Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Mineola Gardens Wellness & Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact male resident, dependent on staff for ADLs and with multiple medical conditions including infectious gastroenteritis/colitis, HTN, and BPH, reported that a male CNA was very rough while turning and wiping him during incontinent care. He stated he informed nursing staff at the time and the Administrator the next day. The ADON and a COTA later received similar reports from the resident describing a male staff member with glasses who moved him roughly and caused rib pain, and the ADON identified a specific CNA from the schedule. The facility’s abuse policy requires mandatory reporters to report suspected abuse and to notify authorities within two hours of forming a suspicion, but the Administrator, despite acknowledging the allegation and the policy, did not report the incident to the state survey agency, instead viewing it as a customer service issue.
A cognitively intact male resident, dependent on staff for ADLs, reported that a male CNA was very rough while providing incontinent care, causing rib pain, and stated he reported this to nursing staff and the Administrator. Therapy staff relayed the allegation to the ADON, who identified the CNA involved and treated the concern as an abuse allegation, but the Administrator decided it was a customer service issue and did not report it to HHSC, despite a written abuse policy requiring all abuse allegations to be reported within two hours. The resident’s care plan did not address his required level of assistance for ADLs, and the CNA later described using significant body strength to turn the resident without obtaining needed assistance.
A cognitively intact male resident, dependent on staff for ADLs and recently admitted with infectious gastroenteritis, colitis, HTN, and BPH, reported that a male CNA was very rough while providing incontinent care, including turning and wiping him, and that this caused rib pain. He reported the incident to nursing staff and then to the Administrator. A COTA relayed the allegation to the ADON, who interviewed the resident, identified the CNA from the schedule, and completed a skin assessment. The Administrator acknowledged being informed of the allegation but chose to treat it as a customer service issue rather than abuse and did not report it to the state agency within the required 2-hour timeframe, despite facility policy and her own understanding that rough handling should be reported as abuse.
A resident with Parkinson’s disease, dementia, and generalized anxiety disorder, who required assistance with bathing, hygiene, and dressing, repeatedly told nursing staff she did not want male staff providing personal or hands-on care. An LVN acknowledged knowing of this preference and stated it should have been added to the care plan, while the ADON indicated such preferences should be reported, discussed by the IDT, and care planned, and the Administrator expected it to be documented so all staff were aware. Despite the facility’s policy requiring a culturally competent, trauma-informed, person-centered care plan addressing psychosocial needs, the resident’s preference for female-only caregivers was not included in her care plan.
A resident with cerebral infarction, bipolar disorder, dementia, and intact cognition required substantial assistance with bathing and personal hygiene per her MDS and care plan, but facility records and interviews showed she did not receive several scheduled showers. Over a one‑month period, her bathing task record lacked entries for multiple shower days, and she reported not receiving showers as scheduled, noting stained clothing and unkempt hair. CNAs and the ADON acknowledged missed showers, citing construction, blocked showers, and workload, while the Administrator stated she was unaware of missed showers and that CNAs were expected to provide bed baths when showers were unavailable. The facility’s shower policy required at least weekly showers and showers upon request, which was not followed in this case.
Surveyors found a Hall 2 medication cart unlocked and unattended near the nurse’s station while residents, staff, and contractors were present nearby. A Regional Nurse confirmed the cart belonged to an LVN who was on a smoke break and stated the cart should have been locked when unattended. In interviews, the LVN acknowledged responsibility for locking the cart and admitted believing it had been locked, while the ADON and Administrator both affirmed that charge nurses and department heads are responsible for ensuring medication carts remain locked whenever staff step away, consistent with the facility’s written medication storage policy requiring carts, rooms, and cabinets to remain locked unless under direct, continuous supervision.
A nurse failed to wear a gown, as required by Enhanced Barrier Precautions, while administering medications through a feeding tube to a resident with multiple medical conditions and severe cognitive impairment. Despite clear signage and available PPE, only gloves were used during this high-contact care activity, contrary to facility policy and infection control protocols.
