, had a Quarterly MDS that did not indicate she was receiving hospice services in Section O item K1. Her care plan, last revised on 11/13/25, included a focus stating that she had a terminal prognosis and/or was receiving hospice services, with interventions referencing coordination with the hospice team if receiving hospice services. Resident #113, a female readmitted to the facility with diagnoses including unspecified dementia, acute respiratory failure with hypoxia, and alcoholic cirrhosis of the liver with ascites, also had a Quarterly MDS that did not include hospice care in Section O0110, K1. Her care plan identified that she required hospice due to terminal illness, and the record included an order to admit to hospice dated 01/27/2026 and a Facility Notification stating she was admitted to hospice on 01/27/2026. During interviews, the MDS D acknowledged that hospice should have been checked on both quarterly assessments and confirmed that Resident #113 was currently on hospice.
PASRR Screening Not Completed for Resident With PTSD
Penalty
Summary
The facility failed to ensure that a resident with PTSD received an accurate PASRR Level 1 screening and that the Local Authority was contacted for a PASRR Level 2 evaluation to determine whether specialized services were needed. The resident’s record showed an admission sheet with PTSD listed as a diagnosis, an MDS assessment documenting a BIMS score of 7 and PTSD in the active diagnoses section, and an active order for Depakote 125 mg, 2 capsules by mouth twice a day for mood. The resident’s care plan also identified a history of trauma and included interventions related to PTSD triggers, anxiety, depression, sleep disturbance, substance abuse, and suicidal thoughts. The resident’s PASRR screening documented no response in the section asking whether there was evidence or an indicator of mental illness. During interviews, the MDS LVN stated that PASRR assessments needed to be accurate because a resident could lose out on services if they qualified, and stated that a Level 1 screening should have been completed after the PTSD diagnosis with the Local Authority involved for a Level 2 evaluation. The MDS LVN also stated the facility did not have a PASRR policy and followed the HHSC website. The DON stated the expectation was that staff be educated on the PASRR process and guidelines and that knowing a resident’s PASRR status was important to provide appropriate services.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of Resident #128’s admission. Resident #128 was admitted on 4/17/2026 with diagnoses including encephalopathy, type 2 diabetes mellitus, cognitive communication deficit, disorientation, hyperlipidemia, alcoholic cirrhosis of the liver, and dementia. The resident’s MDS assessment documented a BIMS score of 14 and also listed dementia, diabetes mellitus, hyperlipidemia, encephalopathy, alcoholic cirrhosis of the liver, cognitive communication deficit, and disorientation. Record review showed the Baseline Care Plan Acknowledgement form stated a copy of the baseline care plan was provided to the resident and the resident representative on 4/17/2026, but the baseline care plan itself was not included in the medical record until 4/21/2026. During interview, the resident stated the facility gave him a plan of care but took it back because he could not read it without reading glasses. The family contact stated she did not receive a baseline care plan and lived out of state. The DON stated the CNAs used the Kardex, which was developed from the care plan, and that if the care plan was not available, staff could ask a nurse about the resident’s level of care. The Administrator stated the resident did not get a baseline care plan until 4/21/2026 and that it was a clinical records error.
Undated Sterile Water on Oxygen Concentrator
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with COPD and severe cognitive impairment. Resident #5 was readmitted to the facility with a history of chronic obstructive pulmonary disease and an order allowing oxygen 2-4 liters via nasal cannula as needed for hypoxia when oxygen saturation was less than 88%. The resident’s care plan included giving oxygen therapy when ordered and as ordered by the physician. During observations, the resident’s oxygen concentrator had a sterile water container attached with no date on it on two separate occasions. Staff interviews showed the CNA was not aware the resident had an oxygen concentrator and was unsure whether the sterile water needed to be dated. The LVN stated sterile water containers used with oxygen concentrators should be dated to show when they were placed on the concentrator and that the nurse was responsible for dating it. The DON stated sterile water was dated to know how long it could remain in the room and that the nurse who replaced it would be the one to date it. The facility policy stated that if using a non-disposable humidifier, the bottle should be changed every seven days and water changed every 24 hours to prevent bacterial contamination.
