Below average — CMS composite of the measures below.
The next survey window likely opens around July 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Parkview Skilled Care And Rehabilitation during CMS and state inspections, most recent first.
Wet food processor container used during puree prep. A dietary employee pureed multiple foods in Kitchen A using a food processor container that had been washed and run through the dishwasher but was still dripping wet. The employee stated she was supposed to let dishes air-dry after sanitizing them and admitted she forgot to do so before using the container. The DM and ADM both stated equipment must be air-dry before food prep, and the facility guideline required sanitized utensils and equipment to air-dry.
Incomplete OOH-DNR forms were found for two residents whose records reflected DNR status. One resident’s form lacked the physician’s license number, date, and signature at the bottom, while another resident’s form had Section B left blank, including the checkboxes identifying the signer’s authority and basis for the order. Staff stated the forms were completed and reviewed by multiple departments, but the ADM had not yet reviewed these two forms.
A resident with advanced dementia, agitation, psychotic disturbance, and elopement risk was moved to a secure/locked unit without an active physician order documenting the criteria for that placement. The DON stated the resident had been assessed, the family/representative agreed, and the move was intended to provide more supervision and a quieter environment, but the required order was overlooked before the transfer.
Medication Cart 1 was observed unlocked on Hall 3, with drawers containing resident medications open and no staff within sight or reach of the cart. CMA C stated she was passing out medication, forgot to lock the cart before entering a resident room, and confirmed it had not been locked. The DON and ADM stated medication carts should be locked when not actively in use, and the facility policy stated medication compartments are locked when not in use.
Failure to Follow Posted Pureed Lunch Menu: A pureed lunch meal was served without all items listed on the approved menu. Observations showed pureed trays included catfish, cowboy beans, and carrots, but no pureed hush puppies or approved substitute. The dietary employee stated she forgot to puree the hush puppies, and the DM, DON, and ADM stated all menu items were required to be served as listed or replaced with an approved substitution.
Failure to use EBP during wound care: A CNA entered a resident’s room without hand hygiene, wore gloves only, and assisted with turning and dressing removal while an LVN performed wound care. The resident had dementia and a chronic coccyx wound with EBP ordered, and the CNA stated he did not think the EBP sign applied to him and was not aware he had to use EBP.
The facility did not ensure that residents and their representatives were invited to participate in care plan meetings, as required by policy. Several residents with varying levels of cognitive impairment and complex medical needs, as well as their family members, reported not being informed or involved in care planning. Documentation lacked evidence of invitations or attendance, and staff could not provide proof of communication regarding care plan meetings.
Twelve residents reported not having access to grievance forms, not knowing about the option to file grievances anonymously, and not being informed about the grievance process. Grievance forms were only available through the DON or AD, and the locked box intended for anonymous grievances was labeled for payments. The grievance procedure was not discussed in Resident Council meetings, and there was no established process for anonymous submissions.
Two residents with documented mental illness diagnoses did not receive accurate PASRR Level I assessments, resulting in the absence of required PASRR Level II evaluations. Both residents had active diagnoses of depression and PTSD, with one also having dementia, but their PASRR Level I forms were incorrectly marked as negative for mental illness. Facility staff confirmed the inaccuracies and the lack of a PASRR policy.
Staff failed to ensure hot foods, specifically tater tots from an outside source, were held and served at the required temperature, as food was placed on the steam table below 135°F and served without verifying temperatures, despite staff training and facility policy requiring hot food to be held at or above 140°F.
A resident with severe cognitive impairment and multiple diagnoses had PRN orders for Lorazepam without a required 14-day stop date or documented justification for extension. Facility staff, including the DON and QA Nurse, confirmed the oversight and indicated that the orders remained active without proper review or discontinuation, contrary to facility policy.
A resident with gastroparesis did not receive metoclopramide as ordered before meals; instead, the medication was administered after breakfast, outside the facility's required time window. The medication aide reported being unable to give the medication before meals due to her schedule, and the DON confirmed the timing did not meet policy requirements.
A CNA failed to change gloves and perform hand hygiene during incontinence care for a resident with multiple chronic conditions, handling clean linen after cleaning the resident without following infection control protocols as required by facility policy.
