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 Mi Casita Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Cell Phone Use During Resident Care: Four confidential residents stated CNAs used personal cell phones while providing peri-care and while feeding residents, making them feel ignored, embarrassed, and that their privacy was violated. The residents reported this happened on every shift and caused delays between bites during meals. The ADM stated residents should receive privacy during care, and the facility policy required residents to be treated with kindness, respect, dignity, privacy, and confidentiality.
Incomplete care planning and failure to follow smoking plan: One resident with chronic respiratory failure, lung cancer, heart failure, and severe cognitive impairment had oxygen use documented in the MDS and physician orders, but the care plan did not include oxygen therapy. Another resident with COPD and tobacco use had a smoking care plan stating his supplies were to be stored at the nurses' station, yet he was observed with a cigarette and lighter in his shirt pocket, and staff could not explain why the plan was not being followed.
Smoking Supplies Not Kept at Nurses' Station: A resident with intact cognition and tobacco use, who was also on O2 via nasal cannula, was observed with a cigarette and lighter in his shirt pocket despite the care plan and smoking assessment stating all smoking materials were to be kept at the nurses' station. The resident said he was allowed to keep the items on him, while an LVN and the DON acknowledged residents were not supposed to have smoking supplies on their person and that staff were responsible for monitoring compliance with the smoking policy.
Missed weekly oxygen tubing changes for two residents receiving O2 therapy. Both residents had COPD or respiratory failure-related diagnoses and physician orders for oxygen equipment and filter changes every Sunday night shift. Observations showed their tubing remained dated from an earlier week, and the ADON stated she was the charge nurse when the change was due but got busy, failed to complete it, and did not report it to the oncoming nurse. The DON stated the facility policy required weekly tubing changes and that charge nurses were responsible for completing and documenting the task.
Medication administration errors exceeded the allowed rate, with 2 errors in 33 opportunities. One resident received an incomplete dose of polyethylene glycol powder because the cap was not filled to the marked 17 g line, and another resident received redness relief eye drops instead of ordered artificial tears. The DON stated staff were expected to follow the 5 rights, and the facility policy required verification of the right medication and dosage before administration.
Improper Storage of Medications and Expired Supplies: The facility failed to store drugs and biologicals properly in Med Cart A, Med Cart B, and Med Room C. During observation with the DON, loose pills were found in Med Cart A, and Med Cart B contained expired supplies, expired hand sanitizer, and an unlabeled cup of white powder that an LVN said was Miralax returned after a resident refused it. Med Room C also contained expired povidone-iodine swab sticks and expired Glucerna shakes.
Spoiled onions were found in the dry pantry during a kitchen observation. Several red onions had sprouts, were soft to touch, and others had dark black and grey mold. The DS said staff were supposed to check the onions daily but likely had not done so for the past couple of days, and the facility's guide required fresh produce to be checked daily for freshness.
Inaccurate oxygen tubing documentation affected two residents who were both on oxygen therapy and had orders for weekly equipment changes. An ADON signed the MAR for the tubing changes before completing them, then failed to change the tubing or notify the oncoming nurse. Observations later showed both residents still had tubing dated from an earlier date, while the DON and ADM stated documentation must be accurate and signed only after care is completed.
Hand Hygiene Not Performed Before Wound Care: An LVN entered a resident's room to provide wound care for a stage 3 heel pressure ulcer, put on clean gown and gloves, and began treatment without washing her hands after entering the room. The resident had COPD, PVD, and moderately impaired cognition. The DON confirmed staff were expected to wash hands before care, and the facility policy stated hand hygiene is indicated immediately before touching a resident and gloves do not replace hand hygiene.
Insufficient room size was identified in 10 semi-private rooms with two beds. Record review showed the rooms were classified for two residents, but observation found each room had 154 square feet instead of the required 160 square feet. The Administrator stated the rooms had a waiver for years, there had been no change to the floor plan, and the facility had no policy for room size waiver.
The facility failed to inform 9 out of 15 residents about their rights to file grievances, including access to grievance forms and the option to file anonymously. The ADM, responsible for handling grievances, did not communicate the grievance process to residents or staff, and the facility lacked postings of the grievance procedure in prominent locations.
