Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pleasant Manor Healthcare Rehabilitation during CMS and state inspections, most recent first.
Therapeutic menus and portion sizes were not followed for two residents on NAS/CC diets. One resident with severe cognitive impairment, HTN, HLD, and class III obesity, and another resident with severe cognitive impairment, DM, malnutrition, and dysphagia, were both served cornbread and sherbet despite CC menu extensions showing different items for CC diets. The facility also served incorrect portion sizes for multiple menu items, and the CDM stated she was not aware serving sizes differed for the various diets.
A resident with multiple wounds, including bilateral heel DTIs, a right lateral ankle wound, a right lateral foot DTI, a right medial ankle arterial wound, and a right medial foot stage 4 pressure injury, did not receive ordered daily wound care for six treatments on two days. The TAR was blank for all six orders, the responsible nurse no longer worked at the facility, and staff interviews showed therapy did not complete weekend treatments while the DON stated there was no plan for how nursing and therapy coordinated the resident’s wound care.
Failure to Obtain Ordered Daily Weights: A resident with HF, HTN, COPD, and depression did not receive ordered daily weights consistently, despite a care plan intervention to obtain weight as ordered and a physician order for daily weights with MD notification for a 3-lb gain in 24 hours. The resident stated staff sometimes weighed her and sometimes did not, and facility leadership gave differing accounts of who was responsible for the task.
Failure to Ensure Ordered Zofran Was Available and Properly Administered A resident with MI, chronic respiratory failure, weakness, and a BIMS of 15 had an order for Zofran 4 mg QID for nausea, but the medication was not delivered from the pharmacy and doses were still documented as given. The resident said he had been waiting for the medication for weeks and was told he was receiving half tablets from other residents’ supply. A med aide said she signed the dose out without seeing it given, and an RN said she never administered it and had not contacted the pharmacy about the missing medication. A second resident with dementia and severe cognitive impairment had a PRN Zofran order, but 29 tablets were missing from her supply while no doses were documented on the MAR. Interviews confirmed the facility was responsible for obtaining the medication, residents should not share meds, and the facility policy required timely receipt and accurate documentation of medications.
Failure to Employ a Qualified Full-Time Social Worker: The facility’s Licensed Social Worker did not hold a current social work license, even though the job description required an LSW or higher-level license. HR confirmed the USW was hired without current licensure, and the ADM stated she was used as the facility’s social worker, represented herself that way to residents and families, signed psychosocial assessments, and participated in the IDT in that role.
Call lights were left out of reach for two residents with significant cognitive and functional impairment. One resident with Alzheimer's disease, dementia, repeated falls, and dependence for many ADLs was observed in bed with the call light hanging out of reach. Another resident with dementia, gait and mobility problems, and fall risk had the call light hanging over the bed rail and on the floor, and she could not reach it when asked. Staff stated call lights should always be within reach, and the facility policy required placing the call device within the resident's reach before leaving the room.
Failure to Reassess and Report Low BP: A resident with CHF, Alzheimer's disease, and severe cognitive impairment had a BP of 94/39 mmHg, causing a CMA to hold valsartan for parameters below the ordered limits. No repeat BP was obtained, no low BP note was documented in the progress note, and the event was not reported as a change in condition to hospice, despite staff stating that abnormal vital signs should be rechecked, documented, and communicated to the RN/MD or hospice provider.
Broken Foyer Skylights Left in Disrepair: The facility failed to maintain a safe, clean, comfortable, and homelike environment when 2 of 4 foyer skylights were found broken with visible holes and shards covered by tape. The LM, ADM, and FMD gave differing accounts of when the damage occurred and when repairs were initiated, and the FMD stated he did not enter the issue into TELS because he called the roofing company directly.
Failure to attempt a GDR for a resident receiving Quetiapine for depression. The resident had severe cognitive impairment, dementia, aphasia, dysphagia, and weakness, and records showed ongoing antipsychotic use without any documented GDR or clinical contraindication. A consultant pharmacist recommended a trial dose reduction, but the physician response was left blank and staff interviews showed the recommendation was not addressed.