A LTC facility failed to implement effective abuse prevention policies, resulting in the mishandling of an alleged abuse incident involving a resident with dementia. The resident reported being hurt by an LVN, but the facility did not document or report the incident to the State Agency. The ADM and DON reviewed video footage and concluded no abuse occurred, but did not follow policy to report all allegations. Staff interviews revealed inconsistencies in handling the incident, highlighting deficiencies in the facility's abuse prevention procedures.
A resident with dementia and a pacemaker was allegedly bumped by an LVN, leading to chest pain and swelling near the pacemaker. Despite the resident's distress and a CNA's report, the facility administrator did not report the incident to HHSC, believing it was not abuse. The administrator reviewed video footage and concluded there was no intentional harm, failing to notify the resident's family or implement protective measures.
A resident with severe cognitive impairment and a history of psychotic disorders was subjected to care by a CNA and a nurse aide despite her resistance and combative behavior. The staff failed to follow protocols for handling combative residents, resulting in the resident sustaining a small skin tear and bruising. The facility's policy required stopping care and notifying the charge nurse, but this was not adhered to, leading to the incident being reported to Health and Human Services.
A resident with dementia and severe cognitive impairment displayed combative behavior during a shower, but staff continued with the care, resulting in physical injuries. The care plan did not address the resident's behavior during showers, and staff failed to follow procedures to stop care and notify a charge nurse. The facility's policies for managing behaviors and care plans were not adequately followed, leading to a deficiency in care.
The facility failed to adhere to professional standards for food service safety, with multiple violations observed during a kitchen tour. Issues included improper food storage, unclean surfaces, expired food items, and staff not wearing hair restraints. Both the Dietary Manager and Administrator acknowledged these issues, which could place residents at risk for foodborne illness.
The facility failed to ensure chemicals were not accessible to residents and were not stored with resident toiletries in two common resident baths and one hall. Surveyors observed chemicals like Fabulosa and Mean Green Cleaner stored alongside resident items, and a housekeeping cart with accessible chemicals was left unattended. Staff interviews revealed a lack of adherence to proper chemical storage protocols and a need for staff education on safe practices.
The facility failed to maintain an infection control program as two CNAs did not follow proper hand hygiene protocols during incontinence care for two residents with severe cognitive impairment, increasing the risk of infection and cross-contamination.
The facility failed to address and resolve grievances for a resident with a history of depression and anxiety. The resident reported multiple issues, including a CNA not offering hydration and changing the resident's preferred shower time. Despite these complaints, the facility did not investigate or document the grievances properly, nor did they provide the resident with written decisions or follow-ups as required by their policy.
The facility failed to implement their abuse prevention policies, resulting in a resident being physically and verbally abused by a CNA. Despite being notified, the Administrator did not reassign the CNA to non-patient care duties, and staff members did not report the abuse, believing no action would be taken.
The facility failed to ensure a safe environment and adequate supervision for residents requiring mechanical lift transfers. Staff frequently transferred residents alone, leading to near-fall incidents due to improper use of the lift and sling. The administration and staff were unaware of the proper procedures and did not have clear policies or training in place.
Wet food processor container used during puree preparation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in Kitchen A. During observation of the puree process, the food processor container was washed in a 3-compartment sink and then run through the dishwasher, but it was placed back on the machine and used while liquid was still dripping from the container. This occurred when carrots and cowboy beans were pureed on one day, and again when baked chicken, cornbread, broccoli, and dinner rolls were pureed on the next day. The observations showed the food processor container was repeatedly removed from the dishwasher and used without being allowed to air dry completely. On one occasion, the container was turned upside down and shaken, and liquid was observed falling out before dinner rolls were added and pureed. The dietary employee stated she was supposed to let the food processor container and other dishes dry after sanitizing them, and stated she was responsible for ensuring the container was dry before using it. She also stated she was nervous and forgot to let the container air-dry before using it, and was not aware she had done it the prior day as well. The DM and ADM both stated that all dishes and equipment must be air-dry before being used to prepare food so sanitizer does not get into the food. The DM stated she observed the employee using a wet food processor container during the puree process, and the ADM stated she was aware the employee did not allow the container to air dry before using it. The facility guideline stated that once utensils and equipment have been cleaned and sanitized, they should be allowed to air dry, and that towels may re-contaminate sanitized surfaces.