The facility failed to meet the dietary preferences of three residents during a lunch meal service, resulting in them receiving hamburgers instead of the requested sour cream enchiladas. This occurred due to a miscalculation in the number of enchiladas prepared, leading to a shortage. The residents involved had various medical conditions, and the facility's policy to provide a diet that meets residents' nutritional and special dietary needs was not followed.
The facility failed to maintain cleanliness and proper food storage in the kitchen, with sticky substances found on appliance handles and improperly sealed food items. Staffing shortages contributed to these issues, as revealed in interviews with the DM and ADM. The facility's policies on food handling and sanitation were not adhered to, posing potential risks of food contamination.
A resident with mild cognitive impairment and several medical conditions was not provided privacy during incontinent care by a CNA, who failed to pull the privacy curtain and left the resident uncovered while sanitizing hands. Despite training, the CNA admitted to rushing and not following proper procedures. The facility's administration was unaware of these lapses until the survey.
A resident with a DNR status had an incomplete Out-of-Hospital DNR form due to a missing date on a witness's signature. Facility staff, including the social worker and administrator, acknowledged the lack of a system to monitor the accuracy of these forms, which could lead to the resident's end-of-life wishes not being honored.
A resident's motorized wheelchair was observed to be soiled with brown spots throughout the day, despite the resident's awareness and discomfort. Facility staff, including CNAs and an LVN, failed to clean the wheelchair promptly, indicating a breakdown in communication and responsibility. The facility's policy on cleaning and disinfection was not followed, impacting the resident's dignity and quality of life.
A resident's portable oxygen tank was improperly stored, left free-standing and unsecured in their room, contrary to facility policy. The resident, with multiple health conditions, relied on staff to manage the oxygen tank, which was not stored in designated holders or carts as required. This posed a potential risk for avoidable injuries.
A LTC facility failed to maintain a medication error rate below 5%, resulting in errors involving three residents. A resident did not receive his prescribed allergy medication, another was underdosed with Gabapentin, and a third was not given Methylphenidate due to staff errors. These incidents highlight failures in medication administration practices.
A Schedule IV narcotic, Lorazepam 2 MG/ML oral concentrate, was improperly stored in an unlocked lockbox within the medication storage room refrigerator. LVN A was unaware of the medication's presence, and the DON and ADON were the only ones with keys to the lockbox. The facility's policy required controlled medications to be stored in separately locked compartments, but this was not followed, leading to a potential risk of medication diversion.
A facility failed to maintain an effective infection control program, as a CNA did not perform hand hygiene between glove changes during incontinent care, and an LVN did not wear proper PPE while providing wound care to a resident on Enhanced Barrier Precautions. Both staff members had received training but admitted to lapses in protocol adherence, potentially risking infection spread.
A facility failed to implement a comprehensive care plan for a resident with dementia who became combative during care. The care plan, which included strategies for managing aggression, was not followed by a CNA, resulting in the CNA being kicked. Interviews revealed the CNA continued care despite the resident's combative behavior, contrary to the care plan's instructions. This deficiency underscores the need for consistent implementation of care plans and adherence to facility policies.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and privacy when CNAs used personal cell phones while providing care, including peri-care. Four confidential residents stated that cell phone use by CNAs made them feel ignored, not a priority, embarrassed, and concerned that the CNA could make a mistake because of distraction from the phone conversation. The residents also stated that their privacy was violated, and that this occurred on every shift. The same residents reported that staff also used personal cell phones while feeding residents during meals, which caused significant wait times between bites. They stated they did not know the names of the CNAs involved and believed that every CNA in the facility used cell phones while performing care. During interview, the ADM stated residents should be provided privacy during resident care, and that staff were trained on privacy, resident rights, dignity, and cell phone usage during orientation and ongoing education. Record review of the facility's Resident Rights policy stated employees shall treat all residents with kindness, respect, and dignity, and that residents have the right to a dignified existence and privacy and confidentiality.
