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 Paradigm At Stevens during CMS and state inspections, most recent first.
A resident with multiple medical conditions reported missing funds from her bank account, which were later found to have been used by a former employee for personal purchases after employment ended. Although the misappropriation was confirmed through investigation, the incident was not reported to law enforcement or the State Agency as required by facility policy and regulations. The facility's reporting system showed no record of the incident being reported.
Two residents with mental health diagnoses experienced ongoing discomfort due to elevated room temperatures, despite the air conditioning being set appropriately and the use of multiple fans. The issue was reported to staff but not effectively addressed, and facility leadership was unaware of the ongoing problem until it was identified during a survey.
A resident's personal refrigerator was found to be operating at 75.3°F and contained perishable food items that were not labeled or dated as required. Staff interviews revealed confusion about responsibility for monitoring refrigerator temperatures and food labeling, and the required temperature log was missing for the month. The facility's policy mandates food labeling, dating, and maintaining refrigerator temperatures at or below 41°F, but these standards were not followed.
The facility failed to follow food safety standards, as a staff member did not change gloves after touching a contaminated surface during meal prep, leading to potential food contamination. Additionally, two pans of cake were left uncovered, and a CNA served a resident bread with bare hands, violating the facility's safe food handling policy.
The facility failed to update care plans for three residents, leading to potential care issues. A resident's care plan did not reflect the use of a bed rail for mobility, another resident's impaired vision and need for optometry care were not documented, and a third resident's care plan omitted a prescribed mood stabilizer. These omissions could impact the residents' care and services.
The facility failed to have a qualified Activities Professional to direct their activities program, affecting all 42 residents. Interviews revealed the absence of a certified Activity Director since April 2024, with only an unqualified activities assistant present. The facility's policy required a qualified director to ensure meaningful, person-centered activities, but this was not met.
A resident with no cognitive impairment experienced blurred vision for over two months without receiving optometry care. The facility was aware of the issue but failed to provide timely care due to a broken wheelchair, which hindered transportation to an external optometrist. The resident's care plan did not reflect her need for optometry care, despite her complaints and staff awareness.
The facility failed to ensure that CNAs demonstrated necessary competencies for safe resident transfers. In one case, two CNAs improperly transferred a resident with hemiplegia using a mechanical lift, failing to widen the base for stability and struggling to maneuver the lift. In another case, a CNA did not hold a swinging spreader bar during a transfer, risking injury to a resident with severe cognitive impairment. These actions did not align with facility policies and training protocols.
The facility failed to remove expired syringes of 0.9% sodium chloride injection from the medication room, as observed by surveyors. Eighteen syringes, expired since February 28, 2025, were found, and the DON acknowledged the oversight, which was against the facility's policy for medication management.
A resident's call light was found on the floor, out of reach, while she was in bed, contrary to her care plan and facility policy. The resident, with a history of multiple health issues, was unable to access the call light, potentially delaying care. Interviews with staff confirmed the oversight, which could increase the risk of falls and injuries.
A facility failed to maintain a clean and homelike environment for a resident by not replacing a heavily soiled mattress. The mattress was stained with urine, covering at least 50% of its surface, and emitted a strong odor. The ADON acknowledged the issue, stating the mattress should be discarded, but it was not reported or addressed by staff. The resident, with severe cognitive impairment, was unaware of the condition until informed. Interviews revealed a lack of attention to the mattress's state, despite facility policies emphasizing cleanliness and dignity.
The facility failed to conduct a criminal background check on a newly hired housekeeper before their employment began, contrary to its policies. The housekeeper started working without a background check, which was only completed a month later. This lapse occurred due to the absence of dedicated HR staff, leading to a potential risk of abuse from inappropriate staff.
Two residents' assessments were inaccurate, leading to deficiencies in their care plans. One resident's MDS did not reflect the use of a bed rail for mobility, while another's MDS inaccurately indicated adequate vision despite complaints of blurred vision. These inaccuracies could result in unmet care needs.
A facility failed to include bowel incontinence in a resident's care plan, despite it being identified in assessments. The resident, with severe cognitive impairment, required bowel incontinent care, but the care plan only addressed bladder incontinence. The MDS nurse mistakenly removed the bowel incontinence care plan, believing the issue was resolved. This oversight was confirmed through interviews and record reviews, highlighting a deficiency in the facility's adherence to care plan policies.
Two residents were at risk due to improper mechanical transfer procedures. CNAs failed to follow safe techniques, such as not widening or locking the lift base and not securing the spreader bar, during transfers. Additionally, a required fall mat was not placed beside a resident's bed, contrary to their care plan. These actions did not align with the facility's safety policies and training.