Incomplete OOH-DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had complete Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms as part of their advance directive records. Resident #74 was admitted with diagnoses including sepsis, atherosclerotic heart disease, and muscle weakness, and the admission record, physician order summary, and care plan all reflected DNR status. However, the OOH-DNR form for this resident did not include the physician’s license number, did not include the date with the physician’s signature, and was not signed at the bottom by the physician. Resident #84 was admitted with diagnoses including acute kidney failure, atrial fibrillation, and heart failure, and the admission record and physician order summary also reflected DNR status. The OOH-DNR form for this resident had Section B left blank, including the checkmark areas identifying the legal basis for the order and the basis for the signer’s authority or knowledge of the patient’s wishes. During interviews, the DON, BOM, RN A, and ADM stated staff were responsible for completing and reviewing the forms, and the ADM stated she had not yet reviewed the OOH-DNRs for these residents. The facility policy stated residents’ choices regarding advance directives should be honored and that residents should have a complete advance directive with all known wishes clearly outlined.
Missing Physician Order for Secure Unit Placement
Penalty
Summary
The facility failed to ensure one resident was free from involuntary seclusion when the resident was moved to a secure/locked unit without a physician order documenting the clinical criteria for that placement. Resident #7 was a female with diagnoses including Alzheimer’s disease, severe dementia with agitation, severe dementia with psychotic disturbance, insomnia, anxiety disorder, and major depressive disorder. Her quarterly MDS showed a BIMS score of 01, indicating severely impaired cognition, and her care plan identified her as high risk for elopement and noted she had attempted to leave the facility several times. The record showed that the resident’s representative signed a secure unit acknowledgment form stating the resident preferred the secure unit and did not wish to move, with elopement risk listed as the reason. On 08/04/2026, the resident was observed in the common area of the secure/locked unit, and RN B stated the resident had been moved there that day for wandering and agitation. During attempted interviews, the resident was unable to state where she was living or whether she knew the door code, and she was not oriented to time or place. The DON stated the facility’s policy was to obtain a physician order before placing a resident in the secure/locked unit, and that the resident had been assessed and found to meet criteria for the unit. The DON also stated the resident’s representative agreed with the move and that the physician order was overlooked and not obtained before the transfer. The order was later entered into the chart, but at the time of the move there was no active physician order for placement in the secure/locked unit.
Unlocked Medication Cart During Medication Pass
Penalty
Summary
Medication Cart 1 was found unlocked during an observation of Hall 3, with drawers 3 and 4 able to be opened and containing resident medications while no staff were within sight or reach of the cart. CMA C was observed opening the door to a resident room and then walking to Medication Cart 1 without first locking it. During interview, CMA C stated she was responsible for the cart at that time, was passing out medication, and forgot to lock it before entering the room. She confirmed the cart had not been locked. The DON stated staff had been trained on medication carts and that training is conducted monthly, including cart cleanliness, storage, and stocking medication. She stated medication carts must be locked if staff walk away and are not within reach or direct eyesight. The ADM stated staff are trained annually and as needed and should lock medication carts when they are not actively being used. Record review of the facility policy titled Storage of Medication Guidelines stated that compartments containing medication are locked when not in use.
Failure to Follow Posted Pureed Lunch Menu
Penalty
Summary
The facility failed to follow the posted Week 5 Tuesday lunch menu for pureed meals by not serving all food items listed on the menu. The menu for the lunch meal included mustard fried catfish, cowboy beans, steamed baby carrots, hush puppies, a lemon wedge garnish, and ambrosia, but the pureed lunch trays observed in the dining room contained mustard fried catfish, cowboy beans, and steamed baby carrots only. No pureed hush puppies were observed on the trays, and no substitute item was served for the missing menu item. During observation, pureed lunch trays were seen in the dining room at 12:15 PM and again at 1:05 PM on the secured unit, and both observations showed the same missing item. In interview, the dietary employee stated she prepared and served the pureed lunch meals and should have served pureed hush puppies with the meal. She stated she realized the hush puppies were missing when she served the last couple of trays and forgot to puree them after getting nervous. She also stated she was responsible for ensuring the hush puppies were served on the pureed trays. The DM stated all food items listed on the meal tickets must be served because the menu was approved by the dietitian and based on residents' requirements. The DON stated all food listed on the meal tickets must be served and match the correct texture for each resident, and that the person serving the tray was responsible for ensuring all food listed on the meal ticket was on the tray before it was given to the resident. The ADM also stated dietary staff must follow the menu and serve all items listed. The facility's Menu Planning Guideline stated menus will be served per the posted menus and, if not available, temporary changes will be noted on the menu substitution sheets.