A nurse failed to notify a physician and a resident's representative after the resident exhibited agonal breathing, fixed pupils, and other signs of acute decline. Despite clear symptoms and facility policy requiring immediate notification, the nurse only monitored the resident and did not contact the physician or family. The oncoming nurse later discovered the situation, called emergency services, and notified all appropriate parties.
A resident with multiple comorbidities and a DNR order experienced a significant change in condition, including agonal breathing and unresponsiveness. An LPN assessed the resident but failed to notify the physician, family, or initiate further interventions, mistakenly believing no action was needed due to the DNR status and a prior family request. The oncoming nurse recognized the emergency, contacted EMS and the appropriate parties, but the resident later died. Facility leadership confirmed the LPN did not follow required protocols for change in condition.
A facility failed to protect two residents from sexual abuse by a CNA. One resident, who is blind and cognitively impaired, reported rectal penetration during showers, confirmed by a hospital exam. Another resident with Parkinson's disease reported an attempted rectal insertion by the same CNA. Despite previous similar allegations against the CNA, the facility did not prevent these incidents, placing residents at risk of further abuse.
A resident accused a CNA of sexual abuse, but the facility failed to immediately suspend the CNA, leaving residents unprotected. The investigation was incomplete, lacking critical evidence and failing to report the incident to law enforcement. The resident had multiple medical conditions and was capable of making informed decisions.
Two residents undergoing dialysis were not accurately coded for hemodialysis treatment in their MDS assessments, despite having physician's orders and regular dialysis schedules. The facility's MDS assessments and care plans failed to document the dialysis treatments, and interviews with staff confirmed these discrepancies. The MDS Coordinator and DON acknowledged the errors, which could impact the residents' care plans.
A resident did not receive 7 out of 11 prescribed doses of Lotemax Ophthalmic Suspension due to the facility's failure to acquire and administer the medication timely. Despite documentation indicating administration, the medication was not available, and staff failed to notify the DON or pharmacy promptly. The facility's policies for urgent medication orders were not followed, leading to missed doses and inaccurate MAR entries.
The facility failed to implement baseline care plans for two residents with ESRD within 48 hours of admission. Despite having physician orders for dialysis, these were not reflected in their care plans. Observations and interviews revealed that the MDS assessments did not code for dialysis, leading to incomplete care plans. The DON and MDS Coordinator acknowledged the oversight, which resulted in inadequate documentation of dialysis needs.
A facility failed to accurately document the administration of Lotemax Ophthalmic Suspension for a resident with multiple health conditions. The medication was recorded as administered by two LVNs on occasions when it was not available in the facility. The DON confirmed the medication could not have been given, and the ADON noted its unavailability despite searches. The facility's policy on medication administration documentation was not followed.
A resident with multiple health conditions, including depressive disorder and Parkinson's Disease, was verbally abused by an LVN during a shift change. The LVN told the resident to leave the nursing station, stating he was "pissing him off," which was confirmed by a witness. The facility's policy emphasizes protecting residents from abuse, but the incident was confirmed as verbal abuse by the facility's investigation.
