Above 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 Mystic Park Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Inaccurate MDS Pain Medication Coding: A resident with diagnoses including stroke, DM2, PTSD, anxiety, HTN, and spinal stenosis had a quarterly MDS that coded no scheduled pain medication use even though the MAR showed he received scheduled Tramadol three times daily and the care plan identified pain medication therapy. The MDS LVN acknowledged the resident should have been coded for scheduled pain medication, and the DON stated MDS assessments should accurately reflect the resident’s status.
A resident with MDD, PTSD, anxiety, and other psychiatric history was not referred for PASRR review despite active diagnoses documented in the MDS, care plan, physician notes, behavioral health notes, and psychiatry follow-up. Staff stated they did not usually complete a PL1 for MDD and would only do one for certain diagnoses or if the resident had behaviors, even though the facility policy required accurate PASARR screening for residents with mental disorders and a new PASRR evaluation when condition changes significantly.
Improper incontinent care and infection control occurred when a CNA cleaned a resident’s penis using one disposable wipe for several passes instead of using a different wipe for each stroke. The resident was frequently incontinent of bowel and bladder, had a hx of UTI, and required substantial to maximal assistance with toileting hygiene. The DON confirmed that using a wipe more than once during perineal care was an infection control issue.
Medication Found on Floor Near Nurse Cart: A blue pill was observed lying on the floor by the 200 hall nurse cart during surveyor observation of medication storage. NA A, an MDS LVN, the RN responsible for the cart, and the DON all stated the pill should not have been on the floor, noting it could be picked up by anyone and should be discarded. Facility policy stated drugs and biologicals are to be stored in locked compartments and kept in their containers.
Dietary staff lacked a current food handler cert for 1 of 11 staff reviewed. An employee was observed in the kitchen cleaning equipment and stated he would be preparing pure diets later that morning. The DS said the only cert on file was the one posted on the wall, while the Administrator later said HR had provided a current cert; however, online verification showed the cert had expired. The facility policy stated the dietary manager was responsible for ensuring dietary staff certs were current.
Kitchen Food Safety Deficiencies: Dish racks were observed on the floor next to the sink instead of being stored off the floor, and the deep fryer contained dark brown oil with visible food particles, sediment, and residue buildup. The DS stated the racks should be stored on a pallet when not in use and said the fryer was cleaned on a weekend schedule, while the facility policy required racks to be stored off the floor and the fryer to be cleaned regularly per manufacturer guidance.
Improper Dumpster Area Sanitation: An observation of Dumpster #1 found dried food debris and spilled waste on the ground, stained concrete around the dumpster, pest control traps stored on the ground nearby, and the drain opening missing a plug. The DS said he was unaware of the debris and missing plug, while the MS said the area was cleaned periodically, the traps were supposed to be picked up by the pest control company, and the drain plug was the responsibility of waste management.
Incomplete and inaccurate PASRR Form 1012 documentation was found for two residents. One resident’s form had missing Yes/No selections, missing onset dates, an incomplete physician signature area, and no entry in the nursing facility action section. The other resident’s form had a missing physician signature date and printed name, omitted several mental health diagnoses listed in the chart, and also left the nursing facility action section blank. Staff interviews showed uncertainty about how the forms were completed and why information had been added years after physician signature.
Hand hygiene and aseptic technique were not followed during medication administration for three residents. An LVN gave PEG-tube medication to a resident with seizures and dementia without sanitizing hands between glove changes or after touching the bed remote and bedside table, a Med Aide applied a lidocaine patch to a resident with diabetes and osteoarthritis without hand hygiene after preparing meds and drawing the curtain, and an LVN inserted a needle into a resident’s insulin pen without cleaning the rubber seal with alcohol first.
The facility failed to follow professional standards for food service safety, as dietary aides improperly handled dishes, risking contamination. Additionally, a sandwich in a resident's refrigerator was unlabeled and undated, contrary to facility policy. The resident, with severe cognitive impairment, was at risk of receiving incorrect or expired food. Staff acknowledged the importance of proper food handling and labeling, highlighting the oversight.
Staff on the 200 unit failed to knock before entering residents' rooms, violating their rights to dignity and respect. A CNA and the MDS Nurse were observed entering rooms without knocking, contrary to facility policy. A resident reported discomfort with staff entering unannounced, especially while sleeping.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documentation. A resident was incorrectly noted as receiving insulin, another was inaccurately documented as not receiving hospice care, and a third was wrongly recorded as discharged to a hospital instead of a foster home. These errors were confirmed through interviews and record reviews, highlighting a lack of understanding and attention to detail by the staff.
