Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Park Place Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively impaired female resident with metabolic encephalopathy, generalized muscle weakness, and a cognitive communication deficit was found on her room floor with a deep, actively bleeding laceration to her left palm. Staff controlled the bleeding, notified clinical leadership and family, and sent the resident to the hospital, where imaging revealed a left humerus fracture and the hand laceration was sutured. Staff could not identify any environmental cause for the injury, and the bedroom and bathroom contained no observed tripping hazards or sharp objects. The ADON and DON, both aware of the 2‑hour reporting requirement for injuries of unknown origin under Provider Letter 2024‑14, relayed the fracture information to the administrator via the administrator in training later that evening. The administrator acknowledged receiving the call but delayed submitting the self‑report to HHSC, resulting in the injury of unknown origin being reported approximately six hours after the incident instead of within the required 2‑hour timeframe.
A resident with a history of cellulitis and oral abscess reported right-sided tooth pain with blood and pus, prompting the DON to request a dental consult and an LVN to obtain an antibiotic order. Although the physician-signed dental paperwork was dated the same day, the SW delayed submitting the dental referral and did not send it until several days later, believing the short antibiotic course was sufficient. Before the referral was sent, the resident developed significant right-sided facial swelling and severe pain, leading an LVN to notify the physician and transfer the resident to the ER, where he was treated for dental pain due to toothache and discharged on additional antibiotics and chlorhexidine with instructions for dental follow-up.
Staff failed to follow Enhanced Barrier Precautions (EBP) for three residents who had active EBP orders and clear EBP signage on their doors. CNAs provided bed bath and peri-care without hand hygiene on room entry and without donning gowns, despite posted instructions to use gloves and gowns for high-contact care. An LVN performed enteral feeding for a resident with a PEG tube without wearing a mask or gown, even though PPE was available at the room entrance and EBP signage specified gown and glove use for device care. In interviews, staff admitted they were trained on EBP but either forgot or did not notice they had not donned required PPE, and leadership acknowledged these failures could lead to cross contamination, infection spread, and sepsis.
Three residents with complex medical and psychosocial needs did not have comprehensive, person-centered care plans implemented within the required timeframe, despite multiple care areas being triggered on their assessments. Staff interviews and record reviews confirmed that no individualized care plans were in place, and facility policy requiring such plans was not followed.
A resident with chronic lower leg ulcers did not have wound care accurately documented in the EMR, with multiple days missing sign-offs and some entries made retroactively. Nursing staff could not identify who made certain entries, and the DON was unable to match staff initials in the system, resulting in incomplete records for ordered wound care.
An LVN failed to consistently perform hand hygiene between glove changes while providing wound care to a resident with open areas on both lower extremities. The LVN omitted hand hygiene at several points during the procedure, despite facility policy and standard precautions requiring it after glove removal and before moving from soiled to clean body sites. The DON confirmed that hand hygiene is expected at each glove change.
A resident with cognitive impairment and multiple medical conditions was physically abused by another resident, who grabbed her shirt and bit her hand, resulting in visible injuries and emotional distress. Both residents had no prior behavioral interventions in their care plans, and staff responded after the incident occurred.
Several residents with complex medical and mental health conditions were admitted without timely or complete baseline care plans, as required. In some cases, essential information such as fall risk precautions, dietary instructions, medication orders, therapy services, and social services were missing, and summaries were not provided to residents or their representatives. Staff interviews revealed that sections of the care plans were not completed due to workload and oversight, and the DON acknowledged the lapse in timely completion.
Several residents with risk factors for skin breakdown did not receive required weekly skin assessments due to failures in the facility's EMR system and staff reliance on electronic prompts. Nursing staff missed multiple weeks of assessments, despite care plans and facility policy requiring them, and this was confirmed through record review, staff interviews, and resident observations.
Staff failed to consistently document and reconcile controlled substances during shift changes, resulting in missing signatures and an unaccounted tablet of hydrocodone/acetaminophen for a resident. Multiple medication carts had incomplete narcotic count sheets, and required shift-to-shift counts were not performed as per facility policy.
A resident with multiple medical conditions reported feeling abused after being left on a bedpan for an extended period. Although the allegation was promptly communicated to facility management and the resident later denied abuse during an interview, the facility did not report the initial allegation to the State Survey Agency within the required two-hour timeframe, as mandated by policy.
A resident with multiple diagnoses, including a sacral pressure ulcer and severe cognitive impairment, was not accurately assessed on the MDS because the wound care report was not kept up to date by the former wound care nurse. As a result, the MDS nurse did not document the pressure wound, leading to an incomplete assessment.
A CNA did not perform hand hygiene between glove changes while providing incontinent care to a resident, despite facility policy and personal knowledge of the requirement. The omission was observed during care and confirmed in interviews, with the CNA attributing the lapse to working too quickly. Facility policies reviewed indicated that hand hygiene is required after glove removal and before donning new gloves.
