Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Star Ranch Rehabilitation And Healthcare Cen during CMS and state inspections, most recent first.
A facility failed to ensure residents promptly received personal mail on Saturdays for 3 of 3 confidential residents reviewed. Residents stated they often had to wait until Monday for mail, while the Activity Director, BOM, DON, and Administrator gave conflicting accounts of who was responsible for weekend mail distribution and acknowledged there was no system in place to ensure Saturday delivery.
Failure to coordinate PASRR services and document required meetings affected three residents with IDD or related conditions. One resident with spina bifida and IDD had no documented annual PCSP meeting in the prior year, another resident with mild intellectual disabilities and mental health diagnoses had no documentation of quarterly PASRR PCSP meetings, and a third resident with IDD had no documentation of habilitation coordination or independent living skills training notes despite those services being recommended. Interviews confirmed the facility lacked a system to track the coordinator’s visits and required PASRR meeting documentation.
Incomplete care planning for ordered medications and diabetic footwear. The facility did not include ordered meds such as Eszopiclone, Lexapro, Mirtazapine, and Zolpidem in residents' comprehensive care plans, and one resident was not measured for diabetic shoes and insoles per MD order. The MDS Coordinator said the missing medication care plans were an oversight, while the DON and Administrator stated care plans are used to direct and guide resident care.
A resident with a continuous O2 order was found without oxygen in place, and an LPN later said the order had been misread. Two other residents with COPD had respiratory equipment that was dirty or outdated, including a gray concentrator filter, tubing and water bottles dated weeks earlier, and tubing lying on the floor with visible dust. Staff gave inconsistent accounts of who was responsible for changing or cleaning the equipment, and the DON acknowledged the dirty equipment and old mask placed residents at risk for respiratory infection or pneumonia.
Controlled medications awaiting disposal were found stored in a locked cabinet in the med room, including Pregabalin, Lorazepam, Tramadol, Fentanyl patches, and Morphine. An LVN said the meds had been there for about a week, were not counted after placement, and one Morphine count sheet was missing from the cabinet. The DON said discontinued narcotics were supposed to be brought to her immediately for reconciliation and locked storage, but she had forgotten to retrieve them.
A resident with dysphagia and malnutrition received a mechanical soft lunch tray without gravy on the meat, and dietary staff could not identify or follow the correct menu and scoop sizes. The cook said she had not been told the proper scoop sizes, and the DM was unsure where the extended menus were. The next day, the DM served puree residents pinto beans and sausage using two 4-oz scoops instead of the 6-oz portion listed on the dietary spreadsheet. The RD, DON, and Administrator all stated the correct serving sizes and menu directions were expected to be followed.
Food was not served palatable or at an appetizing temperature for several residents. A resident said vegetables were mushy and the meal was cold, and during a meal observation the DON and surveyors sampled regular and puree trays that were bland, warm enough only in part, or cold. In a resident group, several residents said the food was cooked hard and they could tell when the Dietary Manager cooked. The DON, Dietitian, and Administrator all acknowledged expectations that meals be palatable and served at an appetizing temperature.
Kitchen sanitation and food handling deficiencies were identified when surveyors observed undated food items in the refrigerator, staff with hair not fully contained in hair nets, and staff entering the kitchen without washing hands. Dirty bowls and saucers were stacked in the clean area, pots/pans and the stove had black buildup, the storage room floor had debris, and the microwave was dirty with food in it. Interviews with the Dietary Manager, Dietitian, DON, and Administrator confirmed expectations for hand hygiene, hair restraints, dating food, and keeping the kitchen clean.
Personal Refrigerator Food Storage and Temperature Monitoring Deficiency: The facility failed to follow its policy for foods brought in by family and visitors for two residents. Surveyors found personal refrigerators with temps outside the required range, missing documentation, undated and unsealed food items, and one freezer without a thermometer. The Activity Director was responsible for checking and logging refrigerator temps, but staff interviews showed inconsistent oversight and uncertainty about acceptable refrigerator and freezer temperatures.
Failure to Complete Ordered Diabetic Shoe Measurement: A resident with DM was ordered diabetic shoes and custom insoles, but therapy never measured him or completed the order. Staff interviews showed the order was passed between LVN, DON, ADON, and the DOR, but no one confirmed the next steps with the podiatrist office, and the resident said he did not recall being contacted by therapy.
Jagged shelving edges were observed on the east hall and west hall where shelving had been attached directly to the wall. The Maintenance Supervisor said he had placed the shelves but had not sanded the rough edges, and the ADON, DON, and Administrator all acknowledged the shelving had jagged edges and had not been finished as expected. Staff stated the condition could cause skin tears, splinters, or cuts for staff, visitors, or residents.
A resident with a g-tube, dysphagia, and malnutrition had an enteral feeding order that omitted the formula strength and the administration method. The chart showed the resident was receiving Isosource 1.5 cal bolus feedings, but the active order only stated enteral feed via g-tube. The MDS Coordinator, LVN, and DON all acknowledged the order was incomplete, and the facility policy required enteral nutrition orders to include the product and administration method.
A resident's Triamcinolone Acetonide cream was found on his bedside table even though there was no order for it, and staff stated medications should not be left at bedside. In a separate event, an LPN left the east hall nurse's cart unlocked in the hallway while gathering supplies and administering insulin, despite stating she knew the cart could be accessed when left open. The DON and Administrator stated carts should be locked whenever unattended, and the facility policy required drugs and biologicals to be stored in locked compartments.
Two residents did not receive meal preferences as ordered. One resident with obesity and malnutrition had an order for large portions, but meal tickets did not reflect it and staff served average portions. Another resident with COPD and obesity was told he could not have over easy eggs and was served eggs cooked hard. Interviews showed the Dietary Manager was responsible for reflecting preferences on meal tickets, while the DON and Administrator expected resident food preferences to be followed.
Incomplete Documentation of Care Conference Participation: The facility failed to accurately document whether two residents or their responsible parties were informed of, attended, or declined quarterly care plan conferences. One resident had COPD, seizures, dysphagia, hypotension, and cognitive impairment, while the other had AFib, HF, HTN, hypothyroidism, hyperlipidemia, dementia, and depression. Care conference forms showed staff attendance, but the sections for resident or RP participation were left blank, and an LVN acknowledged she did not document the invitations or attendance status in the EMR.
A facility failed to keep hospice binders current and coordinated for two residents receiving hospice services. One resident’s binder lacked the latest med profile, recent IDG notes, and recertification paperwork, and it did not include current orders for fentanyl and Zyprexa. Another resident’s hospice med profile was outdated and did not match the facility MAR/orders, with discrepancies in Zoloft and cyclobenzaprine. Staff stated the hospice binder should contain current hospice documentation and match facility orders for continuity of care.
A resident with multiple complex conditions, including post-stroke hemiplegia, dysphagia, psychiatric disorders, and existing skin impairment, was discharged to another nursing facility without a physician discharge order, IDT discharge plan, or completed discharge summary in the EMR. Despite staff describing a process that should include a face sheet, med list, pertinent labs, recent MD documentation, and a discharge assessment or transfer form with a nurse-to-nurse report, the DON confirmed that no transfer form, discharge assessment, or discharge summary was completed, and there was no documentation that current orders, care plan, psychiatric notes, or H&P were sent. This conflicted with facility policy requiring transmission of practitioner contact information, advance directive details, special instructions or precautions, comprehensive care plan goals, and all necessary clinical information to the receiving provider.
The facility failed to implement RD nutrition recommendations for four residents, including those with celiac disease, COPD, diabetes, heart failure, protein‑calorie malnutrition, chronic foot ulcer, dysphagia, and tube feeding. The RD documented recommendations such as ice cream twice daily, a sugar‑free health shake between meals, Prostat 30 cc BID, and Med Pass 2.0 120 cc BID, but these were not entered as physician orders in the EMR, and there was no documentation that the MD was notified to accept or decline them. Residents reported not receiving the recommended supplements, and meal observations confirmed items like ice cream were not provided or listed on diet tickets. The Food Service Supervisor stated she had not received the January recommendations, the RD reported she expected recommendations to be acted upon within 72 hours, and the MD confirmed he had not been notified. The DON and ADON acknowledged that follow‑up on these recommendations had not been completed, contrary to facility policy requiring timely follow‑up and documentation when recommendations are not adopted.
The facility did not maintain adequate nursing staff levels to meet resident care needs, resulting in delayed or missed medication administration for a resident with Parkinson's disease, missed scheduled showers for another resident requiring assistance, and a third resident not being able to get out of bed as requested. Staff and management interviews, along with staffing records, confirmed that staffing levels frequently fell below the facility's own assessment requirements, especially on weekends and night shifts.
A resident with Parkinson's disease did not receive prescribed medications within the scheduled time frames on multiple occasions. Staff administered doses late, failed to give some doses, and documented medications as given without actual administration. The physician and DON were not notified of these deviations, and facility policy requiring timely and accurate medication administration was not followed.
A resident requiring substantial assistance with bathing did not consistently receive scheduled showers, particularly on Saturdays, due to frequent staffing shortages. Although records indicated showers were provided, both the resident and multiple staff confirmed that showers were missed, and nursing leadership was aware of the issue. Facility policy required assistance with hygiene for residents unable to perform these tasks independently.
A dietary aide continued to work in the kitchen with an expired Food Handler Certificate due to lack of monitoring by the Dietary Manager and absence of a facility policy. The aide was aware of the expiration but did not renew the certificate because of financial reasons, and the Interim Administrator was unaware of the lapse or its risks.
A resident with significant mobility and self-care deficits did not receive physician-ordered PT and OT services for seven days due to confusion and oversight following an appeal process. The lapse occurred when the DOR failed to add the resident back to the therapy schedule, and facility leadership was unaware of the missed sessions until after the fact.
Several residents were found to have heating and cooling vents in their rooms covered in a black mold-like substance, with some also present on nearby ceiling tiles. Staff interviews revealed confusion over who was responsible for cleaning the vents, and the maintenance director admitted the vents had not all been cleaned. None of the affected residents had respiratory diagnoses or symptoms, and their care plans did not address environmental cleanliness.
