Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Park Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Employ a Full-Time Social Worker: A facility with 170 licensed beds did not have a full-time qualified social worker after the prior social worker left, and the staff roster showed no social worker employed. The ADM and ADON confirmed only a part-time social worker was available, while the ADM stated other staff, including the MDS nurse, were trying to cover social work duties such as resident assessments and concerns.
A resident with dementia and severe cognitive impairment had a care plan focused on video monitoring, stating the family had chosen to install a camera in her room. Surveyors observed that no camera was present, and the RP and LVN both confirmed the device was missing while the care plan still reflected that it should be in place. The DON stated the care plan had not been updated to match the resident's actual situation.
The facility failed to report multiple alleged abuse/exploitation events within required timeframes, including a resident-to-resident altercation, a resident’s allegation that staff were taking his money, and a resident’s hospitalization after suicidal ideation. Staff and leadership were aware of the incidents, but the DON, SW, and ADM did not ensure the events were self-reported to the SSA as required, despite policies requiring allegations of abuse, neglect, exploitation, and misappropriation to be reported and investigated.
Food Storage and Date Marking Deficiencies: Surveyors found a pan of chicken pot pie in the refrigerator past its discard date and 3 boxes of frozen food stored too close to the ceiling in the walk-in freezer. The DM stated the frozen boxes could interfere with the sprinkler system, and the RD said frozen food should be 18 inches from the ceiling. Facility policy required staff to discard foods past use-by or expiration dates and to monitor refrigerated foods by date.
Personal Refrigerators Not Maintained or Monitored Properly: Surveyors found that a resident’s personal refrigerator was 48 degrees, another resident’s refrigerator was dirty with unlabeled Styrofoam containers of unknown food, and a third resident’s freezer was iced over. Staff gave inconsistent answers about the required temperature range, with logs allowing temperatures up to 46 degrees and the DON/RD giving different expectations. Residents with intact cognition reported using the refrigerators for food storage and not knowing whether staff were checking them.
Failure to Obtain Informed Consent for Antipsychotic Medication: A resident with schizophrenia, anxiety, intermittent explosive disorder, and moderately impaired cognition received Ziprasidone HCl via PEG-tube twice daily, but the facility did not obtain informed consent for the antipsychotic. The resident was observed upset and difficult to understand, and the record showed ongoing administration of the medication while the DON and ADON discussed whether the consent in the chart was sufficient and whether a specific form was required.
MDS inaccurately documented restraint use for a resident with moderately impaired cognition and reduced mobility. The quarterly MDS stated the resident used a trunk restraint on a less than daily basis, but the chart had no physician order or care plan for a restraint device, and staff stated the facility was restraint-free. The resident was observed in her wheelchair without a trunk restraint and was unsure whether her chair had a seatbelt or other restraining device.
A resident with schizoaffective disorder, bipolar disorder, and schizophrenia had a PASARR Level 1 screening that did not identify a PASARR condition, so no Level 2 eval was initiated. The MDS Coordinator later acknowledged the screening should have been positive based on the resident’s MI diagnoses and care record, which also showed impaired cognition, total ADL dependence, antipsychotic use, and psychiatry involvement.
Inaccurate smoking safety care plan: A resident with schizoaffective disorder and severely impaired cognition had a smoking safety screen stating he required monitoring while smoking, but his care plan also listed a smoking apron and supervision. He was observed smoking without a smoking apron, and staff stated he did not require one and were unaware it was included in the care plan.
Failure to maintain dignity during grooming: A resident with cognitive impairment, hallucinations, and a care plan for assistance with personal hygiene was observed multiple times with facial hair on her upper lip and chin. She stated she was embarrassed and felt other residents stared at her, while the ADON, CNA, LVN, and DON said they had not noticed the facial hair or asked whether she wanted it shaved. The facility policy stated residents should be groomed as they wish, including facial hair.
A resident with schizoaffective disorder and severely impaired cognition required direct supervision while smoking, per the care plan and smoking safety screen. Staff observed him smoking in the designated area without supervision, and the assigned CNA stepped away to get a trash bag, leaving the resident unattended despite the facility smoking policy requiring direct supervision at all times.
A resident with anxiety, intermittent explosive disorder, and schizophrenia-related documentation did not receive a timely psych consult as ordered, and the referral process was not completed as expected. The resident was on psychotropic meds and had psychosocial care plan issues, but the record and staff interviews showed the MI diagnosis was not accurately carried into the assessment and care plan, and the resident was observed upset, confused, and դժվար to follow during conversation.
A resident with dementia, depression, and dysphagia was found with no teeth except two black fragments and reported intermittent mouth pain and a desire to see a dentist. Her care plan did not address dental needs, the SW had not yet assessed her for dental services, and leadership was unaware of how dental services were being provided despite a policy for routine and emergency dental care through a contracted dentist.
Menu Lacked Protein at Dinner: The facility served a dinner meal of vegetable soup, salad, crackers, and a cookie without a protein item. A resident with anemia, severe protein calorie malnutrition, and a stage 4 coccyx wound received soup and green beans, while another resident on a controlled carbohydrate diet received soup and a grilled cheese sandwich; the RD said she could not review every meal and the DM noted protein was missing from the menu.
Hand Hygiene Not Performed During Incontinence Care A CNA failed to perform hand hygiene while providing incontinence care to a resident who required staff assistance for all ADLs. During observation, the CNA changed gloves multiple times without sanitizing hands between glove changes while removing a soiled brief, cleansing the resident’s skin, and applying a clean brief. The CNA said she should have used hand sanitizer between each glove change, and the DON stated staff were expected to perform hand hygiene between every glove change and had received infection control training.
Missing Required Nurse Staffing Postings: The facility’s daily nurse staffing posting in the lobby was missing the facility name and the total number and actual hours worked by nursing staff. The DON and ADON stated the posting did not include the required information, and the ADON reported he only had 5 months of staffing postings available instead of the required 18 months. The facility policy required daily posting of direct care staffing information and retention of staffing records for at least 18 months.
Two residents' physician progress notes were not updated to reflect discontinued medications, resulting in discrepancies between the notes and current physician orders. Nursing staff and the DON confirmed that the progress notes still listed medications that had been stopped, while the care plans and orders did not. This lack of alignment was acknowledged by both nursing and medical staff, who cited missed updates and insufficient oversight of documentation accuracy.
Surveyors found that the facility failed to maintain a safe, functional, and sanitary environment, with unresolved maintenance issues such as stained and damaged bathroom fixtures, broken lighting, and water-damaged ceilings in multiple resident rooms and hallways. These deficiencies were known to facility leadership and listed on pending work orders but had not been addressed.