A facility failed to fully care plan a resident's ongoing verbal outbursts and failed to update another resident's care plan after disposable dinnerware was no longer needed. Staff observed the first resident yelling out, grabbing at unseen objects, and being moved away from others when she yelled, while interviews confirmed the behavior was longstanding but not specifically addressed in the care plan. For the second resident, records showed prior dish-washing behaviors had stopped and a note stated foam plates were no longer needed, yet he was still served meals on a foam plate.
Failure to Provide Needed Fingernail Care: A resident with DM, dementia, myopathy, and severe cognitive impairment required partial/moderate help with personal hygiene, but his fingernails were observed long, jagged, and dirty. The resident said nurses refused to cut them, while CNA and RN interviews showed confusion about who was responsible for nail care and that the resident was not on a scheduled nail-trimming date.
A resident with glaucoma, impaired cognition, weakness, and ADL assistance needs was observed shaving herself with a disposable razor and mirror without staff supervision. She later showed surveyors a bag in her purse containing about 5 disposable razors. Staff said they were unaware she had the razors, had not seen her shave before, and daily room checks were missed.
Laundry Room Water Leak Not Addressed: A plumbing line behind the washer in the facility’s only laundry room was observed leaking water onto the floor and into the dirty laundry area, with cloths and blankets placed to soak up the water. Staff reported the leak had been ongoing for months, the FMD had tried Flex Seal spray, and the maintenance logbook and Tels work order report did not document the issue.
A medication cart was left unlocked and unattended in a hallway, with keys on top, while a medication aide was sidetracked. Additionally, the facility's medication storage room was found unlocked and unattended. The facility's policy requires all drugs and biologicals to be stored in locked compartments, accessible only to authorized personnel.
The facility failed to discard expired pantry items in its kitchen, as observed during a survey. Several containers of spices were found with expired dates, which were not discarded as required by food safety standards. Interviews revealed that employees were responsible for labeling food items, but the facility did not adhere to the FDA 2022 Food Code, which mandates discarding food held beyond its expiration date.
A facility failed to ensure a resident's dignity during feeding assistance when an SLP stood over the resident while assisting with eating. The resident, who had Alzheimer's and other health issues, was being evaluated for weight loss. The SLP was unsure about proper feeding assistance protocol, and the facility's training materials lacked guidance on maintaining resident dignity by sitting during assistance.
A facility failed to coordinate PASARR assessments for a resident with severe cognitive impairment and mental health diagnoses. The SW did not assess the resident for PASARR services, and the MDSC did not refer the resident for a Level II PASARR Evaluation. The resident's medical records lacked a P-2 or referral to the LIDDA, and the MDSC failed to retrieve the correct P-1 document indicating a mental illness. This oversight placed residents at risk for exclusion from PASARR services.
A facility failed to include interventions for elopement in a care plan for a resident with severe cognitive impairment and a high elopement risk score. Despite the facility's policy requiring comprehensive care plans, the resident's plan lacked necessary interventions, placing them at risk. Staff interviews revealed a recent change in MDS personnel contributed to this oversight.
A facility failed to maintain clean oxygen equipment for a resident with respiratory issues by not placing the oxygen tubing in a bag when not in use. The resident, who was cognitively intact and had a history of respiratory conditions, expressed a preference for clean equipment. Staff interviews confirmed that the tubing should be changed weekly and bagged, as per physician's orders and facility policy.
A facility failed to monitor a resident's drug regimen by not obtaining a stop date for Cipro, an antibiotic prescribed for a UTI. The resident, with a history of neuromuscular dysfunction and other conditions, received 14 doses without a specified duration. Another antibiotic, Levofloxacin, was later prescribed, but Cipro was not discontinued. Staff interviews revealed a lack of adherence to protocols for obtaining stop dates, and the facility's policy on unnecessary drugs was not followed.
A facility failed to maintain proper infection control when two staff members did not perform hand hygiene between glove changes during peri care for a resident with incontinence. Despite training and policy requirements, this lapse occurred, risking cross-contamination and infection. The resident, with acute respiratory failure and COPD, required careful infection control due to incontinence.
