Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Onion Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple chronic conditions had numerous medications, including psychotropic, cardiac, diuretic, diabetic, and antibiotic therapies, discontinued after the MD assessed acute delirium and chose to minimize medications. MAR review confirmed that drugs such as alprazolam, divalproex sodium, mirtazapine, furosemide, eplerenone, glipizide, potassium chloride, and amoxicillin-clavulanate were stopped. The resident’s MPOA was not informed at the time of these significant treatment changes and only became aware after specifically questioning staff about a missing medication. Interviews with LVNs, the DON, the ADM, and the MD showed that facility practice and policy required nursing staff to notify residents or their representatives of medication changes and changes in condition, but this notification did not occur in this case.
A resident with dementia and behavioral disturbances was discharged from the hospital with an order for Depakote 250 mg BID, but the facility continued to administer the medication only once daily, resulting in six missed doses. Review of records and staff interviews confirmed that the hospital's discharge order was not transcribed or implemented, and there was no documentation of any order to discontinue or change the prescribed regimen.
A resident with severe cognitive impairment and multiple chronic conditions repeatedly refused medication and personal care, but these refusals were not addressed in the care plan. Despite documentation of the refusals by nursing staff and awareness among some team members, the care plan lacked any focus, goals, or interventions for these issues, contrary to facility policy and staff expectations.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely assistance in obtaining an eye exam or having her glasses repaired or replaced. Despite repeated requests from the family and documentation in the care plan, staff turnover and procedural delays resulted in the resident remaining without corrective lenses or vision services for an extended period.
A resident with multiple comorbidities was admitted with a skin alteration on the thoracic spine, but staff failed to initiate wound care interventions or treatment orders as required. The wound was not properly monitored or reassessed, leading to its progression to an unstageable pressure ulcer. Staff interviews and record reviews confirmed that admission protocols for skin assessment and intervention were not followed, resulting in a deficiency and Immediate Jeopardy finding.
A resident with a history of cognitive impairments and high elopement risk left a facility unsupervised and was found miles away. Despite being identified as a high-risk for elopement, the resident's care plan lacked focus on wandering, and staff were unaware of her departure. The facility's policy requiring staff authorization for residents leaving was not followed.
A resident with moderate cognitive impairment and a high risk for elopement left the facility without staff awareness. Despite signing out, staff were unaware of her departure until notified by another facility. The incident was not reported to the State Agency within the required timeframe, as the facility did not consider it an elopement due to the resident signing out. Staff expressed concerns about the resident's cognitive ability to make safe decisions.
A facility failed to implement hospital orders for a resident's diabetes management, resulting in delayed blood glucose monitoring and insulin administration. The resident experienced elevated blood sugar levels and expressed concerns about his care. Staff interviews revealed communication lapses, with the LVN unsure about insulin administration and the NP not informed of elevated levels. The DON acknowledged the oversight, noting that hospital orders should have been followed after review.
Two residents experienced significant delays in receiving their scheduled medications, ranging from 2.5 to 6 hours late, affecting their management of pain, anxiety, and respiratory conditions. The facility's liberal approach to medication administration contributed to these delays, as confirmed by staff interviews and medication records.
Two residents experienced significant medication errors due to delayed administration of their prescribed medications, with delays ranging from 2.5 to 6 hours. One resident reported heightened pain and anxiety symptoms due to the delays, while another experienced late administration of pain and respiratory support medications. Staff interviews revealed that the facility did not adhere to the standard medication administration timeframe, contributing to the deficiencies.
The facility's kitchen failed to meet food safety standards, with issues such as unlabeled and undated food items, inadequate dish sanitization, and improper storage of employee food. The dish machine's sanitizer concentration was below the required level, yet it continued to be used. The Dietary Supervisor and RDN identified these issues, but consistent monitoring and training were lacking.
The facility failed to ensure resident privacy as staff members, including an MDS, LVN, and CNAs, entered residents' rooms without knocking or announcing themselves. Despite being trained on resident rights and privacy, staff cited reasons such as forgetfulness and assumptions about residents' needs for not adhering to the policy. The facility's policy mandates knocking before entering to maintain a homelike environment.