A resident with a history of cardiovascular disease and at risk for skin breakdown developed multiple wounds on the right foot. The facility failed to ensure timely follow-up on a cardiology appointment and a vascular surgery referral, with missed and unrescheduled appointments, lack of documentation, and poor communication among staff. As a result, the resident's wounds deteriorated, leading to gas gangrene and an above-the-knee amputation.
Three residents with significant care needs did not receive timely assistance with ADLs, including incontinent care and bathing. Two residents waited over an hour for staff to respond to call lights for personal hygiene needs, and another received only one documented shower in a month, with staff unable to verify additional care. Facility policies requiring prompt response and regular bathing were not followed, as confirmed by staff interviews and documentation review.
A resident was given the incorrect strength and formulation of a prescribed medication due to unavailability and lack of staff awareness, with the error documented as if the correct medication had been administered. Additionally, expired medications were found on a medication cart, indicating failures in medication storage and removal procedures.
A resident with multiple complex medical conditions, including a tracheostomy, did not have a care plan that addressed tracheostomy or respiratory care needs. The care plan lacked specific interventions, and physician's orders were missing key details such as trach size and necessary equipment. Staff interviews confirmed the omission, and facility policy requiring comprehensive, person-centered care plans was not followed.
A resident with a tracheostomy and complex medical needs did not have required emergency respiratory care equipment, such as a replacement trach, suction catheters, a sterile suctioning kit, or a manual resuscitation bag, at the bedside. Staff interviews and facility policy confirmed these items should have been present for any resident with a trach, regardless of whether it was capped. The resident's care plan and physician orders also lacked necessary details regarding respiratory care.
A CNA failed to properly don PPE, using only one glove and no gown, while assisting a resident with multiple risk factors—including a PICC line, wounds, and an indwelling urinary catheter—during a transfer and catheter care, despite clear EBP signage and available supplies. Staff interviews confirmed knowledge of EBP requirements and the presence of training and visual cues.
A resident with multiple medical conditions, including cognitive deficits and a wound, did not receive timely bathing and hygiene care, resulting in her being found saturated in urine and feces. The CNA responsible was overwhelmed and did not communicate the need for assistance, while the RN acknowledged the responsibility to ensure cleanliness before hospital transport. The DON stated that the facility was not short-staffed, and the CNA and nurses should have ensured the resident received ADL care.
A resident with multiple diagnoses, including type 2 diabetes, was found with an insulin pen on his table, which was not prescribed to him. RN A admitted to leaving the pen, belonging to another resident, on the table by mistake. The DON confirmed that medications should not be left at the bedside or taken into another resident's room, violating the facility's medication administration policy.
A resident with type 2 diabetes was not provided with a physician-ordered Reduced Concentrated Sweets (RCS) diet, as his lunch tray contained regular sugar. The resident's family raised concerns, and staff interviews revealed a lack of awareness and oversight regarding the resident's dietary restrictions. The facility's policy to follow physician's dietary orders was not adhered to, resulting in this deficiency.
The facility failed to maintain an effective infection prevention and control program, as PPE was not readily available for residents requiring Enhanced Barrier Precautions (EBP). Staff, including CNAs and a Corporate Regional RN, did not don necessary PPE when providing care to residents with indwelling catheters, feeding tubes, and wounds. Interviews revealed a lack of adherence to EBP protocols and inconsistent availability of PPE supplies, highlighting deficiencies in the facility's infection control processes.
A resident with multiple health issues was prescribed Sodium chloride 2000 mg every 8 hours, but the facility administered an incorrect dose of 1000 mg every 8 hours due to a transcription error in the EMR. The ADON likely entered the orders incorrectly, and the attending physician was not contacted for clarification. Facility policies on order transcription and confirmation were not followed.
A resident with a history of falls and moderate cognitive impairment fell in the hallway, sustaining facial injuries. The facility failed to notify the family until the next morning, despite policy requirements for immediate notification. The family discovered the injuries during a visit and decided to move the resident to another facility due to the lack of communication.