Two residents in a facility did not receive proper incontinence care, leading to potential infection risks. A male resident with severe cognitive impairment was not cleaned in the suprapubic area, and a female resident with similar impairments did not have her labia area properly cleaned. Both CNAs admitted to forgetting these steps despite having received training. The facility's policy on perineal care was not adhered to, as confirmed by the DON.
Two residents in an LTC facility received inadequate respiratory care. A resident's oxygen concentrator filter was found covered in lint, risking respiratory infection, while another resident's nebulizer mask was improperly stored, increasing infection risk. Staff interviews confirmed these deficiencies, highlighting a failure to follow care plans and facility policies.
A facility failed to assess a resident for bed rail entrapment risk and did not obtain informed consent before installation. The resident, with hemiplegia and dementia, used a bed rail without being informed of risks or providing consent. The facility's policy required a physician's order, assessment, and consent, which were not completed, potentially leading to avoidable accidents.
The facility failed to properly store medications, with a narcotic box not affixed in a refrigerator and Latanoprost eye drops stored at room temperature against label instructions. The DON acknowledged these storage issues, which could lead to drug diversion and reduced medication efficacy.
A facility failed to maintain accurate medical records for a resident, incorrectly documenting Depakote as being for dementia instead of a mood disorder. The error was acknowledged by the ADON, who was responsible for reviewing orders. The resident, with severe cognitive impairment and multiple diagnoses, was not receiving medication for dementia, as confirmed by a psychiatric assessment.
A facility failed to maintain a safe environment for a resident by not repairing a hole in the bathroom door, which was acknowledged by both the resident and maintenance staff. The resident, who is cognitively intact and independent, has a history of Parkinson's disease, increasing the risk of injury due to the damaged door. The facility's policy on maintaining a sanitary environment was not followed.
A facility failed to maintain an effective infection prevention and control program, leading to a scabies outbreak among residents and staff. Two residents with significant medical histories were confirmed positive for scabies and treated with Ivermectin. The DON and Administrator were aware of the outbreak but did not report it to the State Survey Agency in a timely manner. Several staff members were also confirmed positive, with some failing to report symptoms, contributing to the spread of the infection.
A resident with COPD did not receive timely respiratory care, as the facility failed to replace oxygen tubing, humidifier, and nebulizer within the specified timeframe. The resident experienced nosebleeds and soreness due to an empty humidifier, and staff interviews confirmed the oversight, with shifts blaming each other. The facility's policy required weekly changes to prevent infections.
The facility did not ensure full-time RN coverage, as required, with no RN present on specified dates. Interviews and record reviews confirmed the absence of RN A and RN B, leaving non-RNs without necessary supervision and guidance. The Administrator acknowledged the requirement but lacked a policy to ensure compliance.
A facility failed to maintain accurate medical records for a resident on PRN oxygen therapy, as the MARs for April and May did not document the required changes of nebulizer, humidifier, and tubing every seven days. The MDS LVN, new to the role, was unable to update the MDS accurately due to missing documentation, leading to incomplete records.
A resident with a recent AKA and osteomyelitis was discharged without proper home health arrangements or education for IV antibiotics and wound care. The facility failed to provide necessary supplies and relied on the resident's RP to manage care with insufficient guidance, leading to potential medical complications.
The facility failed to develop and implement policies for timely reporting of abuse allegations to the State Survey Agency (HHSC). A resident with a history of false allegations accused an LVN of threatening behavior, leading to police involvement. The facility's DON and Administrator did not report the incident to HHSC within the required 2-hour timeframe, and the facility's abuse policy did not meet state regulations.
The facility failed to report a resident's abuse allegations to the State Survey Agency within the required 2-hour timeframe. The resident, who had a history of false allegations, accused a nurse of threatening behavior. Despite the serious nature of the allegations, the facility did not report the incident promptly, leading to a deficiency.
Failure to Timely Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, were reported immediately or within the required timeframe to the administrator and appropriate authorities. Specifically, an incident involving the misappropriation of a resident's funds by a former employee was not reported to law enforcement or the State Agency as required. The resident, who was cognitively intact and had multiple medical diagnoses including necrotizing fasciitis, diabetes with neuropathy, major depressive disorder, and fibromyalgia, reported missing funds from her bank account. The charge nurse directed the resident to the Business Office Manager and Administrator, who investigated and confirmed that over $300 in purchases were made using the resident's debit card by a former employee after their termination, with items shipped to the ex-employee's home address. Despite confirming the misappropriation, the previous administrator decided not to report the incident, citing the refunded amount and canceled card as reasons. The facility's grievance log and reporting system showed no self-reported incident related to the misappropriation, and the facility's policy required immediate reporting of such incidents. Interviews with the DON and current administrator confirmed that the incident was not reported as required by state and federal regulations, and the facility's own policy. The resident had initially given her debit card to the employee to purchase clothing, but unauthorized charges occurred months after the employee's departure.