A resident with severe cognitive impairment and respiratory failure was ordered oxygen therapy on an as-needed basis, but the care plan was not updated to reflect this intervention. Staff interviews revealed a misunderstanding about care planning requirements for PRN oxygen use, and the omission was confirmed by both the ADON and DON, despite facility policy mandating care plan revisions when a resident's condition changes.
In a dining room, CNAs were observed using personal cell phones while sitting with residents, contrary to facility policy. A resident with intact cognition reported frequent phone use by staff, indicating a lack of care. The facility's policy emphasizes treating residents with dignity and respect.
A facility failed to comply with physician orders for three residents, leading to deficiencies in care. A resident did not receive prescribed insulin due to an LPN's judgment, another missed a scheduled HgA1c lab test, and a third received Midodrine HCl outside prescribed parameters without physician approval. These actions were not documented or communicated to the physician, contrary to facility policy.
A long-term care facility failed to manage medications properly for three residents. An expired insulin pen was found in a nurse's cart, insulin was not administered per physician order for a resident on hospice, and Midodrine HCl was given outside prescribed parameters for a dialysis patient. The DON acknowledged these issues, emphasizing the need for adherence to physician orders and proper medication management.
The facility failed to properly label and store medications in two medication carts. In one instance, three opened Lispro insulin Kwik Pens for a resident were found, but only one had an open date, making it impossible to determine the expiration of the others. Additionally, two loose pills without proper labeling were found in another cart. The DON confirmed that all medications should be labeled correctly, and insulin pens should have open dates to ensure efficacy.
The facility's kitchen failed to meet food safety standards, with unlabeled and expired food, improper hygiene practices by staff, and inadequate temperature control and cleanliness. These issues were observed during a survey, posing a risk of food-borne illness to residents.
The facility failed to maintain accurate medical records and obtain necessary consents for medications. An LPN incorrectly documented the administration of Losartan Potassium for a resident with hypertension, and several residents received antipsychotic medications without the required written consents. These deficiencies were confirmed through interviews and record reviews, highlighting lapses in following facility policies.
A LTC facility failed to maintain an effective infection control program, with staff not adhering to proper hygiene practices. A CNA did not change gloves after touching a privacy curtain before catheter care, another CNA failed to change gloves after colostomy care, and an LVN did not sanitize hands after picking up a pen from the floor before medication administration. Additionally, an LVN did not follow Enhanced Barrier Precautions while administering G-tube medications due to lack of training.
The facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents upon their discharge from Medicare Part A skilled nursing services, despite having benefits remaining. This oversight was attributed to human error, and the administration confirmed the necessity of following Medicare guidelines for financial liability protections.
Two residents' MDS assessments inaccurately reflected their smoking status, with one resident smoking 5-10 cigarettes daily and another 2-5 cigarettes daily, despite being coded as non-smokers. The errors were attributed to an inexperienced MDS nurse who did not review necessary documentation. Despite the inaccuracies, both residents had care plans with appropriate smoking interventions, and staff believed these errors did not impact their care.
A facility failed to complete a baseline care plan within 48 hours for a newly admitted resident with multiple complex medical conditions, including chronic kidney disease and dementia. The plan was completed nine days after admission, contrary to the facility's policy. MDS nurses cited recent turnover as a reason for the delay, acknowledging that it could impact the staff's ability to provide proper care.
A resident with quadriplegia and other conditions was not seen by a physician within the required 30 days after admission, as per Texas Administrative Code. The first documented physician visit occurred 60 days post-admission, although the resident received care from a nurse practitioner. Communication issues between the resident and the physician team were noted.
A facility failed to implement a pharmacist's medication regimen review recommendations for a resident with moderate cognitive impairment and chronic conditions. Despite approval from the physician, necessary orders for BMP and HgbA1c tests were not added to the resident's chart, highlighting an oversight in following established procedures.
A resident with type 1 diabetes did not receive a scheduled HgA1c test every three months as ordered by the physician. The last test was conducted in July, and the subsequent test due in October was missed. The DON confirmed the oversight and acknowledged the importance of following physician orders to monitor the resident's diabetic status.
The facility did not follow the prescribed menu for residents on pureed diets, substituting instant mashed potatoes for pureed tater tots and adding flavoring to vegetables without maintaining a substitution log. The CDM and RD acknowledged these deviations, and the ADON highlighted the importance of adhering to recipes for resident health.
A facility failed to coordinate hospice care and maintain required documentation for a resident receiving hospice services. Despite the resident's satisfaction with care, the facility lacked a current hospice plan of care, and staff interviews revealed unclear responsibilities for maintaining hospice documentation. This deficiency could risk inadequate end-of-life care.
A resident with a history of alcohol abuse was not properly monitored, leading to a non-consensual sexual act with another resident who was unable to consent due to cognitive impairment. The facility failed to implement adequate monitoring and assessment measures, resulting in a deficiency.
A facility failed to update a care plan for a resident with a history of alcohol use and abuse, despite multiple documented episodes of intoxication. The resident's care plan lacked measurable goals and interventions related to alcohol use, and staff interviews revealed that the care plan should have been updated to address the resident's behavior and potential risks. The facility's policy requires care plans to be revised as residents' conditions change, but this was not done in this case.
A resident with multiple health conditions, including diabetes and dementia, did not have complete wound care documentation in their medical records. The facility's TAR showed missing entries for wound care treatments on several dates. Interviews with an LVN and a Treatment Nurse revealed they forgot to document the treatments, despite acknowledging its importance. The DON confirmed the lack of documentation, which was against the facility's policy requiring detailed records of all care provided.
Failure to Employ a Full-Time Social Worker
Penalty
Summary
The facility with 170 licensed beds failed to employ a qualified social worker on a full-time basis after the former social worker left the facility. Record review showed there was no social worker on the staff roster, and interviews with the ADON and ADM confirmed the facility did not have a full-time social worker, although a part-time social worker was being used in the meantime. The ADM stated the former social worker gave notice on April 15, 2026 and left on April 22, 2026, and that the part-time social worker and other staff, including the MDS nurse, were trying to catch up on social work duties such as resident assessments and addressing resident concerns. An email from the ADM indicated the facility hired a full-time social worker to start on May 18, 2026.
Care Plan Not Updated for Missing Video Monitoring Device
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with dementia and lack of coordination, including measurable objectives and time frames to address her medical, nursing, mental, and psychosocial needs. Resident #1 had a BIMS score of 0 out of 15 on the quarterly MDS, indicating severe cognitive impairment. Her care plan included a focus on video monitoring, stating that the family had chosen to install a video monitoring device in her room, initiated 11/06/2025. During observation, Resident #1 was sitting in her wheelchair and did not respond to questions. Her room did not contain a video camera. The resident's RP stated she had placed a video camera in the room to monitor the resident but did not know what happened to it or when it went missing. An LVN confirmed the resident did not have a video camera in the room and reviewed the care plan, confirming it still reflected that the resident was supposed to have one. The DON stated the care plan was not updated to reflect that the resident did not have video cameras in her room and that the facility did not provide video cameras, so they could not follow the care plan for this resident.