Failure to Timely Report Injury of Unknown Origin to HHSC
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin as required by state guidance. A cognitively impaired female resident with metabolic encephalopathy, generalized muscle weakness, and a cognitive communication deficit was admitted with severe cognitive impairment (BIMS score of 4) and required partial to moderate assistance for most functional abilities. On the day of the incident, a nurse’s note documented that at 4:30 PM the resident was heard calling for help and was found on the floor of her room, lying on her back, with a deep, actively bleeding laceration to the palm of her left hand. Staff cleaned and dressed the wound, controlled the bleeding, notified the physician, ADON, DON, and the resident’s family, and called 911 for transfer to the hospital. Hospital records later that evening showed that an x‑ray of the resident’s left humerus revealed a fracture, and the resident received sutures to the laceration. Subsequent observation showed the resident’s left arm was swollen and bruised, with sutures in the left palm, but without obvious signs of pain unless the hand was disturbed. Staff interviews indicated that the LVN who assessed the resident did not know how the laceration occurred and saw nothing in the environment sharp enough to cause it. The CNA who first responded reported hearing the resident call for help, finding her on the floor with a bleeding left hand, and observing no blood elsewhere in the room, noting that the resident had fragile skin. The resident’s bedroom and bathroom were observed to have no tripping hazards or sharp objects. Administrative staff interviews revealed that the ADON was notified shortly after the incident and monitored the completion of x‑rays remotely, learning of the fracture and notifying the DON in the early evening. The DON reported being aware of the requirement to report injuries of unknown origin within two hours and stated she informed the administrator in training so the administrator could self‑report to HHSC. The administrator in training stated she contacted the administrator at approximately 7:15 PM with the fracture information. The administrator acknowledged receiving the call but stated he was doing yard work, then showered and fell asleep, and only later remembered to submit the report. TULIP case details showed HHSC received the report of injury of unknown origin at 10:30 PM, approximately six hours after the 4:30 PM incident, despite the facility’s stated use of Provider Letter 2024‑14, which requires immediate reporting, but not later than two hours after the incident occurs or is suspected for injuries of unknown source and related events.
Failure to Timely Obtain Emergency Dental Services After Reported Tooth Pain and Infection
Penalty
Summary
The deficiency involves the facility’s failure to provide or obtain necessary emergency dental services for one cognitively intact male resident who was admitted and later readmitted with cellulitis and abscess of the mouth. On 3/3/26, the DON documented that a family member inquired about dental concerns for the resident, and the social worker (SW) was consulted to follow up for a dental referral. That same day, an LVN documented that the resident complained of tooth pain with blood and pus coming from the back of the right side of his mouth; the nurse practitioner was notified and ordered amoxicillin 1 g once, then 500 mg three times daily for three days. The quarterly MDS indicated the resident had clear speech, was cognitively intact with a BIMS score of 14, was independent with ADLs, and had no documented mouth or facial pain or oral/dental problems at that time. Despite the consult on 3/3/26, the dental referral was not actually submitted until 3/12/26. The SW later stated she delayed submitting the referral and sent it on 3/12/26 along with other new patient referrals, and that she did not follow up on the 3/3/26 consult because she believed the three-day antibiotic course would prevent issues. The dental office confirmed that the referral for this resident was received on 3/12/26 and that the resident’s new patient packet, which included a physician-signed form dated 3/3/26, was processed, with the resident ultimately seen by the facility’s dentist on 3/17/26. The DON stated she expected timely follow-up on the consult but did not provide a specific timeframe and was unaware that the referral had not been completed until 3/12/26; she also reported that the facility did not have a dental policy. On 3/12/26, prior to the referral being sent, an LVN documented that the resident presented with right-sided facial swelling and reported constant, aching pain rated 8/10, though he was afebrile and vital signs were within normal limits. The physician was notified and ordered transfer to the local ER for evaluation and treatment. The ER after-visit summary documented that the resident was seen for dental pain due to toothache and was discharged on amoxicillin 875-125 mg every 12 hours for seven days and chlorhexidine 0.12% solution twice daily for 14 days, with instructions to follow up with a dentist. The facility’s own documentation and interviews showed that the delay between the initial identification of dental concerns on 3/3/26 and the submission of the dental referral on 3/12/26 constituted the failure to timely obtain necessary emergency dental services for the resident.
Failure to Follow Enhanced Barrier Precautions During Direct Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for three residents who had active physician orders for EBP and visible EBP signage on their doors. Each resident had a documented need for EBP: one resident had a widespread rash and other skin conditions, another had a PEG tube, and a third had other skin changes. Surveyors observed that EBP signage at the room entrances directed staff to clean hands before and after leaving the room and to wear gloves and gowns for high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, assisting with toileting, and device care including feeding tubes. Despite these orders and posted instructions, CNAs and an LVN did not follow EBP requirements during direct care. One CNA entered a resident’s room to perform a bed bath without sanitizing her hands before entry and without donning a gown. Another CNA entered a different resident’s room to provide perineal care and likewise did not sanitize her hands before entering and did not put on a gown. Later, an LVN was observed providing enteral feeding to a resident with a PEG tube without wearing a mask or gown, even though EBP signage and PPE were present at the room entrance. In interviews, the CNAs acknowledged they failed to put on gowns despite having been trained on EBP, and the LVN stated she did not notice she had not put on a gown but was aware of the EBP requirements. The DON, who serves as the Infection Preventionist, and the Administrator acknowledged that staff had been trained and retrained on EBP and stated that such failures could place residents at risk for cross contamination, spread of infection, and sepsis.