A facility failed to provide adequate incontinence care for a resident with severe cognitive impairment and bowel and bladder incontinence, as a CNA did not properly clean the resident's right buttock area after a bowel movement. Additionally, another resident with an indwelling urinary catheter had their catheter drainage bag and tubing touching the floor, posing an infection control risk. These deficiencies could lead to cross-contamination and urinary tract infections.
Expired medications were found in two nursing carts, including Dakin's solution and Urea 20 cream, which were not removed as per facility policy. A resident with multiple health conditions was at risk due to the presence of expired medication. Nurses acknowledged the oversight, and the DON confirmed the responsibility to discard expired medications.
A CNA failed to adhere to Enhanced Barrier Precautions by not wearing a gown while providing suprapubic catheter care to a resident with severe cognitive impairment and multiple medical conditions. Despite a posted sign indicating the need for gloves and a gown, the CNA only wore gloves, potentially risking cross-contamination and infection. The DON confirmed the breach in protocol, which is part of the facility's infection control policy.
Two residents in a shared room experienced a persistent strong odor of urine, despite the room being on a twice-daily cleaning schedule. One resident, frequently incontinent, was observed in a low bed without sheets, and the floor mat was wet with liquid smelling of urine. Staff confirmed the room was cleaned regularly, but the odor persisted, indicating a failure to maintain a sanitary and comfortable environment.
The facility failed to report alleged violations and incidents involving two residents. One resident had unexplained abrasions attributed to EPS movements, which were not reported to HHSC. Another resident experienced an unobserved fall and was sent to the hospital due to anticoagulant use, but the incident was not reported. Staff relied on a provider letter for guidance, believing the incidents did not require reporting, potentially compromising resident safety.
A facility failed to meet the pharmaceutical needs of a resident due to several critical deficiencies. The facility did not clarify orders for Digoxin regarding necessary parameters and labs, did not ensure a pharmacist performed a medication review every 30 days, and failed to monitor Digoxin levels as there was no order for it. This resulted in the resident experiencing nausea multiple times and eventually requiring hospitalization due to digoxin toxicity. The pharmacist did not advise changes to the Digoxin regimen, citing hospice services typically did not require labs for such medications, and did not conduct a pharmacy review during a month when the resident was frequently hospitalized. Staff members acknowledged the lack of monitoring and parameters for Digoxin, noting deviations from standard practices. The facility's policy on Pharmaceutical Services was not effectively implemented in this case, leading to the identified deficiencies.
A facility's failure to collaborate effectively with hospice representatives and coordinate care planning led to a resident experiencing digoxin toxicity and subsequent hospitalization. The facility did not contact the hospice medical physician or nurse to clarify orders for Digoxin, resulting in a lack of parameters and lab monitoring. Clinical notes and interviews with staff, including the DON and admitting nurse, revealed discrepancies in medication management and a breakdown in communication regarding the absence of monitoring parameters for Digoxin.
Inaccurate MDS Pain Medication Coding
Penalty
Summary
The facility failed to ensure Resident #88’s quarterly MDS assessment accurately reflected his status by not documenting his scheduled pain medication use. Resident #88 was a male resident with diagnoses including cerebral infarction, type 2 diabetes mellitus, MDD, spinal stenosis, PTSD, anxiety, and hypertension. His quarterly MDS assessment dated 01/05/2026 documented a BIMS score of 15 and recorded “0. No” for J0100A, indicating he had not received a scheduled pain medication regimen in the last 5 days. Record review showed Resident #88 had an active order for Tramadol 50 mg by mouth three times daily for spinal stenosis, and the January 2026 MAR documented that he received Tramadol as prescribed during the lookback period from 01/01/2026 through 01/05/2026. His care plan also identified that he was on pain medication therapy for spinal stenosis, hemiplegia, and hemiparesis. During interview, the MDS LVN stated the resident should have been coded for scheduled pain medication because he was receiving it, and the DON stated the MDS assessments should be accurate and reflect a clear picture of the resident.