The facility failed to provide adequate personal hygiene care for several residents, including trimming fingernails and toenails and shaving facial hair. A resident with minimally impaired cognition requested nail trimming, but it was not done. Another resident with severely impaired cognition had dirty and untrimmed nails, and a third resident had long, thick toenails that were not addressed. Additionally, a resident with facial hair was not shaved, despite family comments. Staff interviews revealed inconsistencies in care provision and a lack of documentation for care refusals.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in their discharge records. One resident was incorrectly documented as discharged to a hospital when she went home AMA, while another was recorded as discharged home when he was actually transferred to a hospital. These errors were confirmed through record reviews and interviews with staff and family members. The MDS coordinator acknowledged the inaccuracies and began correcting them.
A resident with dementia and depression was not provided with regular, individualized activities, leading to a deficiency in meeting their well-being needs. Despite having a care plan, the resident's participation in activities was minimal, and there was a lack of documentation regarding encouragement or refusals. Interviews revealed the resident enjoyed physical activities, but staff reported difficulties in motivating them. The facility's policies emphasized providing activities based on preferences, but this was not consistently followed.
A resident with multiple health conditions, including heart failure and high blood pressure, did not receive the prescribed no salt added diet due to communication lapses in the facility. Observations showed meals with salt packets, and staff interviews revealed a lack of awareness about the resident's dietary needs. The dietary slip failed to mention the no salt added requirement, leading to the resident receiving an incorrect diet.
Failure to Notify Resident Representative of Significant Medication Discontinuations
Penalty
Summary
The deficiency involves the facility’s failure to immediately inform a resident’s representative when there was a significant alteration in treatment, specifically the discontinuation of multiple medications. An elderly male resident with severe cognitive impairment, metabolic encephalopathy, type 2 diabetes mellitus, altered mental status, unspecified dementia, and acute and chronic respiratory failure with hypoxia was admitted with multiple active care plans addressing cardiovascular status, renal status, pneumonia, diabetes, fluid balance, and antidepressant use. His admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and his MPOA identified a family member as the resident’s representative. On a documented physician visit, the MD’s initial H&P noted that the resident was a poor historian, alert and oriented x0, not eating or drinking, and refusing medications. The MD assessed presumed chronic diagnoses with acute delirium of unknown etiology and determined that the delirium could be related to medications, decreased oral intake, or dehydration. As part of the plan, the MD decided to minimize medications and discontinue several drugs, including Xanax (alprazolam), Depakote (divalproex sodium), mirtazapine, Lasix (furosemide), and potassium chloride. Review of the MAR confirmed that, around this time, orders for amoxicillin-potassium clavulanate, alprazolam, divalproex sodium, mirtazapine, furosemide, eplerenone, glipizide, and potassium chloride were discontinued. Interviews and record review showed that the resident’s family member, who was the MPOA, was not notified when these medications were discontinued. The family member reported not being informed of the medication changes and only learned that the resident was no longer receiving antidepressant or mood stabilizer medications after specifically asking about alprazolam several days later. Nursing staff and leadership (LVNs, DON, and ADM) stated that it was the nurse’s responsibility to notify the resident or POA of medication changes and that family should be notified of any medication changes, change in condition, or refusals. The MD stated he did not personally contact the POA or family unless requested and relied on nursing staff to notify them of changes. Facility in-service records and the written policy on change in condition indicated that residents or their representatives were to be notified of changes in condition and in medical or nursing care, but this did not occur for this resident when the medications were significantly altered.
Failure to Administer Medication as Ordered Following Hospital Discharge
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following the physician's discharge orders after the resident returned from the hospital. The resident, who had a history of dementia with mood disturbances and behavioral issues, was discharged from the hospital with an order for Divalproex Sodium (Depakote) 250 mg to be administered twice daily (BID). However, upon readmission, the facility continued to administer the medication only once daily, as per a previous order, and did not implement the new BID order from the hospital. As a result, the resident missed six doses of the prescribed medication. Review of the resident's medical records and interviews with facility staff revealed that the hospital discharge order for Depakote 250 mg BID was not transcribed into the resident's clinical records or the Medication Administration Record (MAR). The nurse practitioner (NP) and other nursing staff confirmed that there was no documentation of a new order to discontinue the BID dosing or to revert to once-daily dosing. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) both acknowledged that the process for verifying and transcribing new orders upon readmission was not properly followed in this case. The ADON, who was responsible for auditing new admission and readmission medications, did not identify the error until it was brought to her attention during the survey. The resident's care plan and progress notes indicated ongoing behavioral disturbances and a need for mood stabilization, which were to be managed with antiepileptic medication as ordered. Despite the hospital's clear instructions to increase the Depakote dosage to BID, the facility failed to update the medication orders accordingly. There was no evidence in the clinical records of any order to discontinue or modify the hospital's discharge instructions, nor was there documentation explaining the deviation from the prescribed regimen.