A medication aide failed to ensure a resident received their prescribed morning dose of Protonix, leaving the unlabeled pill unsecured on the bedside table for several hours after the resident declined it. Nursing staff confirmed that medications should not be left at the bedside and should be discarded if refused, but this was not done in this instance.
Multiple residents were not adequately supervised, resulting in incidents such as a resident sustaining a cigarette burn, residents assessed as unsafe smokers accessing smoking materials and smoking in unsafe areas without supervision, and a resident with cognitive impairment having unsecured disposable razors left in his room. Staff interviews revealed confusion and lack of awareness regarding supervision requirements and facility policy.
A resident was found with medications and shaving cream left unsecured in their room, without a physician order or assessment for self-administration. Staff interviews confirmed that these items should have been stored in locked compartments or designated storage areas, in accordance with facility policy.
The facility did not ensure that saline eyewash solutions in the kitchen, laundry, medication room, and shower room were within expiration dates, as all reviewed eyewash stations contained expired solutions. Staff interviews revealed confusion about responsibility for monitoring and replacing the solutions, and the facility's policy requiring removal of outdated biologicals was not followed.
Four residents requiring oxygen therapy did not have proper physician orders or documentation, with some receiving oxygen without an order and others not receiving oxygen as ordered. Staff were unaware of missing or incorrect orders, and required signage for oxygen use was not consistently present, resulting in care that did not meet professional standards.
Several residents reported receiving cold, bland, or unappetizing food, and surveyors observed meal service delays and improperly prepared food, with staff citing recipe restrictions and equipment limitations as contributing factors.
A resident with schizoaffective and bipolar disorder was administered Seroquel 25 mg without valid written consent on the required HHSC form, as only a consent for a different dosage was on file. The ADON and Administrator confirmed the oversight, and the facility did not provide a policy on psychotropic medications when requested.
A resident with COPD who required continuous oxygen therapy was unable to leave his room for several days due to the facility's lack of portable oxygen. Despite notifying staff and the Administrator, the resident was not provided with an alternative, resulting in missed activities and restricted mobility.
A resident with Parkinson's disease and intact cognition had an incomplete OOH-DNR form, missing the MPOA's printed name, signature date, and notary signature. Staff interviews revealed confusion over responsibility for DNR documentation, and facility policy required proper inquiry and respect for advance directives.
A resident with moderate cognitive impairment and acute kidney failure was not given a SNF ABN when discharged from Medicare Part A skilled services before covered days were exhausted. Staff interviews confirmed the required notice was not provided, and the facility lacked a policy for issuing SNF ABNs.
A CNA witnessed a resident strike another resident and reported the incident to an LVN, who found no injuries and informed the ADON and Administrator. The incident was not reported to authorities within the required timeframe, and no incident or skin assessment was completed. Facility leadership did not interview the involved residents or ensure proper documentation, resulting in a failure to follow abuse reporting protocols.
A CNA witnessed a resident with behavioral issues physically contact another resident with dementia, but the incident was not thoroughly investigated or reported as required. Although an LVN assessed the alleged victim and found no injuries, no incident report or skin assessment was completed, and the event was not reported to the state agency. Interviews revealed that the Administrator and ADON did not interview the involved parties or ensure proper documentation, contrary to facility policy.
Two residents were affected by inaccurate MDS assessments: one was incorrectly documented as having a feeding tube, and another was mistakenly coded as using a restraint when she actually used a transfer assist bar for mobility. Staff interviews and record reviews confirmed these errors, which were attributed to mistakes in coding and documentation.
Two residents with cognitive impairments and medical needs were observed using oxygen, but their care plans and physician orders did not reflect this intervention. Staff interviews revealed confusion over care plan responsibilities, and facility policy requiring comprehensive, updated care plans was not followed.
A resident receiving Eliquis for atrial fibrillation and a knee prosthesis infection was not monitored for side effects of anticoagulant therapy, despite care plan requirements. Nursing staff and leadership confirmed that monitoring was not documented or entered into the electronic record, and there was no facility policy in place for anticoagulant monitoring.
A resident with a history of seizures and other medical conditions did not receive required routine laboratory tests, including a Comprehensive Metabolic Panel and anti-seizure medication levels, as ordered by the physician. Staff interviews revealed a lack of awareness and an ineffective lab monitoring system, resulting in missed labs and non-compliance with facility policy.
A resident with a seizure disorder had laboratory results indicating subtherapeutic levels of Dilantin and Phenobarbital, but the physician was not notified of these abnormal results until 20 days later, after a surveyor intervened. The delay occurred due to assumptions about physician access to electronic records and a lack of clear responsibility for physician notification, despite facility policy requiring prompt communication of abnormal labs.
A resident with severe cognitive impairment and a mechanically altered diet order was served a ground beef patty instead of the prescribed ground chicken fried chicken. Dietary staff substituted the entree to reserve enough chicken for other residents, and the error was not identified by the charge nurse or dietary manager until after the meal was served, contrary to facility policy requiring adherence to resident menu choices.
The facility did not adhere to professional food safety standards, as evidenced by an unclean ice scoop holder with visible sediment and the failure to dispose of expired boiled eggs in the refrigerator. Staff and administration confirmed that cleaning and food disposal procedures were not followed according to facility policy.
A trash can in the designated smoking area was found to contain a smoked cigarette, rather than only trash. A laundry aide and the administrator both confirmed that staff supervising residents during smoking should ensure cigarettes are extinguished in the proper receptacle, as outlined in the facility's smoking policy.
The facility did not post daily nurse staffing data at the beginning of each shift for two days, displaying outdated information instead. The ADON, responsible for this task in the absence of a DON, missed completing and posting the required forms due to being busy and was unaware of the potential risks to residents. The Administrator confirmed the expectation for daily posting and acknowledged that the failure could prevent residents and families from knowing the staffing levels.
A resident with multiple health conditions fell and sustained serious injuries shortly after being admitted to a facility. The fall occurred because the bed was not properly locked during wound care. Staff believed the bed was secure, but it moved, causing the resident to fall. The facility's fall prevention policy was not fully implemented due to the resident's brief stay.
A resident with multiple health conditions fell from her bed shortly after admission, sustaining serious injuries, including a fractured orbital floor and cervical spine fractures. The facility failed to report the incident to the state agency as required, due to communication breakdowns and a lack of understanding of reporting responsibilities among staff.
The facility failed to maintain a clean and homelike environment in two halls. Hall 200 had a persistent urine odor due to a shortage of cleaning supplies and staff, while several room floors on hall 100 remained dirty despite cleaning efforts. Additionally, a resident's room had peeling wallpaper that was not reported for maintenance. The facility lacked a housekeeping supervisor and a deep cleaning schedule.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. One resident's fall and use of Xanax, another's use of Eliquis, and a third's use of a [NAME] button for enteral feedings were not included in their care plans until after state surveyor intervention.
The facility failed to ensure that a resident requiring respiratory care had physician orders for her Bipap machine, leading to potential risks due to unknown settings. This was confirmed through observations, interviews, and record reviews, highlighting a significant oversight in maintaining proper respiratory care standards.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
Keep residents' personal and medical records private and confidential was deficient because the facility did not ensure residents promptly received their mail on Saturdays for 3 of 3 confidential residents reviewed for resident rights to receive personal mail. During a confidential group interview, 3 residents stated they did not always receive mail on Saturdays and had to wait until Monday when the Activity Director passed it out. During interviews, the Activity Director stated mail should be delivered to residents on Saturdays and that the facility had previously been cited for not delivering mail on Saturdays, with the solution being for the RN Supervisor to deliver mail on Saturday. The Business Office Manager stated weekend mail was placed in a locked box outside her door, that she was the only one with a key, and that there were times she gave Saturday mail to the Activity Director to distribute. The DON stated she was unaware residents were not receiving mail on Saturdays but expected mail to be delivered then, and the Administrator stated there was no system in place to ensure residents received mail on Saturdays.
Failure to Coordinate PASRR Meetings and Document Specialized Services
Penalty
Summary
The facility failed to coordinate with the appropriate State-designated authority for residents with mental disorder, intellectual disability, or related conditions, as reflected in three resident records reviewed for PASRR assessments and services. Resident #6 had diagnoses including spina bifida and IDD, required assistance with multiple activities of daily living, and had a care plan that included specialized services such as habilitation coordination, independent living skills training, behavioral support, and specialized OT. Her PASRR records showed IDD, but the medical record did not indicate that an annual PCSP meeting occurred in 2025; the last meeting documented was 10/23/24. Resident #31 had diagnoses including mild intellectual disabilities, major depressive disorder, anxiety, and mixed obsessional thoughts and acts. Her annual MDS indicated moderate cognitive loss and that she was considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Her care plan stated she was PASRR positive for intellectual disabilities and that PASRR PCSP meetings were to be held with the LMHA and RP at least quarterly, but the EMR contained no documentation of quarterly PASRR PCSP meetings held in 2025. Resident #5 had diagnoses including intellectual disability and developmental disorder of scholastic skills, with a BIMS score of 9 indicating moderate cognitive impairment. His care plan identified him as PASRR positive for IDD and included habilitation and specialized services, and a PCSP meeting documented that habilitation coordination and independent living skills services were recommended. However, the EMR contained no documentation of habilitation coordination or independent living skills training notes. Interviews with the Habilitation Coordinator, MDS Coordinator, DON, Director of IDD Service, and Administrator confirmed there was no documentation after monthly visits, that the facility was not aware of when the coordinator visited, and that there was no system in place to monitor oversight or ensure the required annual and quarterly meetings were held.
Incomplete Care Planning for Ordered Medications and Diabetic Footwear
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for 3 of 4 residents reviewed. Resident #12 had diagnoses including dementia, anxiety, malnutrition, and depression, and her physician orders included Eszopiclone for insomnia, Lexapro for depression, and Mirtazapine for protein-calorie malnutrition. Although these medications were active and administered, the comprehensive care plan dated 04/23/26 did not include care planning for Eszopiclone, Lexapro, or Mirtazapine. Resident #3 had diagnoses including PTSD, depression, and stroke, with a BIMS score of 08 indicating severely impaired cognition. Her physician order dated 06/01/26 included Zolpidem Tartrate 5 mg at bedtime for insomnia, and the MDS indicated she received a hypnotic medication during the look-back period. The comprehensive care plan did not indicate Zolpidem. During interview, the MDS Coordinator stated she reviewed the records and did not see care plans for Resident #12's medications or Resident #3's Zolpidem, and said it was an oversight. Resident #2 was also identified in the deficiency statement as not being measured for diabetic shoes and diabetic insoles per physician order. The facility's policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident and revised as conditions change. The DON and Administrator stated that care plans were a team effort and used to direct and guide resident care, and that if care plans were not done properly, care could be missed.