Therapeutic menus and portion sizes were not followed for residents on CC diets
Penalty
Summary
The facility failed to ensure menus were followed to meet residents’ nutritional needs in accordance with established national guidelines for two sampled residents, R50 and R8. R50’s quarterly MDS showed severe cognitive impairment with a BIMS score of 5 out of 15, and the resident had diagnoses of hypertension, hyperlipidemia, and class III obesity. R50’s diet order was NAS/CC with regular texture and thin liquids, and the care plan identified a nutritional problem related to obesity, chronic illness, and therapeutic diet. During observation, R50 was served cornbread and sherbet with lunch, and the facility’s order listing showed 22 residents were ordered a carbohydrate-controlled diet. R8’s quarterly MDS showed severe cognitive impairment with a BIMS score of 1 out of 15, and the resident had diagnoses of malnutrition, diabetes mellitus, and dysphagia. R8’s diet order was NAS/CC with mechanical soft texture and thin liquids, and the care plan identified a potential nutritional problem related to obesity, risk for malnutrition, DMII, GERD, bariatric surgery status, therapeutic diet, and mechanically altered diet. During observation, R8 was also served cornbread and sherbet with lunch. The facility’s Menu Item Substitution Log showed sherbet was substituted for Butter Bars, and the RD approval section was blank. Record review of the Fall/Winter 2025 Menu Extensions showed CC mechanical soft diets were to receive a half square of a Butter Bar and were not to receive cornbread for that meal. The same menu review also showed portion sizes were not followed for multiple items, including chicken spaghetti casserole, pureed meat, and peas, with regular and CC portions differing from what was served. During interview, the CDM stated the diets were liberal diets and later stated she was not aware that serving sizes differed for the different diets. The RD stated there should be CC menu extensions and said she would not have signed them without CC diets.
Failure to Provide Ordered Wound Treatments
Penalty
Summary
Physician-ordered wound treatments were not provided for one resident with multiple wounds. The resident was admitted with diagnoses including cerebral infarction due to embolism, severe protein calorie malnutrition, difficulty walking, cognitive communication deficit, cataracts, glaucoma, and a stage 4 sacral pressure ulcer. The resident’s MDS reflected a BIMS score of seven, indicating cognitive impairment, and the care plan identified six skin integrity problems: unstageable deep tissue injuries to both heels and the right lateral foot, a non-pressure wound of the right lateral ankle, an arterial wound of the right medial ankle, and a stage 4 pressure injury of the right medial foot. The care plan interventions included administering treatments as ordered. The order summary and TAR showed daily treatments ordered for all six wounds, including betadine to both heels and wound cleansing with xeroform, ABD pad, and kerlix gauze to the other wounds. The treatment record for the resident was blank for all six orders on two consecutive days, indicating the treatments were not completed. The nurse who was responsible for the treatments on those days no longer worked at the facility. During observation, the resident had a cushioned boot on the right lower extremity and stated the sore on the foot was painful and had just been treated. Therapy staff stated they did not complete treatments on weekends and nursing was responsible for them, while the DON stated there was no plan for how nursing and therapy worked together for the resident’s treatments.
Failure to Obtain Ordered Daily Weights
Penalty
Summary
The facility failed to ensure that Resident #13 received daily weights in accordance with the resident’s order, comprehensive care plan, and stated need for monitoring related to heart failure. Resident #13 was a cognitively intact female with diagnoses including heart failure, hypertension, chronic obstructive pulmonary disease, and depression. Her care plan included obtaining weight as ordered, and her physician order required daily weights with notification of the MD for a weight gain of 3 pounds or more in 24 hours. Record review showed multiple dates in February and March 2026 when no daily weight was documented for the resident, despite weights being recorded on some other dates. During interview, Resident #13 stated that staff sometimes obtained her weight and sometimes did not, and that weights were needed to monitor swelling in her legs because she had heart failure. The ADON stated charge nurses were responsible for obtaining daily weights and notifying the physician of weight variance, but did not know why the resident’s weight was not obtained daily. The CDON stated charge nurses were responsible for obtaining daily weights and that the DON and ADON were responsible for monitoring completion, while the ADM stated CNAs were responsible for daily weights for Resident #13. The facility policy stated residents are to receive appropriate treatment and services in accordance with a written plan of care.