Failure to Protect Resident From Rough Handling and to Report Abuse Allegation
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA handled the resident roughly during incontinent care and the allegation was not reported to the state survey agency as required. The resident was an adult male with infectious gastroenteritis and colitis, essential primary hypertension, and benign prostatic hyperplasia with lower urinary tract symptoms. His comprehensive MDS showed intact cognition with a BIMS score of 15, and he was dependent on staff for toileting, showering/bathing, dressing, and personal hygiene. His care plan did not address the level of assistance he required for ADLs. When he was first admitted and needed to be changed because he was dirty, a male CNA provided care and, according to the resident, was very rough when turning and wiping him. The resident reported to nursing staff at the time of the incident and to the Administrator the next day that the CNA had been rough with him and that he should have been treated more gently. Later, the resident also reported to the ADON that a male staff member with glasses and a beard had been rough while changing him and that his right rib cage was hurting. A COTA reported that the resident told her a gentleman with glasses had come into his room in the early morning hours, moved him around roughly, and hurt his rib, and that the resident was upset and wanted the person fired. The ADON reviewed the schedule and identified the staff member as a specific CNA and reported the allegation to the Administrator as an allegation of abuse. The Administrator acknowledged being notified by the ADON that the resident had alleged rough handling by the CNA but chose not to report the incident to the state agency, characterizing it as a customer service issue after speaking with the resident. The Administrator stated that the resident told her the CNA could have been gentler when moving him. The facility’s written Abuse Prevention and Prohibition Program policy states that the facility has zero tolerance for abuse and that all owners, operators, employees, managers, agents, and contractors are mandatory reporters obligated to report known or suspected instances of abuse. The policy further requires that allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime be reported immediately, but no later than two hours after forming the suspicion, to the state survey agency and other authorities. Despite this policy, the Administrator did not report the resident’s allegation of rough handling as abuse. During an interview, the CNA identified by the ADON stated he had provided incontinent care to the resident when he first arrived, turned him on his side as far as he could because the resident was not able to turn well, and used his body strength to push the resident on his side to get him cleaned up. He stated he was not trying to be rough but acknowledged he had to push the resident a little and that he should have obtained another person to help since he was having trouble turning the resident and other staff were busy. The ADON reported that a skin assessment revealed no redness or bruising and that the resident’s rib pain could have been related to an assisted fall the previous day, for which an x-ray was negative. However, the allegation of rough handling during care remained, and the facility did not follow its own abuse reporting requirements by failing to report the allegation to the state survey agency within the required timeframe.
Failure to Report Resident’s Allegation of Rough Handling as Required by Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its written Abuse Prevention and Prohibition Program policy requiring reporting of all abuse allegations to the state survey agency within two hours. The policy, revised 10/24/2022, states the facility has zero tolerance for abuse, neglect, mistreatment, and misappropriation of resident property, and designates the Administrator as responsible for coordinating and implementing abuse prevention policies and for reporting known or suspected abuse. The policy further specifies that allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime must be reported immediately, but no later than two hours after forming the suspicion, to the state survey agency and other appropriate authorities. Resident #3, a male resident with diagnoses including infectious gastroenteritis and colitis, essential primary hypertension, and benign prostatic hyperplasia with lower urinary tract symptoms, was cognitively intact with a BIMS score of 15 and dependent on staff for toileting, showering/bathing, dressing, and personal hygiene. His care plan initiated 03/31/2026 did not address his level of assistance for ADLs. Resident #3 reported that when he first came to the facility, a male CNA was very rough with him while changing and wiping him, and he believed staff should be gentle when providing care. He stated he reported this to a nurse when it happened and to the Administrator the next day, and that the Administrator told him she would investigate but did not return to tell him anything. He also reported that the CNA had not provided care to him again. On 04/09/2026, COTA C reported to the ADON that Resident #3 said a staff member had been rough with him during incontinence care in the early morning hours, describing the staff as a man with glasses and a beard and reporting right rib cage pain. The ADON identified the staff member as CNA D from the schedule, completed a skin assessment that showed no redness or bruising, and reported the allegation to the Administrator the same day as an allegation of abuse. The Administrator acknowledged being notified that Resident #3 alleged CNA D was rough with him but chose not to report the allegation to HHSC, characterizing it as a customer service issue after speaking with the resident, despite stating that rough handling should be reported as abuse and that their policy required reporting any allegation of abuse within two hours. CNA D stated he had provided incontinent care to Resident #3 when he first arrived, had difficulty turning him due to the resident’s limited ability to turn, and used his body strength to push the resident onto his side, acknowledging he should have obtained assistance but did not because others were busy. The Administrator’s failure to report this abuse allegation to HHSC, contrary to facility policy and regulatory requirements, constitutes the cited deficiency.