Respiratory Equipment Not Maintained or Applied as Ordered
Penalty
Summary
Resident #12 had an order for oxygen at 2 liters per minute via nasal cannula continuously, with titration up to 4 liters to keep oxygen saturations above 90% every shift. The resident’s care plan also directed staff to apply oxygen at 2 liters via nasal cannula. During an observation, the resident was up in a chair with no oxygen in place. The resident stated she had been wearing oxygen but was not sure when or why staff stopped applying it. The nurse later stated she had misread the order as oxygen could be applied only if saturations fell below 90%, and she acknowledged the resident did not wear oxygen despite the active continuous order. Resident #27 had diagnoses including dementia, COPD, anxiety, and shortness of breath, and her MDS indicated she required oxygen therapy. Her care plan directed staff to change oxygen tubing as needed and nebulizer tubing every week. During multiple observations, the resident’s oxygen concentrator filter was gray and dirty, and the tubing and empty water bottle were dated 5/24/26. The resident stated staff usually changed the equipment, but it had not been changed that she could recall. Later, the tubing and water bottle remained dated 5/24/26, and the concentrator filter was still dirty. Staff interviews reflected uncertainty about who was responsible for changing the equipment, and the ADON stated the tubing and water bottle should have been changed by 07/02/26, while the DON stated the dirty filter and old nebulizer mask placed the resident at risk for respiratory infection or pneumonia. Resident #9 had COPD and an order for oxygen at 2 to 4 liters per nasal cannula to maintain PO2 greater than 90%. The resident’s oxygen tubing was observed lying on the floor and had a piece of tape dated 06/22/26, with brown dust visible in the wheel-mark pattern on the tubing. The resident was unable to state when the tubing was last changed or how often it was changed. Staff interviews showed differing practices about changing oxygen tubing, with some stating it should be changed weekly or when dirty, while the DON stated she had been advised not to date the tubing and to change it when visibly soiled. The facility policy stated cannula or mask needed to be changed if it malfunctions or becomes visibly contaminated.
Controlled Medications Left Unreconciled in Medication Room
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs in sufficient detail to allow accurate reconciliation and an account of all controlled medications. During an observation in the medication room, controlled medications awaiting disposal were found stored underneath a counter in a locked cabinet that all nurses had a key to, including Pregabalin 25 mg tablets, Lorazepam 0.5 mg tablets, Tramadol 50 mg tablets, Fentanyl 50 mcg patches, and Morphine 100 mg/5 ml. LVN B stated the controlled medications had been under the cabinet for about a week and that discontinued narcotics were supposed to be taken to the DON immediately to be logged and locked in the DON's office. She also stated no one counted the medications once they were placed in the medication room and that the cabinet was missing a count sheet for one Morphine bottle, which she found folded in the narcotic count sheet book. The DON stated her locked area for discontinued narcotic medications was in the ADON's office and that she was the only one with keys. She said she intended to retrieve the discontinued narcotic medications on Monday but forgot, and that her expectation was for nurses to bring discontinued medications to her immediately after removal from the medication cart so she could reconcile them and lock them in her double-locked area. The DON also stated she normally checked with nurses on Monday, Wednesday, and Friday mornings to ensure narcotic medications were reconciled properly. The Administrator stated discontinued narcotic medications should be taken to the DON immediately and that the DON was responsible for ensuring no controlled medications were stored in the medication room.
Incorrect meal portions and missing gravy on mechanical soft trays
Penalty
Summary
The facility failed to ensure meals served met residents’ nutritional needs during lunch service. For Resident #2, a male with morbid obesity, unspecified protein-calorie malnutrition, and a physician order for a regular diet with mechanical soft texture and thin liquids related to dysphagia, the lunch tray observed on 06/29/26 included stuffed bell peppers and okra, but the mechanical soft meat did not have gravy. During the observation, Dietary Manager C and [NAME] E both stated the mechanical soft bell pepper should have had gravy or some type of liquid consistency on it, and [NAME] E said she was not sure where the lunch menu was or what scoop size to use. During the same meal service, [NAME] E stated she had been the cook for about a month and had not been told by anyone, including the dietitian, about the scoop size to use. She said she used a large spoon for puree and a green scoop for regular and mechanical soft foods, but did not know the size of either utensil and served whatever scoop she had. Dietary Manager C also stated she was not sure where the extended menus were or what serving size should have been served for the regular, mechanical soft, or puree lunch. After calling a sister facility or the dietitian, she was told the mechanical soft serving size for stuffed bell pepper and okra should have been 4 ounces, while the regular diet should have received 1 stuffed bell pepper and 4 ounces of okra. When the surveyor and [NAME] E measured the mechanical soft bell pepper, it measured 3 ounces instead of the 4-ounce serving size. On 06/30/26, the Dietary Manager served two scoops of pinto beans and sausage using a 4-ounce scoop for two residents on a puree diet. Later, the Dietary Manager stated she was supposed to give 6 ounces and could not locate the dietary spreadsheet to verify the serving size. The Registered Dietitian stated the correct serving size should be used with all meals, that kitchen staff should use the spreadsheet when serving, and that the spreadsheet indicated the serving size for pinto beans and sausage as well as the need for gravy on mechanical soft meats. The DON and Administrator both stated they expected dietary staff to use the correct serving size and to provide gravy or sauce on mechanical soft diets when called for by the menu.
Food Not Served Palatable or at Appetizing Temperature
Penalty
Summary
Food and drink were not provided in a palatable manner and were not served at an appetizing temperature for 4 of 18 residents reviewed, including Resident #28 and 3 anonymous residents. Resident #28 stated during interview that the vegetables were mushy and the food was cold. During a lunch meal observation, the DON and six surveyors sampled a tray containing pinto beans with sausage, rice, and mixed vegetables, and the DON stated the regular and puree diets did not meet her expectations for flavor or temperature. She said the pinto beans with sausage and mixed vegetables could be warmer, the rice and mixed vegetables were bland, and the puree pinto beans with sausage, rice, and mixed vegetables were cold. During a confidential resident group meeting, 3 residents stated the food was cooked hard and said they could tell when the Dietary Manager cooked. The Dietary Manager said she had only been employed for about 3 weeks and had not had complaints about food. The Dietitian said she was not aware of any food concerns. The DON and Administrator both stated they expected food to be palatable and served at an appetizing temperature, and the DON said the Dietary Manager was responsible for ensuring this. The facility policies reviewed stated meals should be attractively prepared, appetizing, palatable, and served at a safe and appetizing temperature.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation with the Dietary Manager, surveyors found undated food items in the refrigerator, including one container of melons and two juice containers. The kitchen also had staff with hair sticking out of their hairnets, including Dietary Aide L and Dietary Manager C, and [NAME] F and Dietary Aide N entered the kitchen without washing their hands. A pedal trash can was not next to the sink at the time of observation. Surveyors also observed sanitation problems in the kitchen and storage areas. Dirty bowls and saucers were stacked in the clean area, pots, pans, and the stove had black buildup, and the floors in the storage room were dirty with an ice cream cup and a prefilled juice cup under the bottom shelves. The microwave was dirty and had food in it. During interview, Dietary Aide N stated she should have had all of her hair in the hair net and said she knew she was supposed to wash her hands to prevent cross contamination, but she had left the kitchen and returned without washing her hands. Interviews with the Dietary Manager, Dietitian, DON, and Administrator confirmed expectations that hair nets should fully cover hair, staff should wash hands when entering the kitchen and between tasks, food should be dated, dirty dishes should not be stored with clean dishes, and the kitchen should be kept clean. The facility policy titled Food Preparation and Service stated that food and nutrition service employees must prepare and serve food in a manner that complies with food handling practices, wash hands before serving food to residents, and wear hair nets so hair does not contact food.
Personal Refrigerator Food Storage and Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to have and follow a policy for the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Surveyors reviewed the personal refrigerators of two residents and found that both had temperatures outside the facility’s recommended range. One resident’s refrigerator repeatedly measured between 41 and 53 degrees, and the temperature log for that refrigerator also showed multiple days with no documented temperatures. The log was completed by the Activity Director. One resident had a history of schizoaffective disorder, BPH, protein calorie malnutrition, and moderate cognitive impairment with fluctuating inattention and disorganized thinking. His care plan addressed obsessive-compulsive behavior related to saving food, but it did not indicate that his personal refrigerator was monitored for expired foods, dated foods, or temperatures within acceptable parameters. Observations showed unsealed and undated cups of milk in the refrigerator along with bottled juice, and the refrigerator gauge remained at 50 to 52 degrees during repeated observations. The second resident had multiple sclerosis, paraplegia, atrial fibrillation, major depressive disorder, hypertension, neurogenic bowel, and moderate cognitive impairment. His room contained two personal refrigerators, but the temperature log reflected only one refrigerator and did not include the freezer. One freezer did not have a thermometer. Observations found food items in both refrigerators, including unopened and opened packaged foods and a cake with an illegible expiration date, while the refrigerator gauges ranged from 51 to 62 degrees and later 52 to 60 degrees. Staff interviews showed the Activity Director was responsible for checking the refrigerators, but she could not explain why temperatures outside the recommended range were not reported, and other staff were unsure who monitored the refrigerators or what the acceptable temperatures were.