Incomplete Care Planning and Failure to Follow Smoking Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident #7 that included oxygen administration. Resident #7 was admitted and readmitted with chronic respiratory failure, lung cancer, heart failure, and anemia, and the significant change MDS dated 03/10/26 showed a BIMS score of 03 indicating severe cognitive impairment. The MDS also indicated that she used oxygen therapy while a resident. Her comprehensive care plan, last reviewed on 03/25/26, did not include a care plan for oxygen therapy, even though the current physician orders dated 03/27/26 directed that she may use oxygen at 2L per minute via cannula or mask by concentrator or tank, and the MAR showed oxygen administration was signed for daily between 03/04/26 and 03/27/26. During the initial tour on 03/25/26, Resident #7 was observed not wearing oxygen, although she stated she frequently wore oxygen while in bed. An oxygen concentrator with attached tubing was observed at her bedside. In telephone interview on 03/27/26, the MDS Coordinator stated she was responsible for resident care plans and said she must have overlooked adding the oxygen care plan. She stated she usually checked physician orders and the 24-hour report daily to update care plans and that the care plan was used by nursing staff and the interdisciplinary team to know the proper care of the resident. The facility also failed to implement the smoking care plan for Resident #40. Resident #40 was admitted and readmitted with chronic atrial fibrillation, acute lower respiratory infection, and chronic obstructive pulmonary disease, and the MDS dated 06/06/25 showed a BIMS score of 12 and that he currently used tobacco. His care plan, last reviewed on 12/24/25, stated he was safe to smoke unsupervised and that his smoking supplies were stored at the nurses' station, but during the initial tour and again on 03/27/26 he was observed with a cigarette and lighter in his shirt pocket. Staff interviews showed LVN B did not know why he had the items on him, and the DON and ADM stated they did not know why the smoking care plan was not being followed.
Smoking Supplies Not Secured at Nurses' Station
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for one resident who smoked. The resident was admitted and readmitted with diagnoses including chronic atrial fibrillation, acute lower respiratory infection, and chronic obstructive pulmonary disease. The MDS assessment showed a BIMS score of 12, indicating intact cognition, and also documented that the resident currently used tobacco. The care plan stated the resident was a smoker and was safe to smoke unsupervised, with smoking supplies to be stored at the nurses' station, and the Safe Smoking Assessment indicated that all smoking materials would be kept at the nurse's station. During the initial tour, the resident stated he was allowed to keep a cigarette and lighter on his person and had one in his front shirt pocket. He was observed with oxygen via nasal cannula at 3 liters per minute. On a later observation, the resident again had 1 cigarette and 1 lighter in a cigarette box in his front shirt pocket while still on oxygen at 3 liters per minute. An LVN stated she did not know why the resident had smoking items in his pocket and said residents sometimes were non-compliant with smoking policies. The DON stated residents were not supposed to have smoking supplies on their person, but it was sometimes difficult to manage with independent residents who smoke. The ADM stated all staff were responsible to monitor for smoking supplies and that all smoking supplies should be kept in the med room at the nurse's station. The facility policy stated all smoking items, including lighters and cigarettes, shall be kept at the designated area.