Dialysis Communication and Coordination Not Maintained
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who required dialysis was not maintained for Resident #9, a female resident with end stage renal disease, anemia, and unspecified protein-calorie malnutrition. Her care plan identified hemodialysis three times weekly and included interventions for staff to avoid the graft arm for blood pressure or blood draws, monitor the access site, monitor labs, obtain weights, and coordinate with the dialysis center. The physician orders also directed dialysis every Tuesday, Thursday, and Saturday, with transport and a dialysis binder to accompany the resident. Record review of the dialysis communication forms showed repeated gaps in pre-dialysis and post-dialysis documentation, including forms that were missing, incomplete, unsigned, or had blank sections on multiple treatment days. Some dates had no form and no nursing note, while other dates had only partial pre-dialysis or post-dialysis entries. Weight records also showed inconsistent documentation, with several weights recorded as post-treatment weights from the dialysis center and some facility weights missing entirely. During interview, the resident stated nursing staff did not check her fistula and that she checked it herself to ensure it was vibrating. An RN stated she was responsible for the resident on two dates and had not checked the dialysis binder to ensure the pre-assessment form was completed before the resident left for dialysis, explaining that she forgot to look at it. She stated the form needed to be completed by facility staff in both the pre-assessment and post-assessment areas so the facility and dialysis center could compare information and note changes in the resident's condition. The DON stated staff were expected to complete the pre and post assessments, but she had not checked whether the forms were being completed or delegated that task because the facility was still figuring out its processes. The facility policy required baseline information from the dialysis center, monitoring of the access site every shift, documentation of departures and returns, daily weights, and notification of the physician and dialysis center if the resident refused dialysis.
Insulin Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 7 medication carts reviewed, the 100/400 hall nurse cart. During observation of the cart, two insulins were found with no opened date. During interview, an LVN stated that the opened date is important so staff know when the insulin will expire, and the DON stated her expectation that staff check the carts every shift for expired items. Review of the facility policy titled Medication Labels noted that medications are to be labeled in accordance with facility requirements, state, and federal laws, and that each prescription medication label includes an expiration date.
Inaccurate hospice binder code status
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for Resident #82. Resident #82 was a readmitted male with a primary diagnosis of Alzheimer's disease and a BIMS score of 3 out of 15, indicating severely impaired cognition. The resident's care plan and order summary both documented a DNR order, and the medical record contained a DNR document signed by the resident's responsible party and a physician. Record review of the resident's hospice binder showed a page labeling Resident #82 as full code, which did not match the DNR status documented elsewhere in the record. During interviews, the Hospice TM stated the resident was DNR and that DNR documents had previously been sent to the facility for placement in the hospice binder. LVN B confirmed the binder reflected full code status and stated the binder was checked daily. The DON stated hospice binders should be up to date and accurate, but also stated there was no policy regarding hospice binders, and the Administrator stated there was no policy regarding clinical records.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 of 4 days reviewed. On 4/21/26 at 6:42 AM, observation of the Facility Staffing Disclosure posting on a bulletin board near the front entry showed that the clear case was empty and no staffing information was posted. During that observation, the BOM stated that the clear case was where nurse staffing hours were normally posted and said she could let the surveyor know once one was posted. On 4/24/26 at 3:36 PM, the DON stated that it was her responsibility to post the nurse staffing hours daily and that there should always be something in the case even if it was from the previous day. Record review of a facility document titled Mandatory Posting, with no date, showed that Daily Staffing by shift of Licensed and Unlicensed Nursing Staff was on the list.