Failure to Complete Ordered Diabetic Shoe Measurement
Penalty
Summary
The facility failed to ensure proper foot care for a resident with type 2 diabetes mellitus by not having him measured for diabetic shoes and diabetic insoles as ordered by the physician. Resident #2’s record showed a quarterly MDS indicating he could make himself understood and understand others, with a BIMS score of 9 reflecting moderately impaired cognition. His care plan included diabetes-related interventions, including checking his body for breaks in skin and treating them promptly as ordered by the doctor. The order summary dated 06/09/26 directed physical therapy to measure, order, and dispense diabetic shoes and three pairs of heat molded/custom molded diabetic insoles. During interviews, the resident stated he did not recall anyone from therapy talking to him about diabetic shoes. Staff interviews showed the podiatrist had written the order and it was passed from LVN B to the Director of Rehab and then to the ADON, but the order was not carried out. The Director of Rehab stated there was miscommunication and that she should have contacted the podiatrist office right away to determine how to obtain the custom-fit shoes. The ADON stated therapy did not evaluate residents for diabetic shoes and that she should have followed up to see what needed to be done. The DON and Administrator stated the order should have been followed, and the Administrator stated there was no system for monitoring therapy evaluations to ensure orders were followed through.
Jagged shelving edges on east and west halls
Penalty
Summary
The facility failed to ensure the east hall and west hall were free from accident hazards when shelving attached directly to the hall walls had jagged, rough edges. During observation, the east hall shelving was noted to have rough, jagged edges, and the west hall shelving was also observed with jagged, rough edges. The Maintenance Supervisor stated he had placed the shelves on the east and west halls and had not sanded the edges because he did not have time to do so. He also said he had planned to place doors on the outside of the shelves and that the Administrator later instructed him to remove the shelves until he could sand them. During interviews, the Maintenance Supervisor said the rough edges placed staff, residents, and visitors at risk for skin tears. The ADON stated she was aware the shelving on the east and west wings had been painted and replaced but did not realize the edges were rough and jagged, and said the failure to sand the shelving could have caused skin tears for staff, visitors, or residents. The DON said she learned of the issue after surveyors found the shelves and confirmed the shelving had jagged rough edges, noting the failure placed a risk for splinters, skin tears, or cuts. The Administrator stated the areas were cubby holes intended for resident storage and expected the shelves to be sanded prior to painting and then covered.
Incomplete Enteral Feeding Order for Resident with G-Tube
Penalty
Summary
The facility failed to ensure that Resident #4, a male with a gastrostomy tube, unspecified protein-calorie malnutrition, and sequelae of protein-calorie malnutrition, received an enteral feeding order that included the formula strength and the specific administration method. Resident #4's significant change MDS reflected that he rarely or never made himself understood, sometimes understood others, and had long- and short-term memory problems. His care plan identified that he required tube feeding related to dysphagia and that tube feedings were to be administered per physician orders. The physician order summary dated 06/30/26 listed an active order for enteral feed four times daily via g-tube, but it omitted the Isosource strength and did not specify whether the feeding was to be given by bolus or pump. Hospice physician orders dated 06/19/26 were more specific and identified Isosource 1.5, four times daily. During interviews, the MDS Coordinator stated nursing staff had been administering Isosource 1.5 cal bolus feedings via g-tube. The LVN and DON both acknowledged the order was missing the strength and administration method, and the DON stated she could not recall whether she had added the administration method when updating the order. The facility policy on enteral nutrition stated complete orders include the enteral nutrition product and the administration method.
Unlocked Medication Storage and Unsecured Resident Cream
Penalty
Summary
Drugs and biologicals were not stored in a locked compartment when Resident #28's Triamcinolone Acetonide cream 0.5% was found on his bedside table. Resident #28 was a male admitted with COPD, and his annual MDS reflected a BIMS score of 11, indicating moderately impaired cognition. His care plan addressed discoloration to both lower extremities, with interventions to monitor for skin breaks, edema, and increased redness. The order summary showed no order for Triamcinolone Acetonide cream 0.5%. During observations and interviews, the cream was seen on Resident #28's bedside table on more than one occasion. Resident #28 stated a nurse had given him the cream to apply to his legs for a rash, but he could not recall the nurse's name. CNA G and LVN B both stated they did not see the cream on the bedside table during their rounds and stated medications should not be left at bedside. After reviewing the electronic record, LVN B stated Resident #28 did not have an order for the cream and she did not know who gave it to him. The east hall nurse's cart was also observed left open in the hallway while LVN M gathered supplies and administered insulin. LVN M stated she understood she could leave the cart open if it was facing the resident's door and said she had left nurse carts open her entire career that way, though she acknowledged the risk of residents or staff getting into the unlocked cart. The DON and Administrator stated their expectation was that nurses' and medication carts be locked whenever unattended and not in view. The facility policy stated drugs and biologicals are to be stored in locked compartments.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that resident food preferences were honored for 2 residents reviewed for meal choices and dietary accommodations. Resident #2, a male with morbid obesity due to excess calories and unspecified protein-calorie malnutrition, had an order for large portions with every meal, but his lunch meal ticket on 06/29/26 did not reflect large portions and his meals observed on 06/29/26 and 06/30/26 were served as average portions. Resident #2 stated he wanted large portions with every meal, and staff interviews confirmed the meal ticket did not show the preference and that staff relied on the ticket and tray comparison. Resident #28, a male with COPD and morbid obesity due to excess calories, stated he had been told by dietary staff that he could not have over easy eggs. During observations and interviews, he reported receiving eggs cooked very hard and complained about them on multiple occasions. The Dietary Manager stated she instructed cooks to cook eggs hard to prevent salmonella poisoning and told residents they could not have runny eggs, while the Dietician stated over easy eggs could be provided if pasteurized eggs were used and that she had never been told the resident preferred otherwise. Interviews with dietary and nursing leadership showed the meal ticket system did not reliably reflect resident preferences. Staff stated the Dietary Manager was responsible for ensuring meal tickets reflected resident orders and preferences, and the DON and Administrator stated they expected food preferences to be followed. The facility policy stated residents are to receive nourishing, palatable diets that consider resident preferences and that food service staff will inspect trays to ensure the correct meal is provided.
Incomplete Documentation of Care Conference Participation
Penalty
Summary
The facility failed to maintain medical records that were complete and accurately documented for 2 residents reviewed for documentation. For both residents, the electronic medical record did not show whether the resident or the responsible party had been informed of, attended, declined, or otherwise participated in the quarterly care conference meetings. The deficiency was identified through record review and interviews, and the Care Conference & DC Case Management Evaluation forms did not reflect resident or responsible party attendance status. Resident #9 was a female with diagnoses including COPD, seizures, dysphagia, hypotension, and major depressive disorder. Her MDS showed unclear speech, moderate cognitive impairment with a BIMS score of 8, wheelchair use, and varying levels of assistance with eating, dressing, transfers, bed mobility, and toileting. Her care plan included impaired cognitive function and psychosocial well-being focus areas with interventions to provide opportunities for the resident and family to participate in care. The care conference evaluations reviewed for this resident showed that conferences were held in person with staff attendance, but the section for resident or responsible party participation was not completed, and no evaluation was available for two of the expected quarterly conferences. Resident #24 was a female with diagnoses including atrial fibrillation, heart failure, hypertension, hypothyroidism, hyperlipidemia, dementia, and major depressive disorder. Her MDS showed intact cognition with a BIMS score of 15 and no vision, hearing, or communication deficits, along with dependence in several activities of daily living. Her care plan included falls, altered cardiovascular status, discharge planning, and activity involvement, with interventions involving the resident or family. The care conference evaluations reviewed for this resident showed in-person conferences attended by facility staff, but the form did not document whether the resident or responsible party attended, refused, or were invited and absent. During interview, the resident stated she was aware of care plan meetings but could not recall being invited every 90 days and said she chose not to attend because little changed. An LVN acknowledged she invited the resident and sent invitations to the responsible party but did not document that information in the EMR, and the DON stated the form was expected to be completed in its entirety.
Hospice binders were incomplete and medication profiles did not match facility orders
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for two residents receiving hospice services. For Resident #12, the hospice binder in the facility did not contain the most recent medication profile, the last two months of IDG meetings, or an updated recertification form. The binder also did not include orders for Fentanyl Transdermal Patch 12 mcg/hr every 72 hours or Zyprexa 7.5 mg at bedtime, even though those orders were present in the resident’s chart. The resident’s record showed diagnoses including dementia, anxiety, and depression, and the MDS indicated she was on hospice services with moderate cognitive impairment. During interview, the hospice RN stated the facility’s binder should contain supporting hospice documentation, including the face sheet, election form, code status, certification of terminal illness, plan of care, and medications. She said IDG meetings occurred every two weeks and the documentation should be updated the following week, but the updated information for Resident #12 had not been delivered to the facility. She stated the last IDG meetings on 06/12/26 and 06/26/26 had not been provided and that the recertification period beginning 06/18/26 and ending 08/16/26 should also have been in the facility chart. The LVN and DON stated the hospice binder should include required material such as recertification and IDG meetings, and the DON said hospice should correlate with facility nurses regarding medication changes. For Resident #27, the hospice binder contained a medication profile dated 03/30/26 that did not match the facility’s current orders. The hospice medication profile listed Zoloft 25 mg at bedtime and cyclobenzaprine 10 mg twice daily, but the facility order summary showed sertraline 50 mg at bedtime, cyclobenzaprine 10 mg twice daily, and an additional cyclobenzaprine 10 mg every 24 hours as needed for leg cramps. The ADON and DON stated the hospice medication profile should have matched the facility orders and that the hospice nurse should communicate with the facility nurse to ensure there were no new orders. The DON also stated the facility did not have a hospice policy.