Failure to Maintain Comfortable Room Temperature for Two Residents
Penalty
Summary
The facility failed to maintain comfortable temperature levels in a room shared by two residents, both of whom had intact cognition and relevant mental health diagnoses. Despite the air conditioning being set to 72 degrees Fahrenheit, observations showed the room temperature ranged from 75.5 to 80.2 degrees Fahrenheit. Both residents reported discomfort, with one stating she sweated profusely and the other expressing a desire for a cooler environment. The issue had been ongoing since their admission, and although the residents reported the problem to nursing staff, only additional fans were provided, which did not resolve the discomfort. Staff interviews revealed that the hallway and the residents' room frequently became very hot, and the issue had been reported to the ADON in the previous month without resolution. The Maintenance Director was unaware of the specific ongoing issue until the day of the survey, at which point he discovered and repaired a dislodged air conditioning duct. Facility leadership, including the ADON and Administrator, were not aware of the residents' ongoing discomfort prior to the survey. The facility's policy required maintaining proper temperature and ventilation to create a home-like environment, which was not achieved in this instance.
Failure to Maintain Safe Food Storage in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to ensure that food stored in a resident's personal refrigerator was maintained in accordance with professional food service safety standards. During observation, the resident's refrigerator was found to contain several food items, including fruit, open containers of ketchup and mayonnaise, and a partially empty container of lunch meat, all of which felt warm to the touch. The refrigerator temperature was recorded at 75.3 degrees F, and there was no thermometer present. The resident reported that the refrigerator temperature had not been checked recently, and that family members had recently provided groceries. There was no evidence of gastrointestinal illness reported by the resident at the time of the survey. Interviews with staff revealed a lack of clarity regarding responsibility for monitoring and documenting refrigerator temperatures, as well as uncertainty about the facility's policy on labeling and dating food in personal refrigerators. The temperature log for the resident's refrigerator was missing for the relevant month, and the staff member responsible for the log had not performed a check during that period. The facility's policy required all food items to be labeled with the resident's name and date of placement, perishable items to be discarded after three days unless otherwise directed, and refrigerator temperatures to be maintained at or below 41 degrees F. These requirements were not met in this instance.
Food Safety Deficiencies in Meal Preparation and Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen and during meal service to a resident. During meal preparation, a staff member, [NAME] H, did not change gloves or wash hands after touching a potentially contaminated surface, specifically a utensil drawer, before continuing to prepare meals. This action led to the potential contamination of food items such as tortillas, lettuce/tomato mix, and cheese, which were then served to residents. The staff member acknowledged the mistake and recognized the risk of transmitting food-borne illnesses due to this oversight. Additionally, two pans of cake were left uncovered on a prep table to cool, which could lead to contamination. Furthermore, a CNA served a resident two slices of bread using bare hands without washing or sanitizing them, which could also result in cross-contamination. These practices were against the facility's policy on safe food handling, which mandates the use of clean, sanitized utensils and no bare hand contact with food.
Care Plan Revisions Not Updated for Residents
Penalty
Summary
The facility failed to ensure that care plans were revised by the interdisciplinary team after each assessment for three residents. Resident #16's care plan did not reflect the use of a 1/4 bed rail for mobility and transfers, despite physician orders and the resident's own admission of using the bed rail for assistance. This oversight could potentially lead to a decline in the resident's physical mobility or independence. Resident #35's care plan did not indicate her impaired vision or the need for optometry care, even though she had complained about blurred vision and had been waiting for optometry services for several months. The lack of documentation in her care plan could result in her not receiving necessary care and services. Resident #19's care plan failed to include the administration of Depakote Sprinkles Delayed Release, a mood stabilizer prescribed for her bipolar disorder. The omission of this medication from her care plan could affect the accuracy of her treatment and care. The MDS Coordinator acknowledged these deficiencies, noting the importance of updating care plans to ensure residents receive appropriate care and services. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan for each resident, which was not adhered to in these cases.