Failure to Report Abuse, Exploitation, and Self-Harm Incidents
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment were reported within required timeframes to the administrator and to outside authorities. The report identified failures involving a resident-to-resident altercation between two residents, an allegation that a resident’s money was being taken, and a resident’s hospitalization after a suicidal ideation incident. Facility staff acknowledged awareness of these events, but the incidents were not self-reported to the State Survey Agency as required. For the exploitation allegation, a resident with intact cognition and diagnoses including major depressive disorder and anxiety repeatedly stated that staff were taking his money and that the business office manager was personally taking his Social Security money. The social worker and BOM both knew the resident was accusing the facility of stealing his money, but the social worker believed the resident was confused and did not think it needed to be reported. The BOM stated she had told the former administrator about the resident’s concern, but she was not aware the resident was using the word exploitation and said it should have been reported right away. The facility’s grievance policy stated that alleged violations of neglect, abuse, and/or misappropriation of property would be reported and investigated under state law. For the suicidal ideation event, a resident with diagnoses including major depressive disorder, anxiety disorder, bipolar disorder, and schizoaffective disorder came to the nurse’s station with a sharp object, said she was going to end her life, and put the object to her throat. Nursing staff removed the object, kept her in sight, and EMS transported her to the hospital, where documentation reflected suicidal behavior and abrasions to her neck. The DON stated she did not report the incident because the resident did not actually hurt herself and she believed the provider letter did not give guidance for reporting self-harm. The administrator also stated he did not know if he would have reported the incident because he did not know all the facts. The resident-to-resident altercation involved two cognitively impaired residents, one with dementia and a BIMS score of 0 and the other with developmental delays and a BIMS score of 3. One resident was reported to have slapped the other in the face after entering the wrong room. Staff notified the DON, administrator, and physician, and the DON later stated the incident was not reported to the SSA because she believed it did not meet reporting criteria due to the residents’ cognitive impairments. The facility’s self-reported incident log did not show a submission for this event, and the facility policy required allegations to be investigated and reported within required federal timeframes.
Food Storage and Date Marking Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. During observation on 03/10/2026 at 09:15 AM, surveyors found a pan of chicken pot pie in the walk-in refrigerator with a discard date of 03/04/2026. The report also noted that 3 boxes of food products were stored on the top shelf in the walk-in freezer too close to the ceiling, with the exact distance unknown. During interview and observation on 03/12/2026 at 02:40 PM, the Dietary Manager stated the frozen food boxes were too close to the ceiling and could interfere with the sprinkler system if it activated. She also stated that everyone in the kitchen was responsible for discarding foods that had passed discard dates and that the chicken pot pie should have been thrown away. During interview on 03/12/2026 at 06:50 PM, the RD stated frozen food products needed to be 18 inches away from the ceiling for food storage, but she was unsure why. The facility policies reviewed stated that supervisors are responsible for ensuring food items are not past use-by or expiration dates and that refrigerated foods are labeled, dated, and monitored for use by their use-by date, frozen, or discarded.
Personal Refrigerators Not Maintained or Monitored Properly
Penalty
Summary
The facility failed to follow its policy regarding the use and storage of foods brought to residents by family and other visitors, and surveyors found multiple issues with residents’ personal refrigerators. Resident #82, a male with type 2 diabetes and a BIMS score of 15/15, had a personal refrigerator in his room that was observed with a thermometer reading 48 degrees Fahrenheit. He stated he used the refrigerator to store food, could not store ice cream in the freezer because it never got cold enough, and did not know what temperature the refrigerator should be or whether staff were checking it for the proper temperature. No thermometer was observed in the freezer. Facility staff interviews showed inconsistent understanding of the required refrigerator temperature. The ADON who oversaw temperature logs stated the nursing staff used a log allowing residents’ refrigerators to be up to 46 degrees Fahrenheit, and he was not aware refrigerators needed to be below 41 degrees Fahrenheit. Another ADON stated the temperature log used by nursing staff reflected a range of 36 to 46 degrees Fahrenheit. The RD stated nursing staff oversaw the residents’ refrigerators and that the expectation was that refrigerators were below 40 degrees Fahrenheit. The DON stated she was not aware of the needed temperature range and confirmed the nursing staff used a sheet that allowed refrigerator temperatures up to 46 degrees Fahrenheit. Surveyors also observed Resident #106’s personal refrigerator to be dirty and containing two Styrofoam containers with unknown food that were not labeled or dated, and Resident #106 would not say when the refrigerator had last been cleaned or how long the containers had been there. Resident #85, who had type 2 diabetes and a BIMS score of 15/15, had a personal refrigerator with a freezer that was iced over and appeared to contain a ball of ice. He stated the freezer had been iced over for a while. The Maintenance Director stated he was responsible for residents’ personal refrigerators, was not aware of the issues with Residents #106 and #85, and said staff or residents usually verbally told him or entered a computer log for maintenance to fix.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that Resident #4 was informed of, and participated in, her treatment, including advance information about the risks and benefits of proposed care, treatment alternatives, and the option she preferred. The deficiency involved the use of Ziprasidone HCl, an antipsychotic medication ordered for the resident for schizophrenia and administered via PEG-tube twice daily. The report states that the facility did not obtain informed consent for the use of Ziprasidone HCl for this resident. Resident #4’s record reflected diagnoses including diabetes mellitus, anxiety, intermittent explosive disorder, and schizophrenia. Her quarterly MDS showed clear speech, ability to understand others, moderately impaired cognition, mood symptoms, no behaviors, dependence on staff for substantial/maximal assistance with ADLs, wheelchair use, pain with occasional interference in daily activities, risk for shortness of breath, difficulty or pain with swallowing, risk for pressure ulcers, and use of a pressure-reducing mattress and ointments. Her care plan identified psychotropic/antipsychotic medication use related to intermittent explosive disorder and antidepressant use related to depression/insomnia. During observation and interview, Resident #4 was in the hallway in her wheelchair, appropriately groomed, but upset and difficult to understand, with poor recall and an inability to maintain a clear conversation. Her MAR showed Ziprasidone HCl was administered throughout February, and physician documentation reflected the medication was ordered for schizophrenia. The DON stated there was consent in the medical record but was unsure which form, while the ADON stated psychotropic medication required consent and that the facility’s standard psychoactive consent form was sufficient for Ziprasidone, noting that Form 3713 was not required for this medication.