Failure to Follow Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care for a resident who was on enhanced barrier precautions due to a stage IV pressure ulcer and additional skin tears. During a wound care procedure, both the LVN and the DON initially washed their hands and donned gowns and gloves. However, the DON touched non-sterile surfaces, including a window blind, bed controls, and bed linens, and then proceeded to provide direct care to the resident without changing gloves or washing her hands. The LVN, after removing soiled gloves, walked to the treatment cart, obtained clean gloves, and donned them without performing hand hygiene in between. Both staff members acknowledged during interviews that they did not follow proper hand hygiene protocols as outlined in the facility's policy and their training. The resident involved was non-responsive during the procedure and had a significant medical history, including Parkinsonism and a stage IV pressure ulcer requiring daily wound care. The failure to perform hand hygiene at appropriate times during wound care was observed and confirmed by both staff members involved.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or injuries of unknown source were reported immediately, but not later than two hours after the allegation was made, for one resident whose records were reviewed for suspicious injuries. The resident in question had a history of cerebral infarction and unspecified dementia, with severe cognitive impairment and disorganized thinking. She resided in a secure care unit due to her dementia and risk for elopement, and required supervision for mobility and activities of daily living. On the date in question, the resident was noted to have bruising on her right temple and left hand, with the temple bruise later worsening and requiring hospital evaluation. Staff interviews and record reviews revealed that the initial discovery of the bruising was made during a shift change, with the night nurse reporting the findings to the day nurse. The day nurse assessed the resident, notified the physician, and reported the findings to the ADON/DON. However, the incident was not reported to the administrator until the following day, rather than immediately as required by facility policy and state regulations. The administrator confirmed that she was not informed of the incident until the next day, and that the required report to the state was made only after she became aware of the situation. The facility's policy required immediate verbal reporting of suspected abuse, neglect, or injuries of unknown source to the Abuse Preventionist or designee, and for the administrator to report qualifying incidents to the state within the required timeframe. Despite these policies, the delay in reporting the resident's injury of unknown origin resulted in noncompliance with regulatory requirements. The deficiency was identified through observation, interviews with staff and the resident's physician, and review of medical records and facility policies.
Failure to Adhere to PPE Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not adhere to proper use of personal protective equipment (PPE) during wound care for residents on enhanced barrier precautions. For one resident with Type 1 Diabetes and Peripheral Vascular Disease, staff did not don gloves or gowns while exposing and observing a wound, despite the care plan specifying enhanced barrier precautions. The staff involved admitted to forgetting or misunderstanding the need for PPE, even though the resident had an open wound and was on enhanced barrier precautions. In additional observations, staff did not follow correct procedures for removing PPE after providing wound care to two other residents with cognitive impairments and vascular dementia. Specifically, staff removed gloves and gowns in a manner that could lead to contamination, such as touching the front of the gown with bare hands and not following recommended glove removal techniques. Interviews with staff and administration confirmed a lack of adherence to established protocols for donning and doffing PPE, with staff acknowledging the importance of these practices but failing to implement them correctly during care. The facility's own infection control policy and CDC guidelines were not followed, as staff did not consistently wear or remove PPE as required when providing care to residents with wounds or indwelling devices. The Director of Nursing and Assistant Director of Nursing both recognized the correct procedures and the necessity of PPE use, but these were not observed in practice during the survey. The deficiency was identified through direct observation, interviews, and record review, demonstrating a breakdown in infection control practices for multiple residents.
Failure to Maintain Resident Privacy and Dignity During Wound Care
Penalty
Summary
The facility failed to maintain resident privacy and dignity during wound care for two residents. In one instance, a resident with Type 1 Diabetes and Peripheral Vascular Disease, who was cognitively intact, received wound care in a shared room without the door, blinds, or privacy curtain being closed, while the roommate was present. The resident reported that privacy was inconsistently provided and expressed feeling neglected. The Assistant Director of Nursing (ADON) acknowledged that the privacy curtain should have been used and admitted not considering the resident's preference due to familiarity with the roommate. In another case, a resident with Vascular Dementia, Type 2 Diabetes, and Aphasia, who had severely impaired cognitive skills, underwent wound care in a private room where the blinds were not closed, although the door was shut. The LPN involved stated that full privacy measures, including closing doors, curtains, and blinds, were expected but not followed. Both the ADON and Director of Nursing (DON) confirmed that privacy should always be provided during care, regardless of the resident's ability to communicate discomfort, and recognized that the failure to do so could compromise resident dignity.