Lack of Qualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that their activities program was directed by a qualified professional, affecting all 42 residents. The facility lacked a qualified Activities Professional, which could result in residents not receiving individualized activities tailored to their skills, abilities, and interests. The facility's contract binder confirmed the absence of a qualified Activity Director. Interviews with the MDS Coordinator and the Administrator revealed that the facility had not had a certified Activity Director since April 2024 and December 2024, respectively. Both acknowledged the presence of an activities assistant who was not qualified to lead specialized activities. The facility's policy, revised in June 2019, required a qualified Activity Director to oversee the program, ensuring activities were meaningful and person-centered, adaptable for residents with limitations, and scheduled at various times to meet diverse needs.
Failure to Provide Timely Optometry Care Due to Transportation Issues
Penalty
Summary
The facility failed to ensure that a resident received necessary optometry care, resulting in a deficiency. The resident, who had a BIMS score indicating no cognitive impairment, reported experiencing blurred vision since before Thanksgiving 2024. Despite the resident's complaints and the facility's awareness of the issue, the resident did not receive optometry care for over two months. The facility had been attempting to secure in-house optometry services but had not yet succeeded, and in the meantime, residents were supposed to be sent out for such services. The delay in care was exacerbated by a broken wheelchair, which was the only one suitable for the resident's weight, preventing transportation to an external optometrist. The facility staff, including the MDS Coordinator and the DON, were aware of the situation but did not take sufficient action to resolve the transportation issue, such as checking with a nearby sister facility for a suitable wheelchair. The resident's care plan did not reflect any need for optometry care, despite the resident's complaints and the staff's awareness of her vision issues.
Inadequate Competency in Resident Transfers
Penalty
Summary
The facility failed to ensure that licensed staff demonstrated the necessary competencies and skill sets for safe resident transfers, as evidenced by incidents involving three CNAs. In one instance, CNA C and CNA K improperly transferred a resident with hemiplegia using a mechanical lift. They did not widen the base of the lift for stability, failed to lock the lift when stationary, and struggled to maneuver the lift, causing the resident to rock side to side. Additionally, the resident's feet became stuck under the actuator, and CNA K had to pull them free, which could have led to injury. Both CNAs admitted to not following their training protocols during the transfer. In another incident, CNA D and CNA E transferred a resident with severe cognitive impairment and multiple physical disabilities using a mechanical lift. During the transfer, CNA E failed to hold the spreader bar, which was swinging over the resident's head, potentially risking injury. Although CNA E had received training and passed a skill check-off evaluation, she admitted to forgetting to hold the bar due to nervousness. The DON confirmed that CNA E should have held the spreader bar to prevent it from hitting the resident's head. The facility's policy on transfers and lifts emphasizes safety and minimizing injury risk, but the actions of the CNAs did not align with these guidelines. The mechanical lift's owner's manual also specifies that the base should be widened for stability and locked when stationary, which was not adhered to in these incidents. These failures in following proper procedures during resident transfers could place residents at risk for avoidable falls and injuries.
Expired Syringes Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the removal of expired medications from the medication room. During an observation, surveyors found eighteen syringes of 0.9% sodium chloride injection for flush, each containing 10 milliliters, that had expired on February 28, 2025, inside the 3-side medication room. This oversight was acknowledged by the Director of Nursing (DON) during an interview, who admitted that the expired syringes should have been discarded according to the facility's policy. The facility's policy, titled Consultant Pharmacist Services Provider Requirements, mandates the checking of medication storage areas and medication carts for proper storage, labeling, cleaning, and removal of expired medications. Despite this policy, the expired syringes remained in the medication room, posing a risk of inaccurate drug administration and potentially ineffective therapeutic outcomes. The facility did not have any residents requiring intravenous therapy that would necessitate the use of these normal saline syringes for flush.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach while she was positioned on her bed, which is a violation of the resident's right to reasonable accommodation of needs and preferences. The resident, a female with a history of traumatic subdural hemorrhage, dysphagia, hypertension, extrapyramidal and movement disorder, difficulty in walking, and muscle wasting and atrophy, was observed lying on her bed with the call light on the floor beside her roommate's bed, out of her reach. This was contrary to her comprehensive care plan, which specified that the call light should be within reach and answered in a timely manner. Interviews with the resident, an LVN, and the DON confirmed that the call light was not within reach, which could delay care and services. The resident expressed that she was unable to reach the call light and did not know why it was placed on the floor. The LVN and DON acknowledged that the call light should have been accessible at all times, as per the facility's policy revised in December 2023. This oversight could potentially place residents at risk for delays in care and increased risk of falls and injuries.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident, specifically by not replacing a heavily soiled mattress. The mattress, used by a resident with severe cognitive impairment and multiple health conditions, was observed to be covered with urine stains over at least 50% of its surface, emitting a strong odor of urine. The Assistant Director of Nursing (ADON) acknowledged the mattress's condition, stating it should be discarded due to its severe staining and odor, which could not be adequately cleaned for continued use. Despite the facility's policy requiring staff to maintain a clean and dignified environment, the issue was not reported or addressed by the staff, and the resident was unaware of the mattress's condition until it was brought to her attention. Interviews with the resident and a Certified Nursing Assistant (CNA) revealed that the resident did not spend much time in her room and was unaware of the mattress's condition. The CNA, who often worked with the resident, admitted to not paying attention to the mattress's state and expressed uncertainty about its cleanliness. The facility's policies on dignity and environmental cleaning emphasize the importance of maintaining a clean and orderly environment, yet these were not adhered to in this instance, leading to the deficiency.