Failure to Complete and Communicate Required Discharge Documentation
Penalty
Summary
Surveyors identified a failure to ensure that discharge information was documented in the medical record and appropriately communicated to the receiving provider for one resident. The resident was an older female with multiple significant diagnoses, including cerebral infarction with right-sided hemiplegia, dysphagia, hyperlipidemia, Buerger's disease, psychotic disorder, and major depressive disorder. Her MDS showed short- and long-term memory deficits, modified independence in decision-making, inattention, disorganized thinking, verbal behaviors, and dependence in most ADLs with a mechanically altered diet. Her care plan included DNR status, behavior issues such as yelling and cursing at staff, refusal of psychiatric treatment and incontinent care, use of bedside loops, anticoagulant use, contractures, foot drop, and an existing skin impairment. Record review showed that, despite this complex clinical profile, the resident’s EMR contained no physician’s order to discharge, no Interdisciplinary Team discharge plan, and no completed discharge summary. The care plan had a closing date, but there was no documentation of the required discharge elements such as the practitioner’s contact information, advance directive information, special instructions or precautions for ongoing care, or comprehensive care plan goals being included in the discharge documentation. The DON reported that the discharge nurse only completed a progress note indicating the resident was transferred via ambulance with medications and personal belongings, without documenting the receiving location or whether a report was called and clinical records were sent. Interviews with LVNs and the DON revealed that staff understood, in general terms, that discharges should include a face sheet, medication list, pertinent labs, recent physician documentation, and a discharge assessment or transfer form, and that a nurse-to-nurse report should be called to the receiving facility. However, for this resident, the DON confirmed that neither a transfer form nor a discharge assessment and discharge summary were completed, and there was no documentation that current physician’s orders, care plan, psychiatric notes, or a history and physical were sent to the accepting facility. The facility’s own policy required that specific information, including practitioner contact information, resident representation and advance directive information, special instructions or precautions, comprehensive care plan goals, and all necessary clinical information, be conveyed to the receiving provider, but this was not documented for the resident’s discharge to another nursing facility of her choice.
Failure to Implement RD Nutrition Recommendations for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents maintained acceptable nutritional status by not implementing or acting upon registered dietician (RD) recommendations for four residents. For the first resident, who had celiac disease and cystic fibrosis with intestinal manifestations, the RD documented a recommendation for ice cream twice daily with lunch and dinner to address nutritional needs. The electronic medical record (EMR) contained no corresponding physician order, and there was no documentation that the physician had been notified to accept or decline the recommendation. The resident’s care plan referenced RD evaluation and diet change recommendations as needed, but the diet order remained unchanged since its original entry, and the resident reported never receiving ice cream with meals. Observation of a lunch meal confirmed that ice cream was not provided and was not listed on the tray ticket. For the second resident, who had COPD, hypertension, diabetes type II, heart failure, and obesity, the RD recommended a sugar-free health shake once daily between meals. The EMR showed no order for the health shake and no documentation that the physician had been contacted regarding the recommendation. The resident’s care plan included interventions for providing diet as ordered and RD evaluation as needed, but the diet order had not been updated since its original date. The resident stated he had not received a health shake between meals and did not recall ever receiving one. Weight records showed a significant weight loss over a one‑month period, and there was no evidence that the RD’s recommendation had been translated into an active order or implemented. For the third resident, who had peripheral vascular disease, a chronic left foot ulcer, protein‑calorie malnutrition, anemia, and hypertension, the RD recommended ice cream with lunch and Prostat 30 cc twice daily for low albumin. The physician’s orders did not include ice cream with lunch or Prostat, and there was no documentation that the physician had been notified to accept or decline these recommendations. The care plan referenced a regular diet with house shake once daily, med pass twice daily, fortified cereal, and providing supplements as recommended or ordered, but the new RD recommendations were not reflected in the orders. The resident reported not receiving ice cream with lunch or a protein drink twice daily, and observation of a lunch meal confirmed that ice cream was not provided and not listed on the diet ticket. For the fourth resident, who had metabolic encephalopathy, cerebral infarction, Parkinsonism, dysphagia, and a feeding tube, the RD recommended Med Pass 2.0, 120 cc twice daily, to prevent further weight loss. The physician’s orders did not include Med Pass 2.0 twice daily, and the care plan focused on tube feeding with Jevity 1.5 and pleasure feedings, along with RD evaluation and monitoring of caloric intake. Nursing staff confirmed there was no order for Med Pass 2.0 twice daily. Interviews with the Food Service Supervisor indicated that dietary recommendations were to be provided to the DON for physician review and that nursing was responsible for entering orders into the EMR and notifying dietary so changes could be added to tray tickets; the supervisor reported not receiving any January recommendations for these four residents. The RD stated she provided recommendations within 24 hours of her visit and expected them to be acted upon with the physician within 72 hours, consistent with facility policy, but the physician later confirmed he had not been notified of the RD’s recommendations for these residents. The DON and ADON acknowledged that the recommendations had been assigned for follow‑up but were not completed, and the DON stated it was her responsibility to ensure timely physician notification, in accordance with the facility’s policy requiring consultant recommendations to be followed up within 72 hours and non‑accepted recommendations to be documented in the nurse’s notes and on the recommendation sheet.
Failure to Provide Sufficient Nursing Staff and Timely Care
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff on a 24-hour basis to meet the care needs of all residents, as required by resident care plans and the facility assessment. On multiple occasions, medication administration for a resident with Parkinson's disease and other conditions was delayed beyond the scheduled time window, and in some cases, doses were not administered as ordered. Staff interviews revealed that these delays and omissions were due to short staffing, with medication aides and nurses reporting being the only staff available to administer medications during certain shifts. Documentation showed that staff did not always notify the physician or DON when medications were given late or missed, and some staff admitted to marking medications as given in the MAR without actually administering them. Another resident, who required substantial assistance with bathing due to impaired balance and other health issues, reported not receiving scheduled showers on Saturdays. Staff interviews confirmed that showers were sometimes missed due to short staffing, particularly on weekends. Staff described working across multiple areas of the building and being unable to complete all required care tasks. The facility's own assessment indicated a need for a specific number of CNAs per shift, but staffing records showed that these levels were not consistently met, especially on weekends and night shifts. A third resident, who was cognitively intact but required total assistance with mobility and ADLs, reported not being able to get out of bed as requested, particularly on weekends when staffing was low. Staff confirmed that there were times when only one or two aides were available for the entire building, making it difficult to provide timely care. Management interviews revealed a lack of awareness of the facility's staffing requirements and no policy for staffing, despite the facility assessment specifying minimum staffing levels. Review of staffing records over several months showed repeated instances where the number of CNAs and medication aides fell below the assessed requirements.
Failure to Administer Medications as Scheduled and Document Accurately
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident with Parkinson's disease and dyskinesia. The resident was prescribed Carbidopa-Levodopa and Buspirone to be administered three times daily. Record reviews showed that on multiple occasions, these medications were not administered within the scheduled time window, and in some cases, doses were either missed or documented as given without actual administration. Medication administration records indicated that staff administered the resident's morning medications late, outside the scheduled 7:00 a.m. to 10:00 a.m. window, and the noon doses were either not given or were documented as given close to the previous dose. Staff interviews revealed that the late administration was due to short staffing, and in some instances, staff marked medications as given on the Medication Administration Record (MAR) without actually administering them. Staff did not notify the physician or the Director of Nursing (DON) about the late or missed doses, nor about the documentation discrepancies. Further interviews with the Assistant Director of Nursing (ADON), DON, and the attending physician confirmed that medications should be administered within a specific time frame and that deviations should be reported. The facility's policy required medications to be administered safely, timely, and as prescribed, with staffing arranged to prevent interruptions. However, the facility did not ensure adherence to these procedures, resulting in the resident not receiving medications as scheduled.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
A deficiency occurred when a female resident with diagnoses including congestive heart failure and schizoaffective disorder, who required substantial assistance with bathing, did not consistently receive scheduled showers on Saturdays. The resident was cognitively intact and her care plan specified that staff were to assist with bathing, particularly washing her back areas. Although the facility's records indicated that all scheduled showers were provided, the resident reported missing showers on Saturdays, attributing this to staff shortages. Multiple staff interviews confirmed that there were frequent staffing shortages, especially on weekends, which led to missed showers for several residents, including this resident. Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) acknowledged that when short-staffed, it was not always possible to provide all required care, including showers. One CNA stated she provided a shower to the resident after the resident reported missing her scheduled shower. Another staff member admitted to not giving any showers on a specific Saturday due to being assigned throughout the building and being short-staffed. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were aware of the missed showers, with the ADON stating she had completed charting under the impression that showers had been given, though they had not. The DON and Interim Administrator both acknowledged being informed by the resident about missed showers and confirmed that staff were responsible for ensuring showers were provided. The facility's policy required that residents unable to perform activities of daily living independently receive necessary assistance, including with hygiene and bathing.
Failure to Ensure Dietary Staff Maintained Current Food Handler Certification
Penalty
Summary
The facility failed to ensure that dietary staff maintained current Food Handler Certificates, specifically for one dietary aide. Record review showed that the dietary aide's Food Handler Certificate had expired prior to her continued service in the kitchen. The Dietary Manager acknowledged awareness of the expiration but did not monitor or ensure timely renewal of the certificate. The aide herself was aware of the expiration but did not renew due to financial constraints. The Dietary Manager and the human resources department were identified as responsible for tracking and maintaining these certifications, but neither took action to prevent the lapse. Interviews revealed that the Interim Administrator was unaware of the expired certificate and did not know the associated risks. Additionally, the facility did not have a policy in place regarding the maintenance of food handler certificates. The lack of oversight and absence of a formal policy contributed to the deficiency, resulting in dietary staff working without the required certification.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
A deficiency occurred when a resident did not receive physician-ordered physical therapy (PT) and occupational therapy (OT) services for a total of seven days in June. The resident, who was cognitively intact and had significant mobility and self-care deficits, was admitted with diagnoses including atrial fibrillation, muscle weakness, unsteadiness, and a cognitive communication deficit. Orders were in place for both PT and OT to be provided multiple times per week, but therapy was not delivered from 06/16/25 through 06/20/25 and again from 06/23/25 through 06/24/25, as confirmed by therapy logs and progress notes. The lapse in therapy services was linked to confusion surrounding the appeal process after a Notice of Medicare Non-Coverage (NOMNC) was issued. The responsible party (RP) communicated that the appeal was won, but therapy was not resumed promptly due to an oversight by the Director of Rehabilitation (DOR), who admitted to forgetting to add the resident back to the therapy schedule. During this period, the resident remained in bed and did not receive the ordered therapy, which was corroborated by both the resident and the RP during interviews. Interviews with facility staff, including the DOR, Assistant Director of Nursing (ADON), Director of Nursing (DON), and interim Administrator, revealed a lack of awareness regarding the missed therapy sessions. The DOR acknowledged responsibility for ensuring therapy was provided as ordered and attributed the failure to an oversight. The ADON and DON were not aware of the missed sessions, and the DON stated there was no policy in place regarding therapy provision. The interim Administrator also confirmed that the DOR was responsible for ensuring therapy orders were followed.