Failure to Use EBP During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when CNA B did not use Enhanced Barrier Precautions (EBP) during wound care for Resident #9. Resident #9 was an [AGE]-year-old female admitted on 9/21/2022 with a history of irritable bowel syndrome, cough, unspecified dementia, and a pressure ulcer of the sacral region. Her quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment. Physician orders included a clean stage II injury to the coccyx and initiation of EBP for a chronic wound until the wound was resolved. During wound care observation, an EBP sign and PPE storage box were present in the resident’s room, but CNA B entered without hand hygiene and put on gloves only. CNA B assisted in turning the resident and removing her pants while LVN D provided wound care, but did not wear a gown while assisting. After the wound care was completed, CNA B assisted the resident in adjusting in bed. In interview, CNA B stated he had not thought he was trained on infection control, was not aware he had to use EBP with the resident, and had seen the EBP sign but did not think it applied to him. The DON stated staff were trained on EBP and that staff assisting with wound care should use hand hygiene, gowns, and gloves before providing care.
Failure to Involve Residents and Representatives in Care Plan Development
Penalty
Summary
The facility failed to ensure that care plans were developed in consultation with residents and their representatives for four out of six residents reviewed. Specifically, there was no evidence that residents or their family members were invited to participate in care plan meetings. Documentation for care plan meetings was incomplete, lacking information on the date, time, attendees, and invitations for the meetings. Residents and their family members reported not being aware of or involved in care plan meetings, and some were unfamiliar with the concept of a care plan meeting altogether. For example, one resident with paraplegia and multiple medical conditions, who was cognitively intact, stated he had not been invited to a care plan meeting and was unaware of such meetings. His family member also confirmed not being involved or informed about care planning, despite recent acute health events. Another resident with moderate cognitive impairment and complex medical needs, as well as her family member, reported not being informed or involved in care plan meetings, with the family member expressing a desire to participate. Additional residents with moderate cognitive impairment and significant medical diagnoses, including those requiring oxygen therapy and those with Parkinson's disease, also indicated they had not participated in or been informed about care plan meetings. Staff interviews confirmed that care plan meetings were the responsibility of the MDS Coordinator, who stated that invitations were sent via mail or email but could not provide evidence of such communication. The facility's policy required that residents and their representatives be invited to care plan meetings at least quarterly, but there was no documentation to support that this occurred.
Failure to Provide Access and Information on Grievance Procedures
Penalty
Summary
The facility failed to provide residents and their representatives with information regarding their rights to file grievances, including the process for submitting grievances anonymously. During a Resident Council meeting, 12 out of 22 residents reported they did not have access to grievance forms, were unaware of the option to file grievances anonymously, and did not know where or how to submit an anonymous grievance. These residents, all of whom had resided in the facility for over six months, stated that grievance forms were only available by requesting them from the Activities Director (AD), and that the AD typically completed the forms during council meetings when complaints were voiced. The grievance procedure had not been discussed in Resident Council meetings. A review of the facility's grievance policy confirmed that anonymous grievances could be submitted in a locked box on hall 3. However, surveyor observation revealed that the box was labeled for payments and not for grievances, and grievance forms were not available in the hallways. The Director of Nursing (DON), who served as the Grievance Officer, stated that grievance forms were kept in her office and with the AD, and that staff typically completed the forms for residents. The DON also acknowledged there was no established procedure for residents to submit grievances anonymously and was unaware that the grievance process was not being discussed in Resident Council meetings.