MDS inaccurately documented restraint use
Penalty
Summary
The facility failed to ensure Resident #5’s quarterly MDS accurately reflected her status regarding restraint use. The resident’s record showed she was an [AGE]-year-old female admitted on [DATE] with a diagnosis of other reduced mobility. Her quarterly MDS submitted 2/24/2026 indicated a BIMS score of 12 and documented in Section P0100 that she used a trunk restraint on a less than daily basis, even though the Order Summary Report did not show a physician’s order for any restraint device. The Care Plan Report also did not show care planning for a restraint device. During observations on 3/11/2026, Resident #5 was seen in her wheelchair without a trunk restraint, and she was again observed later the same day without one. She was unsure whether her wheelchair had a seatbelt or other restraining device. The ADON stated there were no residents using seatbelts or other trunk restraints and that the facility was restraint-free. The MDS staff later stated the resident did not use any type of restraint and that the information had been entered in error.
PASARR Screening Not Completed Accurately for Resident with MI Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program for one resident with mental illness diagnoses. Resident #100 was admitted with schizoaffective disorder, bipolar type, bipolar disorder, seizures, and COPD. The resident’s quarterly MDS reflected moderately impaired cognition, clear speech, no observed mood disorder, no behaviors, dependence on staff for all ADLs, use of a pressure-reducing mattress, and active diagnoses of bipolar disorder and schizophrenia. The care plan documented impaired thought processes related to schizophrenia, use of Risperdal for schizoaffective disorder, bipolar type, and a psychosocial well-being mood problem related to schizoaffective disorder, bipolar type. A psychiatry note also identified mental illness, schizoaffective disorder, and an order for Risperdal. During interview and record review, the MDS Coordinator stated the resident’s PASRR Level 1 Screening did not identify a PASARR condition and therefore no Level 2 evaluation was required. After reviewing the record with the surveyor, she acknowledged the resident had schizophrenia and bipolar diagnoses and that the Level 1 Screening should have been positive and triggered a Level 2 evaluation by the Local Authority. She stated she had been auditing files since being hired four months earlier but had not yet reviewed this resident’s record and would make changes and submit Form 1012 to request a PASRR 2 evaluation.
Inaccurate smoking safety care plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #81, a [AGE]-year-old male admitted with schizoaffective disorder and severely impaired cognition, as reflected by a BIMS of 00 on the annual MDS. The resident’s Smoking Safety Screen dated 2/19/2026 stated that he required monitoring while smoking. However, the care plan report printed 3/10/2026 identified him as a smoker who was unsafe to smoke, allowed him to smoke with supervision and a smoking apron in place, and listed both smoking apron use and supervision as interventions. During an observation on 3/10/2026 at 3:11 PM, Resident #81 was seen in the designated smoking area of the memory care unit without a smoking apron. In interviews, a CNA and the ADON stated that he did not require a smoking apron, and the ADON said he had never required one and was unaware the care plan included that intervention. The MDS staff member responsible for smoking safety care planning also said she was unsure why the care plan contained a smoking apron because he had never required one. The facility policy on care plans stated that areas of concern identified during assessment would be evaluated before interventions were added to the care plan.
Failure to Maintain Resident Dignity During Grooming
Penalty
Summary
The facility failed to ensure Resident #74 was treated with respect and dignity in relation to grooming. Resident #74, who was admitted with nicotine dependence, lack of coordination, auditory hallucinations, and major depressive disorder, had an MDS documenting impaired vision, a BIMS score of 7/15, hallucinations, use of a manual wheelchair, and a need for partial/moderate assistance with personal hygiene, including shaving. Her care plan also stated she required assistance from one staff member with personal hygiene. Observations showed Resident #74 sitting in her wheelchair outside with facial hair on her upper lip and chin on multiple occasions, and later in her room with the same facial hair present. During interview, Resident #74 stated she was embarrassed and felt other residents stared at her because of the facial hair, and said she had had it for about 2 weeks. Staff interviewed, including the ADON, CNA, LVN, and DON, stated they had not noticed the facial hair and had not asked her if she wanted it shaved. The facility policy on dignity stated residents are to be cared for in a manner that promotes self-worth and that residents are groomed as they wish, including facial hair.
Failure to Supervise Resident While Smoking
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for Resident #81, a male resident with schizoaffective disorder and severely impaired cognition, as reflected by a BIMS score of 00 on the annual MDS assessment. His care plan stated that he was a smoker, was unsafe to smoke, required a smoking apron, and needed supervision while smoking. The Smoking Safety Screen also noted that he required monitoring while smoking. On 3/10/2026, Resident #81 was observed in the designated smoking area of the memory care unit without staff supervision. The door to the smoking area leading into the memory care unit was propped open, and no staff were within eyesight while he continued smoking. CNA D later stated he was responsible for supervising the resident but had stepped away to get a trash bag from a supply closet, and said the resident had finished smoking so it was okay to leave him unsupervised. The ADON stated that the resident required supervision while smoking and that staff supervising smokers should remain outside directly supervising residents who require supervision and should not leave them unattended. The facility smoking policy stated that residents with restricted smoking privileges requiring monitoring shall have direct supervision at all times while smoking.
Failure to Obtain Psych Consultation and Address Mental Health Needs
Penalty
Summary
The facility failed to provide medically related social services for one resident with mental health diagnoses by not ensuring a psychology/psychiatry consultation was obtained as ordered and by not developing interventions that were targeted and meaningful to the resident. The resident’s record reflected diagnoses including anxiety, intermittent explosive disorder, diabetes mellitus, and later documentation of schizophrenia. The resident was also receiving psychotropic medications, including ziprasidone, sertraline, and trazodone, and had care plan problems related to psychosocial well-being, dependent behavior, disease process, and nursing home placement. The resident’s physician progress note documented a mental illness diagnosis of schizophrenia, and a progress note from the nurse practitioner stated to encourage alternative medications, nursing and psychology techniques for anxiety and sleep management and to consider psychology/psychiatry consult as needed. Physician orders also included behavior monitoring and psychoactive medication monitoring. However, the record review and staff interviews showed that the referral for psych services was not completed as expected, and the DON stated the referral may have been lost and was not sent to the psych agency until after the issue was identified. During observation, the resident was seen in the hallway in a wheelchair, dressed and groomed appropriately, but was upset and spoke about an employee stealing money from her bank and hiding in the restroom. The resident’s conversation was difficult to follow, and she lost her train of thought and could not clearly recall when the alleged theft occurred or identify the staff member. The MDS Coordinator stated the resident should have had schizophrenia listed in the medical record based on the hospital discharge summary and medication orders, and the DON stated the missing diagnosis could cause the resident’s assessment and care plan to not include a significant diagnosis and could result in the resident not receiving necessary services.