Failure to Care Plan Resident's Refusal of Care and Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a documented history of refusing care and medication. Despite multiple nurse progress notes and eMAR entries indicating repeated refusals of both medication and personal care such as showers and bed baths over several months, there was no corresponding focus, goals, or interventions in the resident's care plan addressing these refusals. The care plan did not reflect the resident's ongoing pattern of care and medication refusal, which was a significant omission given the resident's severe cognitive impairment and complex medical diagnoses, including acute on chronic heart failure, vascular dementia, and cognitive communication deficit. Interviews with facility staff, including nurses, the MDS Coordinator, the Wound Care Nurse, the Administrator, and the DON, revealed a lack of communication and follow-through regarding the resident's refusals. While some staff were aware of the refusals and discussed them in clinical meetings, others, including the MDS Coordinator and DON, were not aware or did not recall these issues being brought up. Staff consistently stated that refusals of care and medication should be included in the care plan to ensure all team members are informed and appropriate interventions can be implemented. The facility's own policy required the interdisciplinary team to develop a comprehensive, person-centered care plan with measurable objectives and time frames to address all identified needs, including those related to medical, nursing, mental, and psychosocial care. However, the lack of documentation and care planning for the resident's refusals meant that staff did not have clear guidance or interventions to address these behaviors, as required by policy and best practice.
Failure to Assist Resident in Accessing Vision Services
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision abilities by not assisting in making necessary appointments for vision services. The resident, who had severe cognitive impairment and multiple diagnoses including vascular dementia and heart failure, was identified as being at risk for impaired visual function. The care plan included interventions such as arranging consultations with an eye care practitioner and reminding the resident to wear glasses. Despite these interventions, the resident did not have corrective lenses and did not receive timely assistance in obtaining an eye exam or having her glasses repaired or replaced. The resident's family began requesting assistance with the resident's glasses in early March, reporting that the glasses were loose and needed adjustment. Over the following months, the family repeatedly followed up with various facility staff regarding the status of the glasses and the need for an eye exam. The situation was complicated by staff turnover, including the departure of the staff member initially handling the request and the absence of a social worker for a period of time. Communication between the family and facility staff documented ongoing concerns about the resident's missing or broken glasses and the lack of an optometrist appointment. Facility staff acknowledged that the optometry provider required a minimum number of residents to schedule a visit, which further delayed the resident's access to vision services. The administrator and social worker confirmed that the resident's vision needs were not addressed due to staff changes and procedural delays. The resident remained without corrective lenses or an eye exam for several months, despite ongoing requests and documented needs.
Failure to Provide Timely Pressure Ulcer Care on Admission
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate pressure ulcer care and prevent the development of a new unstageable pressure ulcer for one resident at risk. Upon admission, the resident, an 89-year-old female with multiple comorbidities including pulmonary hypertension, chronic kidney disease, venous insufficiency, diabetes, and a history of myocardial infarction, was noted to have a skin alteration described as an abrasion or erythema on the thoracic spine. The initial assessment documented the presence of a wound, but no specific wound care interventions or treatment orders were initiated at that time. The resident's Braden score indicated a high risk for pressure sore development, and the care plan identified the potential for pressure ulcer development, but interventions were not implemented as required. Between the resident's admission and several days afterward, there was a lack of wound care treatment and preventive interventions. The wound was not properly monitored or reassessed, and no weekly skin/pressure ulcer assessment was documented until several days after admission. The wound subsequently progressed to an unstageable pressure ulcer, as confirmed by a wound care physician who performed debridement and described the wound as having slough and devitalized tissue. The physician and wound care nurse both indicated that the wound was not properly identified or managed upon admission, and the charge nurse responsible for the admission acknowledged an oversight in not initiating orders or monitoring the wound, citing insufficient education on admission expectations for skin concerns. Interviews with facility staff, including the DON and wound care physician, confirmed that the wound was mischaracterized at admission and that the required steps for assessment, documentation, and intervention were not followed. The facility's policies required a thorough skin check and immediate initiation of a wound flow sheet and treatment orders when a wound is identified, but these procedures were not adhered to. This failure placed the resident at risk for the development and worsening of a pressure ulcer, resulting in the identification of an Immediate Jeopardy situation by surveyors.