Missed Weekly Oxygen Tubing Changes
Penalty
Summary
The facility failed to ensure that oxygen tubing was replaced every seven days for two residents who were receiving respiratory care under physician orders. Resident #1 was a cognitively intact male with diagnoses including right heart failure, acute and chronic respiratory failure, peripheral vascular disease, acute pulmonary edema, and dependence on supplemental oxygen. Resident #17 was a cognitively intact female with diagnoses including COPD, acute and chronic respiratory failure, heart failure, peripheral vascular disease, and dependence on supplemental oxygen. Both residents had care plans and current physician orders allowing oxygen by cannula or mask and directing that oxygen equipment and filters be changed weekly on Sunday night shift. Record review showed that the weekly oxygen equipment change order was documented on the MAR as due on Sundays, with initials entered on 03/01/26, 03/08/26, 03/15/26, and 03/22/26. However, during observations on 03/25/26 and 03/26/26, both residents were receiving oxygen at 3 L/min via nasal cannula, and the tubing for each resident was dated 03/15/26 rather than having been changed on the scheduled weekly date. Resident #17 stated that one staff member was good about changing the tubing and adding water to the canister, but not all staff did. Resident #1 stated staff usually changed his oxygen tubing, but he did not recall when it was last changed. During interview, the ADON stated she had worked as charge nurse on the Sunday night shift when the tubing should have been changed for both residents, but she got busy, failed to change the tubing, and failed to report the missed task to the oncoming nurse. The DON stated the facility policy required oxygen tubing to be changed every week on Sunday and that night shift charge nurses were responsible for completing and documenting the task. The facility policy titled Administration of Oxygen and Maintenance of Tubing and Equipment also stated that tubing would be dated and changed weekly.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent, with a reported rate of 6.06% based on 2 errors in 33 medication administration opportunities for 2 of 3 residents reviewed. One error involved a resident admitted with pneumonia, acute cystitis without hematuria, and constipation, who had a physician order for Polyethylene Glycol 3350 Powder 17 grams by mouth daily mixed with 4 to 6 ounces of water. During observation, Med Aide C filled the bottle cap only halfway in the white section rather than to the top of the marked white section, then mixed the powder with about 4 ounces of water and administered it to the resident. The medication label directed that the cap be filled to the top of the white section marked 17 grams, and Med Aide C stated she did not know this requirement because no one had told her. The second error involved a resident with fracture of coccyx, lack of coordination, and dry eye syndrome, who had an order for Artificial Tears Ophthalmic Solution 1% to be instilled in both eyes three times daily. During observation, Med Aide C administered Redness relief eye drops instead of the ordered Artificial Tears. Med Aide C later stated she noticed the drops were different but gave them because that was what the facility provided. The DON stated staff were expected to observe the 5 rights for medication administration, and the facility policy required verification of the right medication and right dosage before administration.
Improper Storage of Medications and Expired Supplies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles in 2 of 4 medication carts and 1 of 2 medication rooms reviewed. During observation of Med Cart A with the DON, two loose pills were found in the second drawer, including one light gray oblong pill and one yellow/orange oblong pill. The DON stated she believed the light gray pill was memantine and thought the yellow/orange pill was a different dose of memantine. During observation of Med Cart B with the DON, expired and unlabeled items were found, including 32 sureprep pads with an expiration date of 11/15/25, aloe vera hand sanitizer with an expiration date of 08/22, a 30 mL medicine cup containing 15 mL of white powder that was unlabeled, and eucalyptus hand sanitizer with an expiration date of 08/22 sitting on top of the cart. An LVN stated the white powder was Miralax that had been taken to a resident who refused it, and he placed it back in the cart rather than wasting it. In Med Room C, the DON observed 4 packs of povidone-iodine swab sticks with an expiration date of 05/25 and 4 bottles of Glucerna hunger smart shakes with an expiration date of 07/01/25 in the refrigerator. The facility policy stated drugs and biologicals are to be stored in their received packaging and discontinued, outdated, or deteriorated items are to be returned to the dispensing pharmacy or destroyed.
Spoiled onions left in dry pantry
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. During an initial kitchen observation tour, the dry pantry contained a plastic bin dated 2/24/26 with red onions inside. Six of the red onions had green sprouted shoots and were soft to touch, and four red onions had dark black and grey molded areas and were also soft to touch. During interview, the DS stated staff were supposed to check the red onions every day and said it was likely they had not been checked in the past couple of days. She stated the date on the bin was when the onions were received and that the kitchen was very hot, which could cause the onions to go bad faster. The DS stated the onions should have lasted 2 weeks in the dry pantry with the heat. The facility's Use by date Guide stated fresh fruits and vegetables are to be checked daily for freshness, and the food receiving and storage policy stated dry foods in bins must be checked weekly for perishable changes and discarded if their integrity has changed.