Failure to Timely Report Allegation of Rough Handling as Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse to the state survey agency as required by its abuse prevention policy and federal and state regulations. A cognitively intact male resident with diagnoses including infectious gastroenteritis and colitis, essential hypertension, and benign prostatic hyperplasia was dependent on staff for toileting, bathing, dressing, and personal hygiene. His care plan initiated on 03/31/2026 did not address his level of assistance for ADLs. Shortly after admission, he required incontinent care and later reported that a male CNA had been very rough with him during changing, turning, and wiping, stating that staff were supposed to be gentle when providing care. He reported this to a nurse when it happened and to the Administrator the next day, and stated the Administrator told him she would investigate but did not return to tell him anything. On 04/09/2026, the COTA reported to the ADON that the resident said a staff member was rough with him in the early morning hours and had hurt his rib. The resident described the staff member as a man with glasses and a beard. The ADON interviewed the resident, who repeated that a staff member was rough while changing him and reported right rib cage pain. The ADON reviewed the schedule, identified the staff member as a CNA, and completed a skin assessment that showed no redness or bruising. The ADON stated she reported the resident’s allegation of abuse to the Administrator as soon as she was able that same day because it was an allegation of abuse, and acknowledged that all allegations of abuse must be reported and investigated. The COTA confirmed that the resident was upset, reported that a gentleman with glasses had moved him roughly and hurt his rib, and that she attempted to report to the Administrator but, finding her absent, reported to the ADON. The Administrator acknowledged that the ADON notified her of the resident’s allegation that the CNA was rough with him, but stated she did not report the incident to the state agency because, after speaking with the resident, she considered it a customer service issue rather than abuse. The Administrator also stated that rough handling or moving roughly should be reported as abuse and that any allegation of abuse must be reported to the state agency within 2 hours. The facility’s written Abuse Prevention and Prohibition Program policy requires that allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported immediately, but no later than 2 hours after forming the suspicion, when the alleged violation involves abuse or results in serious bodily injury. Despite this policy and the Administrator’s own statements about reporting requirements, the allegation involving rough handling by the CNA was not reported to the state agency within the required timeframe.
Failure to Care Plan Resident Preference for Same-Gender Caregivers
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan that reflected a resident’s stated preference to not receive personal or hands-on care from male staff. The resident, an elderly female with Parkinson’s disease, dementia with moderately impaired cognition (BIMS score of 12), and generalized anxiety disorder, required assistance with bathing, personal hygiene, and dressing. Her comprehensive MDS assessment showed she could make herself understood and usually understood others. Record review of her care plan, initiated in March 2026, did not include her preference to have only female staff provide personal care, despite her having communicated this preference to nursing staff. During interviews, the resident reported that she had told a nurse she did not want men cleaning her up or touching her and that she had to repeatedly tell nurses she did not want male staff providing this care. An LVN confirmed awareness of the resident’s preference for female-only caregivers and stated that this preference should be included in the care plan, noting that the ADON and DON were responsible for adding it. The ADON stated she did not specifically recall this resident expressing the preference but acknowledged that such preferences should be placed on assignment sheets and included in the care plan, and that nurses should report them to administration for interdisciplinary discussion and care planning. The Administrator reported she was not aware of the resident’s preference and stated she expected such information to be in the care plan so all staff would know and residents’ rights would be respected. The facility’s own care planning policy required a culturally competent, trauma-informed, person-centered care plan with measurable objectives and timetables to meet medical, nursing, mental, and psychosocial needs, but this preference was not incorporated into the resident’s care plan.