Failure to Complete Accurate PASRR Level I Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that all residents with mental illness diagnoses received accurate Pre-admission Screening and Resident Review (PASRR) Level I assessments, resulting in two residents not being properly identified for further PASRR Level II evaluation. Both residents had documented diagnoses of major depressive disorder and post-traumatic stress disorder (PTSD), with one also having dementia. Despite these diagnoses, their PASRR Level I forms incorrectly indicated that they did not have a mental illness. For one resident, medical records showed active diagnoses of depression and PTSD, moderate cognitive impairment, and ongoing treatment with Sertraline for depression. The care plan included interventions for mood problems related to depression, dementia, and PTSD. However, the PASRR Level I form for this resident was marked as negative for mental illness, and no PASRR Level II evaluation was conducted. The second resident also had active diagnoses of major depressive disorder and PTSD, was cognitively intact, and was prescribed Buspirone for anxiety. The care plan included referrals to mental health authorities and therapy. Despite these documented mental health conditions, the PASRR Level I form was marked negative for mental illness, and no PASRR Level II evaluation was completed. Interviews with facility staff confirmed the inaccuracies in the PASRR Level I assessments and the absence of a PASRR policy at the facility.
Failure to Maintain and Monitor Hot Food Holding Temperatures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during a lunch meal. Staff brought in hamburgers and tater tots from an outside source and placed them on the kitchen steam table. When temperatures were checked, the tater tots measured 129 degrees F, which is below the required holding temperature. The dietary manager acknowledged the low temperature and attempted to reheat the tater tots using the fryer. Despite this, staff proceeded to serve the tater tots from the dining room steam table without verifying the temperature of the food being served. Interviews with the dietary manager and another staff member revealed that food temperatures were not checked on the dining room steam table before serving, contrary to facility policy and staff training. Both staff members stated that food should be served at or above 140 degrees F, and acknowledged that the required temperature checks were not performed. The DON confirmed that maintaining proper food temperatures is necessary to prevent spoilage and ensure palatability, and that staff had been trained on these procedures. Facility policies reviewed also specified the required temperature range for hot food holding.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days unless the attending physician or prescribing practitioner documented the appropriateness of extending the order. A resident with severe cognitive impairment, anxiety disorder, Alzheimer's disease, diabetes, and major depressive disorder had multiple PRN orders for Lorazepam Oral Concentrate with indefinite end dates. These orders were not discontinued or reviewed for duration, and no documentation was provided to justify extending the PRN orders beyond 14 days. Interviews with the DON and QA Nurse confirmed that the PRN psychotropic medication orders lacked required stop dates and that staff were responsible for monitoring and auditing such orders. The QA Nurse acknowledged the oversight and indicated that the medication had not been discontinued because she was waiting for a response from the physician. The facility's policy required monthly reassessment of psychoactive medications, but this was not followed in the case of the resident.
Failure to Administer Metoclopramide as Ordered Before Meals
Penalty
Summary
A deficiency occurred when a resident with a history of gastroparesis, acute kidney failure, depression, anxiety, and hypertension did not receive her prescribed medication, metoclopramide, as ordered. The physician's order specified that metoclopramide 10 mg should be administered orally before meals. However, on the date in question, the medication was documented as given at 07:30 AM, but direct observation showed that the medication was actually administered at 08:45 AM, after the resident had already finished breakfast. The medication administration record, pharmacy label, and facility policy all indicated the medication should be given before meals and within one hour of the scheduled time. Interviews with the DON and the medication aide confirmed that the medication was not given at the correct time, with the aide stating she was unable to administer it before meals due to her medication pass schedule. The DON acknowledged that the medication was late and that all nursing staff had been trained on medication administration times. The facility's policy required medications to be given within one hour before or after the scheduled time, which was not followed in this instance.