Failure to Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for three residents within the required timeframe. Record reviews showed that for each of these residents, no care plan was implemented within 21 days of admission, despite multiple care areas being triggered by their admission MDS assessments. These care areas included cognitive loss/dementia, ADL function/rehab potential, urinary incontinence/indwelling catheter, psychological well-being, falls, nutritional status, pressure ulcer, pain, and other significant health concerns. The residents affected had complex medical histories, including conditions such as rheumatic mitral stenosis, bipolar disorder, chronic kidney disease, diabetes mellitus type 2, atrial fibrillation, fractured femur, hypertension, and obesity. Their assessments indicated varying levels of cognitive impairment and substantial assistance required for activities of daily living. Despite these needs, the electronic health record reviews confirmed that no individualized care plans were in place for these residents during the survey. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the care plans had not been completed as required. The MDS Coordinator was unable to explain why the previous MDS nurse had not completed the care plans, and both staff members acknowledged the importance of care plans in providing individualized care. Facility policy also required the development and implementation of comprehensive care plans to meet each resident's needs, but this was not followed for the residents in question.
Failure to Accurately Document Wound Care and Identify Staff in EMR
Penalty
Summary
The facility failed to ensure that medical records for a resident receiving wound care were accurately documented in accordance with professional standards. Specifically, the Wound Assessment Record (WAR) for one resident did not reflect that wound care to both lower extremities was completed as ordered for multiple days in October. The documentation was incomplete, with several dates missing sign-offs, and there was no way to verify that the care had been provided on those days other than verbal confirmation from nursing staff. Additionally, some entries were made retroactively, and the staff member responsible for certain initials in the electronic medical record (EMR) could not be identified. The resident involved had a history of diabetes, non-pressure chronic ulcers of both lower legs, congestive heart failure, hypertension, and atrial fibrillation. Physician orders required daily wound care, including cleansing, application of Xeroform, ABD pads, and gauze wrapping. The care plan and Minimum Data Set (MDS) confirmed the need for ongoing wound care and indicated the resident was moderately cognitively impaired but able to communicate needs. Despite these requirements, the WAR did not consistently show that wound care was performed as ordered, and staff interviews revealed that documentation was sometimes completed after the fact or not at all. Interviews with the DON and nursing staff confirmed that there was confusion regarding documentation practices, with some nurses documenting in different parts of the EMR or forgetting to sign off on the WAR. The DON was unable to determine the identity of a staff member whose initials appeared in the EMR, and the facility's policy only allowed authorized users with assigned credentials to access and document in the system. The lack of accurate and timely documentation meant that it could not be proven that the resident received the ordered wound care on the specified dates.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene practices during wound care performed by an LVN. During wound care for a resident, the LVN did not consistently perform hand hygiene between glove changes, specifically after removing gloves and before donning new gloves while applying creams and dressings to the resident's lower extremities. The LVN did perform hand hygiene at the start of care and at certain points, but omitted it at several critical steps, contrary to facility policy and standard precautions. Interviews with the LVN revealed uncertainty regarding when hand hygiene should be performed during glove changes, while the DON stated that hand hygiene is expected before care, any time gloves are changed, and when hands are visibly soiled. Review of facility policies confirmed that hand hygiene is required immediately after glove removal and before moving from a soiled to a clean body site. The observed lapses in hand hygiene occurred during wound care for a resident with open areas on both lower extremities, as the LVN alternated between tasks without consistently following hand hygiene protocols.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and multiple medical conditions, including dementia, diabetes, depression, anxiety disorder, and Parkinson's disease, was not protected from physical abuse by another resident. The incident took place when another resident, who had severely impaired cognition and a history of neurological and behavioral diagnoses, grabbed the first resident's shirt around the neck, stretching the fabric, and bit her hand. The victim sustained a visible bite mark on the back of her left hand and redness to her chest, resulting in pain, anxiety, and emotional distress. The records indicate that both residents had no prior documented behaviors or care plan interventions addressing aggression or risk of resident-to-resident altercations. The incident was witnessed by staff who responded to a disturbance in the facility's entrance/lobby area. Upon arrival, staff found the victim pressing her hand against her chest and standing a few feet away from the aggressor, who was seated in a wheelchair. Immediate assessments revealed the physical injuries described, and the aggressor was subsequently sent to the hospital for evaluation due to his aggressive behavior and a change in baseline condition. Interviews with staff and the residents confirmed that the two individuals had previously sat together in the dining room and that, following the incident, the victim chose to avoid the aggressor. The facility's policy states that all residents have the right to be free from abuse by anyone, including other residents. However, the lack of prior behavioral interventions or monitoring for either resident contributed to the failure to prevent this episode of physical abuse.