Failure to Ensure Ordered Zofran Was Available and Properly Administered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring prescribed Zofran 4 mg was accurately acquired, received, dispensed, and administered for two residents. One resident, who had diagnoses including myocardial infarction, chronic respiratory failure, muscle weakness, difficulty walking, and a BIMS score of 15, had an order for Zofran 4 mg four times daily for nausea. His medication administration record showed multiple doses were documented as given even though the medication had not been delivered from the pharmacy, and he stated he had been waiting for the medication since the prior month and was receiving half tablets. He also stated he was told the medication came from other residents because the facility had plenty. Record review and interviews showed the medication was not in the building when staff documented it as administered. A medication aide stated she could not locate the resident’s Zofran in the cart and had signed it out as given because she was told by an RN to do so, although she did not actually see the medication administered. The RN stated she did not give the medication, did not pull it from the emergency cart, and knew the resident had not had any Zofran in the building because it had never been delivered from the pharmacy after being ordered. She also stated she had not contacted the pharmacy to ask why it was not delivered. The investigation found that another resident, who had dementia with a BIMS score of 02 and an order for Zofran 4 mg every 8 hours as needed, had 29 tablets missing from her supply, while her MAR showed no doses administered. Observation showed she had only one tablet left from the original 30-tablet supply. Interviews with hospice, pharmacy, the MD, and facility leadership confirmed that residents should receive their own medications, that the facility was responsible for ordering medications not covered by hospice, and that sharing medications was not appropriate. The facility also had a policy requiring timely receipt of medications and prompt reporting of discrepancies and omissions to the pharmacy.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility with 121 licensed beds failed to employ a qualified social worker on a full-time basis. Survey review showed the facility’s licensed capacity was 132 beds, and the all-staff list identified the USW as the Licensed Social Worker. The job description for the Social Worker position required current licensure as an LSW or higher-level license, and the USW signed that job description on 11/12/2024. Record review and interviews showed the USW did not hold a current social worker license through the Texas Behavioral Health Executive Council. An HR email dated 10/13/2025 documented that HR requested the USW’s social worker license, and the USW replied that she had not gotten it yet and would be testing on 12/8/2025. HR stated the USW was hired on 11/11/2024 and that she did not have a current license. The ADM stated he hired the USW, identified her as the qualified social worker for social services, and said she represented herself to residents, families, and staff as a social worker, signed psychosocial assessments as the social worker, and participated in the interdisciplinary team in that role. He also stated that when she failed her licensure exam in January 2025, he told her she had one more chance to pass before they would need to find a qualified candidate.
Call Lights Left Out of Reach for Two Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach. Resident #20, an 83-year-old female with diagnoses including Alzheimer's disease, repeated falls, lack of coordination, and dementia, had a quarterly MDS assessment showing a BIMS score of 00 and dependence for multiple ADLs. Her care plan identified communication problems related to TIAs, dementia, and difficulty hearing, and included interventions to keep the call light in reach and encourage use of the bell for assistance. During observation, she was lying in bed and her call light was hanging to the right side of the head of the bed, out of her reach. Resident #50 had diagnoses including dementia, abnormalities of gait and mobility, lack of coordination, hypertension, and muscle weakness. Her quarterly MDS assessment showed a BIMS score of 04 and need for supervision or assistance with several ADLs, while her care plan identified fall risk related to poor safety awareness and high-risk medication and included keeping the call light within reach. During observation and interview, her call light was hanging over the left side of the bed rail and on the floor, and she was unable to reach it when asked. Staff interviews showed that LVNs, CNAs, the CDON, and the ADM all stated that call lights should be within reach at all times and that staff entering resident rooms were responsible for ensuring this. The facility policy titled Call Light/Bell Policy stated that the call device should be placed within the resident's reach before leaving the room. Despite these expectations and policy, both residents were observed with call lights out of reach.
Failure to Reassess and Report Low Blood Pressure
Penalty
Summary
The facility failed to reassess, report, and document a change in condition for Resident #19 after a low blood pressure reading was obtained. Resident #19 was a [AGE]-year-old male admitted with congestive heart failure, Alzheimer's disease, and muscle weakness, and his BIMS evaluation reflected severely impaired cognition. On 01/30/2026 at 10:10 AM, his blood pressure was 94/39 mmHg sitting in the right arm, and the ordered Valsartan 320 mg was held by the medication aide because the blood pressure was below the medication parameters. No additional blood pressure readings were taken after the low reading, and no note of low blood pressure was documented in the resident's progress note. Interviews with staff reflected that abnormal vital signs were expected to be rechecked, reported to the charge nurse, and communicated to the physician or hospice provider when appropriate, but the low blood pressure event for Resident #19 was not reported as a change in condition to hospice on that date. The facility policy stated that when a CMA holds a blood pressure medication because parameters are low, the licensed nurse must be notified and intervene as appropriate, including rechecking vital signs and informing the physician or hospice provider.