Failure to Coordinate PASRR Review for Resident With MDD and PTSD
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for Resident #88 and did not refer the resident to the appropriate state-designated mental health authority for review despite diagnoses of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). Resident #88’s record showed an admission history that included stroke, type 2 diabetes mellitus, MDD, spinal stenosis, PTSD, anxiety, and hypertension. The quarterly MDS documented a BIMS score of 15, and Section I listed depression and PTSD as active psychiatric/mood disorders. The resident also had an active order for Celexa 10 mg daily for depression and was receiving it as ordered on the January 2026 MAR. Additional record review showed care plans addressing risk for retraumatization related to PTSD and a mood problem related to major depressive disorder and anxiety disorder. Physician and behavioral health documentation described increased yelling out, impulsivity, mood changes, delusions, increased anxiety, being easily angered, disoriented, withdrawn, and a psychiatric history with extensive treatment and hospitalizations. Psychiatry follow-up also listed major depressive disorder and chronic PTSD as active medical problems. During interviews, MDS staff stated they did not usually complete a PL1 for MDD, that PTSD could be case-by-case, and that they would not do a PL1 if the resident was not having behaviors. The facility policy stated it was the facility’s policy to complete an accurate PASARR screening for individuals with a mental disorder and that a new PASRR evaluation is required if a resident’s condition changes significantly.
Improper Incontinent Care and Infection Control During Perineal Cleaning
Penalty
Summary
The facility failed to ensure proper incontinent care for a resident who was frequently incontinent of bowel and bladder and had diagnoses including obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, and a history of urinary tract infections. The resident’s quarterly MDS reflected moderate cognitive impairment and substantial to maximal assistance needed for toileting hygiene. The care plan directed staff to check for incontinence, wash, rinse, and dry soiled areas, and provide antibiotic therapy as ordered related to a urinary tract infection. During an observation of incontinent care, CNA D cleaned the resident’s penis by making several passes with one disposable wipe in a back-and-forth motion. During a joint interview, CNA E stated she observed CNA D make more than one pass with one disposable wipe, and both CNAs stated that using a disposable wipe more than once was a break in infection control and cross contamination. The DON stated that a disposable wipe should only be used once and then discarded, and that using it for more than one pass was an infection control issue and could result in the resident getting an infection. The facility policy required washing the peri area using front-to-back strokes, and CNA D’s competency training instructed staff to use a different wipe for each stroke.
Medication Found on Floor Near Nurse Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with currently accepted professional principles when a blue pill was found lying on the floor by the 200 hall nurse cart. The observation was made on 3/31/26 at 10:24 AM during surveyor review of medication storage practices, and the pill was identified by staff as appearing to be a medication. The finding involved 1 of 4 medication carts observed for medication storage. During interviews, NA A stated the item looked like a medication lying on the ground, and MDS LVN B stated the blue pill should not have been on the floor for patient safety and that it should have been picked up. RN J, who was responsible for the 200-hall nurse cart, stated the pill should not be lying on the floor because anyone could pick it up and it should be discarded. The DON also stated there should not be pills on the floor and that if a pill is on the floor, it should be discarded in the proper way. Facility policy titled Medication Access and Storage stated that drugs and biologicals are to be stored in locked compartments under proper temperature controls and kept in their containers.
Dietary Staff Lacked Current Food Handler Certification
Penalty
Summary
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. The facility failed to employ sufficient staff with the appropriate competencies and skill set to carry out food and nutrition services for 1 of 11 dietary staff reviewed. Specifically, [NAME] I did not have a current Food Handler Certificate. Record review showed a Texas Food Manager Certification Program certificate dated 03/03/2021 with a handwritten expiration date of 03/03/2026 and the handwritten word "Keyed" with a check mark on the document. The facility staff list showed [NAME] I was hired on 06/18/25. During observation on 3/31/26 at 9:15 a.m., [NAME] I was in the kitchen cleaning a microwave and stated he would be preparing pure diets around 11 a.m. that morning. During interviews on 04/02/26, the DS stated the only food handler certificate he had for [NAME] I was the one hanging on the wall dated 03/03/2021 and that all staff were expected to have current food handlers certificates if they were working in the kitchen. The Administrator later stated HR had provided a current certificate, but record review of the online database showed the certificate number belonged to [NAME] I, with a course name of Texas Food Manager Exam English, an issue date of 03/02/2021, and an expiration date of 03/01/2026. The facility policy stated the dietary manager was responsible for ensuring food handler certifications were current for dietary staff.