Failure to Maintain Clean and Sanitary Resident Room Vents
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for four residents by not ensuring that the heating and cooling vents in their rooms were free from a black mold-like substance. Observations on the specified date revealed that the vents in the rooms of these residents were visibly covered in this substance, with some also present on adjacent ceiling tiles. Multiple residents reported that the vents had appeared this way for several months, and at least one resident stated he had complained about the issue but could not recall to whom. None of the residents involved had documented pulmonary diagnoses or reported current respiratory symptoms. Interviews with staff, including a nurse, CNA, housekeeper, and the maintenance director, revealed a lack of clarity regarding responsibility for cleaning the vents. The nurse and CNA, both regularly assigned to the affected hall, had not noticed the black substance and were unsure whether housekeeping or maintenance was responsible for vent cleaning. The housekeeper stated that vent cleaning was not part of housekeeping duties and believed it was handled by maintenance. The maintenance director acknowledged that he had noticed the issue during the winter months and was in the process of cleaning the vents but had not completed the task. The facility's policy on providing a homelike environment requires a clean, sanitary, and orderly setting for residents. However, care plan reviews for the affected residents did not address the need for a clean environment or any respiratory issues. The ADON confirmed that maintenance was responsible for vent cleanliness and emphasized the importance of clean vents to prevent respiratory issues, particularly for residents with chronic pulmonary conditions.
Unsecured Medication Left at Bedside After Administration Refusal
Penalty
Summary
A deficiency occurred when a medication aide failed to ensure that a resident received their prescribed morning dose of Protonix, a medication used to treat GERD. The medication was left in an unlabeled, unsecured cup on the resident's bedside table for several hours after the resident declined to take it during the morning medication pass. The resident, who had diagnoses including Parkinson's disease, type II diabetes, a history of fracture, GERD, and chronic pulmonary embolism, was cognitively intact and able to make himself understood. Facility records indicated that the resident required supervision or moderate assistance with most activities of daily living, but could independently reposition and transfer except for tub/shower transfers. Interviews with nursing staff confirmed that medications should not be left at the bedside and that any refused medication should be properly discarded. The medication aide responsible for the morning pass acknowledged not ensuring the resident took all medications and not removing the refused pill. The facility's policy required medications to be administered as ordered and within one hour of the prescribed time, and specified that only residents with physician approval could self-administer medications. However, the policy did not address leaving unlabeled medications at the bedside.
Failure to Prevent Accident Hazards and Inadequate Supervision of Smoking and Sharp Objects
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. One resident, who had a history of seizures and required assistance with daily activities, sustained a cigarette burn on his thigh after dropping a cigarette while smoking. Documentation showed that he was assessed as an unsafe smoker and required supervision and a smoking apron, but on observation, he was not wearing the apron while smoking under supervision. There was no evidence that the incident was reported to the state, and staff interviews revealed a lack of awareness and follow-up regarding the incident and required interventions. Another resident, diagnosed with multiple sclerosis and assessed as an unsafe smoker, was allowed to sign out and smoke in an unsafe area without supervision and kept cigarettes, a vape, and a lighter in his possession. Staff interviews indicated confusion about the resident's supervision requirements and the facility's smoking policy, with some staff believing the resident could make his own decisions despite being deemed unsafe. Observations confirmed that the resident was unsupervised while smoking and vaping, and staff were unaware of the full extent of his access to smoking materials. Additional deficiencies included a resident assessed as a safe smoker who was observed smoking on the side of a residential street after signing out, and another resident with severe cognitive impairment who also signed herself out to smoke in an unsafe area. Furthermore, a resident with moderate cognitive impairment and dependence on staff for personal hygiene was found to have seven disposable razors stored insecurely in his room, accessible on top of his mini refrigerator. Staff acknowledged that razors should not be left in resident rooms and should be disposed of in sharps containers after use, but the razors remained accessible for an extended period.
Removal Plan
- Residents #22, #48, and #32 will be supervised when in an unsafe area. The physician was notified of both the smoking and residents leaving safe supervised area.
- All smoking assessments were audited for accuracy and care plan updated as indicated. Residents #22, #48, and #32 were reassessed and evaluation determined they are safe smokers and able to vape safely. Resident #25 was reassessed and evaluation determined he is an unsafe smoker.
- All smokers were reassessed, and changes made to safe or unsafe smoking, including vaping as indicated.
- Assessments completed by Corporate Clinical Specialist and Corporate Case Mix. Residents assessed to be unsafe will be supervised and smoking supplies will be held at the nurse's station. Residents assessed to be a safe smoker will be able to smoke unsupervised at their leisure in the designated smoking area.
- An emergency care plan meeting was conducted with residents (#22, #48, #32, and #25) regarding safe supervision and smoking policy, to include vaping. Residents #22, #48 and #32 were informed they can smoke only in the smoking area of the facility. Resident #25 was informed that he remains an unsafe smoker and must be supervised. All smoking residents were educated in regards to the smoking area of the facility and informed that location is the only place they can smoke. Care plans updated as indicated to include education regarding safety plan and pedestrian safety.
- Ombudsman notified of the incident with Resident #22, #48, and #32 smoking unsupervised in an unsafe area. Informed of Resident #25 incident of cigarette burn.
- Medical Director notified of the incident with Resident #22, #48, and #32 smoking unsupervised in an unsafe area. Informed of Resident #25 incident of cigarette burn.
- Corporate Clinical Specialist in-serviced Administrator and ADON regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, smoking assessment accuracy, designated smoking areas, and remaining in safe supervised area. Competency verified by quiz.
- Facility Administrator and ADON in-serviced all staff regarding Accident/Hazard Supervision, specifically in regard to safe smoking policy, designated smoking areas, and remaining in safe supervised area. Competency verified by quiz. Staff will not be allowed to work until completion.
- Corporate Clinical Specialist in-serviced staff on residents that are safe smokers and those that are not, and how to find that information.
- Corporate Clinical Specialist, or designee, in-serviced licensed nurses on completing smoking risk assessment accurately as related to current health concerns/conditions, resident capabilities, and resident smoking material preference (cigarettes and/or electronic cigarettes). In-service included that Licensed Nurses are responsible for completing the smoking assessments upon admission, change of condition, and quarterly.
- The above training regarding Accident/Hazard Supervision, specifically in regard to safe smoking and safe supervision will be implemented into new hire orientation.
- To monitor compliance, residents will be monitored by the DON/designee through observations and communication with staff daily and monthly.
- DON/designee will review smoking assessments weekly and monthly.
- The QA committee will meet weekly to review compliance with the plan of action. If no further concerns are noted, the facility will continue to be monitored as per the routine facility QA committee.
Failure to Secure Medications and Biologicals in Locked Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments accessible only by authorized personnel, as required by policy. During observations, a resident was found with a bottle of fluticasone propionate nasal spray and biotene dry mouth moisturizing spray on his bedside table, and a can of barbasol shaving cream on his windowsill. Record review showed that there were no physician orders addressing the use of these items, and the resident had not been assessed for self-administration of medications. The baseline care plan indicated the resident required assistance with personal hygiene and oral care. Interviews with staff revealed that the resident's family member often brought in medications and other items, and that the resident had not been evaluated for self-administration. Staff confirmed that medications should be stored on the medication cart and shaving cream in the storage closet or shower room, not left at bedside. Facility policy required all drugs and biologicals to be stored securely in locked compartments, but this was not followed in the case of this resident.
Expired Saline Eyewash Solutions at Multiple Facility Locations
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment by not ensuring that saline eyewash solutions at four locations—the kitchen, laundry, east wing medication room, and east wing shower room—were within their expiration dates. Observations revealed that all reviewed eyewash stations contained expired saline solutions, with specific expiration dates noted on the bottles. Staff interviews confirmed that the expired solutions had not been replaced, and there was confusion among staff regarding responsibility for monitoring and replacing the eyewash solutions. The maintenance staff member acknowledged responsibility for checking the eyewash stations but admitted to missing the scheduled checks, and the dietary supervisor indicated that replacements had not been available when needed. Further interviews with staff, including a registered nurse, a certified nursing assistant, the assistant director of nursing, and the administrator, revealed a lack of clarity regarding the monitoring process and policy adherence for eyewash solution expiration. The facility's policy on the storage of drugs and biologicals requires that outdated or deteriorated items be returned or destroyed, but this was not followed for the eyewash solutions. No information about residents' medical history or condition was provided in relation to this deficiency.
Failure to Ensure Proper Orders and Documentation for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care consistent with professional standards for four residents who required oxygen therapy. For one male resident with metabolic encephalopathy, oxygen was administered via nasal cannula at 2 liters per minute, but there was no physician's order for oxygen in his chart. The resident reported using oxygen continuously due to shortness of breath, and both the charge nurse and ADON were unaware of the missing order until notified by the surveyor. The ADON stated that orders were entered based on hospital discharge paperwork, and if oxygen was not listed, it was not entered. The administrator confirmed that nursing management was responsible for ensuring orders were documented and placed in the electronic medical record. Another female resident with dementia, shortness of breath, diabetes, and hypertension had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, during observation, she was found in bed without oxygen, and there was no oxygen concentrator in her room. The resident was unable to confirm if she used oxygen, and her MDS assessment did not indicate oxygen use during the look-back period, despite the care plan requiring it. A third female resident with a history of UTI, stroke, diabetes, and hypertension was observed receiving oxygen at 3 liters per minute via nasal cannula, but there was no physician's order for oxygen until after surveyor intervention. Additionally, there was no oxygen sign on her door as required by facility policy. A fourth female resident with apraxia, shortness of breath, hypertension, dementia, and depression was also found to be using oxygen without a corresponding physician's order in the record until after surveyor intervention. Staff interviews revealed a lack of awareness regarding the need for written orders and proper documentation for oxygen therapy, and the facility's policy required verification of a physician's order prior to administration.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
Surveyors found that the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for several residents and during one observed meal. Multiple residents reported receiving cold, bland, or unappetizing food, with one resident specifically noting a burned roll that was inedible. Observations during meal service revealed issues with tray delivery, as staff had difficulty locating and serving trays efficiently, resulting in delays. During a sampled lunch, surveyors and the Dietary Manager noted that some food items were not fully cooked, bland, or not warm. Interviews with staff, including the Dietary Manager, ADON, and Executive Director, confirmed awareness of the issues, with explanations citing recipe adherence, lack of seasoning due to dietary restrictions, and logistical challenges such as insufficient food carts. The Dietary Manager acknowledged being in training and expressed concerns about the ability to serve hot food due to equipment limitations. Staff agreed that residents should receive hot and palatable meals, and recognized that the current practices were not meeting this expectation.