Broken Foyer Skylights Left in Disrepair
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when 2 of 4 skylights in the foyer were found broken with visible holes and broken shards underneath tape that had been placed over the damage. During observation, the foyer skylights were noted to be in disrepair, and the condition was documented as having existed for an unknown amount of time. The report states that the broken skylights were visible from the facility front entrance area and that the condition could affect residents, staff, or visitors entering through the front doors. During interviews, the LM stated the skylights had broken due to wind and that he did not remember exactly when they broke, though he thought it was at the beginning of 2026. He also stated he was not sure when the maintenance director contacted a contractor to measure and replace them. The ADM stated the skylights had just been fixed and later said he could not find documentation showing the facility had reached out for the skylights to be repaired before the survey team arrived. The FMD stated he identified the broken skylights on Monday, contacted the roofing company, and that the company measured and installed new skylights on Wednesday. He also stated he did not enter the issue into the TELS system because he called the roofing company directly. The facility policy stated that repair requests may be entered into the TELS system to create a work order.
Failure to Attempt GDR for Psychotropic Medication
Penalty
Summary
The facility failed to ensure Resident #9 was free from unnecessary psychotropic medication use when it did not attempt a gradual dose reduction (GDR) for Quetiapine Fumarate and did not document that a GDR was clinically contraindicated. Resident #9 was a male resident with unspecified dementia, lack of coordination, aphasia, dysphagia, and muscle weakness, and his BIMS score was 04, indicating severe cognitive impairment. His quarterly MDS reflected that he was taking an antipsychotic medication on a routine basis, and the care plan addressed psychotropic medication use with a goal to reduce psychoactive medication use through the review date. Physician orders showed Quetiapine Fumarate 200 mg by mouth twice daily for depression, started on 06/01/2024, and the medication administration record showed he continued to receive it in March 2026. Record review showed there had been no GDR for the medication. A consultant pharmacist communication dated 05/19/2025 recommended evaluating the resident for a trial dose reduction and suggested reducing Quetiapine 200 mg BID to 150 mg BID, but the physician response area was blank. In interviews, the MD stated he had started with the facility in June 2025 and would need to review the resident’s records and behaviors to determine whether a GDR would be beneficial; the CDON stated pharmacy recommendations were reviewed by the nurse practitioner or physician, but she was not sure why this resident’s GDR recommendation was not addressed; and the ADM stated the DON/ADON were responsible for monitoring GDRs and pharmacy recommendations.
Incomplete care planning for resident behaviors and dining needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #25 that addressed her verbal behaviors and included measurable objectives and timeframes. Resident #25 was a [AGE]-year-old female with diagnoses including non-Alzheimer's dementia, malnutrition, hyperlipidemia, diabetes mellitus, and anemia. Her quarterly MDS indicated she was rarely or never understood, and the behavior section did not identify verbal, physical, or other behavioral symptoms during the look-back period. Her comprehensive care plan included a focus on communication problems related to hearing deficit and impaired cognition/dementia, along with a psychotropic medication focus, but the documented interventions did not specifically address her yelling out or include interventions tied to those behaviors. During observations, Resident #25 was seen in her room screaming out while lying in bed without other apparent signs of pain or distress, and later was observed in the sitting room grabbing at things that were not visible and occasionally screaming out. Staff interviews confirmed that yelling out was a normal and ongoing behavior for her. An LVN stated the resident had been yelling out since she began working at the facility, that the resident was often placed in the living area to watch television, and that the resident yelled for no particular reason. A CNA stated the resident would pull on things, reach for things that were not there, and yell, and that staff would take her back to her room if she yelled around other residents. Another LVN stated the resident would mumble, staff could not understand her, and yelling had always been her normal behavior, but the root cause was unknown. The MDSC stated she was responsible for comprehensive care planning and believed the verbal outbursts may have become so normalized that they were not documented by direct care staff, which prevented them from being reflected on the MDS and then translated into the care plan. The ADM stated that yelling out was a behavior discussed almost every morning, but it failed to be care planned. The CDON stated she did not know what interventions were determined to help manage or reduce the yelling, and that individualized interventions should have been documented in progress notes and listed in the care plan if they were effective. The facility policy required the interdisciplinary team to develop a comprehensive person-centered care plan with measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The facility also failed to update Resident #65's care plan to reflect that he no longer required disposable dinnerware. Resident #65 was a 79-year-old male with diagnoses including alcohol use, alcohol polyneuropathy, dementia, and type 2 diabetes. His quarterly MDS showed severe cognitive impairment with a BIMS score of 01, and he required supervision or touching assistance with eating and used a wheelchair. His care plan had documented prior behaviors involving washing dinnerware in the toilet and being provided disposable plates only, but those behaviors were later marked discontinued as no longer applicable. A progress note stated that the resident had no current behaviors of washing dishes in the toilet and no longer needed Styrofoam plates for meals. Despite that, an observation showed him being served lunch on a foam plate in the dining room, and staff interviews indicated they were unaware of why he was still receiving foam plates.