Failure to Conduct Timely Criminal Background Check
Penalty
Summary
The facility failed to implement its written policies and procedures that prohibit and prevent abuse, neglect, and misappropriation by not conducting a criminal background check on a newly hired staff member, housekeeper-F, before their employment began. Housekeeper-F was hired and started working at the facility on February 5, 2025, but their criminal background was not checked until March 6, 2025. This oversight occurred because the facility did not have dedicated human resources staff, and the associated facility's staff, who occasionally handled these checks, missed conducting the background check before the hiring date. The facility's policy requires prospective employees to authorize the facility to obtain investigative and/or consumer reports, including criminal history, for pre- and post-employment evaluation. However, this policy was not followed in the case of housekeeper-F, as their background check was delayed until after they had already started working. Although housekeeper-F's criminal background was clear when eventually checked, the failure to conduct this check prior to employment could potentially place residents at risk of abuse from inappropriate staff.
Inaccurate Resident Assessments Lead to Deficient Care Plans
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. Resident #16's quarterly Minimum Data Set (MDS) did not reflect the use of a 1/4 bed rail for mobility and transfers, despite physician orders and the resident's own admission of using the rail for assistance. The MDS Coordinator acknowledged the oversight, noting that the inaccuracy could result in the care plan not reflecting necessary assistive devices, potentially affecting the resident's physical mobility and independence. Similarly, Resident #35's quarterly MDS inaccurately indicated she had adequate vision, despite her complaints of blurred vision and a pending optometrist appointment. The facility Ombudsman and the resident herself confirmed the vision issues, which were not documented in the care plan due to the MDS inaccuracy. The MDS Coordinator admitted that the failure to accurately assess the resident's vision could lead to a lack of necessary vision services. The facility's policy requires a registered nurse to conduct or coordinate each assessment with the interdisciplinary team, ensuring comprehensive and accurate evaluations.
Failure to Address Bowel Incontinence in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental needs. Specifically, the care plan did not address the resident's bowel incontinence, despite it being identified in the comprehensive assessment. The resident, who had severe cognitive impairment and was always bowel incontinent, did not have a care plan reflecting this condition, which could lead to inadequate care. The MDS nurse acknowledged the oversight, stating that the care plan for bowel incontinence was mistakenly removed, believing the issue was resolved when it was not. This error was confirmed through interviews and record reviews, which showed that the resident continued to require bowel incontinent care. The facility's policy required that care plans be reviewed and revised after each assessment, but this was not adhered to, resulting in a deficient practice that could risk the resident not receiving proper care.
Deficiencies in Mechanical Transfer Procedures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision during mechanical transfers for two residents. In the first instance, two CNAs did not follow safe transfer techniques when moving a resident with hemiplegia from the bed to a wheelchair using a mechanical lift. The CNAs did not widen or lock the base of the lift, causing instability, and one CNA pulled on the resident's feet when they became stuck under the actuator. Additionally, a fall mat, which was part of the resident's care plan to prevent injury from falls, was not placed beside the bed as required. In the second instance, during the transfer of another resident with severe cognitive impairment and multiple physical disabilities, a CNA failed to hold the spreader bar of the mechanical lift, allowing it to swing dangerously close to the resident's head. This oversight occurred despite the CNA having received training on the proper use of the lift. The resident's care plan required total assistance with transfers, including the use of a mechanical lift, due to the resident's significant mobility and cognitive challenges. Interviews with the DON and DOR confirmed that the staff did not adhere to the facility's policies and training regarding mechanical lifts. The facility's policy emphasized the importance of maintaining the lift's base in a wide position for stability and ensuring the resident's safety during transfers. The failure to follow these procedures placed the residents at risk of injury during the transfers.