Failure to Provide Scheduled Showers and Hygiene Assistance for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dependent resident received necessary assistance with activities of daily living, specifically scheduled showers, to maintain personal hygiene and grooming. The resident was an older female with cerebral infarction, bipolar disorder, and dementia, but had intact cognition with a BIMS score of 15 and was usually able to understand and be understood by others. Her MDS and care plan documented that she required substantial/maximal assistance with showering/bathing and lower body dressing, and extensive assistance with showering and personal hygiene due to weakness of her dominant side. Review of her bathing task record for a one‑month period showed no documentation that she received showers on three scheduled dates. During observation and interview, the resident reported she was not receiving showers as scheduled, stating her last shower was several days prior and that she was supposed to receive one the previous day. She also reported CNAs told her they were too busy and had 18–20 residents to care for. At the time of observation, she had light brown stains on her white shirt and reported she could not fix the back of her hair because she had not received a shower and her hair was messy from lying on the pillow. Staff interviews confirmed missed showers and inconsistent monitoring. A CNA acknowledged missing some showers for this resident and others, attributing it to construction and cold water, and stated that on one day the showers were unavailable due to construction. The ADON stated CNAs documented on bathing task records and shower sheets but could not provide shower sheets for the resident, citing missing items due to construction. The ADON was aware showers were missed on a specific day because painters blocked off both showers and stated some residents received bed baths, but she did not know how they ensured all residents received baths that day. She also noted the resident’s shower schedule had been changed, and that the resident should have received a shower on the new schedule to avoid going many days without one, and admitted she had not been able to monitor to ensure showers were not missed during remodeling and room changes. The Administrator stated she was not aware residents were not receiving showers as scheduled, acknowledged that painters had blocked both showers on one day without notifying her, and stated CNAs were supposed to provide bed baths to residents scheduled for showers. The facility’s policy stated residents are offered a shower at least once weekly and as requested, underscoring that the documented and reported missed showers were inconsistent with facility policy.
Unlocked and Unattended Medication Cart on Hall 2
Penalty
Summary
The deficiency involved the facility’s failure to ensure that drugs and biologicals were stored in locked compartments in accordance with professional standards. During an observation on 04/14/2026 at 2:09 PM, the Hall 2 medication cart was found unlocked and unattended near the nurse’s station, with residents, staff, and multiple workers painting in the area. The Regional Nurse observed the state surveyor standing by the unlocked cart and then locked it, stating that the cart was the responsibility of LVN A, who should have locked it before stepping away. The Regional Nurse reported that LVN A was outside on a smoke break and confirmed that medication carts should not be unlocked when unattended for the safety of the medications. In subsequent interviews, LVN A acknowledged responsibility for ensuring the medication cart was locked and stated he thought he had locked it before going outside, recognizing that if carts were left unlocked, a patient or anyone could access the medications. The ADON stated that charge nurses were responsible for locking medication carts every time they stepped away, emphasizing that only the person responsible for the cart should be able to access it. The Administrator stated that medication carts were expected to be locked whenever nurses walked away or were no longer facing the cart, and that all department heads were responsible for ensuring carts were locked and for reporting any unlocked carts. Review of the facility’s “Medication Storage” policy, revised 01/2026, showed that medication carts, rooms, and cabinets must remain locked at all times unless under direct and continuous supervision, and specifically required carts to be locked when turning away, when more than arm’s reach away, and during breaks, meals, or when leaving the unit.
Failure to Follow Enhanced Barrier Precautions During Feeding Tube Medication Administration
Penalty
Summary
A registered nurse failed to adhere to the facility's Enhanced Barrier Precautions (EBP) policy while administering medications through a jejunostomy tube to a resident. The resident, who had a history of feeding difficulties, oropharyngeal dysphagia, cerebral infarction, and required a feeding tube for nutrition and medication, was under EBP due to the presence of an indwelling medical device. The nurse donned gloves but did not put on a gown before performing the high-contact activity, despite clear signage and available personal protective equipment (PPE) outside the resident's room indicating that both gloves and a gown were required for such care activities. The nurse acknowledged during an interview that she should have worn a gown and attributed the oversight to nervousness. Both the Director of Nursing and the facility's Infection Preventionist confirmed that the expectation and policy require staff to wear gloves and gowns when providing care involving feeding tubes to prevent the spread of infections. A review of the facility's policy further supported that device care, such as feeding tube use, necessitates the use of both gloves and a gown as part of EBP.