Inaccurate Oxygen Tubing Documentation
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices by inaccurately documenting oxygen tubing changes for 2 residents. Resident #1 was a cognitively intact male with diagnoses including right heart failure, acute and chronic respiratory failure, peripheral vascular disease, acute pulmonary edema, and dependence on supplemental oxygen. His care plan and physician orders required oxygen therapy and weekly oxygen equipment changes and filter cleaning on Sunday night shift, with staff to initial when oxygen was used. Record review showed the ADON signed the MAR for an oxygen tubing change for Resident #1 on 03/22/26 even though the change did not occur. During observations on 03/25/26 and 03/26/26, Resident #1 was receiving oxygen at 3 L/min via nasal cannula, and the oxygen tubing was still dated 03/15/26. Resident #17 was a cognitively intact female with diagnoses including COPD, acute and chronic respiratory failure, heart failure, peripheral vascular disease, and dependence on supplemental oxygen. Her care plan and physician orders also required oxygen therapy and weekly oxygen equipment changes and filter cleaning on Sunday night shift, with staff to initial when oxygen was used. For Resident #17, the MAR likewise showed the ADON signed for an oxygen tubing change on 03/22/26 even though it was not completed. Observations on 03/25/26 and 03/26/26 showed Resident #17 receiving oxygen at 3 L/min via nasal cannula, and the tubing was dated 03/15/26. During interview, the ADON stated she worked the night shift on 03/22/26, signed for the tubing changes for both residents, intended to complete the task later, but got busy and failed to change the tubing or report the incomplete task to the oncoming nurse. The DON and ADM stated documentation should be accurate and that tasks should be signed only after completion; the facility policy required documentation to be objective, complete, accurate, and to include the date and time the procedure or treatment was provided.
Hand Hygiene Not Performed Before Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents reviewed for infection control. Resident #32 was an [AGE] year-old male admitted with chronic obstructive pulmonary disease, a stage 3 pressure ulcer of the right heel, and peripheral vascular disease. His MDS assessment showed a BIMS score of 09, indicating moderately impaired cognition, and his care plan identified an actual pressure injury to the right heel. The physician order directed treatment to the right outer heel stage 3 pressure ulcer with cleansing, pat drying, application of iodosorb and calcium alginate, clover, and bordered gauze during the day shift. During observation of wound care, LVN B entered Resident #32's room, set supplies on a tray, put on a clean gown and gloves, and began wound care to the right heel without washing her hands after entering the room and before putting on clean gloves. In interview, LVN B stated she had been trained to wash her hands before providing care, had last been trained a few months earlier on infection control, and said it had slipped her mind to wash her hands after entering the room. The DON stated staff were expected to wash their hands before starting care and confirmed LVN B had been trained on infection control in February 2026. The facility's hand hygiene policy stated hand hygiene is the primary means to prevent the spread of healthcare-associated infections, is indicated immediately before touching a resident, and that gloves do not replace hand hygiene.
Insufficient Room Size in Semi-Private Resident Rooms
Penalty
Summary
The facility failed to provide 80 square feet of floor space per resident in 10 of 40 semi-private resident rooms containing two beds, specifically Rooms #1, 3, 5, 8, 27, 29, 30, 31, 32, and 33. Record review of Texas Health and Human Services Form 3740 dated 01/8/25 documented that these rooms were classified as Title 18/19 semi-private rooms for two residents. During an interview on 03/27/26, the Administrator stated she wanted to apply for the room size waiver and said these rooms had a waiver for years with no change to the floor plan. During a general observation tour on 03/27/26, surveyors noted that the 10 semi-private rooms had 154 square feet instead of the required 160 square feet for two residents. In a later interview, the Administrator stated there had been no issues with the room size in the past 34 plus years and that there was no facility policy for room size waiver.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to provide residents and their representatives with information on their rights related to filing grievances or concerns. This deficiency was identified for 9 out of 15 confidential residents, who reported during a Resident Council meeting that they did not have access to grievance forms, were unaware of the option to file grievances anonymously, and had not been informed about the grievance procedure. Additionally, there were no postings of the grievance procedure in prominent locations within the facility, and residents did not know where to acquire a grievance form, who to submit it to, or what the process entailed once a grievance was filed. The facility's Administrator (ADM), who was responsible for handling grievances, admitted to not informing residents or the Activities Director about the location of grievance forms and was unaware of the need for residents to have access to these forms or the option to submit grievances anonymously. The ADM also stated that grievance forms were kept in her office and at each nurse's station, but residents did not request or complete them independently. The facility's grievance policy, last revised in June 2005, outlined procedures for investigating grievances and informing residents of the findings, but the ADM was not aware of the policy's requirements, including the timeframe for addressing grievances.