Failure to Provide Needed Fingernail Care
Penalty
Summary
The facility failed to ensure Resident #12, who was unable to complete activities of daily living independently, received needed grooming care when his fingernails were not trimmed or cut. Resident #12 was an [AGE] year-old male admitted on [DATE] with diagnoses including diabetes mellitus, unspecified dementia, myopathy, and unspecified abnormalities of gait and mobility. His MDS reflected a BIMS score of 07, indicating severe cognitive impairment, and he required partial/moderate assistance with personal hygiene. His care plan and bedside Kardex directed staff to physically assist with all ADLs as needed. During observation on 03/03/2026 at 10:44 AM, Resident #12 was noted to have long, jagged fingernails extending past his fingertips with black dirt and debris under them. He stated the nurses refused to cut his fingernails and that he did not like them long. Interviews with CNA A, RN C, the CDON, and the ADM showed confusion about who was responsible for nail care, with staff stating that CNAs should not clip diabetic residents' nails, that nurses were responsible for clipping, and that Resident #12 was not on a scheduled date for trimming. The facility policy stated that residents unable to carry out ADLs should receive necessary services to maintain good nutrition, grooming, and personal oral hygiene from qualified staff.
Unsafe Self-Shaving and Unsecured Razors
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for one resident who kept disposable razors in her possession and used them without supervision. Resident #77 had diagnoses including high blood pressure, renal insufficiency, hyponatremia, glaucoma, muscle weakness, and cognitive communication deficit. Her MDS reflected she needed partial/moderate assistance with oral hygiene, dressing, and personal hygiene, and her BIMS score was 12, indicating moderately impaired cognition. Her care plan identified her as at risk for impaired visual function related to glaucoma and as having an ADL self-care performance deficit related to weakness, unsteady gait, and impaired cognition. During observation, the resident was seen shaving herself with a disposable razor while holding a handheld mirror and using outside light to see, and she was able to shave her chin for about 5 minutes without staff approaching her. In interviews, she stated she had glaucoma, used eye drops, and kept a plastic bag of approximately 5 disposable razors in her purse, which she showed to the surveyor. Staff stated they were not aware she had disposable razors in her possession, that they had not previously seen her shave herself, and that no one was assigned to check her room daily, so daily checks were missed.