Failure to Notify Physician and Family After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a nurse failed to immediately notify a resident's physician and representative after a significant change in the resident's condition. The resident, an elderly female with chronic atrial fibrillation, repeated falls, and dementia, was found by a CNA to be experiencing agonal breathing, cold skin, fixed pupils, no urine output, and lethargy. The nurse on duty, LVN A, assessed the resident and noted these symptoms, but did not contact the physician or the resident's family, instead choosing to monitor the resident throughout the remainder of her shift. LVN A stated that she believed the resident was actively dying and, due to the resident's DNR status and a social worker note indicating the family did not want to be called in the middle of the night unless it was an emergency, she did not notify anyone. However, interviews with other staff, including the DON, another LVN, and the administrator, confirmed that the resident was not on hospice and that the nurse should have notified the physician and the family immediately upon recognizing the change in condition. The oncoming nurse, LVN C, upon receiving report and assessing the resident, called 911, notified the nurse practitioner, the family, and the DON. The facility's policy required prompt notification of the physician and resident representative in the event of a significant change in condition. The failure to follow this protocol was confirmed through interviews and record review, with multiple staff members expressing that the nurse's actions did not meet expectations. The physician also stated that he would have wanted to be notified and would have given orders for the resident to be sent to the hospital. The incident was identified as a deficiency and Immediate Jeopardy, as the nurse did not act in accordance with facility policy or professional standards.
Failure to Notify Physician and Family or Initiate Interventions After Resident Change in Condition
Penalty
Summary
A deficiency occurred when a resident with chronic atrial fibrillation, repeated falls, and dementia experienced a significant change in condition during the early morning hours. The resident, who had a DNR order but was not on hospice, was found by a CNA to have not voided during the shift and was exhibiting agonal breathing, cold skin, and fixed pupils. The CNA immediately notified the nurse (LVN A), who assessed the resident and noted low vital signs and signs of active dying. Despite these findings, LVN A did not notify the physician, nurse practitioner, or the resident's family, nor did she initiate any interventions or further assessments beyond monitoring the resident at 15-minute intervals. LVN A stated she believed that because the resident was a DNR and the family had previously requested not to be called during the night unless it was an emergency, no further action was required. She also mistakenly believed the resident was on hospice. The oncoming nurse (LVN C), upon receiving report and assessing the resident, immediately recognized the severity of the situation, called EMS, notified the NP, family, and DON, and arranged for the resident to be transported to the hospital, where the resident was later pronounced deceased due to cardiopulmonary arrest. Interviews with facility leadership, including the DON and Administrator, confirmed that LVN A failed to follow professional standards of practice by not notifying the appropriate medical providers or the family and by not initiating timely interventions in response to the resident's change in condition. The facility's policy required prompt notification of the physician and representative in the event of a significant change, which was not followed in this case. The DON and Administrator both described the nurse's actions as neglectful and not in accordance with facility protocols.
Failure to Protect Residents from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect two residents from sexual abuse by a certified nursing assistant (CNA A). The first resident, who is blind and has severe cognitive impairment, reported that CNA A penetrated his rectum with a finger during showers. This resident had a history of refusing showers and was diagnosed with major depressive disorder and intellectual disabilities. The incident was reported to the local police, and a hospital examination confirmed the resident's complaint of rectal pain. The facility's records indicated that CNA A had previously been accused of similar behavior by another resident in 2023. The second resident, who has heart failure and Parkinson's disease, reported that CNA A attempted to insert a finger into his rectum during a shower. This resident initially denied any abuse when asked by staff but later admitted to the surveyor and the Director of Nursing (DON) that he had not been truthful due to fear of being labeled a troublemaker. The resident expressed feelings of embarrassment and shame, which contributed to his initial reluctance to report the incident. The facility's records and interviews revealed that CNA A was scheduled to work on the days the alleged incidents occurred. Despite the facility's policy on abuse prevention, the CNA continued to work until the allegations were reported. The facility's administrator acknowledged the suspicious nature of multiple similar allegations against CNA A, although the allegations were not confirmed. The facility's failure to prevent these incidents placed residents at risk of further abuse and emotional distress.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and theft, specifically in the case of a resident who accused a CNA of sexual abuse. The incident occurred when the resident, who had a history of making false accusations, alleged that the CNA had inserted a finger into his rectum during care. Despite the accusation, the CNA was not immediately suspended and continued to work until the end of his shift, which left the resident and other vulnerable residents unprotected. The facility also failed to ensure a thorough investigation of the abuse allegations. The investigation report lacked critical evidence, such as the resident's interview, safe surveys, and documentation of the LVN's education on the abuse policy. Additionally, the facility did not report the allegations of sexual abuse to local law enforcement, which is a requirement under their policies. The failure to notify the police was acknowledged by the current administrator, who stated that the previous administrator should have reported the incident. The resident involved in the incident had multiple medical conditions, including hypertension, depressive disorder, mild cognitive impairment, anxiety disorder, Type 2 diabetes, and cerebrovascular disease. The resident was interviewable and capable of making informed decisions, with no history of similar allegations. The lack of immediate action and thorough investigation placed the resident and others at risk of further abuse, neglect, and emotional distress.