Dietary Preferences Not Met for Residents
Penalty
Summary
The facility failed to provide a diet that met the daily nutritional and special dietary needs of three residents, taking into consideration their preferences. During a lunch meal service, sour cream enchiladas were prepared as the main entree, but there were not enough enchiladas for all residents who requested them. As a result, some residents, including Resident #16, Resident #25, and Resident #40, were served hamburgers and potato chips instead. This substitution did not align with the residents' preferences and dietary needs. Resident #25, a male with a history of contracture, major depressive disorder, and hypokalemia, expressed that he had requested enchiladas but received a hamburger instead. He noted that this was the first time such an incident occurred. Resident #40, who has major depressive disorder, anemia, and severe protein-calorie malnutrition, also requested enchiladas but was served a hamburger. He mentioned that this was not a frequent occurrence but had happened before. Resident #16, with end-stage renal disease, type 2 diabetes mellitus, and cirrhosis of the liver, also did not receive the requested enchiladas and noted that the dietary department had been running out of food lately. Interviews with staff revealed that there was a miscalculation in the number of enchiladas prepared, as 75 enchiladas were made for 39 residents, each requiring two enchiladas, resulting in a shortage. The dietary manager and other staff members acknowledged the issue, attributing it to possible last-minute changes in residents' meal preferences or incorrect marking of dietary slips. The facility's policy requires that each resident be provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, considering their preferences, which was not adhered to in this instance.
Deficiency in Kitchen Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage in the kitchen, as observed during a kitchen tour. Specifically, the handles of three freezers, two refrigerators, and one oven were found to have dry, sticky substances on them. Additionally, a gallon-sized zip lock bag of fruit loops in the pantry was not fully sealed, and a bag of lunch meat in the refrigerator had an illegible date and was also not fully sealed. These observations indicate a failure to adhere to professional standards for food service safety. Interviews with the Dietary Manager (DM) and Assistant Dietary Manager (ADM) revealed that the facility was short-staffed due to an employee quitting, which contributed to the lack of cleanliness and improper food storage. The DM acknowledged that the dietary staff usually followed a daily cleaning schedule, but due to the staffing shortage, there was insufficient time to ensure kitchen items were cleaned. Both the DM and ADM admitted that the zip lock bags used for food storage did not always seal properly, especially when staff were in a hurry, leading to potential risks of food contamination and foodborne illness. The facility's policies on food receiving, storage, and sanitation, revised in November 2022, were not followed as required.
Failure to Maintain Resident Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure that Resident #33 was treated with respect and dignity during incontinent care, as observed during a survey. CNA D did not pull the privacy curtain before performing incontinent care, which risked exposing the resident if someone entered the room. Additionally, CNA D left Resident #33 uncovered while sanitizing his hands in the restroom, exposing the resident's lower back and buttocks. This lack of privacy was acknowledged by CNA D, who admitted to rushing and not following proper procedures despite having received training on maintaining resident privacy. Resident #33, a male with mild cognitive impairment and several medical conditions including Type 2 Diabetes Mellitus, cerebral infarction, and anxiety, was always incontinent of bowel and bladder. The facility's policies on dignity and resident rights emphasize the importance of treating residents with respect and ensuring their privacy during personal care. However, the facility's administration, including the ADM and DON, were unaware of the privacy lapses until the survey. They both acknowledged the importance of maintaining resident privacy and the potential negative outcomes of failing to do so.