Laundry Room Water Leak Not Addressed
Penalty
Summary
The facility failed to maintain dry, water-leak-free conditions in its only laundry room, where a plumbing line on the dirty side behind the washing machine was observed leaking water onto the floor and into the dirty laundry collection room. During the observation, a blue cloth was placed at the back of the main leak area to soak up water, and white blankets were placed at the corners of the washing machine nearest the wall to absorb water from the leak. Laundry Service Staff I stated the leak had been occurring since around the end of December 2025 and that she had notified the FMD at that time. She reported that she had been using dry blankets to soak up the water while the leak continued from the main water line behind the washing machine and sometimes flowed into her work area. The FMD stated Staff I reported the leakage to him two weeks earlier and that he had applied Flex Seal spray, but the leak started again. The FMD described the leak as minor and said it could be dried with a blanket. The ADM stated the unresolved leak could pose a fall hazard to laundry staff. Review of the maintenance logbook and Tels work order report did not address the laundry room water leak.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely, as observed on 01/08/2025. A medication cart was left unlocked in the hallway outside a resident's room, with the keys placed on top, while the medication aide (MA B) was inside a restroom washing hands and obtaining gloves. This action left the medications accessible to unauthorized individuals, including residents, staff, and visitors. Additionally, the facility's only medication storage room was found unlocked and unattended, further compromising the security of medications. Interviews with MA B and the Director of Nursing (DON) revealed that MA B was aware of the policy to never leave a medication cart unlocked and unattended, but was sidetracked while looking for gloves. The DON confirmed that the medication storage room should have been locked and that staff had been instructed to keep medication carts locked and keys on their person. The facility's policy mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel, to prevent unauthorized access and potential drug diversion.
Failure to Discard Expired Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in its only kitchen, as observed during a survey. Specifically, the facility did not ensure that expired pantry items were discarded, which could potentially place residents at risk for health complications and foodborne illnesses. During an inspection of the kitchen pantry, several containers of spices, including Italian Seasoning, Parsley Flakes, Ground Cumin Seeds, Ground Turmeric, and Curry Powder, were found with expired dates written on them. These items were not discarded as required by food safety standards. Interviews with the Dietary Manager (DM) and Assistant Dietary Manager (ADM) revealed that employees were responsible for labeling food items with the received date, date of opening, and expiration date if a use-by date was not printed on the product. The facility claimed to follow guidance from the Texas Food Establishment Rules (TFER). However, a review of the FDA 2022 Food Code indicated that food held beyond its labeled use-by or expiration date must be discarded, and expired food often falls into the category of unsafe food that should be discarded. The facility's failure to discard expired food items was a direct violation of these standards.
Failure to Ensure Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure the dignity and independence of a resident during a dining experience. Specifically, a Speech-Language Pathologist (SLP) stood over a resident while assisting her with eating, which compromised the resident's right to be treated with respect and dignity. The resident, an elderly female with Alzheimer's, difficulty in walking, muscle weakness, cognitive communication deficit, and osteoporosis, was observed during a lunch service where the SLP was conducting an evaluation due to the resident's recent weight loss. The SLP admitted to being unsure about whether she should sit or stand while assisting the resident, indicating a lack of clarity in training. The Director of Rehabilitation (DOR) stated that the expectation was for staff to be seated while assisting residents with feeding, although this was not explicitly covered in evaluations. The facility's feeding checklist for training staff did not include instructions for staff to sit while providing feeding assistance. This oversight in training and practice led to the failure in promoting the resident's dignity and independence during meals.
Failure to Coordinate PASARR Assessments for a Resident
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program for Resident #63, who was reviewed for PASARR services. The social worker (SW) did not assess Resident #63 for a referral for PASARR services based on his behaviors. Additionally, the Minimum Data Set Coordinator (MDSC) did not refer Resident #63 for a Level II PASARR Evaluation by the local Local Intellectual and Developmental Disability Authority (LIDDA). This oversight placed residents at risk for exclusion from PASARR services. Resident #63, a male with severe cognitive impairment, was admitted to the facility with diagnoses of Depression, Unspecified, and Schizophrenia, Unspecified. Despite these diagnoses, the SW was unaware of them and did not refer the resident for a P-2 evaluation. The resident's medical records did not reveal a P-2 or referral to the LIDDA. The MDSC, who was responsible for PASARR eligibility and referrals, failed to retrieve the correct P-1 document from the Simple database, which indicated the presence of a mental illness (MI). This error resulted in the absence of a P-2 submission for the LIDDA. The facility's administrator stated that the SW and MDSC were responsible for PASARR eligibility and referrals. The facility followed PASARR division guidelines, and safeguards such as team meetings and MDSC checks were in place. However, the failure of the SW to assess the resident for MI and the MDSC's failure to retrieve the correct P-1 document from Simple were identified as process failures. The CMS RAI Manual requires a Level II Resident Review Evaluation referral for individuals exhibiting symptoms suggesting a mental illness diagnosis.