Failure to Obtain Written Consent for Psychoactive Medication Administration
Penalty
Summary
The facility failed to obtain valid written consent for the administration of a psychoactive medication, Seroquel 25 mg, for a resident with schizoaffective disorder and bipolar disorder. Although there was a signed consent form for Seroquel 50 mg, there was no written consent on the required HHSC Form 3713 for the 25 mg dosage that was actively being administered. The resident had a moderately impaired cognition, as indicated by a BIMS score of 10, and was taking antipsychotic medication daily during the review period. The care plan documented the use of psychotropic medication for schizophrenia and psychotic disorder, with interventions to administer medications as ordered and consult with pharmacy. Interviews with the ADON and Administrator revealed that responsibility for obtaining the correct psychotropic medication consents rested with the ADON and DON. The ADON acknowledged that the consent for the correct medication and form was present, but the dosage did not match the current order, and this discrepancy was missed during recent audits. The facility did not provide a policy regarding psychotropic medications when requested by surveyors.
Failure to Provide Portable Oxygen Restricted Resident's Mobility
Penalty
Summary
The facility failed to ensure that a resident with COPD who required continuous oxygen therapy had access to portable oxygen, which prevented him from leaving his room. The resident reported being confined to his room for several days due to the unavailability of portable oxygen, missing facility activities as a result. He stated that he had informed several staff members and the Administrator about the issue, but no alternative options were provided, and the portable oxygen was still not delivered. Record reviews confirmed the resident's diagnosis of COPD and the physician's order for continuous oxygen via nasal cannula. The care plan included monitoring for respiratory compromise. The Administrator acknowledged being informed about the shortage of portable oxygen and stated that he contacted the DME company to order more but did not seek alternative sources to bridge the gap. The facility's policy requires residents to receive adequate and appropriate care and services, including a physical environment that ensures their well-being.
Incomplete OOH-DNR Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was completed in accordance with requirements. Specifically, the OOH-DNR for a male resident with Parkinson's disease, who was cognitively intact and aware of his DNR status, was missing the Medical Power of Attorney's (MPOA) printed name, the date the document was signed by the MPOA, and the notary's signature. The resident's care plan indicated he was a DNR and that his advanced directive options and rights were to be reviewed with him and his family. Interviews with facility staff revealed confusion regarding responsibility for ensuring DNR forms were properly completed. The Regional Social Worker acknowledged the missing information on the resident's OOH-DNR and stated that the Administrator and Director of Nursing (DON) were responsible for overseeing DNR accuracy. The Administrator confirmed the expectation that DNRs be fully completed, including all required signatures and dates, and identified the Regional Social Worker as responsible for monitoring DNRs. Facility policy required inquiry about advance directives upon admission and respect for such directives in accordance with state law.
Failure to Provide SNF ABN Notification for Medicare Coverage Change
Penalty
Summary
The facility failed to inform a resident of changes in Medicare coverage and potential financial liability for services not covered, as required. Specifically, a male resident with acute kidney failure and moderate cognitive impairment, who was receiving occupational and physical therapy, was not provided with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when he was discharged from Medicare Part A skilled services before his covered days were exhausted. This notice would have informed him of his option to continue services at his own expense. Interviews with facility staff, including the Regional Financial Specialist and the Administrator, confirmed that the Business Office Manager (BOM) was responsible for issuing the SNF ABN but failed to do so. The staff acknowledged the importance of providing the form to ensure the resident was aware of his financial responsibilities. Additionally, it was revealed that the facility did not have a policy regarding the issuance of SNF ABNs.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of resident-to-resident abuse was reported to the appropriate authorities within the required timeframe. Specifically, a CNA witnessed one resident strike another on the right arm and immediately reported the incident to an LVN. The LVN assessed the resident for injuries, found none, and reported the incident to the ADON and Administrator. Despite this, the incident was not reported to the state agency within two hours as required by regulation. The Administrator did not report the incident, stating that there was no injury and that the resident who was allegedly struck denied being hit. The Administrator also did not interview either resident involved in the incident. The ADON was under the impression that another resident had witnessed the event and did not speak to the involved residents or instruct the LVN to complete an incident report or skin assessment. The Executive Director stated that reporting was not necessary due to the cognitive status of the resident who allegedly struck the other. Record review showed that no incident or skin assessment was completed for either resident. The facility's own Abuse Prohibition Policy requires all allegations of abuse to be reported immediately or within two hours. The failure to report the witnessed incident of potential abuse in a timely manner constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate and Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and respond to an alleged incident of abuse involving two residents. According to the report, a CNA witnessed one resident, who has a history of behavioral issues and severely impaired cognition, physically contact another resident on the right arm. The CNA immediately reported the incident to an LVN, who assessed the alleged victim for injuries and found none. The LVN then reported the incident to the ADON and Administrator. Despite this, no incident report or skin assessment was completed, and the event was not reported to the state agency as required by facility policy. The resident who was allegedly struck has a diagnosis of dementia/Alzheimer's and impaired cognitive function, but was documented as able to make herself understood and understand others. The resident who allegedly struck her has paranoid schizophrenia, a BIMS score indicating severe cognitive impairment, and a documented history of behavioral symptoms directed toward others. The care plans for both residents included interventions for their respective cognitive and behavioral issues, but there is no documentation that these interventions were reviewed or updated in response to the incident. Interviews with facility staff revealed confusion and lack of follow-through regarding the reporting and investigation process. The Administrator and ADON did not interview the residents involved or the CNA who witnessed the incident, and the Administrator stated he did not report the incident to the state agency because there was no injury. The ADON stated she expected an incident report and skin assessment to be completed, but this was not done. The facility's Abuse Prohibition Policy requires thorough investigation and timely reporting of all allegations, which was not followed in this case.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one male resident with a history of paranoid schizophrenia and severe cognitive impairment, the quarterly MDS assessment incorrectly indicated the presence of a feeding tube, despite documentation and staff interviews confirming that he had not had a feeding tube for several years. The resident's care plan did not address a feeding tube, and both the MDS Coordinator and ADON acknowledged the error, attributing it to a mistake in coding. For a female resident with multiple sclerosis and intact cognition, the quarterly MDS assessment inaccurately documented the use of a restraint. In reality, the resident used a transfer assist bar to aid with movement, which was not considered a restraint according to facility staff and regional case mix personnel. The resident's care plan described the use of hand hoops and transfer bars for positioning and self-care, but not as restraints. Staff interviews confirmed the coding error and emphasized the importance of accurate assessments for proper care planning.
Failure to Care Plan Oxygen Use for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed all the needs of two residents, specifically regarding their use of oxygen. For one resident, documentation showed she was severely cognitively impaired and required extensive assistance with daily activities. Although she was observed using oxygen and reported needing it for two years, her care plan and physician orders did not reflect this intervention. The omission was confirmed through record review and direct observation. Another resident, who was moderately cognitively impaired and had diagnoses including apraxia, dyspnea, and dementia, was also observed using oxygen. However, her care plan did not include oxygen use, and physician orders for oxygen were only updated after surveyor intervention. Prior to this, the only related order was for changing oxygen tubing as needed for infection control, with no standing order for oxygen administration documented in her records. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans, particularly for acute changes such as new oxygen orders. The MDS nurse, ADON, and other staff acknowledged that care plans should have included oxygen use for these residents but cited gaps in communication and documentation as reasons for the oversight. Facility policy requires comprehensive care plans to be developed and updated to reflect residents' current needs, but this was not followed in these cases.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for side effects of the anticoagulant medication Eliquis. The resident, a cognitively intact female with diagnoses including atrial fibrillation and atherosclerotic heart disease, was prescribed Eliquis for atrial fibrillation and for an infection and inflammatory reaction due to a knee prosthesis. The care plan required staff to monitor and document any adverse reactions to anticoagulant therapy, such as bleeding, bruising, or changes in mental status. However, review of the medication administration record showed no evidence that monitoring for side effects was performed during the specified period. Interviews with nursing staff and facility leadership revealed that the responsibility for entering and ensuring monitoring for anticoagulant side effects was not fulfilled. The nurse assigned to the resident did not see any monitoring listed in the electronic record, and the ADON acknowledged that the monitoring was overlooked and not added to the computer system. The facility did not have a policy on anticoagulant monitoring or medication administration, and the lack of monitoring was attributed to an oversight by the admitting nurse and a lack of backup checks by other staff.
Failure to Ensure Timely Laboratory Services for Resident
Penalty
Summary
The facility failed to ensure that laboratory services were provided as ordered for one resident, resulting in missed routine laboratory tests. Specifically, a male resident with a history of seizures, anemia, glaucoma, and high blood pressure did not have his Comprehensive Metabolic Panel (CMP) drawn every six months as ordered, nor were his Phenobarbital and Dilantin levels checked every three months as required by physician orders. Review of the resident's electronic health record showed that the last CMP was drawn in July, and the last Phenobarbital and Dilantin levels were drawn in November, with no subsequent labs documented. Interviews with facility staff revealed that nurses were responsible for entering lab orders into the electronic system, which was accessible to the outside lab company. However, the ADON admitted to being unaware of the missed labs until questioned by the surveyor and acknowledged the absence of an effective lab monitoring system. The facility's policy required that laboratory services meet residents' needs and that results be reported promptly, but these procedures were not followed in this case, leading to the deficiency.