Failure to Align Hospice Care Plan with Ordered Diagnoses
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting a focus area and interventions for the resident's ordered hospice care diagnosis. Record review showed that a female resident with severe cognitive impairment and multiple diagnoses, including senile degeneration of the brain and cerebral atherosclerosis, was admitted to hospice care. However, the care plan only included senile degeneration of the brain as the hospice diagnosis, while the hospice order also listed cerebral atherosclerosis. This discrepancy was identified during a review of the resident's records and confirmed by the Director of Nursing (DON), who acknowledged that the care planned diagnosis should match the medical diagnoses and orders. The DON stated that the facility's process is to include the diagnosis from the order in the care plan, and upon review, recognized that the hospice order diagnosis did not match the care planned diagnosis for the resident. The facility's policy requires the comprehensive care plan to describe the services needed to attain or maintain the resident's highest practicable well-being, but in this case, the care plan did not reflect all relevant hospice diagnoses as ordered. This failure was identified through observation, interview, and record review, and was acknowledged by facility leadership as not meeting expectations for care planning.
Unauthorized Electronic Signing of Physician Orders Using Physician Credentials
Penalty
Summary
The facility failed to ensure that physician orders were properly signed and dated by the responsible physician, specifically Physician R, as required during each visit. Instead, the Medical Records Director was instructed by Administrator O to electronically sign Physician R's orders in the electronic medical record (EMR) system using Physician R's username and password. This practice was carried out for an extended period, with the Medical Records Director logging into the EMR approximately twice a month to sign off on pending orders for Physician R. The Medical Records Director reported that she was initially asked to perform this task after the previous DON left, and that she continued to do so under the direction of Administrator O, despite feeling uncomfortable and recognizing through later training that this was not appropriate. The deficiency was discovered during an audit conducted by the Regional Medical Records Director, which revealed over 100 unsigned physician orders pending in the EMR. Upon investigation, it was found that the Medical Records Director had been using credentials provided by Administrator O to sign these orders, and that this practice had been ongoing for several years. Interviews with staff, including the ADON and MDS Coordinator, confirmed that they were unaware of this practice and that Physician R was not signing his own orders in the EMR. Physician R himself stated that he was not aware his credentials were being used in this manner and that he had been signing paper documents provided to him during his visits, believing these included all necessary orders. The facility's own policies and the Medical Director Agreement required that only the physician sign their own orders, and that usernames and passwords not be shared. The Medical Records Director did not report the inappropriate practice to anyone else, citing fear of job loss, even though an anonymous compliance hotline was available. The improper signing of orders was not detected until the audit, and no evidence was found that the Medical Records Director or Administrator O originated or created new orders, only that they signed off on existing ones entered by nursing staff.
Failure to Develop and Implement Comprehensive Care Plan for Resident Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's identified needs, specifically omitting interventions for physical and verbally aggressive behaviors. The resident in question, an elderly female with Alzheimer's Disease and severe cognitive impairment, had documented incidents of both physical and verbal aggression toward others, as well as other behavioral symptoms such as wandering and inappropriate behaviors. Despite these behaviors being identified in assessments and incident reports, the care plan did not include specific interventions or measurable objectives to address the aggressive behaviors. Record reviews showed that the resident had a history of behavioral symptoms, including an incident where she attempted to strike another resident after a verbal altercation. Staff interviews confirmed that the resident was redirectable and that monitoring was implemented after the incident, but these interventions were not reflected in the resident's care plan. Multiple staff members, including LVNs, CNAs, ADONs, the MDS Coordinator, and the Administrator, acknowledged that the care plan should have been updated to include the resident's aggressive behaviors and appropriate interventions. The facility's own policy required the development and implementation of a person-centered comprehensive care plan to address each resident's medical, physical, mental, and psychosocial needs. However, the care plan for this resident did not include interventions for her aggressive behaviors, despite clear evidence from assessments, incident reports, and staff interviews that such behaviors were present and required management.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent care for a resident with multiple diagnoses, including dementia, schizophrenia, bipolar disorder, and chronic incontinence. The CNA was observed wiping the resident's perineal area and then, without changing soiled gloves, touched the bed linen. After removing soiled gloves and using hand sanitizer, the CNA donned clean gloves but again failed to change gloves after wiping fecal material from the resident's legs, subsequently touching the resident and clean brief with contaminated gloves. The Director of Nursing (DON) assisted during the care but did not notice the improper glove use or cross-contamination at the time. Interviews with the CNA revealed she had received recent training on proper perineal care and acknowledged the need to change gloves when soiled, but did not recall the specific lapses observed. The DON confirmed the facility's policy required glove changes and hand hygiene after perineal care and before touching clean linens or briefs. Facility policies reviewed indicated hand hygiene should be performed after contact with body fluids, after removing gloves, and after handling soiled linens, but these procedures were not followed during the observed care event.