Removal Plan
- One on one in service with LVN Charge Nurse to review admission Skin Assessment/ Documentation Treatments and Notification. Overview of Resident #1 and education on expectations of interventions, notification, and documentation. LVNs knowledge and effectiveness of training by conducting quiz, chart audit and feedback given with results of audit, will continue training. LVN received counseling for insufficient assessment and documentation.
- Resident #1's head-to-toe skin assessment completed. Initiated medication review by Medical Provider, Wound Care Provider review of treatment orders for appropriateness. Social Service Assessment conducted to ensure psychosocial well-being. No mental anguish or psychological distress related to delay in treatment, notification of findings communicated to medical provider and Resident #1.
- In service provided to Administrator and DON by Clinical Resource on New Admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions. In serviced on following up on new admission with chart audits and continue education and counseling as needed by Clinical Resource.
- 100% Charge Nurse In-Service for New Admission Skin Assessment/ Documentation Treatments and Notification. PRN nurses in serviced. We do not utilize agency staff. New staff will be in serviced upon hire. Nurses will not work floor until in serviced.
- Nurse Management in service for New Admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions.
- Admissions, MDS, DOR, ADOR, Treatment Nurse, ADON informed of IJ, and template reviewed.
- Medical Director notified of IJ. Medical Director involved in development of plan and in agreement.
- An Ad hoc QA meeting will be completed. Attendees will include ED, DON, ADON, Clinical Resource, and Medical Director. Meeting will include the Plan of Removal and interventions.
- Audit on current residents with pressure ulcers.
- Audit on new admissions without Treatment Nurse Assessment. New admission Treatment Nurse Assessments are in place, Treatment in place when appropriate.
- Skin sweep on with residents with wounds and new admissions. Resulted in no new finding.
- RCA/QIT with IDT and Medical Director. IDT meet to discuss initial admission skin assessments that identify skin issues without treatment orders being placed initially by charge nurse and then a delay in treatment. This was often found on Friday admissions, where the treatment nurse did not see patients until the following week. All nurses being in-serviced prior to working their next shift on Admission skin assessment process, implementing orders and interventions and documentation. Treatment nurse was only assessing patient's that it was communicated had wounds. Treatment nurse or designee is to complete a skin assessment on all admissions on next working day to ensure accurate assessment and treatments are appropriate.
- Treatment Nurse, Admissions Nurse and MDS Resource to conduct in service to nurses trained on New Admission Skin Assessment/ Documentation Treatments and Notification and expectation.
- DON or designee to verify nurse knowledge on New Admission Skin Assessment/ Documentation Treatments and Notification by quizzing 5 nurses weekly and ongoing for nurse new hires
- Summary of IJ and corrective action to be reviewed by QAPI Committee monthly or until substantial compliance established.
- Care Plan audit for all residents with pressure/skin alterations. Care Plans update for appropriate interventions.