Failure to Complete and Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for several residents, as required by policy and CMS guidelines. Specifically, the baseline care plan was not provided to one resident or their representative, and for three other residents, the baseline care plans were either incomplete or not developed within the required timeframe. The documentation review showed missing signatures, incomplete sections, and lack of acknowledgment by residents or their representatives. For one male resident with multiple complex diagnoses, including respiratory failure, depression, PTSD, hypertension, heart failure, COPD, benign prostatic hyperplasia, and obstructive uropathy, there was no indication that the baseline care plan was provided to him or his representative before his death. Another male resident with diagnoses such as type 2 diabetes, sepsis, prostate neoplasm, atrial flutter, anxiety disorder, depression, and hypertension had a baseline care plan that was signed and acknowledged, but the process for other residents was not completed as required. A female resident with mood disorder, schizoaffective disorder, morbid obesity, diabetes, general anxiety, vascular dementia, and depression had a baseline care plan that lacked essential information, including fall risk precautions, dietary instructions, medication orders, therapy services, and a summary provided to her. Another female resident with a femur fracture, delirium, and hypertension had a baseline care plan missing dietary instructions, social services, therapy services, and a summary for her or her representative. Staff interviews confirmed that sections of the baseline care plans were not completed on time due to workload and oversight, and the DON acknowledged the responsibility for timely completion was not met.
Failure to Complete Weekly Skin Assessments for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards of practice to prevent pressure ulcers, as evidenced by the lack of weekly skin assessments for seven residents reviewed for skin assessments. These residents had multiple risk factors for skin breakdown, including impaired mobility, incontinence, diabetes, dementia, and other chronic conditions. Despite care plans indicating the need for regular skin assessments and interventions to prevent pressure injuries, electronic medical records showed that weekly skin assessments were not completed for several consecutive weeks for these residents. Observations and interviews revealed that the facility's new electronic medical record (EMR) system did not consistently generate reminders or assignments for weekly skin assessments if the previous assessment was not completed. Nursing staff, including LVNs and RNs, reported relying on the EMR to prompt them for required assessments, and some were unaware that missed assessments would prevent future reminders. The Director of Nursing (DON) confirmed that the issue with the EMR had led to missed weekly skin assessments and that staff were responsible for completing these assessments unless the resident was under the care of the wound care nurse and physician. Record reviews and direct observations of the affected residents indicated that, at the time of survey, no new pressure ulcers were identified, but some residents had other skin issues such as bruising, healed wounds, or areas of redness. The facility's policy required weekly risk and skin assessments, but these were not consistently performed as documented in the residents' records. Staff interviews further confirmed that the lack of completed assessments could result in residents not receiving necessary care.
Failure to Accurately Reconcile and Document Controlled Substances
Penalty
Summary
The facility failed to maintain an adequate system for the receipt and disposition of controlled drugs, resulting in the inability to accurately reconcile and account for all controlled substances. Specifically, staff did not consistently sign out or count narcotics during shift changes on multiple medication carts. For one resident, a nurse administered hydrocodone/acetaminophen but did not document the administration on the narcotic count sheet for two consecutive night shifts. This led to a discrepancy in the medication count, with one tablet unaccounted for until it was verbally confirmed by staff that the medication had been given. Observations and interviews revealed that medication aides and nurses did not perform required narcotic counts together during shift changes on several occasions. Staff members reported that if a medication aide was not present, the nurse should count with another nurse, but this protocol was not consistently followed. Review of narcotic count sheets showed numerous missing signatures for both off-going and on-coming shifts across three different medication carts throughout the month, indicating a pattern of noncompliance with established procedures. The facility's policy required that controlled substances be counted at the end of each shift by both the off-going and on-coming staff, with any discrepancies reported to the director of nursing. However, the director of nursing and the administrator were unaware of the extent of missing signatures and incomplete counts until the issue was brought to their attention. The lack of proper documentation and shift-to-shift reconciliation created gaps in the facility's ability to ensure the security and proper administration of controlled medications.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, as required by regulation and facility policy. Specifically, a male resident with multiple medical conditions, including atrial fibrillation, cardiomyopathy, muscle weakness, and incontinence, reported to a physical therapy assistant (PTA) that he felt abused after being left on a bedpan for an extended period. The resident stated that he was left on the bedpan for approximately 90 minutes and described this as abuse. The PTA documented the grievance and immediately notified the management team and the Administrator. Upon receiving the report, the Director of Nursing (DON) and the Administrator promptly interviewed the resident, who then denied being abused and attributed his frustration to a loss of independence and anxiety about an upcoming discharge. Despite the resident's denial during the interview, the initial allegation of abuse was not reported to the State Survey Agency within the required two-hour window. The Administrator acknowledged that the facility's policy mandates reporting all alleged abuse to the state agency within two hours, regardless of subsequent resident statements. The facility's failure to report the initial allegation of abuse within the mandated timeframe constituted a deficiency. The report and interviews confirmed that the staff were aware of the reporting requirements, and the facility's policy was clear on the need for immediate reporting of all alleged violations involving abuse, neglect, or mistreatment, but the required notification to the state agency did not occur as stipulated.