Kitchen Food Storage and Fryer Oil Maintenance Deficiencies
Penalty
Summary
The facility failed to store dish racks off the floor in the kitchen. During an observation on 03/31/26 at 9:23 a.m., one dish rack with two other dish racks on top of it was directly on the floor next to the sink. During the same observation, the DS stated the dish racks should not be on the floor and should be stored on top of a pallet when not in use because the floor was dirty. Record review of the facility policy titled Dish Handling stated that after dish racks have been emptied, racks must be stored off of the floor. The facility also failed to maintain the deep fryer oil in accordance with its cleaning practices. During an observation on 3/31/26 at 9:31 a.m., the deep fryer contained oil that was dark brown with visible food particles and sediment throughout, was not transparent, and obscured visibility to the bottom of the fryer; residue buildup was noted along the interior surfaces. The DS stated he cleaned the fryer every weekend and last cleaned it on 3/29/26, and said it was normal for the oil to get that dark because it was used to fry a lot of food for residents. A later observation on 04/02/26 showed the fryer oil appeared light in color and transparent with very little visible debris, and the DS stated the fryer had been cleaned and the oil changed on 3/31/26. Record review of the Weekly Deep Cleaning Schedule for March 2026 showed fryer oil changes and cleaning entries, and the facility policy titled Deep Fryer Cleaning Policy & Procedure stated the deep fryer would be cleaned on a regular basis as recommended by the manufacturer.
Improper Dumpster Area Sanitation
Penalty
Summary
Dispose of garbage and refuse properly. During an observation of Dumpster #1, the exterior dumpster area had visible dried food debris and spilled waste on the ground next to the dumpster, and the surrounding concrete surface had multiple darkened stains and residue. Several pest control traps were observed stored directly on the ground adjacent to the dumpster, and the drain opening at the bottom of the dumpster was not sealed with a plug. During interview, the DS stated he was unaware of the food spilled by the dumpster and said it may have just happened, although the surveyor pointed out that the food appeared dried up and contained rice and a fry. The DS also stated he was unsure why the pest traps were stored outside the dumpster and was unaware the drain plug was missing. The MS stated he cleaned and pressure washed the dumpster area every 6 months and had cleaned it again that week, that some stains were oil from the dumpster trucks, that the traps were supposed to be picked up by the pest control company but were not, and that the drain plug was supplied by waste management and was their responsibility to place on the dumpster. Record review of the facility policy titled Waste Management and Cleaning stated the dumpster area is to be observed daily by the plant team between breakfast and lunch, with maintenance/housekeeping concerns reported to the appropriate department and the perimeter area checked daily for odors and excess waste.
Incomplete and Inaccurate PASRR Form 1012 Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents on Mental Illness/Dementia Resident Review (Form 1012) documents. For one resident, the form showed a dementia review with physician attestation, but the mental illness section was incomplete because not all diagnoses had Yes or No selections, onset dates were missing for applicable diagnoses, the physician signature and date were not completed in that section, and the nursing facility action section did not indicate whether the PASRR Level 1 remained negative or whether a new Level 1 screening had been submitted. The resident’s record included diagnoses of schizophrenia, major depressive disorder, and dementia, and the MDS showed moderate cognitive impairment, depression, schizophrenia, and non-Alzheimer’s dementia. For the second resident, the Form 1012 also contained incomplete and inconsistent entries. The dementia section included a diagnosis date and the physician attestation area, but the physician signature date was not completed and the physician’s printed name was missing. In the mental illness section, schizoaffective disorder and bipolar disorder were identified, but other diagnoses in the medical record, including psychosis, mood disorder, depressive episodes, and generalized anxiety disorder, were not indicated on the form. The nursing facility action section was also left blank regarding whether the PASRR Level 1 remained negative or whether a new screening had been submitted. The resident’s record showed diagnoses of schizoaffective disorder, bipolar type, dementia, psychosis, bipolar disorder, depressive episodes, mood disorder, and generalized anxiety disorder, and the MDS reflected moderate cognitive impairment, anxiety, depression, bipolar disorder, psychotic disorder, and non-Alzheimer’s dementia. During interview, the MDS LVN stated the 1012 forms had been completed by another staff member who no longer worked at the facility and said he was unsure why information had been added to one resident’s form years after it had been signed by the doctor. He stated he understood the form was valid if a doctor signed it and said both residents had dementia as a primary diagnosis, so their PASRR Level 1 screens were answered no for mental illness and a 1012 form was completed instead. The DON stated she was unsure whether the 1012 forms were completed correctly and needed to ask her resource. During a later interview, the PASRR assessor stated that if a resident had a primary diagnosis, a new 1012 did not need to be completed if a new mental illness diagnosis was added, that it did not matter how much time had passed as long as the physician signed the 1012, and that the facility should not have added information to the forms years later.