Failure to Promptly Notify Physician of Abnormal Anticonvulsant Lab Results
Penalty
Summary
The facility failed to promptly notify and follow up with the ordering physician regarding laboratory results that were outside of the clinical reference range for one resident with a seizure disorder. Specifically, the resident had active orders for Phenytoin (Dilantin) and Phenobarbital to manage seizures, and laboratory results collected and approved showed both medication levels were low. Despite this, the physician was not notified of the abnormal results until 20 days later, after a state surveyor brought the issue to the attention of the Assistant Director of Nursing (ADON). The physician subsequently gave orders to adjust the medication dosages and recheck levels. Interviews revealed that the ADON expected charge nurses to notify the physician of abnormal labs but assumed the physician was reviewing results in the electronic medical record system, which the physician was unable to access due to technical issues. The facility's policy required prompt notification of abnormal lab results to the ordering provider, but this was not followed. The ADON and Director of Nursing (DON) were identified as responsible for monitoring and overseeing labs, but the process failed in this instance, resulting in a significant delay in physician notification.
Failure to Follow Prescribed Menu for Mechanically Altered Diet
Penalty
Summary
The facility failed to follow the prescribed menu for a resident requiring a mechanically altered diet. Specifically, the resident, who had a history of myocardial infarction and severe cognitive impairment, was ordered to receive a ground chicken fried chicken entree for lunch. Instead, the resident was served a ground beef patty. The resident's care plan and physician orders specified a mechanically altered diet, and the lunch meal ticket indicated ground chicken fried chicken as the correct entree. Staff interviews confirmed that the resident did not receive the correct meal, and the dietary staff member responsible admitted to substituting ground beef for ground chicken to ensure enough chicken was available for residents on regular diets who requested seconds. The dietary manager was unaware of the substitution until after the meal was served and stated that the menu should have been followed for all diet textures. The charge nurse responsible for checking the resident's tray did not recognize the substitution and only became aware of the issue after it was pointed out by a state surveyor. The facility's policy required that menus be developed and prepared to meet resident choices, but this was not followed in this instance, resulting in the resident not receiving the ordered meal.
Failure to Maintain Food Safety Standards in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the ice scoop holder in the main dining room was observed to have orangish-brown sediment in the bottom, and records indicated it had not been cleaned since the last documented date. The Dietary Manager confirmed that kitchen staff were responsible for cleaning the ice scoop holder and acknowledged the presence of sediment when shown. The daily cleaning list provided showed the last cleaning date, with no evidence of more recent cleaning. Additionally, a bag of boiled eggs in the refrigerator was found with only one date and was not disposed of within the required timeframe. The Dietary Manager stated that eggs should be discarded within seven days of opening, and that all kitchen staff were responsible for timely removal of expired food. Interviews with the Dietary Manager, ADON, and Administrator confirmed expectations that kitchen staff should regularly check expiration dates, dispose of outdated foods, and clean the ice scoop holder and ice machine according to facility policy. Facility policies reviewed indicated that food storage areas should be kept clean, all foods in the refrigerator should be labeled and dated, and all equipment and food contact surfaces should be cleaned and sanitized per policy and manufacturer instructions. The failure to follow these procedures was acknowledged by staff and administration during interviews.
Failure to Enforce Smoking Safety Policies in Designated Area
Penalty
Summary
The facility failed to establish and enforce policies regarding designated smoking areas and smoking safety. During an observation, a trash can in the designated smoking area was found to contain a smoked cigarette, rather than only trash. A laundry aide confirmed that staff responsible for supervising residents during smoking should check the trash can to ensure cigarettes are not discarded there, as this could pose a fire risk. The administrator acknowledged that cigarettes should be extinguished in the proper receptacle and that staff supervising residents should monitor this process. Review of the facility's smoking policy indicated the facility is responsible for providing a safe and hazard-free environment for residents assessed as safe for smoking privileges.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information at the beginning of each shift for two days during the review period in April 2025. Specifically, on April 22 and April 23, the staffing sheets displayed were dated April 21, and the current staffing data, including the total number of hours worked by licensed nurses and certified nurse aides as well as the daily census, was not posted as required. Observations confirmed that the outdated staffing sheets were hung on the employee bulletin board by the time clock in the hallway leading to the smoking area. During interviews, the ADON, who was responsible for daily staffing in the absence of a DON, acknowledged missing the completion and posting of the staffing forms for the two days, citing being busy as the reason. The ADON also indicated a lack of awareness regarding the risks to residents from not posting the staffing information, stating she understood it as a regulatory requirement. The Administrator confirmed that the expectation was for the ADON to complete and post the staffing data daily and recognized that the failure could result in residents and families not being aware of the staffing numbers.
Resident Fall Due to Unlocked Bed
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that adequate supervision was provided to prevent accidents, resulting in a fall for one resident. The incident involved a resident who was admitted to the facility with multiple diagnoses, including heart failure, hypertension, diabetes, anxiety, and COPD. The resident was admitted from a short-term general hospital and had been in the facility for only about an hour before the incident occurred. During the admission process, the resident was being assessed and wound care was being provided by a registered nurse and a certified nursing assistant. The bed was not properly locked, which led to the bed moving and the resident falling to the floor. The fall resulted in significant injuries, including fractures to the orbital floor and cervical spine, as well as a laceration and hematoma to the head and eye. The resident was subsequently sent to the emergency room for evaluation and treatment. Interviews with the staff involved revealed that both the registered nurse and the certified nursing assistant believed the bed was locked, but it was not. The facility's Fall Prevention Program policy requires that all residents be assessed for fall risk at admission and that specific interventions be implemented to minimize falls. However, due to the resident's short time in the facility, a baseline care plan had not been completed, and the necessary precautions were not in place, leading to the accident.
Failure to Report Resident's Serious Injuries After Fall
Penalty
Summary
The facility failed to report an incident involving a resident who sustained serious injuries after falling out of bed shortly after being admitted. The resident, a female with a history of heart failure, hypertension, diabetes, anxiety, and COPD, was admitted to the facility from a hospital. Within approximately an hour of her arrival, she fell from her bed, resulting in a fractured orbital floor and cervical spine fractures. Despite the severity of the injuries, the facility did not report the incident to the state agency as required by regulations. Interviews with facility staff revealed a lack of communication and understanding of reporting responsibilities. The MDS Coordinator/ADON was aware of the fall and communicated with the resident's family but did not receive information about the extent of the injuries. The Marketer was informed of the injuries by the hospital but did not report them to the facility's Administrator, as there was no administrator at the time. The Regional Nurse was informed of the fall but did not consider it reportable due to it being a witnessed event, and was unaware of the full extent of the injuries until notified by a surveyor. The facility's policy on abuse prohibition requires reporting of serious bodily injuries within two hours, but this protocol was not followed. The failure to report the incident in a timely manner could place residents at risk of injuries, abuse, and/or neglect. The facility's lack of a clear reporting process and communication breakdown among staff contributed to the deficiency.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in two halls, specifically hall 100 and hall 200. Hall 200 was observed to have a strong urine odor on multiple occasions, and the housekeeping aide confirmed that the facility was short on cleaning supplies and lacked a housekeeping supervisor. The Administrator acknowledged the issue but did not smell the urine odor himself. The facility did not have a housekeeping cleaning and deep cleaning checklist, and the deep cleaning was not performed due to staff shortages and lack of supplies. Several room floors on hall 100 were observed to be unclean with light and dark spots. Housekeeper G, who started working at the facility recently, confirmed that the floors remained dirty despite cleaning efforts and that the facility had run out of the correct cleaning chemicals. The Administrator, who also served as the housekeeping supervisor, acknowledged the issue and mentioned a Performance Improvement Project (PIP) for deep cleaning, but no schedule for deep cleaning was produced. Resident #45's room had peeling wallpaper, which the resident and staff were aware of but had not reported in the maintenance book. The Maintenance Supervisor planned to replace the wallpaper with textured paint but had no written plans. The Administrator was unaware of the issue but stated that all staff should report maintenance needs in the maintenance book. The facility policy emphasized providing a safe, clean, and homelike environment, which was not upheld in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident #9, a [AGE] year-old female with anxiety, high blood pressure, heart failure, and diabetes, experienced a fall in the shower room that was not included in her care plan. Additionally, her use of Xanax for anxiety was not care planned until after state surveyor intervention. The MDS nurse and DON acknowledged the oversight, emphasizing the importance of care plans for continuity of care and best possible outcomes for residents. Resident #16, a [AGE] year-old female with anxiety, sleep apnea, COPD, and pulmonary hypertension, was on anticoagulant therapy with Eliquis. However, her care plan did not include any interventions or monitoring related to the use of Eliquis until after state surveyor intervention. The MDS nurse and DON admitted that the omission was an oversight and stressed that care plans should reflect residents' care and needs to ensure they receive appropriate care. Resident #43, a [AGE] year-old female with cerebral palsy, high blood pressure, dysphasia, and epilepsy, required a feeding tube and the use of a [NAME] button for enteral feedings. Her care plan did not include the use of the [NAME] button or the schedule for changing the extension tubing every 14 days. The DON and Administrator acknowledged that the omission placed the resident at risk for improper care and potential infection. The facility's policy on comprehensive person-centered care plans emphasized the need for measurable objectives and timetables to meet residents' needs, which were not met in these cases.
Failure to Ensure Proper Respiratory Care Orders
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care was provided such care consistent with professional standards of practice. Specifically, the facility did not have physician orders for the resident's Bipap machine, which is essential for managing her conditions, including sleep apnea, COPD, and pulmonary hypertension. The resident's comprehensive care plan indicated the use of a Bipap machine at night, but there were no corresponding physician orders in the electronic medical records. This oversight was confirmed through observations, interviews, and record reviews, revealing that the nurses were unaware of the correct Bipap settings, which are crucial for proper respiratory care. During interviews, the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged the absence of the necessary orders and the potential risks associated with not having the correct settings for the Bipap machine. The Administrator also confirmed that all residents should have orders to ensure proper care. The facility's policy on medication orders emphasized the importance of maintaining a current list of orders in each resident's clinical record, including specific details for oxygen orders. The failure to adhere to this policy could lead to respiratory complications for residents requiring such care.
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 117 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bonham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seven Oaks Nursing & Rehabilitation | 1.2 mi | ★★★★★ | 2 | 0 |
| Clyde W Cosper Texas State Veterans Home | 1.2 mi | ★★★★★ | 20 | 0 |
| Mullican Care Center | 10.4 mi | ★★★★★ | 1 | 0 |
| Honey Grove Nursing Center | 16.4 mi | ★★★★★ | 10 | 1 |
| Denison Nursing And Rehab | 23 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.