Inaccurate MDS Assessment Due to Incomplete Wound Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) admission assessment accurately reflected the status of a resident who had a pressure wound. Specifically, the MDS for this resident did not indicate the presence of a pressure ulcer, despite the resident's medical record and diagnoses confirming its existence. The resident, a male with multiple diagnoses including spinal stenosis, atherosclerotic heart disease, hypertension, spondylosis, dementia, diabetes mellitus, hemiplegia, and a sacral pressure ulcer, was admitted to the facility and had a severely impaired cognition as indicated by a BIMS score of 3. Interviews with facility staff revealed that the MDS nurse relied on the wound care report to complete the MDS, but the former wound care nurse had not kept the wound care report up to date and had failed to include this resident. As a result, the MDS nurse did not document the pressure wound on the MDS. Both the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the wound care report was incomplete and that the information should have been included in the MDS assessment, as required by facility policy.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by a certified nursing assistant (CNA) not performing hand hygiene between glove changes during incontinent care for a resident. During the observed care, the CNA performed hand hygiene and donned gloves before starting, but after removing gloves following perineal cleaning, did not perform hand hygiene before putting on a new pair of gloves. This process was repeated when the CNA changed gloves again to assist the resident with clean clothing, again omitting hand hygiene between glove changes. Interviews with the CNA confirmed awareness of the requirement to perform hand hygiene between glove changes, but the CNA stated that the step was skipped due to working too quickly. The Director of Nursing (DON) also confirmed the expectation for hand hygiene before and after glove use and after providing care. Review of facility policies on hand hygiene and perineal care further supported that hand hygiene is required after glove removal and before donning new gloves, especially after contact with soiled or contaminated articles and after providing personal care.
Failure to Ensure Timely Specialist Referrals and Follow-Up Leads to Amputation
Penalty
Summary
The facility failed to ensure that a resident received care and services in accordance with professional standards of practice, specifically by not following up on critical medical appointments and referrals. The resident, who had a history of cardiovascular disease and was at risk for skin breakdown, was admitted with orders for a cardiology follow-up and later developed multiple wounds on the right foot. Despite physician orders and wound care recommendations for a vascular surgery referral due to deteriorating arterial wounds and poor blood flow, the facility did not ensure timely scheduling or follow-up of these appointments. Documentation shows that the cardiology appointment was missed and not rescheduled, and the vascular referral was delayed, with staff failing to document missed appointments or notify appropriate personnel. Multiple staff interviews revealed confusion and lack of clarity regarding responsibilities for entering, scheduling, and following up on physician orders and specialist referrals. The charge nurse, treatment nurse, and transportation driver each described breakdowns in communication and process, including a missed vascular appointment due to transportation issues and lack of documentation or rescheduling. The treatment nurse admitted to not following up on the wound doctor's orders and not documenting attempts to schedule the vascular appointment. The Director of Nursing was unaware of the missed appointments until after the resident's condition had significantly deteriorated. As a result of these failures, the resident's wounds worsened over several weeks, eventually developing gas gangrene and requiring an above-the-knee amputation. The resident was transferred to the hospital in an unkempt and malodorous state, with extensive gangrene to the right foot and lower leg. Staff interviews and record reviews confirmed that the lack of timely follow-up and documentation on critical medical appointments directly contributed to the resident's decline and subsequent amputation.
Failure to Provide Timely ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. For one resident with multiple fractures, cognitive deficits, and impaired mobility, observations showed that her call light for assistance remained unanswered for over an hour while she waited for incontinent care. Her care plan indicated she required maximum assistance with bathing and was dependent on staff for all ADLs due to her condition. Another resident, who had diagnoses including muscle weakness and cognitive communication deficit, also experienced significant delays in receiving incontinent care. Observations revealed that her call light was on for over an hour, with multiple staff members entering and exiting the room without providing the needed care. The resident and her family confirmed that staff were slow to respond to call lights. The facility's policy required all staff to respond promptly to call lights, but this was not followed, as confirmed by the DON, who stated that waiting over an hour for care was unacceptable. A third resident, with dementia and anxiety disorder, was found to have received only one shower during the entire month, according to the facility's shower log. Although staff believed this was a documentation issue, they could not provide evidence that more showers were given. The facility's policy required regular bathing services, but documentation did not support that this standard was met for the resident.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the accurate acquisition, receipt, dispensing, and administration of medications for one resident and failed to properly manage medication storage on one medication cart. Specifically, a medication aide administered calcium carbonate 500 mg tablets, crushed, to a resident instead of the prescribed calcium carbonate 750 mg with simethicone 250 mg chewable tablets, as ordered by the physician. The correct medication was not available on the medication cart, and staff were unaware if it was available elsewhere in the facility. The medication administration record was documented as if the correct medication had been given, despite the substitution. Additionally, expired medications, including acetaminophen, melatonin, and ondansetron, were found on the first-floor east hall nurse's medication cart. These expired medications had not been removed in accordance with facility policy, which requires immediate removal and disposal of outdated, contaminated, discontinued, or deteriorated medications. Interviews with staff confirmed that monthly reviews were expected, but expired medications remained accessible on the cart at the time of the survey.