Incomplete DNR Form Puts Resident's Wishes at Risk
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate advance directives, specifically for one resident who was listed as Do Not Resuscitate (DNR). The resident, an elderly female with a history of cerebral infarction, dementia, and type 2 diabetes, had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was incomplete due to a missing date accompanying one of the witness's signatures. This oversight was identified during a review of the resident's records, which included a physician order summary and care plan indicating a DNR status. Interviews with facility staff, including the social worker (SW) and the administrator (ADM), revealed that there was no system in place to monitor the accuracy of OOH-DNR forms. Both the SW and ADM acknowledged that the OOH-DNR form was not valid if not filled out correctly, and they confirmed the missing information on the form. The SW admitted that human error was the reason for the incomplete form and stated that she was responsible for ensuring the forms were completed correctly. The ADM also confirmed the lack of a monitoring system and stated that the Director of Nursing (DON) should be responsible for reviewing the forms for accuracy.
Failure to Maintain Cleanliness of Resident's Wheelchair
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, specifically in maintaining the cleanliness of the resident's wheelchair. The resident, who was cognitively intact and had multiple medical conditions including paraplegia and incontinence, was observed using a motorized wheelchair that was visibly soiled with brown spots on the backrest and seat. Despite the resident's awareness and discomfort with the soiled condition of the wheelchair, it remained uncleaned throughout the day. Interviews with the facility staff, including CNAs and the LVN, revealed a lack of awareness and responsibility in addressing the cleanliness of the resident's wheelchair. The CNAs were responsible for cleaning the wheelchair when soiled, but the assigned CNA did not notice or clean the wheelchair during her shift. The LVN was also unaware of the soiled condition until later in the day, indicating a communication breakdown among the staff regarding the resident's needs. The facility's policy on cleaning and disinfection of resident-care items was not adhered to, as the wheelchair was not cleaned promptly despite being visibly soiled. The Director of Nursing and the Administrator acknowledged the importance of maintaining a sanitary environment and the potential for embarrassment to the resident. However, the failure to clean the wheelchair in a timely manner demonstrated a deficiency in the facility's care practices, impacting the resident's dignity and quality of life.
Improper Storage of Portable Oxygen Tank
Penalty
Summary
The facility failed to ensure the proper storage of a portable oxygen tank for a resident, which posed a potential risk for avoidable injuries. During an observation, the oxygen tank was found free-standing and resting against a wall in the resident's room, unsecured and not stored in a designated holder or cart. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that staff had been verbally trained on securing oxygen tanks, yet the tank was left unsecured, contrary to the facility's policy. The resident involved was a male with end-stage renal disease, heart failure, and chronic respiratory failure, who used a wheelchair independently. The resident reported that staff were responsible for handling the oxygen tank, including placing it on and off his wheelchair for dialysis trips. Despite the facility's policy requiring oxygen tanks to be stored in racks with chains, sturdy carts, or approved stands, the tank was left in the resident's room, creating a potential hazard. The facility's policy also prohibited storing oxygen cylinders in resident rooms or living areas, highlighting a lapse in adherence to safety protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.52% based on 3 out of 46 opportunities. This involved three residents who experienced medication administration errors. The errors were observed during medication administration observations and involved two medication aides, MA A and MA B, who failed to administer medications as per the physician's orders. Resident #43, a male with a history of dementia, anemia, malnutrition, major depressive disorder, and allergic rhinitis, did not receive his prescribed Fluticasone Propionate Nasal Suspension for allergies. MA A documented the administration of the medication in the MAR but later admitted during an interview that she did not administer the medication and was unsure why she marked it as given. This oversight could potentially lead to the resident not receiving the necessary therapeutic treatment for his allergies. Resident #44, a male with multiple diagnoses including diabetes, peripheral vascular disease, and respiratory issues, was underdosed with Gabapentin, a medication for nerve pain. MA B administered only one capsule instead of the prescribed two, failing to verify the medication with the order prior to administration. Additionally, Resident #23, a male with vascular dementia and other neurological conditions, was not given his prescribed Methylphenidate due to MA B's distraction during the medication pass. MA B failed to verify the medications in the cup with the physician's orders, leading to the omission of the controlled medication. These errors highlight the facility's failure to ensure proper medication administration practices, as outlined in their policy.