- Audit new Admissions for initial skin assessment and treatment nurse assessment, ensuring interventions and orders in place.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment for a resident, who was identified as having a high risk for elopement. The resident, who had a history of psychotic disorder with delusions, generalized anxiety disorder, dementia, and unsteadiness on feet, left the facility without staff awareness. The resident was found approximately 4.2 miles away at a store off a major highway, after being contacted by an outside party. This incident occurred despite the resident's care plan indicating a need for supervision and assistance with decision-making. The resident's quarterly Elopement/Wandering Evaluation had previously indicated a high risk for elopement, yet there was no focus area related to wandering or elopement in the care plan. Staff interviews revealed that the resident had a history of attempting to leave the facility and required frequent redirection. On the day of the incident, the resident signed out at the front desk, but staff were unaware of her departure until notified by an external party. The facility's policy required staff to be informed and to authorize any resident leaving the premises, which was not adhered to in this case. Interviews with staff and family members highlighted a lack of communication and understanding of the resident's cognitive abilities and the facility's elopement policy. The resident's family member expressed concern over the resident's ability to leave the facility unsupervised, given her cognitive impairments. The facility's Director of Nursing and Administrator initially did not consider the incident an elopement, as the resident had signed out, but staff and family members disagreed, citing the resident's cognitive limitations and the potential for harm.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report an incident involving a resident who left the facility without staff awareness, which was not reported to the State Agency within the required timeframe. The resident, a female with a history of psychotic disorder, generalized anxiety disorder, dementia, and unsteadiness, was identified as having a moderate cognitive impairment with a BIMS score of 10. Despite being at high risk for elopement, as indicated by her quarterly Elopement/Wandering Evaluation, the resident managed to leave the facility and was later found at a nearby store. On the day of the incident, the resident signed herself out at the front desk, but staff were unaware of her departure until a call was received from another facility. The resident was brought back to the facility by the Administrator and the DON, who did not consider it an elopement because the resident had signed out and was deemed cognitively intact by the DON. However, staff interviews revealed that the resident was known to attempt to leave the facility daily and required redirection, indicating a lack of awareness and supervision by the facility staff. The facility's failure to report the incident to the State Agency was based on the belief that it was not an elopement due to the resident signing out. However, staff members, including a CNA and an LVN, expressed concerns about the resident's cognitive ability to make safe decisions and the potential risk of harm. The facility's policy did not address reporting elopements to the State, and the incident was not reported as required by HHSC guidelines, which mandate reporting emergency situations that pose a threat to resident health and safety within 24 hours.
Failure to Implement Hospital Orders for Diabetes Management
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not implement hospital orders for blood glucose monitoring four times a day and administering sliding scale insulin four times a day upon the resident's admission. This lapse in care persisted from the resident's admission date until two weeks later, during which time the resident experienced elevated blood sugar levels and expressed concerns about his diabetes management. The resident, who was admitted with diagnoses including type II diabetes, had a hospital discharge summary indicating the need for insulin administration based on a sliding scale. However, the facility's records showed that the resident's blood sugar was only monitored twice a day, and insulin was not administered according to the hospital's instructions. The resident reported feeling unwell and expressed worry about his diabetes management, noting that he had asked the nursing staff about his insulin but did not receive satisfactory responses. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's elevated blood sugar levels. The LVN was unsure why the resident had not been on insulin earlier, and the NP stated she was not informed of the elevated blood sugar levels until much later. The DON acknowledged that hospital orders should have been implemented after the NP's review and that the nurses should have notified the NP about the resident's elevated blood sugar levels. The facility did not provide policies on physician notifications and new admissions/orders from the hospital when requested.
Medication Administration Delays
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications to meet the needs of each resident. Specifically, two residents experienced significant delays in receiving their scheduled medications over a period of several days. These delays ranged from 2.5 to 6 hours past the ordered times, affecting medications critical for managing conditions such as pain, anxiety, and respiratory support. One resident, a cognitively intact female with a history of type II diabetes, depression, asthma, and a femur fracture, reported that her medications were consistently administered late. This included medications for pain, anxiety, and other conditions, which she stated led to heightened symptoms of pain and anxiety. The resident's medication administration records confirmed multiple instances of late administration, including significant delays in the morning and afternoon doses. Another resident, also cognitively intact, with diagnoses of hypertension, scoliosis, and rheumatoid arthritis, experienced delays in receiving pain and respiratory medications. Although this resident reported that the delays did not always affect her, the medication administration records showed that her treatments were administered several hours late on multiple occasions. Interviews with facility staff revealed that the facility did not adhere to the standard one-hour window for medication administration, opting instead for a more liberal approach, which contributed to the delays.