Failure to Report Serious Injury of Unknown Source as Required by Policy
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse and neglect, as evidenced by the handling of a serious injury of unknown source involving a resident. The administrator did not follow the Abuse/Neglect/Exploitation (ANE) policy, which requires reporting all injuries of unknown source resulting in serious bodily injury to the state agency (HHSC) within specified timeframes. Specifically, a resident with multiple diagnoses including dementia, major depressive disorder, Parkinson's disease, and metabolic encephalopathy experienced an unwitnessed fall, resulting in a laceration to the forehead that required six sutures. The incident was documented, and the family, hospice, and physician were notified, but the required report to HHSC was not made. Interviews with the DON, RN, and administrator confirmed that the fall was unwitnessed and resulted in significant injury, but the event was not reported to the appropriate authorities as required by facility policy and state regulations. The resident was severely cognitively impaired, frequently incontinent, at risk for falls, and required substantial assistance with activities of daily living. Despite the clear policy on reporting such incidents, the administrator and DON did not consider the event as abuse or neglect and therefore did not report it, leading to a deficiency in the facility's abuse and neglect prevention procedures.
Failure to Timely Report Unwitnessed Fall with Serious Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, as required by regulation. Specifically, a resident with multiple diagnoses including dementia, major depressive disorder, Parkinson's disease, and metabolic encephalopathy experienced an unwitnessed fall resulting in a laceration to the forehead. The resident was sent to the emergency room, received six sutures, and returned to the facility the same day. Despite the serious nature of the injury and the fact that the fall was unwitnessed, the incident was not reported to the State Survey Agency (HHSC) by the administrator as required. Record reviews confirmed that the resident was severely cognitively impaired, required substantial assistance with activities of daily living, and was at risk for falls. The care plan documented multiple risk factors, including impaired cognitive and neurological function, impaired vision, and a history of falls. The incident report and progress notes indicated that the resident was found on the floor with a laceration, and staff responded by notifying the family, hospice, and physician, and arranging for emergency care. However, there was no documentation or evidence that the incident was reported to the appropriate state authorities within the required timeframe. Interviews with facility staff, including the DON and administrator, confirmed that the unwitnessed fall with injury was not reported to HHSC. Staff stated that they did not consider the incident to be abuse or neglect since they believed they understood how the fall occurred, despite the lack of witnesses. The facility's own policy required reporting of all injuries of unknown source or those resulting in serious bodily injury within two hours, but this procedure was not followed in this case.
Failure to Implement Comprehensive Care Plan for Fall Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including dementia, repeated falls, a stage 4 pressure ulcer, and a history of seizures. The resident's care plan specified the use of fall mats as an intervention due to her history of falls and behaviors such as intentionally placing herself on the mats or throwing herself to the floor. However, during an observation, the fall mat was found propped vertically against a chair rather than being placed on the floor next to the resident's bed as required by her care plan. Interviews with staff and the resident's family revealed that the mat had been moved to accommodate a visitor and was not returned to its proper position. The Director of Nursing and MDS nurse confirmed that the fall mats were part of the care plan to address the resident's behaviors and risk of falls. The facility's policy requires the development and implementation of a comprehensive care plan with measurable objectives and timeframes, but this was not followed in this instance, resulting in the resident not receiving the specified intervention.