Failure to Follow Infection Control Protocol During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident. The CNA did not change contaminated gloves or perform hand hygiene before handling clean linen after cleaning the resident, despite being trained to do so. This lapse was observed during incontinence care, where the CNA transitioned from a dirty to a clean task without changing gloves or washing hands, contrary to facility policy and infection control guidelines. The resident involved was a cognitively intact female with a history of chronic respiratory failure with hypoxia, end stage renal disease, and type 2 diabetes, and was frequently incontinent of bowel and bladder. The resident's care plan required peri-care after each incontinent episode. The facility's hand-washing policy specified hand hygiene after contact with body fluids or potentially contaminated items, which was not followed in this instance.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement effective abuse policies and procedures, which resulted in the mishandling of an alleged abuse incident involving a resident. The resident, who had a history of dementia and was severely cognitively impaired, reported being hurt by a staff member, LVN C. Despite the resident's complaint of chest pain and the presence of lumps near her pacemaker, the facility did not document the incident or report it to the State Agency as required by their policies. The incident was not properly investigated or documented by the facility. The ADM, who was responsible for coordinating the abuse prevention program, did not report the incident to the State Agency, believing there was no allegation of abuse. The ADM and DON reviewed video footage and concluded that there was no evidence of abuse, but they did not follow the facility's policy to report all allegations of abuse. Additionally, the ADM did not respond to text messages from LVN D, who assessed the resident and reported her findings, including the resident's pain and swelling. Interviews with staff revealed inconsistencies in the handling of the incident. CNA A reported the incident to the ADM, but the ADM did not take further action to protect the resident or investigate the allegations thoroughly. The facility's failure to report the incident and protect the resident during the investigation process was a significant deficiency in their abuse prevention policies and procedures.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and a Licensed Vocational Nurse (LVN) to the Health and Human Services Commission (HHSC) within the required timeframe. The incident involved a resident with dementia and a pacemaker, who was allegedly bumped by an LVN while the LVN was pushing a wheelchair. The resident complained of chest pain and was observed to have two lumps near her pacemaker, which were tender to touch. Despite these observations, the facility administrator did not report the incident to HHSC, as she did not believe it constituted abuse. The administrator, who was responsible for coordinating the facility's abuse prevention program, was informed of the incident by a Certified Nursing Assistant (CNA) but did not take immediate action to report it. The administrator reviewed video footage of the incident and concluded that there was no evidence of abuse, as the LVN did not intentionally bump the resident. The administrator also did not notify the resident's family or implement protective measures, as she believed there was no allegation of abuse. Interviews with staff revealed that the resident was upset and in pain following the incident, and a Licensed Vocational Nurse (LVN) assessed the resident and administered pain medication. However, the administrator did not respond to the LVN's text messages regarding the resident's condition. The facility's policies require that all suspected or alleged incidents of abuse be reported to the appropriate state agencies, but this was not done in this case, leading to a deficiency in the facility's handling of the situation.
Failure to Prevent Abuse During Resident Care
Penalty
Summary
The facility failed to ensure a safe environment free from abuse for a resident who was combative during care. The resident, who had severe cognitive impairment and a history of psychotic disorders, was subjected to care by a CNA and a nurse aide despite her resistance and combative behavior. The resident was known to exhibit physical and verbal behavioral symptoms, and her care plan indicated she was at high risk for side effects and physical injury due to psychotropic medications. On the day of the incident, the resident was agitated and refused to go to the shower, but the staff continued with the showering process, during which the resident was combative and attempted to hit and bite the staff. The staff involved, CNA A and NA B, did not follow the facility's protocol for handling combative residents, which required stopping care and notifying the charge nurse. Instead, they continued with the shower, restraining the resident's arms to complete the task. This resulted in the resident sustaining a small skin tear and bruising on her hands and forearms. The facility's policy emphasized preventing abuse and required staff to stop care when a resident becomes combative, but this was not adhered to in this case. Interviews with staff and family members revealed that the resident's family had requested to be notified if the resident became combative, but this was not done until after the shower was completed. The facility's failure to follow its own policies and the resident's care plan led to the incident, which was later reported to Health and Human Services. The staff involved were aware of the protocols but did not implement them, resulting in the resident's distress and physical harm.