Significant Medication Errors Due to Delayed Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who experienced delays in receiving their prescribed medications. Resident #1, a cognitively intact female with multiple diagnoses including type II diabetes, depression, asthma, and a femur fracture, did not receive her scheduled medications on time from June 24 to June 27, 2024. The medications, which included those for pain, anxiety, and other conditions, were administered between 2.5 to 6 hours late. Resident #1 reported that the delays in receiving her pain and anxiety medications significantly affected her, causing heightened symptoms. Similarly, Resident #2, also cognitively intact and diagnosed with hypertension, scoliosis, and rheumatoid arthritis, experienced delays in receiving her medications. Her pain and respiratory support medications were administered late on multiple occasions, with delays ranging from 3 to 5 hours. Although Resident #2 stated that the delays did not always affect her, the facility's failure to administer medications on time was evident. Interviews with staff revealed that the facility did not adhere to the standard practice of administering medications within one hour before or after the scheduled time. The Medication Aide (MA) acknowledged difficulties in meeting this timeframe, while the Administrator (ADM) admitted that significant delays in administering pain, anxiety, or breathing treatments were not acceptable. The facility's policy required medications to be administered as prescribed, yet the liberal medication pass approach contributed to the observed deficiencies.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in its kitchen, as observed during a survey. The deficiencies included improper labeling and dating of food items, inadequate sanitization of dishes, and improper storage of employee personal food items alongside resident food items. These failures were identified during observations of the walk-in refrigerator, where several food items were found unlabeled and undated, and employee lunches were stored without separation from resident food items. The dishwashing process was also found to be deficient, with the sanitizer concentration in the dish machine measuring below the required 50 ppm. Despite the dish machine being serviced recently, the concentration remained at 25 ppm during multiple checks. The Dietary Supervisor acknowledged the issue and mentioned that a technician had been called to address it. However, staff continued to use the dish machine for washing and sanitizing dishes, contrary to the expected protocol of using alternative methods like the three-compartment sink or paper products when the dish machine was not functioning properly. Interviews with the Dietary Supervisor and the Registered Dietitian Nutritionist (RDN) revealed a lack of consistent training and monitoring of the dish machine's operation. The RDN had previously identified issues with the dish machine and had communicated these concerns to the facility's administration. However, the Dietary Supervisor, who was relatively new, did not check the dish machine daily and relied on staff to do so. The facility's monthly kitchen sanitation audits also reflected ongoing issues with labeling and dating of food items and incomplete dish machine logs, indicating a systemic problem in maintaining food safety standards.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure personal privacy for residents during care, as observed in the actions of several staff members, including MDS B, LVN C, CNA G, CNA H, and CNA J. These staff members entered the rooms of two residents without knocking or announcing themselves, which is a violation of the facility's policy on resident privacy. Specifically, CNA H was observed entering a resident's room without knocking while offering water, and LVN C entered another resident's room without announcing himself. Similar actions were noted with CNA J, who entered rooms to collect lunch trays, and MDS B and CNA G, who also failed to knock or announce themselves before entering residents' rooms. Interviews with the involved staff revealed that they had been trained on resident rights and privacy, and they acknowledged the importance of knocking and announcing themselves to respect residents' privacy and maintain a homelike environment. However, reasons for not adhering to this practice varied, including forgetfulness and assumptions about residents' needs. The facility's Administrator and DON emphasized the importance of this practice to ensure residents feel respected and comfortable in their living environment. The facility's policy on dignity and respect clearly states that staff should knock before entering a resident's room, highlighting the deficiency in practice observed during the survey.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary personal hygiene services to residents who were unable to perform activities of daily living independently. Specifically, Resident #70, a female with minimally impaired cognition, expressed a desire for her fingernails to be trimmed, but this was not done despite her requests. Observations showed her nails were long, and staff acknowledged the need for trimming but did not follow through. Similarly, Resident #8, a male with severely impaired cognition, had dirty and untrimmed fingernails, and there was no regular schedule for nail care, leading to neglect in maintaining his personal hygiene. Resident #83, a female with severely impaired cognition, had long, thick, and jagged toenails, which were not addressed by the staff. Despite the presence of a CNA in her room, the toenails were not trimmed, and there was confusion about whether hospice or facility staff were responsible for her nail care. Additionally, Resident #4, a female with severely impaired cognition, had noticeable facial hair that was not shaved, despite her family member's comments about her appearance. The staff did not consult with the family or take action to address her grooming needs. Interviews with staff, including CNAs and the DON, revealed inconsistencies in the provision of nail care and shaving services. There was a lack of documentation for refusals of care, and staff were unclear about their responsibilities and the procedures for addressing residents' personal hygiene needs. The facility's policy emphasized the importance of maintaining residents' dignity and quality of life, but the observed deficiencies indicated a failure to adhere to these standards.