Failure to Arrange Dental Services for Resident With Broken Teeth
Penalty
Summary
The facility failed to assist a resident in obtaining routine and 24-hour emergency dental services when the resident had a broken tooth that caused discomfort. Resident #12 was admitted and re-admitted with diagnoses including dementia, major depressive disorder, and dysphagia. Her quarterly MDS showed a BIMS score of 15 out of 15, indicating intact cognition, and that she required supervision or touching assistance with oral hygiene. The MDS also reflected a mechanically altered diet and no reported mouth or facial pain, discomfort, or difficulty chewing at that time. However, the resident’s care plan did not address dental issues, and the order summary listed dental care as PRN. During observation, Resident #12 had no teeth except for two tiny black tooth fragments on the bottom front center and stated she had not been seen by a dentist. She later told RN E that her teeth had fallen out and that she experienced pain from time to time, and she said she wanted to see a dentist. The social worker stated he had been at the facility for about 6 weeks and had not yet assessed her for dental services, and he could not say when she was last seen by a dentist because there were no care conference notes about dental services. The ADM stated he was not aware of how dental services worked for the building, and the DON was also not aware. The facility policy stated routine and emergency dental services were available through a contract with a licensed dentist who came to the facility monthly.
Menu Lacked Protein at Dinner
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced dinner meal that met residents’ daily nutritional needs for 1 of 21 meals on the Week 4 menu. The dinner on Tuesday, Day 24 of the Week 4 menu, was documented as homemade vegetable soup, house salad with dressing, crackers, and a chocolate chip cookie, and surveyors identified that the meal did not include a protein item. The Dietary Manager acknowledged noticing that protein was missing from the dinner meal, and the Registered Dietitian stated she had reviewed the menu but was not able to review every single meal of every single day because she was at the facility for a limited time. The RD also stated she could not verify the meal in question did not have protein, and that protein was important to include for balance. Resident #7 had diagnoses of anemia and severe protein calorie malnutrition, required substantial/max assistance with eating, had a mechanically altered diet order, and had a healing stage 4 coccyx wound. On observation, the resident was served soup and green beans for dinner and stated she had enough to eat with the soup. Resident #85 had a controlled carbohydrate diet order, was independent with eating, and had no weight loss; on observation, his dinner tray had vegetable soup and a grilled cheese sandwich. He stated he did not get enough food overall, though later said the meal was enough because he ordered a grilled cheese sandwich. The facility policy stated menus must meet residents’ nutritional needs and provide a variety of foods from the basic daily food groups, and the USDA Dietary Guidelines cited in the report reflected that a diet should include protein, dairy, healthy fats, vegetables, fruits, and whole grains.
Hand Hygiene Not Performed During Incontinence Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when CNA C did not perform hand hygiene while providing incontinence care to Resident #76. Resident #76 was a female admitted to the facility with a diagnosis of dementia, and her annual MDS reflected a BIMS score of 15, indicating intact cognition. Her care plan stated that she required staff assistance for all ADLs. During an observation on 3/13/2026 at 9:15 AM, CNA C was seen performing incontinence care for Resident #76 and changed gloves 12 times without performing hand hygiene between removing soiled gloves and putting on clean gloves. CNA C removed a soiled brief, cleansed the resident’s skin, and applied a clean brief. When interviewed, CNA C stated she should have used hand sanitizer between each glove change to prevent infections but forgot because she was nervous. The DON stated that staff were expected to perform hand hygiene between every glove change and that all staff had received infection control and hand hygiene training.
Missing Required Nurse Staffing Postings
Penalty
Summary
The facility failed to post required nurse staffing information on a daily basis in the front lobby receptionist area. On 3/10/2026, 3/11/2026, 3/12/2026, and 3/13/2026, observations showed the nurse staffing posting was present but missing the facility name and the total number and actual hours worked by nursing staff. The report states the posting was required to include the facility name and the total number and actual hours worked by registered nurses, LPNs/LVNs, and CNAs directly responsible for resident care per shift. During interview on 3/12/2026, the DON stated the nurse staffing posting did not include the facility name or the total and actual hours for nursing staff and said she was going to check on the 18 months of retention. The ADON stated he was responsible for the postings, did not have 18 months of retention, and did not have the facility name on the posting. He reported having a binder with 5 months of nursing staffing postings, including November 2025 through March 12, 2026, and stated he was not trained and followed what previous staff typed out for the postings. Record review of the facility policy, Posting Direct Care Daily Staffing Numbers, dated July 2016, reflected that the facility would post staffing information daily and keep staffing records for a minimum of 18 months.
Physician Progress Notes Not Updated to Reflect Discontinued Medications
Penalty
Summary
The facility failed to ensure that physicians' progress notes accurately reflected the current medication regimen for two residents. For one resident with polyneuropathy, the Lidocaine patch was discontinued in the physician's orders and medication administration record, but the most recent physician progress note still indicated the patch should be continued at bedtime. The care plan did not mention the medication, and nursing staff were unaware of the last administration, leading to confusion about the resident's current treatment. For another resident with a history of tremors, Benztropine Mesylate had been discontinued months prior, and there were no active orders for the medication. However, the physician's progress notes continued to state that Benztropine should be continued. The care plan did not reference the medication, and nursing staff confirmed the discrepancy between the progress notes and the actual orders, acknowledging the importance of consistency for resident care. Interviews with staff, including LVNs and the DON, revealed a lack of oversight in ensuring that physician progress notes were updated to match current orders. The DON stated that she did not review the quality or accuracy of the physician's notes, and the physician acknowledged that updates to progress notes may be missed when medication changes occur. Facility policy and OBRA regulations require that clinical records, including physician progress notes, accurately reflect the resident's current plan of care.
Failure to Maintain Safe and Sanitary Resident Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, functional, sanitary, and comfortable environment across three of four resident hallways. Observations revealed unresolved maintenance issues in several resident rooms, including a yellow stain with missing caulking around a toilet bowl, a large black stain on a bathroom door, a chipped bathroom tile, broken floor molding, a missing section of a bathroom door jamb, a door penetration near a bathroom door handle, and a broken bathroom ceiling light. Additionally, a significant water stain and peeling paint were noted on a hallway ceiling adjacent to a resident room. Interviews with the Maintenance Director and Administrator confirmed that these areas requiring repair were known to the facility and were listed on a posted work order log. The facility's policy requires the Maintenance Director to review, prioritize, and ensure completion of work orders, but the observed deficiencies had not yet been addressed at the time of the survey. No information was provided regarding the medical history or condition of specific residents affected by these environmental deficiencies.