Hand Hygiene and Insulin Pen Cleaning Not Followed During Medication Pass
Penalty
Summary
The facility failed to maintain its infection prevention and control program during medication administration for three residents. During a medication pass for a resident with seizures, dementia, and gastrostomy status, an LVN prepared levetiracetam for PEG-tube administration, then returned to the bedside, drew the privacy curtain, and put on gloves without washing or sanitizing hands. While wearing gloves, the LVN handled the resident’s bed remote and bedside table, removed the gloves, then put on another pair of gloves without hand hygiene before administering the medication through the gastrostomy tube. The LVN stated she had forgotten to sanitize her hands between glove changes and when touching the bed remote and bedside table. During a medication pass for a resident with diabetes, infection following a procedure, and osteoarthritis, a Med Aide administered oral medications, obtained a lidocaine patch and gloves, and placed them on the bedside table. The Med Aide then drew the privacy curtain, did not wash or sanitize her hands, and put on gloves before applying the patch to the resident’s left shoulder. The Med Aide stated she forgot to sanitize her hands after preparing the medications and after drawing the curtain, and stated hand hygiene should have been performed before putting on gloves because of cross contamination and the possibility of infection being passed to the resident or other residents. For a resident with type 1 diabetes, long-term insulin use, heart failure, end stage renal disease, and dependence on renal dialysis, an LVN retrieved the resident’s insulin pen from the medication cart and inserted a needle into the pen without sanitizing the rubber seal with an alcohol swab. The LVN stated she had forgotten to sanitize the rubber seal before inserting the needle and before injecting insulin, and stated cleaning the seal was important to prevent contamination because the seal is punctured with a needle used on the resident. The DON stated the rubber seal of an insulin pen was supposed to be cleaned with an alcohol swab prior to inserting the needle to prevent cross contamination and that cross contamination could cause infection.
Improper Food Handling and Labeling in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen and a resident's personal refrigerator. Dietary Aides were seen handling dishes improperly, touching the inside rims of plates and cups, which could lead to contamination. Despite being trained, the aides were observed making these errors, and the Dietary Supervisor acknowledged the risk of contamination and foodborne illnesses due to these practices. Additionally, a sandwich provided by the facility was found in a resident's personal refrigerator without a label or date. The resident, who had severe cognitive impairment and required assistance with eating, had a sandwich stored in a manner that did not comply with the facility's policy. The lack of labeling and dating could result in the resident receiving an incorrect diet texture or consuming expired food, potentially leading to foodborne illness. Interviews with staff, including the Dietary Supervisor and the Director of Nursing, confirmed the importance of proper food handling and labeling. The staff acknowledged the oversight in labeling the sandwich and the potential risks associated with improper food storage and handling. The facility's policy requires that all food brought to residents be inspected and properly labeled, which was not followed in this instance.
Failure to Knock on Residents' Doors
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect by not ensuring staff knocked before entering residents' rooms. This deficiency was observed on the 200 unit, where both a CNA and the MDS Nurse entered multiple resident rooms without knocking. Specifically, CNA K was seen entering several rooms without knocking, including moving furniture and straightening up rooms, while the MDS Nurse also entered a room without knocking. During interviews, CNA K acknowledged the importance of knocking for privacy, while the MDS Nurse denied failing to knock. Resident #25, a cognitively intact male with mobility issues, reported that staff sometimes entered his room without knocking, which he found unsettling, especially when he was asleep. The facility's policy on Resident Rights, Dignity, and Respect mandates that staff knock before entering a resident's room, highlighting a discrepancy between policy and practice. The DON stated that staff should knock if they know a resident is in the room, but if the resident is known to be elsewhere, entering without knocking was deemed acceptable.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. Resident #61's MDS inaccurately indicated that he received insulin injections, although he was only treated with Metformin and Trulicity, which is not an insulin. Interviews with the resident, LVN, DON, and MDS Nurse confirmed the error, highlighting a lack of understanding about the medication by the staff involved. Resident #148's admission MDS incorrectly stated that he was not receiving hospice care, despite being admitted to the facility on hospice services. The comprehensive care plan and physician orders confirmed the resident's hospice status, but the MDS Nurse admitted to mistakenly coding the MDS, which did not reflect the resident's actual care needs. Resident #95's discharge MDS inaccurately documented that he was discharged to a hospital, while records and interviews confirmed he was discharged to a foster home. The MDS Nurse acknowledged the error, emphasizing the importance of accurate MDS documentation for determining resident status and facility reimbursement. These inaccuracies in MDS assessments could potentially lead to inadequate care and services for the residents involved.