Failure to Develop Comprehensive Care Plan for Tracheostomy Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the tracheostomy care needs of a resident. Record review showed that the resident was admitted with multiple diagnoses, including anemia, dysphagia following cerebral infarction, COPD, GERD, and acute kidney failure, and had undergone surgery on the digestive system. Despite these complex medical needs, the resident's care plan did not include any care area or interventions related to tracheostomy or respiratory care. Additionally, physician's orders did not specify tracheostomy size, replacement cannula, suction machine, manual resuscitation bag, or dietary changes. Interviews with facility staff revealed that the MDS coordinator, who was responsible for initiating and updating care plans, acknowledged that the care plan had been revised but did not address tracheostomy care, and was unsure how this omission occurred. The DON confirmed that the interdisciplinary team is responsible for developing individualized care plans and emphasized the importance of updating care plans to communicate residents' needs and ensure proper care. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the resident in question.
Failure to Provide Required Respiratory Care Equipment for Resident with Tracheostomy
Penalty
Summary
A resident with a history of acute respiratory failure, tracheostomy, muscle weakness, dysphagia, and cognitive communication deficit was not provided with necessary respiratory care equipment as required by professional standards and facility policy. Observations revealed that the resident, who had a capped tracheostomy tube, did not have a replacement trach, suction catheters, a sterile suctioning kit, or a manual resuscitation bag at the bedside. The resident's care plan and most recent MDS assessment did not reflect the need for respiratory care, and physician orders lacked specification of trach size. Interviews with the Regional Nurse Consultant and an RN confirmed that essential emergency tracheostomy equipment should be kept at the bedside for any resident with a trach, regardless of whether the trach is capped. Facility policy also required the presence of specific emergency tracheostomy supplies at the bedside. The absence of these items constituted a failure to provide safe and appropriate respiratory care for the resident in accordance with professional standards, the care plan, and physician orders.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident requiring Enhanced Barrier Precautions (EBP). During an observation, a CNA assisted a male resident, who had multiple risk factors including bacteremia, chronic wounds, a PICC line, and an indwelling urinary catheter, to transfer from his wheelchair to his bed and adjusted his urinary catheter drainage bag. The CNA did not don a gown and only wore one glove on her left hand, despite being aware of the resident's need for EBP and the requirement to use both gown and gloves for direct care. PPE supplies were available outside the resident's room, and the room was clearly marked to indicate EBP was required. Interviews with the CNA and facility leadership confirmed that staff had been trained on EBP protocols, and that visual cues and PPE supplies were in place to support compliance. The CNA acknowledged her failure to fully don PPE, attributing it to not expecting the resident to request a transfer at that time and only having one glove available. Facility policy required the use of gown and gloves for high-contact care activities, including transferring and device care, for residents with wounds or indwelling medical devices.
Failure to Provide Timely ADL Care and Hygiene
Penalty
Summary
The facility failed to maintain grooming and personal hygiene for a resident who was dependent on staff for activities of daily living (ADL) care. The resident, who had multiple medical conditions including fractures, sepsis, and cognitive deficits, was not provided timely bathing and hygiene care. During an interview and observation, the resident expressed that she had not received her daily cleaning, which was crucial due to a wound on her coccyx. The resident was found saturated in urine and feces, with a dressing that had not been changed since two days prior. She reported that CNAs often did not return after responding to her call light, leaving her feeling dirty and embarrassed, especially during a recent hospital visit. The CNA responsible for the resident admitted to being overwhelmed with the workload and did not communicate the need for assistance. The RN on duty acknowledged that it was his responsibility to ensure the resident was clean before hospital transport, but the wound care nurse was not available. The Director of Nursing stated that the facility was not short-staffed and that the CNA and nurses should have ensured the resident received ADL care. The wound care nurse confirmed that when working the floor, each nurse was responsible for their treatment and wound care duties. A confidential interviewee corroborated the resident's condition, stating that the resident was dirty and saturated in urine when picked up for hospital transport.
Improper Medication Handling and Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, as evidenced by an incident involving the improper handling of medication. A resident, who had multiple diagnoses including type 2 diabetes mellitus, was found with an insulin pen on his over-the-bed table. The resident was unable to explain how the insulin pen, which was not prescribed to him, ended up on his table. This incident was observed during a visit by the resident's family, who questioned the presence of the insulin pen. An interview with RN A revealed that he was responsible for administering medications and had mistakenly left the insulin pen, which belonged to another resident, on the table while assisting with activities of daily living. The Director of Nursing confirmed that medications should not be left at a resident's bedside and that no resident's medication should be taken into another resident's room. The facility's policy on medication administration emphasizes administering medication as ordered and observing resident consumption, which was not adhered to in this instance.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a resident received a therapeutic diet as prescribed by his physician. The resident, an elderly male with multiple diagnoses including type 2 diabetes mellitus, was observed with a lunch tray containing six packs of regular sugar, despite having a physician-ordered Reduced Concentrated Sweets (RCS) diet. The resident's family questioned the presence of sugar on the tray, given his diabetic condition. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's dietary restrictions. A CNA was unaware of the resident's diet restriction, citing his recent admission as a reason. The Director of Nursing (DON) and a Registered Nurse (RN) acknowledged the oversight, admitting that the dietary staff should have removed the sugar from the tray, as the diet slip clearly indicated an RCS diet. The facility's policy mandates adherence to physician's dietary orders, but this was not followed, leading to the deficiency.