Failure to Address High Elopement Risk in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident identified as being at high risk of elopement. The resident, a male with severe cognitive impairment, was assessed with a high elopement risk score of 14. Despite this assessment, the resident's care plan, last revised in October 2024, did not include any interventions for elopement or wandering. This oversight placed the resident at risk of having unmet needs related to their safety and well-being. Interviews with facility staff revealed that the responsibility for creating care plans lay with the MDS Coordinator. However, due to a recent change in personnel, the Director of Nursing acknowledged that the resident's care plan did not address the elopement risk. The MDS resource, who had been in the position since 2019, confirmed that residents with any risk of elopement should have specific interventions included in their care plans. The facility's policy mandates that a comprehensive care plan be developed within seven days of completing the resident's minimum data set, which was not adhered to in this case.
Failure to Maintain Clean Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not placing the resident's oxygen tubing in a bag when not in use. This oversight was observed during a survey, where the oxygen tubing was found laying on top of the concentrator and not dated. The resident, who was cognitively intact, expressed that the nurses generally changed her oxygen tubing weekly, but she preferred it to be clean due to her respiratory condition. The resident had a history of heart failure, acute upper respiratory infection, obstructive sleep apnea, and shortness of breath, and her care plan included interventions for oxygen therapy as ordered by the physician. Interviews with facility staff, including an LVN and the DON, confirmed that the oxygen tubing should be changed weekly and kept in a bag when not in use, as per the physician's order and facility policy. The DON stated that staff were educated on these procedures, and the facility policy required oxygen equipment to be maintained in a clean and sanitary manner. The failure to adhere to these standards could lead to respiratory infections, as noted by the staff, although the report does not specify any direct consequences for the resident involved.
Failure to Monitor and Discontinue Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was adequately monitored and free from unnecessary drugs. Specifically, the facility did not obtain a stop date for an antibiotic, Cipro, prescribed to a resident for a urinary tract infection. The resident, a male with a history of neuromuscular dysfunction of the bladder, hypertension, legal blindness, and a history of brain cancer, was prescribed Cipro starting on January 1, 2025, but the order lacked a specified duration for the antibiotic therapy. The resident's care plan indicated that the Cipro was intended for a short-term treatment of 5 to 7 days, yet the medication administration record showed that the resident received 14 doses without a stop date being clarified. Additionally, another antibiotic, Levofloxacin, was prescribed for a different infection, but the facility did not discontinue the Cipro when the new antibiotic was ordered. Interviews with facility staff, including an LVN, the DON, and a PA, revealed that there was a lack of adherence to the protocol of obtaining stop dates for antibiotics, and the oversight was not caught until later. The facility's policy on unnecessary drugs, which requires that each resident's drug regimen be free from unnecessary drugs, was not followed. The failure to obtain a stop date for the Cipro and the concurrent use of two antibiotics without proper coordination could potentially lead to negative effects, although no immediate adverse effects were noted for the resident during the time of the deficiency.
Inadequate Hand Hygiene During Peri Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA C and NA D during peri care for Resident #75. During an observation, both staff members did not wash their hands or use alcohol-based hand sanitizer when changing gloves while removing a soiled brief and applying a clean brief. This lapse in protocol occurred despite the facility's policy, which requires hand hygiene after removing gloves, and the training provided to staff on infection control measures. Resident #75, a cognitively intact [AGE] year-old female, was admitted with diagnoses including acute respiratory failure and chronic obstructive pulmonary disease. Her care plan highlighted the need for vigilant infection control due to her bowel and bladder incontinence. Interviews with the involved staff and the Director of Nursing (DON) confirmed that the expected procedure was not followed, posing a risk of cross-contamination and potential infection to the resident.
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 252 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waxahachie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care Of Waxahachie | 3.3 mi | ★★★★★ | 11 | 1 |
| Legend Oaks Healthcare And Rehabilitation - Waxaha | 5.8 mi | ★★★★★ | 9 | 0 |
| Midtowne Meadows Health & Rehab | 11.6 mi | ★★★★★ | 1 | 0 |
| Midlothian Healthcare Center | 11.6 mi | ★★★★★ | 2 | 0 |
| Renaissance Rehabilitation And Healthcare Center | 11.9 mi | ★★★★★ | 4 | 0 |
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.