Inaccurate MDS Assessments for Dialysis Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents undergoing dialysis, which could potentially impact the care and services they receive. Resident #14, a male with multiple diagnoses including end-stage renal disease (ESRD), was not accurately coded for hemodialysis treatment on his quarterly MDS assessments. Despite having physician's orders and hospital progress notes indicating the need for regular hemodialysis, the MDS assessments did not reflect this, and the care plans did not address the resident's ESRD. Observations and interviews confirmed that Resident #14 was attending dialysis sessions, yet this was not documented in the MDS or care plans. Similarly, Resident #33, who also had ESRD and was dependent on renal dialysis, was not accurately coded for dialysis treatment in the MDS assessments. The resident's physician's orders specified dialysis treatment days, and interviews confirmed the resident's dialysis schedule. However, the MDS assessments and care plans failed to document the dialysis treatment, and the baseline care plan did not address the resident's ESRD. Interviews with staff, including the MDS Coordinator and the DON, revealed that the dialysis treatments were not addressed in the admission assessments or care plans. The MDS Coordinator and the DON acknowledged the discrepancies in the MDS assessments and care plans for both residents. The MDS Coordinator confirmed that the RAI manual was used as a guideline for completing the MDS assessments, but the dialysis treatments were not coded as required. The DON confirmed that the lack of coding for hemodialysis could lead to discrepancies in the residents' care plans, and both the MDS Coordinator and the DON acknowledged that the residents' dialysis treatments were not addressed in the admission assessments.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of medications for a resident, specifically concerning the Lotemax Ophthalmic Suspension prescribed for eye conditions. The resident, who had multiple health issues including COPD, Multiple Sclerosis, and Dementia, was prescribed Lotemax eye drops to be administered twice daily. However, the facility did not provide 7 out of 11 doses between the specified dates, and there were discrepancies in the Medication Administration Record (MAR) indicating doses were administered when the medication was not available. The initial dose of Lotemax was delayed by approximately 19 hours after being prescribed, and subsequent doses were missed due to the medication not being available in the facility. Despite documentation indicating administration, the medication was not delivered until the following day, and further doses were missed over the next few days. The facility staff, including the LVNs and ADON, failed to notify the Director of Nursing (DON) or the pharmacy about the unavailability of the medication in a timely manner, resulting in missed doses and inaccurate MAR entries. Interviews with staff revealed a lack of communication and action to obtain the medication urgently, despite the pharmacy's capability to deliver medications 24/7. The DON was not informed of the missing medication until several days later, and attempts to obtain the medication from a local pharmacy were unsuccessful. The facility's policies and procedures for urgent medication orders and handling medication shortages were not followed, contributing to the deficiency in pharmaceutical services for the resident.