Inadequate Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide appropriate incontinence care for Resident #27, who was always incontinent of bowel and bladder and had severe cognitive impairment. During an observation, CNA-E did not adequately clean the resident's right buttock area after a bowel movement. Although CNA-E cleaned the resident's left buttock and middle area, including the anus, she did not turn the resident to his left side to clean the entire right buttock area. This oversight was acknowledged by CNA-E, who admitted that she thought a single wipe was sufficient. The Director of Nursing (DON) confirmed that the resident should have been turned to ensure complete cleaning to prevent possible unclean status. The facility also failed to ensure proper catheter care for Resident #82, who had an indwelling urinary catheter due to obstructive and reflux uropathy. During an observation, the resident's catheter drainage bag and tubing were found touching the floor while she was seated in a wheelchair. LVN M, upon being informed by the State Surveyor, acknowledged that the catheter bag and tubing should not be on the floor due to infection control concerns and the risk of kinking, which could impede urine flow. The DON reiterated that the catheter and tubing should not touch the floor to prevent infection and potential urine retention. These deficiencies in care could place residents at risk for cross-contamination and the development of urinary tract infections. The facility's policies on incontinence care and catheter care were not adhered to, as evidenced by the observations and interviews conducted during the survey.
Expired Medications Found in Nursing Carts
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the removal of expired medications from nursing carts, as observed in two instances. On January 22, 2025, a bottle of Dakin's solution, which expired in November 2024, was found in the 300-hall nursing cart. A nurse acknowledged the presence of the expired medication and admitted that it should have been discarded according to facility policy. The potential harm identified was the risk of using expired medication, which might not have therapeutic effects. Additionally, a cream of Urea 20 intensive Hydrating cream, expired on November 13, 2024, was found in the 200-hall nursing cart. This medication was intended for a resident with a history of hemiplegia, type 2 diabetes, hypertension, and a risk of developing pressure ulcers. The nurse confirmed the expired medication's presence and acknowledged that it should have been removed. The Director of Nursing reiterated that nurses are responsible for discarding expired medications from the carts, as per the facility's policy.
Infection Control Breach During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident. The resident, a male with severe cognitive impairment and multiple medical conditions including anoxic brain damage, quadriplegia, epilepsy, acute respiratory failure, and acute kidney failure, required suprapubic catheter care. Despite a posted sign indicating the need for gloves and a gown during high-contact care activities, the CNA entered the resident's room, sanitized her hands, and donned gloves but failed to wear a gown while performing the catheter care. The CNA acknowledged her failure to wear a gown, attributing it to nervousness and forgetfulness, and recognized the potential risk of infection to the resident. The Director of Nursing (DON) confirmed that the CNA should have worn a gown in accordance with the facility's infection control policy, which mandates the use of gloves and gowns during high-contact activities such as catheter care. This oversight in following established protocols could lead to cross-contamination and infections, compromising the safety and well-being of residents requiring assistance with treatments.
Failure to Maintain a Sanitary and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two residents sharing a room, as evidenced by a persistent strong odor of urine. Observations revealed that the room had a strong urine smell, particularly on one resident's side, and the floor mat was found to be wet with standing liquid that smelled of urine. Despite the room being on a twice-daily cleaning schedule, the odor persisted, and the cleaning solutions used were the same as those for other rooms. One resident, who was frequently incontinent of urine and bowel, was observed in a low bed on the floor without sheets, and the mattress was slightly away from the wall. The resident's care plan included interventions for incontinence and potential behavior problems, such as urinating in common areas or in bed. The other resident, who was severely cognitively impaired and also frequently incontinent, was observed in bed watching TV during one of the visits. Interviews with staff, including the DON and housekeeping employees, confirmed that the room was cleaned twice daily and as needed due to the resident urinating on the floor. The fall mat was replaced when wet, and the room was cleaned with the same solutions as other rooms. Despite these efforts, the strong urine odor persisted, indicating a failure to maintain a sanitary and comfortable environment for the residents.