Failure to Update Care Plan for Oxygen Use
Penalty
Summary
The facility failed to review and revise the care plan for a resident after a comprehensive assessment, specifically neglecting to update the care plan to reflect the resident's use of oxygen. The resident, a 74-year-old male with diagnoses including unspecified dementia, respiratory failure with hypoxia, and general anxiety disorder, had a physician's order for oxygen to be used as needed. Despite this order, the care plan dated several months after the oxygen order did not include any mention of oxygen use. Observations confirmed that the resident was using an oxygen concentrator, and interviews with staff revealed that the omission was due to a misunderstanding that only full-time oxygen use required care planning. Both the ADON and DON acknowledged that the resident's as-needed oxygen use was not included in the care plan, contrary to facility policy, which requires care plans to be revised as residents' conditions change.
Failure to Maintain Resident Dignity in Dining Room
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity in the Station 4 dining room, as observed on 12/18/24. Certified Nursing Assistants (CNAs) W and X were seen using their personal cell phones while sitting at a dining table with two unidentified residents. This behavior was contrary to the facility's policy, which prohibits CNAs from using phones in the dining room to ensure they are available to assist residents as needed. During an interview, CNA X acknowledged that she was not supposed to be on her phone, and the Director of Nursing (DON) confirmed that CNAs were not allowed to use phones in the dining room. Resident #62, who was diagnosed with mononeuropathy and had intact cognition as per the Annual MDS assessment, reported that nursing staff frequently used their phones in the dining room. Although he had not observed them using phones while feeding residents, he noted that they made calls while waiting for meal trays, which made him feel that the staff did not care. The facility's policy on Quality of Life-Dignity, revised in August 2009, emphasizes that residents should be treated with dignity and respect at all times, which includes maintaining and enhancing their self-esteem and self-worth.
Medication and Lab Order Non-Compliance
Penalty
Summary
The facility failed to administer medications and conduct necessary lab tests according to physician orders for three residents, leading to deficiencies in care. Resident #22, who was on hospice care and had severe cognitive impairment, did not receive her prescribed Humalog KwikPen insulin as per the sliding scale order. Despite her blood sugar levels indicating the need for insulin, the LPN decided not to administer it, believing it was unnecessary. This decision was made without consulting the physician or documenting the rationale, contrary to the facility's policy. Resident #31, who had moderate cognitive impairment and a history of diabetes, did not have her HgA1c lab drawn every three months as ordered by her physician. The last lab was conducted in July, and the subsequent test due in October was missed. The DON confirmed the oversight and acknowledged the importance of these tests in monitoring the resident's diabetic status, although the reason for the missed lab was not identified. Resident #53, who was cognitively intact and had multiple health issues including end-stage renal disease, received Midodrine HCl outside the prescribed parameters. The medication was administered despite the resident's systolic blood pressure being above the threshold set by the physician. The LPN used personal judgment to administer the medication, anticipating a drop in blood pressure during dialysis, but did not seek physician approval for this deviation. The DON was unaware of this breach in protocol, which was not documented in the resident's progress notes.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and management of medications, as evidenced by the presence of an expired Glargine Kwik Pen in the Hall 100 Nurse's cart for a resident. The pen was marked with an open date that exceeded the 28-day usage period, indicating it was expired. Both the LVN and the DON acknowledged the oversight, with the LVN admitting responsibility for removing expired medications and marking open dates. The facility's policy requires that expired medications be returned or destroyed, but this was not adhered to, potentially compromising the efficacy of the insulin administered to the resident. Another deficiency involved the administration of insulin for a resident on hospice care. The resident's blood sugar levels were recorded at 150 on two occasions, yet the insulin was not administered as per the physician's sliding scale order. The LPN responsible for the administration chose not to give the insulin, believing the resident's blood sugar was within range, despite the physician's order. The DON stated that the nurse should have followed the physician's order or obtained a hold order if the insulin was not to be administered. A third issue was identified with the administration of Midodrine HCl for a resident undergoing dialysis. The medication was administered despite the resident's systolic blood pressure being above the physician-ordered threshold. The LPN used personal judgment to administer the medication, anticipating a drop in blood pressure during dialysis. However, the DON indicated that the medication should have been held according to the physician's order, and any deviation should have been communicated to the physician for approval.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to professional principles, specifically concerning the labeling and storage of medications in two medication carts. In the Hall 100 Nurse's cart, three opened Lispro insulin Kwik Pens for a resident were found, but only one had an open date marked. This lack of labeling made it impossible to determine how long the other two pens had been opened, raising concerns about their expiration. The resident involved was an elderly woman with a history of metabolic encephalopathy and type 2 diabetes mellitus, and her medication order required precise administration of insulin Lispro. The absence of open dates on the insulin pens could lead to the administration of expired medication, which may not be effective. Additionally, the Hall 100 Medication Aide's cart contained two loose pills in separate blister packs without any pharmacy labels indicating the resident's name or cautionary information. These pills were identified as Diltiazem 120mg and Metoprolol 100mg. The medication aide acknowledged that the pills should not have been left loose in the cart without proper labeling. The Director of Nursing confirmed that all medications should be properly labeled and that insulin pens should be marked with open dates to ensure they are used within their effective period. The facility's policy requires that improperly labeled drug containers be returned to the pharmacy for correct labeling before storage.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas. During an inspection, it was observed that prepared salads in a refrigerator were not labeled with discard dates, and drinks were incorrectly labeled with only initials. Additionally, in the walk-in refrigerator, food items such as ham salad and cheese were found past their use-by dates, which were subsequently discarded by the Certified Dietary Manager (CDM). These labeling and storage issues indicate a lack of compliance with food safety protocols. Further observations revealed that Dietary Aides were not following proper hygiene practices. Dietary Aide T and another staff member, [NAME] U, were seen wearing nose rings while handling food, which contradicts the U.S. Food and Drug Administration's guidelines that prohibit jewelry, except for a plain ring, during food preparation. Additionally, personal beverages and outside food were found in the food preparation area, which the CDM acknowledged should not be present, although they deemed the beverages acceptable. The facility also failed to maintain proper temperature control and cleanliness in the kitchen. A refrigerator temperature was recorded at 42°F, above the recommended 41°F, without further investigation or documentation of corrective measures. Dusty debris was found on the apparatus holding kitchen utensils, indicating a lapse in cleanliness. These deficiencies collectively pose a risk of food-borne illness to residents consuming meals prepared in the facility.