Incorrect Air Mattress Setting for Resident with Pressure Ulcer
Penalty
Summary
A deficiency was identified when a resident with a stage 4 sacral pressure ulcer was found to have an air mattress set incorrectly for her weight. The resident, who weighed 114 pounds and had diagnoses including dementia, repeated falls, a stage 4 sacral pressure ulcer, and osteoporosis with fracture, was observed to have her air mattress dial set to over 310 pounds. The care plan and physician orders specified the use of an air mattress, and the resident's medication administration record indicated the mattress was provided as ordered. However, the mattress setting did not correspond to the resident's actual weight. During interviews, the resident reported discomfort on the air mattress. The DON and MDS LVN confirmed that the air mattress should be set according to the resident's weight and that nurses were responsible for making these adjustments. The DON was unaware that the mattress was set incorrectly and stated there was no policy in place regarding the adjustment of air mattress settings. This failure to ensure the correct mattress setting constituted a deficiency in providing necessary treatment and services to promote healing and prevent further pressure ulcers.
Resident Safety Hazard Due to Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that the environment for a resident, who was on anticoagulant therapy and had a history of diabetes, was free from potential hazards. During an observation, the resident was found in possession of a pair of nail clippers, which posed a risk of self-injury and potential complications due to his diabetic condition. The resident, who had moderate cognitive impairment, was attempting to use the clippers himself, despite the risk of injury and infection. The Assistant Director of Nursing (ADON) was informed and subsequently secured the clippers. The Director of Nursing (DON) acknowledged the potential risk of infection if a diabetic resident were to injure themselves with nail clippers. It was noted that the resident's family often brought him items, which could have included the clippers. The facility did not have a policy on accidents and hazards, and the DON mentioned the need to monitor items brought by family members more closely. The facility's lack of a specific policy and the oversight in monitoring items brought by family members contributed to the deficiency.
Improper Incontinent Care Practices in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder and bowel, leading to a risk of urinary tract infections. The resident, who was severely cognitively impaired and had an indwelling urinary catheter, was observed with stool and remnants of a thick white substance on her thighs and buttocks. During care, CNAs used improper techniques by wiping in a back-and-forth and circular motion instead of the required front-to-back motion, and they reused wipes instead of discarding them after each pass. This improper cleaning method was acknowledged by the CNAs during interviews, and it was noted that one of the CNAs had not received competency training at the facility. The Director of Nursing (DON) confirmed that the expected procedure was to wipe from front to back and discard wipes after each use to prevent cross-contamination and infection. The facility's policy on perineal care also emphasized the importance of using a new wipe for each pass and wiping from the urethral area toward the rectal area. The DON, who was newly employed, was unsure if the CNAs had completed any competency training for incontinent care, which contributed to the deficiency in care provided to the resident.
Incomplete Medical Records for Resident's Arm Sling Use
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the use of a left arm sling. The resident, who was severely cognitively impaired and had functional limitations in range of motion, was observed wearing a left arm sling without a corresponding written physician's order. The resident's medical records, including the Order Summary Report and Medication Administration Record (MAR), did not reflect an updated order for the continued use of the sling, despite hospice recommendations and observations by nursing staff. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed the absence of a physician's order for the sling's continued use. The LVN acknowledged that the Order Summary was not updated to reflect the hospice's recommendation, and the DON emphasized the necessity of a physician's order for monitoring the sling's use and potential skin issues. The facility's policy on physician's orders was not adhered to, resulting in incomplete documentation of the resident's care plan.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by deficiencies observed in the care of two residents. Resident #33, who had a colostomy, was not identified for Enhanced Barrier Precautions (EBP), and there was no signage indicating the need for such precautions in or around her room. This oversight was confirmed by staff interviews, where it was acknowledged that EBP signage should have been posted to prevent infections. The facility's internal document on EBP did not provide a clear system for informing staff about which residents required these precautions. In the case of Resident #31, the facility failed to ensure proper infection control practices during catheter and incontinent/peri care. Observations revealed that CNAs A and B did not change gloves or perform hand hygiene appropriately while providing care. CNA A used soiled gloves to handle clean items and did not change gloves after cleaning stool, which could lead to cross-contamination. CNA B also failed to sanitize her hands between glove changes, further contributing to the risk of infection. Interviews with the CNAs and the DON confirmed these lapses in infection control practices. The facility's policy on hand hygiene and PPE was not adhered to during the care of Resident #31. The policy outlined the importance of hand hygiene before and after patient contact and after removing gloves, but these steps were not followed by the CNAs. The DON acknowledged that the failure to perform hand hygiene and the movement from dirty to clean areas without proper precautions could result in the resident developing an infection. These deficiencies highlight significant gaps in the facility's infection control program, potentially putting residents at risk for infections.