Failure to Report Alleged Violations and Incidents
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, within the required timeframes. Specifically, the facility did not report an incident involving a resident who was found with abrasions on her right shoulder and elbow. These injuries were not witnessed and were attributed to the resident's extrapyramidal side effects (EPS) movements. Despite the facility's internal assessment, the injuries were not reported to the Health and Human Services Commission (HHSC) as required, which could have ensured a proper investigation into the cause of the injuries. Another incident involved a resident who experienced an unobserved fall and was subsequently sent to the hospital for evaluation. The resident was on an anticoagulant, which necessitated a hospital evaluation to rule out any potential bleeding. The facility did not report this fall to the HHSC, citing guidance from a provider letter that suggested such incidents did not require reporting if they were not suspicious or of unknown source. However, the lack of reporting could have prevented a thorough investigation into the circumstances surrounding the fall. Interviews with facility staff, including the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), revealed a reliance on the updated provider letter for guidance on reporting requirements. The staff believed that the incidents did not meet the criteria for mandatory reporting. However, the failure to report these incidents to the appropriate authorities could have compromised the health and safety of the residents by not ensuring a comprehensive investigation into the causes of the injuries and fall.
Deficiencies in Pharmaceutical Services and Digoxin Monitoring
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident (Resident #1) due to several critical deficiencies. Specifically, the facility did not clarify orders for Digoxin regarding the need for parameters and labs, did not ensure the pharmacist performed a medication review every 30 days, and failed to monitor Resident #1's Digoxin levels as there was no order for it. This led to Resident #1 experiencing nausea multiple times and eventually requiring hospitalization due to digoxin toxicity, with elevated digoxin levels indicating a serious health risk. The facility's pharmacist did not advise any changes to the Digoxin regimen during a review, citing that hospice services typically did not require labs for such medications. Additionally, the pharmacist did not conduct a pharmacy review for Resident #1 in March 2024, as the resident was in and out of the hospital. The facility's policy on Pharmaceutical Services outlined the importance of accurate acquiring, receiving, dispensing, and administering of drugs but was not effectively implemented in Resident #1's case, leading to the identified deficiencies. During interviews, staff members acknowledged the lack of monitoring and parameters for Resident #1's Digoxin, with the admitting nurse and pharmacist both noting deviations from standard practices. The facility's failure to ensure proper medication monitoring and review processes for Resident #1 resulted in a critical deficiency that put the resident at risk of adverse health outcomes, including hospitalization and potential harm.
Coordination and Monitoring Gaps in Hospice Care for Digoxin Management
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to collaborate with hospice representatives and coordinate hospice care planning for a resident (Resident #1) receiving hospice services. Specifically, the facility did not contact the hospice service medical physician or nurse to clarify physician orders for Digoxin, leading to a lack of parameters and lab monitoring for potential toxicity. This failure resulted in the resident experiencing digoxin toxicity, leading to hospitalization for complaints of nausea. The report highlighted that the hospice physician did not typically order parameters or labs for digoxin and acknowledged the need for improved communication and monitoring in such cases. The deficiency was further underscored by the facility's admission sheet and clinical notes, which revealed discrepancies in the monitoring and management of Resident #1's medications, particularly Digoxin. Despite the resident's complaints of nausea and hospitalization due to digoxin toxicity, the facility did not have appropriate parameters or lab orders in place for monitoring the resident's condition. Interviews with staff members, including the Director of Nursing (DON) and admitting nurse, indicated a lack of questioning or clarification regarding the absence of parameters for digoxin, highlighting a breakdown in communication and oversight in the care planning process for hospice residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 941 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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| Ignite Medical Resort San Antonio, Llc | 2.5 mi | ★★★★★ | 18 | 0 |
| Mesa Vista Inn Health Center | 2.7 mi | ★★★★★ | 24 | 0 |
| Northgate Health And Rehabilitation Center | 2.7 mi | ★★★★★ | 29 | 0 |
| Silver Creek Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
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