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their discharge records. Resident #96's discharge Minimum Data Set (MDS) inaccurately indicated that she was discharged to a Short Term General Hospital, while in reality, she was discharged home against medical advice (AMA). This error was identified through a review of the resident's face sheet, nursing progress notes, and an interview with the resident's family member, who confirmed that the resident left the facility with them and was not hospitalized. Similarly, Resident #97's discharge MDS incorrectly stated that he was discharged home, whereas he was actually transferred to an acute care hospital for further medical treatment. This was corroborated by nursing progress notes that documented the resident's transfer to the hospital for a paracentesis and subsequent admission for bronchitis. Interviews with the MDS coordinator and the Director of Nursing (DON) confirmed the inaccuracies in the MDS assessments for both residents. The MDS coordinator acknowledged the responsibility for ensuring the accuracy of the MDS assessments and was observed correcting the errors. The facility's policy mandates comprehensive and accurate assessments, which were not adhered to in these cases, potentially affecting the residents' care and quality of life. The Administrator emphasized the importance of accurate MDS assessments, as inaccuracies could lead to incorrect information being used for care planning and payment purposes.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities to a resident, leading to a deficiency in meeting the resident's physical, mental, and psychosocial well-being needs. The resident, a male with dementia, muscle wasting, and adjustment disorder, was observed to have little interest in activities and exhibited symptoms of depression. Despite having a care plan that included goals and interventions for activity involvement, the resident's participation in activities was minimal, and there was a lack of documentation regarding encouragement or refusals of activities. Interviews with staff and family members revealed that the resident enjoyed physical activities and had a history of being a mechanic, indicating a preference for tinkering and outdoor activities. However, the resident was often found sleeping in bed, and staff reported difficulties in motivating him to participate in activities. The activity staff and therapy team provided some one-on-one activities, but these were infrequent, and there was no evidence of consistent encouragement or engagement in activities that aligned with the resident's interests. The facility's policies on activities and nursing services emphasized the importance of providing activities based on residents' preferences and maintaining their quality of life. However, the lack of regular, individualized activities for the resident, as well as insufficient documentation of activity participation, highlighted a failure to adhere to these policies. This deficiency placed the resident at risk of decreased well-being, as noted in the report.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide the physician-prescribed therapeutic diet to Resident #298, who was supposed to be on a no salt added diet due to her medical conditions, including atrial fibrillation, severe protein-calorie malnutrition, chronic diastolic heart failure, morbid obesity, and high blood pressure. Despite the dietary order specifying no salt added, observations revealed that Resident #298 received meals with salt packets, and her meal tickets did not reflect the no salt added requirement. Interviews with staff, including LVNs and the Dietary Supervisor, indicated a lack of awareness and communication regarding the resident's dietary needs, with the dietary slip failing to mention the no salt added diet. The process for updating dietary orders involved communication slips, but there was a disconnect between the orders and what was communicated to the dietary staff. The Dietary Supervisor relied on receiving a yellow diet slip to know the resident's dietary needs, but the slip for Resident #298 only mentioned a house shake at lunch and dinner, omitting the no salt added requirement. The Director of Nursing confirmed that dietary orders were supposed to be communicated clearly, but the system did not notify staff of pending orders, leading to potential oversights. This failure to provide the correct diet placed Resident #298 at risk for health complications related to her heart condition.
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 291 citations issued within 25 miles in the last 12 months — including the 19 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 Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southpark Meadows Nursing And Rehabilitation Cente | 1.8 mi | ★★★★★ | 5 | 0 |
| Brodie Ranch Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 3 | 1 |
| Marbridge Villa | 3.6 mi | ★★★★★ | 0 | 0 |
| West Oaks Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 13 | 0 |
| Brush Country Nursing And Rehabilitation | 6.6 mi | ★★★★★ | 23 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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