Inadequate Incontinence Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinence care for two residents, leading to potential risks of cross-contamination and urinary tract infections. Resident #11, a male with severe cognitive impairment and multiple health issues, including diabetes and reduced mobility, did not receive proper cleaning of the suprapubic area during incontinence care. The CNA responsible for his care admitted to forgetting to clean the area due to nervousness, despite having received peri-care training the previous year. The resident's care plan required cleaning of the perineal area with each incontinence episode and monitoring for signs of urinary tract infections. Similarly, Resident #143, a female with severe cognitive impairment and frequent bladder incontinence, did not receive adequate cleaning of the labia area during incontinence care. The CNA providing care also admitted to forgetting to separate and clean the labia area due to nervousness, despite having received training. The facility's policy on perineal care, which emphasizes maintaining privacy, reducing infection risk, and promoting skin integrity, was not followed. The Director of Nursing confirmed the lapses in care and acknowledged the need for proper cleaning to prevent infections.
Deficient Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents requiring oxygen therapy, leading to deficiencies in their care. Resident #16, who has a history of hemiplegia, hemiparesis, and chronic obstructive pulmonary disease, was observed receiving oxygen therapy via a nasal cannula. However, the oxygen concentrator filter was found to be covered with white residue and lint, which could potentially lead to an upper respiratory infection. Interviews with the LVN and DON confirmed that the filter was not maintained according to the facility's policy, which requires regular cleaning to prevent contamination. Resident #13, a female resident with a history of sepsis, acute respiratory failure, pneumonia, type 2 diabetes mellitus, and sleep apnea, was also found to be at risk due to improper respiratory care. Her nebulizer mask was observed on the dresser without being covered in a plastic bag, which is necessary to prevent infection when not in use. The LVN and DON acknowledged that the mask should have been stored properly to avoid potential contamination. These observations and interviews highlight the facility's failure to adhere to professional standards of practice and the residents' comprehensive care plans. The lack of proper maintenance and storage of respiratory equipment could lead to respiratory infections, compromising the health and safety of residents receiving oxygen therapy.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess a resident for the risk of entrapment from bed rails before their installation. Specifically, the nursing staff did not complete a necessary assessment, attempt the use of alternatives, review the risks versus benefits, or obtain informed consent from the resident or their representative. This deficiency was identified for one resident who was reviewed for bed rail use. The resident, who had a history of hemiplegia and dementia, was observed using a bed rail without having been informed of the associated risks or having provided consent. The facility's policy required a physician's order, a completed assessment, and a signed consent before the use of side rails. However, the resident's assessment did not reflect the use of a bed rail, and there was no documentation of a discussion about the risks and benefits or an attempt to use alternatives. Interviews with the MDS Coordinator and the Director of Nursing confirmed these oversights, highlighting the importance of ensuring that assistive devices are safe and appropriate for residents. The facility's failure to adhere to its policy could potentially lead to avoidable accidents involving residents who use bed rails.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required. In the 4-side medication room, a narcotic box inside a refrigerator was not permanently affixed, which contained 12 capsules of Dronabinol 5 mg for a resident with multiple health issues, including moderate cognitive impairment and respiratory failure. The Director of Nursing (DON) acknowledged that the narcotic box should have been permanently affixed to prevent drug diversion. Additionally, two unopened bottles of Latanoprost 0.005% ophthalmic solution were improperly stored at room temperature in a medication aide cart, despite the label instructions to keep them refrigerated until opened. The DON confirmed that the medications were not stored according to the label instructions and facility policy, which could render them ineffective. The facility's policy requires medications needing refrigeration to be kept at a specific temperature range with a thermometer for monitoring.
Inaccurate Documentation of Medication Order
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to a deficiency in documentation. Specifically, the psychiatric provider prescribed Depakote for a mood disorder, but the facility incorrectly documented the medication as being for dementia. This error was found in the physician's order and the medication administration record, which both inaccurately stated that the Depakote was for dementia. The Assistant Director of Nursing (ADON) acknowledged that the order was entered incorrectly by a nurse who received the verbal order from the psychiatric provider. The resident involved was an elderly male with multiple diagnoses, including heart failure, muscle weakness, mood disorder, dementia, type 2 diabetes mellitus, and hypoxemia. The resident's significant change Minimum Data Set (MDS) indicated severe cognitive impairment, requiring assistance with transfers. The psychiatric assessment confirmed that the resident's dementia was not being treated with medications, highlighting the inaccuracy in the facility's records. The ADON was responsible for reviewing and auditing all orders but failed to identify the error, which could lead to errors in care and treatment.