Deficiency in Dementia Care for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, leading to a deficiency in care. The resident, who had severe cognitive impairment and a history of psychotic disorders, displayed combative behavior during a shower. Despite the resident's resistance and agitation, staff continued with the shower, resulting in physical injuries such as a skin tear and bruising. The resident's care plan was not updated to address her combative behavior during showers, and staff did not follow procedures to stop care when the resident became combative. The incident involved a resident who was admitted with diagnoses including Alzheimer's disease and unspecified psychosis. The resident had a history of aggressive behavior, which was documented in her care plan. However, the care plan lacked specific interventions for managing her behavior during showers. On the day of the incident, the resident was combative, swinging her arms and attempting to hit staff. Despite this, the staff proceeded with the shower, and the resident sustained injuries, including a skin tear and swelling in her fingers. Interviews with staff revealed that they were aware of the resident's combative behavior but did not follow the facility's policy to stop care and notify a charge nurse. The staff involved did not use the call light to request assistance, and the resident's family member, who had requested to be notified in such situations, was not called until after the shower was completed. The facility's policies and procedures for managing behaviors and care plans were not adequately followed, contributing to the deficiency in care.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, surveyors observed multiple violations, including gummy buildup on the fryer, cooked breakfast food stored on top of raw bacon in a stained box, rusted and soiled surfaces, and wet drinking glasses stacked improperly. Additionally, containers of juice and shakes were stored in undrained ice, and dented cans of food were found in the storage area. Expired food items, such as cottage cheese labeled 'Best by 4/29/24,' were also found in the walk-in refrigerator, which had rusted racks and a soiled floor with food debris. The upright dicer had dried food on the blades, and a rear kitchen table had a rusty lower shelf where food equipment was stored. Staff were observed entering the kitchen without hair restraints, handling food items improperly, and storing health shakes in undrained ice. The Dietary Manager admitted to being aware of some of these practices, such as storing cooked food on top of raw food and the use of undrained ice for drinks, but stated that the department was short-staffed and that she tried to do daily rounds. The Administrator was not aware of the issue with containers of cooked foods stored directly on top of containers of raw foods and believed that staff could go by the wall without hair restraints. Both the Dietary Manager and Administrator acknowledged that these issues could place residents at risk for foodborne illness. Record reviews revealed that an in-service training was conducted on 4/11/24, covering topics such as wearing hairnets, cleaning schedules, labeling and dating food items, and cleaning up spills immediately. However, the Dietary Manager admitted that the dietary issues occurred due to staff not knowing or being aware of proper procedures. The facility's current policy on sanitation and food handling outlined the responsibilities of the Food Service Director, but the observed deficiencies indicated a lack of adherence to these procedures, potentially compromising the safety and well-being of the residents.
Improper Chemical Storage in Resident Areas
Penalty
Summary
The facility failed to ensure that chemicals were not accessible to residents and were not stored with resident toiletries and personal items in two of four common resident baths and one of four halls. On multiple occasions, surveyors observed chemicals such as Fabulosa, Mean Green Super Strength Cleaner and Degreaser, Diversity Crew Clean Toilet Bowl Cleaner, and aerosol cans stored alongside resident use items like toilet tissue, hair conditioner, and body wash. These chemicals were found in unlocked cabinets in the 200 and 400 hall baths, posing a risk of chemical exposure to residents. Additionally, a housekeeping cart with accessible chemicals was left unattended in hall 400, further increasing the risk of resident exposure to hazardous substances. Housekeeper A admitted to leaving the cart unattended and acknowledged the potential harm to residents if they came into contact with the chemicals. CNA B also confirmed that cleaners were typically stored on the bottom shelf of the cabinet, mixed with resident toiletries, which could lead to accidental misuse. Interviews with LVN A, the Housekeeping Supervisor, the DON, and the Administrator revealed a lack of adherence to proper chemical storage protocols and a need for staff education on safe chemical storage practices. The facility's policy on storage areas emphasized the importance of maintaining a clean and safe environment, but the observed practices did not align with these guidelines. The report highlights the potential for resident harm due to the improper storage of chemicals and the need for improved oversight and staff training to prevent such incidents in the future.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases. Specifically, two CNAs did not follow proper hand hygiene protocols during incontinence care for two residents. CNA C did not wash her hands or use alcohol-based hand sanitizer before donning clean gloves after removing dirty gloves while providing incontinence care for a resident with severe cognitive impairment and a history of urinary and bowel incontinence. Similarly, CNA D did not wash her hands or use alcohol-based hand sanitizer between glove changes while providing incontinence care for another resident with severe cognitive impairment and an indwelling catheter, increasing the risk of infection and cross-contamination. During the observations, CNA C and CNA D were seen removing dirty briefs, cleaning the residents' peri areas, and changing gloves without performing hand hygiene. CNA D acknowledged that she was trained to wash her hands before and after resident care, after handling soiled items, and between glove changes, but failed to do so during the observed care. The ADM and DON confirmed that staff are trained on hand hygiene upon hire, annually, and as needed, and that improper handwashing could lead to the spread of infection. However, they were not aware of the specific instances of non-compliance observed during the survey. The facility's policies on infection prevention and control, as well as handwashing guidelines, emphasize the importance of hand hygiene, including the use of alcohol-based hand rubs and soap and water. The CDC guidelines also recommend using an alcohol-based hand sanitizer immediately after glove removal. Despite these policies and training, the observed failures in hand hygiene practices by CNA C and CNA D indicate a lapse in adherence to infection control protocols, potentially putting residents at risk for infection and cross-contamination.