Failure to Implement Baseline Care Plans for Dialysis Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans for two residents with End Stage Renal Disease (ESRD) within 48 hours of their admission. Resident #14, a male with multiple diagnoses including ESRD, was admitted without a care plan addressing his dialysis needs. Despite having physician orders for dialysis and dietary requirements, these were not reflected in his baseline care plan. Observations noted that Resident #14 was attending dialysis sessions, but the necessary care instructions were absent from his care documentation. Similarly, Resident #33, also diagnosed with ESRD, did not have his dialysis needs addressed in his baseline care plan. His physician orders included specific instructions for dialysis treatment and monitoring, which were not incorporated into his care plan. Interviews with staff revealed that the MDS assessments failed to code for dialysis, leading to incomplete care plans for both residents. The MDS Coordinator and the Director of Nursing (DON) acknowledged the oversight in not addressing the residents' dialysis treatments in their care plans. The deficiency was further highlighted by the fact that the facility's staff, including agency nurses, were aware of the dialysis requirements but did not document these in the residents' care plans. The DON confirmed that the responsibility for reviewing and updating care plans lay with her and the Assistant Director of Nursing (ADON), and that the MDS Coordinator was responsible for ensuring accurate MDS assessments. The lack of documentation and coding for dialysis in the MDS assessments contributed to the failure in providing adequate care plans for the residents with ESRD.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in the accurate documentation of medication administration for a resident. The resident, a female with multiple diagnoses including Chronic Obstructive Pulmonary Disease, Multiple Sclerosis, and Dementia, was prescribed Lotemax Ophthalmic Suspension to be administered twice daily. However, the medication was not available in the facility at the times it was documented as administered by LVN F and LVN G. The initial dose was recorded as given on June 20, 2024, but the medication was not delivered until the following day. Additionally, the medication was documented as administered on June 23, 2024, despite being unavailable earlier that day. Interviews and record reviews revealed discrepancies in the documentation of the medication administration. The Director of Nursing (DON) acknowledged that the nurses could not have administered the medication as it was not present in the facility. The Assistant Director of Nursing (ADON) confirmed the unavailability of the medication on June 23, 2024, despite thorough searches. Attempts to contact the involved nurses, LVN F and LVN G, were unsuccessful. The facility's policy requires the individual administering medication to initial the Medication Administration Record (MAR) after giving each medication, which was not accurately followed in this case.
Verbal Abuse Incident During Shift Change
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically an LVN, during a shift change. The incident involved a resident who was at the nursing station while the LVN was giving a report to the oncoming nurse. The LVN told the resident to leave because he was "pissing him off," which was confirmed by a witness statement from another LVN. The resident, who was cognitively intact and used a wheelchair for mobility, had a history of depressive disorder, major depressive disorder with psychotic features, Parkinson's Disease, hypertension, angina pectoris, cerebrovascular accident, acute myocardial infarction, and chronic diastolic congestive heart failure. The resident's care plan included interventions for delirium or acute confusional episodes and attention-seeking behavioral problems. The care plan emphasized the need to reassure and de-escalate situations, anticipate and meet the resident's needs, and educate on conditions. Despite these interventions, the LVN's actions during the shift change were deemed verbally abusive, as confirmed by the facility's investigation and a witness statement. The LVN did not return to the facility after the incident, having quit his position. The facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy, dated April 2021, states that residents have the right to be free from abuse by anyone, including facility staff. The policy emphasizes establishing and maintaining a culture of compassion and caring, particularly for residents with behavioral, cognitive, or emotional problems. The facility confirmed the allegation of abuse, and the incident was investigated by the previous administrator, who verified the occurrence of verbal abuse.
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Nursing homes near Mineola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Mineola | 1.1 mi | ★★★★★ | 22 | 1 |
| Quitman Wellness & Rehabilitation | 9.7 mi | ★★★★★ | 11 | 0 |
| Avir At Lindale | 11 mi | ★★★★★ | 14 | 0 |
| Colonial Nursing & Rehabilitation Center | 11.4 mi | ★★★★★ | 8 | 0 |
| Avir At Bradburn | 12.9 mi | ★★★★★ | 7 | 2 |
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