Improper Storage of Schedule IV Narcotic in Medication Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, specifically in the medication storage room refrigerator. During an observation, it was found that a Schedule IV narcotic, Lorazepam 2 MG/ML oral concentrate, was stored in an unlocked lockbox within the refrigerator. The padlock for the lockbox was unsecured and open, which was confirmed by LVN A, who was unaware of the medication's presence in the lockbox and did not have a key to it. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were the only ones with keys to the lockbox, and the DON was also unaware of the medication being stored there. Interviews with the DON and the Administrator (ADM) revealed that the medication storage room was supposed to remain locked at all times, and narcotics required a double locking process. The DON stated that nursing staff were responsible for ensuring proper storage and reconciliation of medications at the end of each shift. However, the oversight occurred possibly due to the medication being brought by Hospice and overlooked during staff reconciliation. The facility's policy required Schedule II-V controlled medications to be stored in separately locked compartments, but this was not adhered to, leading to the potential risk of medication diversion.
Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving staff and residents. In the first incident, a Certified Nursing Assistant (CNA) did not perform hand hygiene between glove changes while providing incontinent care to a resident with multiple health conditions, including sacral spina bifida, paraplegia, and end-stage renal disease. The CNA admitted to not sanitizing her hands between glove changes, attributing it to an oversight when the resident requested care unexpectedly. Despite having received training on proper hand hygiene, the CNA acknowledged the risk of spreading bacteria and germs due to this lapse. In the second incident, a Licensed Vocational Nurse (LVN) failed to wear the appropriate personal protective equipment (PPE) while providing wound care to a resident on Enhanced Barrier Precautions (EBP) due to multiple pressure ulcers. Although the LVN initially donned a gown and gloves, she neglected to put on a gown upon re-entering the room to continue wound care after retrieving additional supplies. The LVN, who had been trained on EBP, recognized the importance of wearing proper PPE to prevent infection spread but admitted to forgetting to wear a gown during the procedure. Interviews with the facility's administration and nursing staff revealed that they were unaware of these lapses in infection control practices prior to the survey. Both the Administrator and Director of Nursing (DON) emphasized the importance of adhering to hand hygiene and EBP protocols to prevent infection spread. The facility's policies on hand hygiene and EBP were reviewed, highlighting the expectations for staff to follow these guidelines to minimize the risk of healthcare-associated infections.
Failure to Implement Comprehensive Care Plan for Combative Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3). The care plan did not include measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. Specifically, the facility did not ensure staff implemented the care plan for a resident who became combative during incontinent care, placing the resident at risk of not having their individual care needs met. The resident, a male with a history of dementia, cerebral infarction, psychotic disorder, major depressive disorder, and other conditions, was admitted to the facility with severe cognitive impairment. The resident's care plan indicated he required assistance for toileting and transfers and had behaviors of resisting care due to dementia. The care plan outlined strategies for managing aggression, such as allowing the resident to make decisions about treatment, providing clear explanations, and returning later if the resident resisted care. However, during an incident, a CNA continued to provide care despite the resident becoming combative, resulting in the CNA being kicked in the mouth. Interviews with staff revealed that the CNA did not follow the care plan's instructions to stop care and report the incident to a nurse. Instead, the CNA continued care due to being short-staffed. The facility's policy and procedure for comprehensive care planning and behavioral assessment were not effectively implemented, as evidenced by the failure to adhere to the care plan and manage the resident's behavior appropriately. This deficiency highlights the need for consistent implementation of care plans and adherence to facility policies to ensure residents' needs are met safely and effectively.
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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.
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Nursing homes near Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mesquite Post Acute Care | 0.2 mi | ★★★★★ | 11 | 0 |
| Lakeside Rehabilitation And Care Center | 0.6 mi | ★★★★★ | 7 | 0 |
| Lubbock Health Care Center | 0.6 mi | ★★★★★ | 6 | 0 |
| Southern Specialty Rehab & Nursing | 0.7 mi | ★★★★★ | 13 | 2 |
| The Mildred & Shirley L. Garrison Geriatric Educat | 1.5 mi | ★★★★★ | 14 | 5 |
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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.