Deficiencies in Medical Record Accuracy and Consent for Medications
Penalty
Summary
The facility failed to maintain accurate and complete medical records for its residents, as evidenced by several deficiencies identified during a survey. One significant issue involved the incorrect documentation of medication administration for a resident with hypertension. The resident's Medication Administration Record (MAR) indicated that Losartan Potassium, a blood pressure medication, was administered despite the resident's blood pressure being outside the prescribed parameters. The LPN responsible for administering the medication acknowledged the error, stating that she likely clicked the wrong button in the system, marking the medication as administered when it should have been held. This error was not documented in the resident's progress notes, and the physician was not notified of the deviation from the prescribed parameters. Additionally, the facility failed to obtain the necessary signed consents for administering antipsychotic medications to several residents. One resident was given Risperdal for bipolar disorder without the required written consent on Form 3713. Another resident received Quetiapine for schizoaffective disorder, and yet another was administered both Risperdal and Paroxetine without the appropriate consents. The facility's policy requires that consents be obtained and documented before administering such medications, but this was not adhered to, as confirmed by interviews with nursing staff and the Director of Nursing (DON). The lack of proper documentation and consent for medication administration could potentially place residents at risk of receiving inappropriate care. The facility's policies on medication administration and behavioral assessment were not followed, leading to these deficiencies. The DON confirmed that the facility did not obtain the necessary consents and acknowledged the potential adverse effects on residents if medications were administered without proper authorization.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several lapses in proper hygiene and protective measures by staff members. One incident involved a CNA who did not change gloves or sanitize hands after touching a privacy curtain before proceeding with catheter and peri-care for a resident with severe cognitive impairment and an indwelling catheter. This oversight was acknowledged by the CNA, who admitted to being focused on the task and not realizing the potential for spreading germs from the curtain to the resident. Another deficiency was observed when a CNA failed to change gloves after emptying a colostomy bag and before touching various surfaces in the bathroom. The CNA admitted to not knowing where to place the basin to change gloves, which led to potential contamination of the bathroom door and shower handles. Despite having received training and competency checks in colostomy care, the CNA used a basin due to the liquid nature of the colostomy contents, which was not part of her usual practice. Additionally, an LVN did not wash or sanitize her hands after picking up a pen from the floor before administering medication to a resident. The LVN acknowledged forgetting to perform hand hygiene, despite being trained in infection control and medication administration. Furthermore, another LVN did not follow Enhanced Barrier Precautions while administering medications via a G-tube, as she was not wearing a gown and was unaware of the requirement due to a lack of training. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not adhered to, contributing to these deficiencies.
Failure to Provide Medicare Coverage Notices
Penalty
Summary
The facility failed to provide necessary notifications to two residents regarding changes in their Medicare Part A coverage. Specifically, the facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNF ABN) to these residents when they were discharged from Medicare Part A skilled nursing services, despite having benefits remaining. This notice is crucial as it informs residents that Medicare will no longer cover skilled services, ensuring they are aware of their financial responsibilities. The absence of this notification was identified for two residents who completed their Medicare Part A stays within the six months prior to the survey. Interviews with the facility's administration confirmed that the failure to provide the SNF ABN was due to human error. The administration acknowledged that the facility is required to follow Medicare Part A rules and the Medicare Claims Processing Manual for financial liability protections. Despite the oversight, it was noted that the residents were not placed in harm or at risk for denial of future Medicare Part A participation. The facility's guidelines, as per the Medicare Claims Processing Manual, necessitate issuing an ABN when a Medicare service is deemed not reasonable and necessary, or when providing custodial care.
Inaccurate MDS Assessments for Smoking Status
Penalty
Summary
The facility failed to ensure the comprehensive assessments accurately reflected the smoking status of two residents, leading to discrepancies in their Modified Significant Change MDS assessments. Resident #26's assessment inaccurately indicated that he was not a current tobacco user, despite documentation showing he smoked 5-10 cigarettes per day. Similarly, Resident #49's assessment also incorrectly stated he was not a current tobacco user, although records showed he smoked 2-5 cigarettes per day. These inaccuracies were found in the MDS assessments completed by MDS H, who was inexperienced and did not review the necessary documentation, such as the residents' smoking safety screen assessments. Interviews with facility staff revealed that the responsibility for ensuring the accuracy of the MDS assessments lay with the RN signing off on the assessments, as well as the corporate MDS nurse overseeing them. The MDS F, who started working at the facility in October 2024, stated that the errors were likely due to MDS H's inexperience and lack of access to the necessary documentation. Despite the incorrect coding, both residents had care plans with appropriate smoking interventions, and the staff believed these errors did not impact the residents' care. The facility's policy required all individuals completing any portion of the MDS Resident Assessment Form to sign the document, attesting to the accuracy of the information. However, MDS H, who was still in training and working for another facility, did not know to request additional documentation to accurately complete the assessments. The Director of Nursing confirmed the inaccuracies but noted that the residents' care plans included current smoking interventions, suggesting that the incorrect coding did not affect the residents' care.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, a woman with multiple diagnoses including chronic kidney disease, type 2 diabetes, dementia, schizophrenia, bipolar disorder, and anxiety disorder, was admitted to the facility. Despite her complex medical needs, her baseline care plan was not completed until nine days after her admission, which was a deviation from the facility's policy that mandates the creation of such a plan within 48 hours to ensure immediate care needs are met. Interviews with the facility's MDS nurses revealed that the responsibility for completing baseline care plans lies with them. However, due to recent turnover in the MDS nurse position, the baseline care plan for this resident was not completed on time. The MDS nurse acknowledged that the delay in completing the baseline care plan could result in staff not having the necessary information to provide appropriate care to the resident. The facility's policy, revised in 2016, clearly states the requirement for a baseline care plan to be developed within 48 hours of admission to address the resident's immediate care needs.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at least once every 30 days for the first 90 days after admission, as required by the Texas Administrative Code. Specifically, a resident diagnosed with quadriplegia, polyneuropathy, and hypertensive heart disease was not seen by a physician until 60 days after admission. This oversight was identified during a review of the resident's Physician Progress Notes, which revealed that the first comprehensive note by the physician was dated two months post-admission. Interviews conducted with the resident and the physician highlighted communication issues between the resident and the physician team. The resident expressed concerns about the lack of response to his medication issues and felt that communication with the physician team was problematic. The physician, MD D, acknowledged that while he often saw the resident informally, he did not document these interactions, and the first formal documentation occurred 60 days after admission. Despite the delay in physician visits, the physician noted that the resident received care from a nurse practitioner, which he believed mitigated the impact of the late physician visit.