Facility Fails to Maintain Safe Environment Due to Damaged Bathroom Door
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public, as evidenced by a hole in the bathroom door of a resident's room. The hole, measuring 20 cm in width and 3 cm in length, was observed in the bathroom door of a female resident who was cognitively intact and independent in her daily activities. The resident, who has a history of Parkinson's disease and other medical conditions, expressed awareness of the hole and a desire for it to be repaired. The maintenance staff acknowledged the presence of the hole and suggested that it might have been caused by the room door hitting the bathroom door. The facility's policy on environmental cleaning emphasizes maintaining a clean and sanitary environment to minimize infection risks, yet this policy was not adhered to in this instance. The failure to address the hole in the bathroom door could potentially lead to injury, particularly given the resident's medical conditions, which include increased tremors and unsteady gait.
Infection Control Deficiency: Scabies Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in an outbreak of scabies among residents and staff. Two residents, both with significant medical histories, were confirmed positive for scabies. Resident #1, a male with diabetes and Alzheimer's disease, was found to have scabies following a skin scraping test. Resident #2, a female with atopic dermatitis and reduced mobility, was also confirmed positive for scabies. Both residents were placed on enhanced barrier precautions and treated with Ivermectin. The Director of Nursing (DON) and the Administrator were aware of the scabies cases among residents and staff but failed to report the outbreak to the State Survey Agency (HHSC) in a timely manner. The DON acknowledged that any infection affecting two or more residents should be considered an outbreak and reported. Despite this, the Administrator initially believed the scabies cases were not a notifiable incident and only recognized the need to report after confirming multiple cases. Interviews with staff revealed that several employees, including CNAs and an LVN, were also confirmed positive for scabies. Some staff members had experienced symptoms but did not report them to the DON or Administrator, contributing to the spread of the infection. The facility's policy required the Administrator or DON to report such incidents, but this was not done promptly, potentially putting other residents, staff, and the community at risk.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required tracheostomy care and tracheal suctioning, as per professional standards of practice. The resident, a 71-year-old male with diagnoses including depression, dementia, COPD, and anemia, was observed receiving oxygen at 2 liters per minute. However, the oxygen tubing, humidifier, and nasal cannula were not replaced within the facility's specified timeframe, which was every Wednesday during the night shift. The humidifier bottle was found empty, and the nebulizer was dated over a month prior, indicating it had not been changed weekly as required. The resident reported experiencing nosebleeds and soreness due to the lack of humidified oxygen and stated that staff shifts were blaming each other for the oversight. Interviews with facility staff, including an LVN and the ADON, confirmed that the humidifier, tubing, and nebulizer should be changed weekly to prevent infections and ensure proper oxygen flow. The LVN admitted to not changing the equipment and acknowledged the charge nurse's responsibility to check and replace the oxygen apparatus. The ADON could not explain why the equipment was not changed as per the facility's procedures and reiterated the importance of changing the equipment every seven days. The facility's Oxygen Therapy policy also emphasized the need to exchange the humidifier when empty and change the tubing if discolored or contaminated.
Failure to Provide Full-Time RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) to serve as the Director of Nursing on a full-time basis, as required. During the month under review, the facility employed two RNs, RN A and RN B, neither of whom clocked hours on the specified dates. This lack of RN presence was confirmed through record reviews and interviews with staff, including RN A, who stated she was not present on the specified dates. The absence of an RN on these days meant that there was no RN available to provide necessary supervision to non-RNs, mentor other nurses, or declare a resident deceased. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that there was no policy or procedure in place for ensuring RN coverage for 8 hours each day. The Administrator acknowledged the requirement for daily RN coverage but could not explain the lack of RN presence on the specified dates. Staff members, including an LVN and a CNA, emphasized the importance of having an RN for guidance and supervision. At the time of the survey exit, the facility had not provided a policy for ensuring 8-hour RN coverage.
Incomplete Medical Records for Oxygen Therapy
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was prescribed PRN oxygen therapy. The resident, a 71-year-old male with diagnoses including depression, dementia, COPD, and anemia, was not documented as having their nebulizer, humidifier, and oxygen tubing changed every seven days as per the facility's procedure. This oversight was identified during a review of the resident's Medication Administration Records (MARs) for April and May 2024, which did not capture the necessary procedures for changing the equipment. Interviews with the MDS LVN revealed that the MARs were not accurate for oxygen therapy, as they lacked directives for changing the equipment every seven days. The MDS LVN, who was new to the position, stated that the absence of documentation on the MARs prevented her from updating the MDS accurately. The facility's policy requires direct observation and communication with residents and staff to ensure accurate assessments, but the lack of communication and documentation led to the deficiency in maintaining the resident's medical records.