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances in accordance with its policy for one resident. The resident, who was cognitively intact and had a history of major depressive disorder and anxiety, reported multiple grievances from February 2024 to April 2024. These grievances included issues such as a CNA not offering hydration, leaving the hall unattended, using the wrong lifting technique on the resident's roommate, and changing the resident's preferred shower time. Despite these complaints, the facility did not investigate or document the grievances properly, nor did they provide the resident with written decisions or follow-ups as required by their policy. The resident expressed feelings of neglect and frustration, stating that the staff made it difficult to live at the facility and that their concerns were not being addressed. The resident had communicated these issues to the administrator multiple times, both verbally and through text messages, but did not receive any formal acknowledgment or resolution. The administrator admitted to not following the formal grievance process, citing a personal relationship with the resident as the reason for handling the complaints informally. Interviews with the CNA and other staff members revealed a lack of awareness and communication regarding the resident's grievances. The CNA stated that they were unaware of any issues related to hydration and had not been addressed about the incidents. The administrator and DON also demonstrated a lack of understanding of the facility's grievance policy and failed to ensure that grievances were documented, investigated, and resolved promptly. This failure to follow the grievance policy had the potential to cause residents to feel helpless and diminish their quality of life.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. A confidential staff member knowingly failed to report allegations of abuse regarding a resident to the abuse coordinator after the resident reported that a CNA physically and verbally abused them. The resident stated that the CNA hit them on the head with a closed fist and called them derogatory names. Despite the resident's report, the staff member did not report the incident, believing that the facility administration would not take any action. The Administrator was notified by an HHSC worker about the abuse allegations but failed to reassign the CNA to duties that did not involve patient care. The CNA continued to work their entire shift, and the Administrator only instructed the CNA to avoid the resident who made the allegations. The Administrator admitted to being unaware of the specific requirements of the facility's abuse policy and stated that they would deal with the abuse allegation after the HHSC staff left the facility. Interviews with other staff members revealed that they were aware of the CNA's behavior but did not report it, either because they believed no action would be taken or because they were unsure of the reporting process. The Director of Nursing also stated that they had not received any complaints about the CNA and were unaware of any concerns from the resident. The facility's policies on reporting abuse, protecting residents during investigations, and reassigning staff accused of abuse were not followed, leading to a failure to protect the resident from further harm.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and adequate supervision for residents requiring mechanical lift transfers. Observations, interviews, and record reviews revealed that staff frequently transferred residents alone using a mechanical lift, which required two people for safety. This practice was confirmed by multiple confidential interviews and by the residents themselves, who reported near-fall incidents due to improper use of the lift and sling. Resident #2, a male with Parkinson's disease and seizure disorder, reported that staff often transferred him alone using the mechanical lift, and he nearly fell out of the lift two months prior due to a loose sling strap. Similarly, Resident #3, a female with Parkinson's disease and anxiety, confirmed that staff sometimes transferred her alone, and she had almost fallen out of the lift because the sling strap was not secured properly. Observations of staff using the lift revealed that they did not examine the sling prior to operation nor did they lock the wheels during the transfer. Interviews with the facility's administration and staff indicated a lack of awareness and inconsistent practices regarding the use of the mechanical lift. The Administrator (ADM) and Director of Nursing (DON) were unaware that staff were using the lift alone and did not have clear policies or training in place to ensure the use of two staff members for safety. The MDS Coordinator acknowledged that two staff should be used for safety but admitted that staff were not trained accordingly. The facility's policy and the Hoyer lift manual both emphasized the need for proper assessment and the potential requirement for two staff members during transfers, which was not consistently followed in practice.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Big Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Big Spring Center For Skilled Care | 0.5 mi | ★★★★★ | 7 | 0 |
| Lamun-lusk-sanchez Texas State Veterans Home | 3.6 mi | ★★★★★ | 0 | 0 |
| Focused Care At Hogan Park | 36.3 mi | ★★★★★ | 4 | 0 |
| Focused Care At Midland | 37.2 mi | ★★★★★ | 6 | 0 |
| Mitchell County Nursing And Rehabilitation Center | 37.2 mi | ★★★★★ | 10 | 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 October 2026) and official state health department websites.