Failure to Implement Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's medication regimen review recommendations for a resident were reviewed and acted upon by the attending physician. Specifically, after a medication review conducted on 11/18/24, the facility did not update the doctor's orders for a resident as recommended by the pharmacist and approved by the physician. This oversight involved the omission of orders for BMP and HgbA1c tests, which were suggested to monitor the resident's health conditions, including type 2 diabetes, hypertension, and chronic kidney disease. The resident in question had a moderate cognitive impairment, as indicated by a BIMS score of 9 out of 15. Despite the pharmacist's recommendation and the physician's approval, the necessary orders were not added to the resident's medical chart. Interviews with facility staff revealed that this was an oversight, and the facility did not provide requested policies for pharmacy reviews or following doctor's orders, indicating a lack of adherence to established procedures.
Failure to Conduct Scheduled HgA1c Test for Resident
Penalty
Summary
The facility failed to provide timely laboratory services for a resident, specifically neglecting to perform a scheduled HgA1c test every three months as ordered by the physician. The resident, an elderly woman with a history of cerebral infarction, quadriplegia, and type 1 diabetes mellitus, was supposed to have her HgA1c levels monitored to manage her diabetes effectively. However, the last recorded HgA1c test was conducted in late July, and the subsequent test due in October was not performed. During an interview, the Director of Nursing (DON) confirmed the oversight, acknowledging that the test was not conducted as per the physician's orders. The DON was unaware of the reason for the lapse but recognized the importance of adhering to the physician's orders to monitor the resident's diabetic status. This failure to conduct the necessary lab test could potentially compromise the resident's health management.
Failure to Follow Prescribed Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on pureed diets during the dinner meal on December 18, 2024. The menu for that day included pureed substitutes such as Pureed Sloppy [NAME], Pureed Tater Tots, and Pureed Soft Cooked Vegetables. However, during the preparation of the meal, the staff member responsible for pureeing the food decided to use instant mashed potatoes instead of pureed tater tots, citing difficulty in achieving the correct consistency for the tater tots. Additionally, the staff member pureed cabbage for the vegetable portion and added chicken base and lemon pepper to the pureed vegetables for flavor enhancement. The Certified Dietary Manager (CDM) confirmed the substitution of instant mashed potatoes for pureed tater tots and the addition of flavoring to the vegetables, explaining that these changes were made to ensure resident safety and palatability. However, there was no substitution log maintained to document these changes, which is a requirement when deviations from the menu occur. The Registered Dietitian (RD) acknowledged the absence of a substitution log and noted that such logs should be maintained and signed. The Assistant Director of Nursing (ADON) emphasized the importance of following recipes to maintain residents' health, stabilize weights, and control sodium intake. The facility's policy on standardized recipes, revised in April 2007, mandates the use of standardized recipes in food preparation.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified during a review of the records and interviews with staff, revealing that the facility did not maintain the required hospice forms and documentation, including the current hospice plan of care. This lack of documentation and coordination could potentially place residents receiving hospice services at risk of inadequate end-of-life care. The resident in question, who was on hospice services, had a terminal prognosis related to senile degeneration of the brain and severe cognitive impairment. Despite the resident expressing satisfaction with the communication between the facility and hospice, the facility's records did not contain evidence of the current hospice plan of care. Interviews with staff, including the LPN, ADON, and social worker, indicated a lack of clarity and responsibility regarding the maintenance and verification of hospice documentation. The facility's contract with the hospice and its internal policy outlined the responsibilities for coordinating care and maintaining documentation. However, interviews with the DON and other staff members revealed inconsistencies in understanding and executing these responsibilities. The DON stated that the social worker was responsible for the hospice binders, while the social worker indicated that nursing staff were responsible for verifying the current plan of care. This miscommunication and lack of clear responsibility contributed to the deficiency identified by the surveyors.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. On the night of the incident, a resident who was intoxicated and aggressive was not properly monitored and was left unsupervised in his room for 15 minutes. During this time, he left his room and was found by a CNA engaging in a non-consensual sexual act with another resident who was unable to consent due to severe cognitive impairment. The resident who committed the act had a history of alcohol abuse and was known to the facility staff. Despite this, his care plan did not include any interventions for alcohol use, and there were no orders to stop medications when the resident was actively drinking. The facility's staff failed to conduct a proper assessment or implement adequate monitoring measures when the resident returned to the facility intoxicated. The incident was not immediately reported to the appropriate authorities, and there was a lack of documentation regarding the monitoring of the intoxicated resident. The facility's policies on abuse and neglect were not effectively implemented, leading to a failure to protect the vulnerable resident from harm.
Failure to Update Care Plan for Resident with Alcohol Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of alcohol use and abuse. The resident, who was cognitively intact and had diagnoses including alcohol abuse with alcohol-induced anxiety disorder and major depressive disorder, had five documented episodes of alcohol intoxication or smelling of alcohol. Despite these incidents, the resident's care plan did not include measurable goals, objectives, or interventions related to alcohol use and abuse. Interviews with facility staff, including the MDS Nurse, ADON, and DON, revealed that the care plan should have been updated based on the resident's repeated alcohol use and intoxication. The staff acknowledged that the care plan is a tool to coordinate care and communicate necessary interventions, and it should have been revised to address the resident's alcohol use and potential risks, such as holding medications with MD approval when the resident was actively drinking. The facility's policy on comprehensive person-centered care plans requires that they include measurable objectives and timetables to meet residents' needs and be revised as residents' conditions change. However, the care plan for this resident was not updated despite multiple incidents of alcohol use, and the interdisciplinary team did not address the resident's drinking behavior during their meetings.
Incomplete Wound Care Documentation for a Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding wound care documentation. The resident, a male with a history of cerebral vascular accident, diabetes mellitus type 2, hyperlipidemia, anxiety, dementia, and arterial sclerotic heart disease, had a diabetic ulcer on the right foot and a stage 4 decubitus ulcer on the left heel. The facility's treatment administration record (TAR) for October 2024 showed blank spaces for the resident's wound care treatments on four specific dates, indicating a lack of documentation. Interviews with the staff, including an LVN and a Treatment Nurse, revealed that they forgot to sign the TAR after performing the treatments on the resident's feet on the specified dates. Both staff members acknowledged the importance of documenting treatments to ensure accurate medical records. The facility's Director of Nursing confirmed the lack of documentation and stated that it was expected for staff to document treatments in the electronic medical record. The facility's policy on charting and documentation emphasized the need for detailed documentation of all services provided to residents, including the date, time, and name of the individual providing 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 927 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Atrium Rehabilitation Center | 0.5 mi | ★★★★★ | 1 | 0 |
| Wurzbach Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 0 | 0 |
| Sorrento | 1.1 mi | ★★★★★ | 17 | 0 |
| Remington Transitional Care Of San Antonio | 1.5 mi | ★★★★★ | 3 | 0 |
| The Heights At Medical Center | 1.5 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oak Park Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.