Inadequate Discharge Planning and Education for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who had undergone a left above-knee amputation (AKA) and was receiving IV antibiotics for osteomyelitis. The resident was discharged without the arrangement of necessary home health services for wound care and IV medication administration. Additionally, the resident's responsible party (RP) was not provided with adequate education on IV antibiotic administration, midline catheter care, or wound care for the surgical incision. The discharge process was inadequately managed, as the facility did not provide the RP with essential supplies for midline catheter and wound care. Interviews revealed that the facility staff assumed the RP had nurse friends who could assist with the resident's care, leading to a lack of formal arrangements for home health services. The RP expressed discomfort with administering the IV medication and reported that the facility only provided verbal instructions, which were insufficient for the resident's complex medical needs. The facility's discharge process was further compromised by a lack of written discharge instructions due to computer downtime. The Director of Nursing (DON) and other staff members acknowledged the abrupt nature of the discharge and the absence of proper documentation and education. The facility's policy on discharge/transfer was not followed, as it required the development of a safe discharge plan and the provision of written instructions, which were not adequately executed in this case.
Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation, specifically in reporting abuse within 2 hours to the State Survey Agency (HHSC). This deficiency was identified during a review of the facility's policy titled 'Abuse, Neglect, and Exploitation Prevention Policy and Procedure,' which did not include guidelines for reporting to the State Survey Agency/HHSC. The failure to report an allegation of abuse made by a resident until surveyor intervention could place all residents at risk for potential abuse due to unreported allegations of abuse. The incident involved a resident with a history of inappropriate behaviors, including making false allegations. The resident accused an LVN of threatening to shove a back scratcher down his throat and called the local police. The police arrived, interviewed the resident, and found no charges pending. The facility's DON and Administrator were informed of the allegations but did not report them to HHSC within the required 2-hour timeframe. The Administrator initially believed she had 24 hours to report the allegations and was waiting for the final police report before reporting to HHSC. Interviews with the resident, CNA, LVN, DON, and Administrator revealed inconsistencies in the facility's response to the allegations. The Administrator later acknowledged that allegations of abuse should be reported within 2 hours and verified this information online. The facility's abuse policy, last reviewed in December 2023, did not meet state regulations for reporting abuse within 2 hours to HHSC. The Administrator was unaware of this deficiency until surveyor intervention.
Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to report allegations of abuse made by a resident to the State Survey Agency within the required timeframe. The resident, who had a history of inappropriate behaviors and false allegations, accused a nurse of threatening to put a back scratcher down his throat. The resident also claimed that his belongings were being taken and that he was being poisoned. Despite these serious allegations, the facility did not report the incident to the State Survey Agency within the mandated 2-hour window. Interviews with staff and the resident's parole officer revealed that the resident had a pattern of making false allegations and moving between nursing homes. The staff had been instructed to handle the resident with two-person assistance to protect themselves from false accusations. The Director of Nursing (DON) and the Administrator were aware of the resident's behaviors and had documented them as target behaviors in his care plan. However, they did not report the allegations to the State Survey Agency, believing that the resident's history of false allegations and the lack of police action made the report unnecessary. The facility's policy on abuse, neglect, and exploitation required immediate reporting of such allegations to the State Health Department, local law enforcement, and the local ombudsman. However, the policy did not explicitly mention the State Survey Agency. The Administrator initially believed they had 24 hours to report the allegations but later confirmed that the correct timeframe was 2 hours. Despite this, the report was not made within the required period, leading to a deficiency in the facility's handling of abuse allegations.
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.
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What surveyors actually found near you
We read the 66 citations issued within 25 miles in the last 12 months — 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Yoakum
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Yoakum Nursing And Rehabilitation Center | 2 mi | ★★★★★ | 5 | 0 |
| Shiner Nursing And Rehabilitation Center Inc | 9.9 mi | ★★★★★ | 13 | 0 |
| Whispering Oaks Rehab & Nursing | 14.7 mi | ★★★★★ | 0 | 0 |
| Hallettsville Nursing And Rehabilitation | 15.7 mi | ★★★★★ | 10 | 0 |
| Cuero Nursing And Rehabilitation Center | 15.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.