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that a working call system was available in each resident's bathroom and bathing area, specifically affecting one resident. Resident #41, who has a history of dementia, atherosclerotic heart disease, and chronic obstructive pulmonary disease, was observed using his call light, which did not illuminate the nurse call light outside his room. This malfunction was confirmed during an interview with the resident, who reported that it took a long time, approximately two hours, for staff to respond to his call light. The call light was lit at the pull station but not outside the door, indicating a malfunction. Further investigation revealed that the call light system was not functioning properly, as confirmed by a CNA and the ADON, who both verified that the call light was not sounding at the nurse's station. The Maintenance Director later reported that the call light had been fixed and explained that the system could be grounded if the call light was pulled without being reset. The facility's maintenance policy outlines the repair and replacement of damaged equipment, but the issue with the call light system had not been addressed promptly, leading to the deficiency.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident in the Memory Care wing. The resident, who had a history of wandering and was at risk for elopement, managed to undo the lock on his window, kick out the screen, and leave the facility undetected. This incident occurred despite the resident's care plan, which included interventions to prevent wandering and elopement. The resident was not located until the following morning, indicating a lapse in supervision and monitoring. The resident involved was a male with severe dementia, major depressive disorder, paranoid schizophrenia, and epilepsy. His care plan noted his risk for wandering due to disorientation and impaired safety awareness. On the day of the incident, the resident was last seen in his room after receiving medication. Staff later discovered his absence and the open window, suggesting he used a closet rod to unscrew the window fastener and escape. The facility's response to the missing resident included implementing elopement protocols, notifying family and authorities, and conducting a search. The resident was eventually found unharmed but disoriented. The incident highlighted the need for improved safety measures and supervision to prevent similar occurrences, as the resident's actions posed a risk of harm, serious injury, or death.
Failure to Inform Resident and Responsible Parties of Medication Changes
Penalty
Summary
The facility failed to ensure that Resident #1 was fully informed and understood the risks and benefits of his treatment, specifically regarding the administration of the antipsychotic medication Escitalopram Oxalate (Lexapro). The facility did not obtain a signed consent for the medication, and the resident's responsible party was not informed of the benefits, risks, and options available after a recommendation to increase the dosage. This failure was identified through interviews and record reviews, which revealed that the resident's responsible parties were not notified of the medication changes, leading to concerns about the resident's increased sleepiness and potential adverse reactions to the medication. Resident #1, an elderly male with severe cognitive impairment, dementia, insomnia, and major depressive disorder, was admitted to the facility with a care plan that included the use of antidepressant medication. Despite the care plan's requirement to educate the resident and family about the medication's risks and benefits, the facility did not obtain a signed consent for the use of Lexapro. Additionally, when the dosage of Lexapro was increased, the facility failed to inform the resident's responsible parties, leading to confusion and dissatisfaction among the family members. Interviews with the resident's responsible parties and facility staff revealed a lack of communication and documentation regarding the medication changes. The responsible parties expressed concerns about the resident's increased sleepiness and the lack of notification about the dosage increase. Facility staff, including the ADON and DON, admitted that the facility's policy did not require notification for dosage changes of existing medications, which contributed to the oversight. The facility's policy on psychotropic drugs and resident rights emphasized the importance of informed consent and communication, but these procedures were not followed in this case.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northgate Health And Rehabilitation Center | 0 mi | ★★★★★ | 29 | 0 |
| Ignite Medical Resort San Antonio, Llc | 0.4 mi | ★★★★★ | 18 | 0 |
| Huebner Creek Health & Rehabilitation Center | 0.5 mi | ★★★★★ | 26 | 0 |
| Sorrento | 0.6 mi | ★★★★★ | 17 | 0 |
| Remington Transitional Care Of San Antonio | 0.6 mi | ★★★★★ | 3 | 0 |
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