Inadequate Infection Control and PPE Availability
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for three residents. Observations revealed that containers with clean PPE products and containers to discard used PPE were not available in the halls or nearby the rooms of the residents requiring EBP. This deficiency was noted for residents with indwelling catheters, feeding tubes, and wounds, which necessitated the use of gowns and gloves during direct care. During the survey, it was observed that staff members, including CNAs and a Corporate Regional RN, did not don the required PPE when providing care to residents. For instance, CNA A and the Corporate Regional RN assisted a resident without wearing gowns, despite the presence of an orange magnet indicating the need for EBP. Similarly, CNA E failed to don PPE while transferring another resident and handling their urinary catheter drainage bag. Interviews with staff revealed a lack of adherence to EBP protocols, with some staff members acknowledging the absence of PPE supplies as a reason for non-compliance. The facility's policy on Enhanced Barrier Precautions was not effectively implemented, as evidenced by the inconsistent availability of PPE supply boxes and the lack of specific EBP indications in residents' care plans. Interviews with the ADONs and the DON highlighted the absence of a robust process to ensure the presence and supply of PPE on each hall. The facility's failure to integrate a comprehensive infection control process placed residents at risk for the transmission of communicable diseases and infections.
Medication Administration Error Due to Transcription Mistake
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services to meet the needs of a resident, specifically in the administration of Sodium chloride. The resident, a male with multiple diagnoses including intracranial injury, neck fracture, hypoxemia, disorientation, chronic respiratory failure, and hyponatremia, was prescribed Sodium chloride 2000 mg every 8 hours following a hospital visit. However, the facility administered an incorrect dose of 1000 mg every 8 hours over several months, from March to July, and missed a dose entirely on one occasion in July. The error originated from a transcription mistake when entering the hospital discharge orders into the facility's electronic medical records (EMR). The admitting nurse or the Assistant Director of Nursing (ADON) was responsible for entering these orders, but there was a lack of clarity on who actually performed the task. The ADON admitted to likely being the one who entered the orders and acknowledged the oversight. The attending physician expected the orders to be entered as per the hospital's summary and noted that no one contacted him to verify or change the order. The facility's policies required licensed nurses to transcribe physician orders accurately and confirm them with the physician if needed. However, these procedures were not followed, leading to the resident receiving an incorrect medication dosage. Interviews with staff revealed a lack of adherence to the policy, as the nurse did not reach out to the physician for clarification, especially given the discrepancy between oral and G-tube administration instructions.
Failure to Notify Family After Resident Fall
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative after an accident involving the resident, which resulted in injury and had the potential for requiring physician intervention. The incident involved a female resident with a history of myocardial infarction, falls, cerebral infarction, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. The resident, who had moderate cognitive impairment, fell in the hallway and sustained a bruise and an abrasion to her face. The family was not notified until the next morning, despite the facility's policy requiring immediate notification. The incident report indicated that the fall occurred at 5:35 PM, but the family was not informed until 10:25 AM the following day. The resident's nurse assessed the injuries immediately but did not notify the family due to the resident's refusal of care and the nurse's failure to remember the notification requirement. The family discovered the injuries during a visit the next morning and expressed their dissatisfaction with the lack of communication, leading them to decide to move the resident to another facility. Interviews with the facility staff, including the Administrator, RN, LVN, ADON, and DON, revealed that the staff were aware of the requirement to notify the family immediately after such incidents. However, the nurse on duty failed to do so, resulting in a misunderstanding and loss of trust between the family and the facility. The facility's policy on fall management clearly stated the need for immediate family and physician notification, which was not adhered to in this case.
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 175 citations issued within 25 miles in the last 12 months — including the 11 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tyler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Rose Trail | 1 mi | ★★★★★ | 23 | 3 |
| Avir At Petal Hill | 1 mi | ★★★★★ | 8 | 2 |
| The Waterton Healthcare & Rehabilitation | 2.6 mi | ★★★★★ | 5 | 0 |
| Providence Park Rehabilitation And Skilled Nursing | 3.2 mi | ★★★★★ | 1 | 1 |
| Avir At Azalea Heights | 3.2 mi | ★★★★★ | 11 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.