Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rayburn Health Care & Rehabilitation during CMS and state inspections, most recent first.
Surveyors observed two medication carts on a secure unit left unlocked and unattended by a certified medication aide, with drawers open, keys left in the lock, and medication cups containing a pill and crushed medication with a brown substance and a wooden spoon sitting on top of one cart. The carts contained OTC products and multiple residents’ bubble-blister medication packets, while several residents and a visitor were in the nearby hallway. The medication aide was in the employee break room away from the carts and later acknowledged responsibility for the carts and awareness of training to keep them locked. The DON and Administrator stated that all nursing staff, including medication aides, are expected and trained to keep medication carts locked when not in use, consistent with the facility’s written policy requiring the carts to be secured during med pass.
Care plans were not revised for several residents when their needs changed. One resident’s diet changed to pureed with nectar/mildly thick liquids, another changed from Full Code to DNR, a third was placed on O2 after a decline, and a fourth returned with a left arm immobilizer/splint after a fall. Records, observations, and staff interviews showed the care plans did not reflect these current orders and interventions.
A medication cart and the med storage room contained expired 0.9% sodium chloride vials and expired lab vials. An LVN, MDS Nurse, ADON, DON, and Administrator all stated the expired items were overlooked, even though staff were responsible for checking carts and the med room for expired meds and supplies.
The facility failed to keep complete medical records for two residents. One resident with dementia, psychosis, and wandering behaviors was on the secured unit without a physician order to reside there, even though the care plan identified elopement risk. Another resident with Alzheimer’s disease and lung disease was placed on oxygen after a decline in condition, but the chart did not contain a physician order for oxygen at the time; an LVN said she received a verbal order from hospice and did not transcribe it right away.
The facility failed to maintain infection control practices for several residents. An LVN performed G-tube care for a resident on EBP without a gown, a CNA entered a resident’s room on Contact Isolation for MRSA without PPE and without hand hygiene, EBP signage was missing for a resident with a hemodialysis catheter, and another resident’s oxygen tubing was found on the floor, not bagged, and later was unlabeled and undated.
Incomplete OOH-DNR Form Left Resident Without a Valid Advance Directive: A resident with dementia, CHF, atrial fibrillation, and convulsions had a DNR order and a care plan for code status, but the OOH-DNR in the record was incomplete because the second witness signature was not dated. The SW and DON stated the form was not valid without that date, meaning the resident would be treated as full code and CPR would be initiated if needed.
A resident with ESRD and a chest dialysis catheter was admitted for outpatient hemodialysis and had a physician order for EBP due to indwelling medical devices. The baseline care plan did not reflect EBP or isolation precautions, and only noted hemodialysis. Staff, including the Regional Nurse, Regional DON, DON, and Administrator, acknowledged the baseline should have been accurate and complete.
Improper Storage of Open Frozen Food Items: Open, unlabeled, and unsealed packages of frozen biscuits and tater tots were found in freezer #4, with the food exposed to the elements. The Dietitian Manager said the biscuits were not resealed after the box was opened, and the tater tots should have been resealed and labeled with the food name, open date, and use-by date. A dietary staff member said she did not know who left the bags open, and the Administrator said staff were expected to close, seal, label, and date open food items.
The facility failed to maintain RN coverage for eight consecutive hours daily and did not have a DON licensed in Texas. The DON held a Florida RN license and a Texas LVN license, but not a Texas RN license. This oversight was discovered through interviews and record reviews, revealing potential risks to resident care due to inadequate nursing oversight.
The facility failed to maintain a clean environment in the secured unit, with observations revealing dusty and debris-laden floors, grime buildup, and inadequate cleaning in resident rooms. Interviews with housekeeping staff indicated they were trained to clean daily, but the Housekeeping Supervisor admitted the unit did not meet cleanliness standards.
The facility inaccurately documented the use of restraints for three residents, indicating Geri-chairs as restraints in their MDS assessments. Observations and staff interviews confirmed that the chairs were not restraints, as the residents did not attempt to leave them. The MDS nurse's misunderstanding of guidelines led to these errors, which were later identified by the Regional RN and DON.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with prostate cancer, hypertension, and PVD. The resident, who required continuous oxygen and was on antidepressants, did not have a care plan initiated, as revealed during a survey. Interviews indicated that floor nurses were responsible for this task, but it was not completed, leaving staff without essential guidance for the resident's care.
A facility failed to implement a comprehensive care plan for a diabetic resident, who was on a low concentrated sweet (LCS) diet. The care plan did not address the inclusion of a health shake, and the resident was given a regular health shake high in sugar without physician approval. The resident refused meals, and there was no documentation of notifying the physician about the need for a change in the care plan.
The facility failed to ensure a safe environment in Hall 200 by improperly storing flammable lighter fluid near the building, accessible to residents and visitors. The Maintenance Supervisor admitted responsibility for ensuring flammable chemicals are stored at least 20 feet away but was unsure who left the fluid there. The Administrator emphasized the importance of correct chemical storage to prevent accidents.
A resident with chronic pain and rheumatoid arthritis did not receive her routine hydrocodone/APAP medication for three doses due to a shortage at the facility. Instead, she was given morphine sulfate, which provided only partial relief. The nursing staff attempted to address the issue by contacting the pharmacy and the resident's physician, but procedural limitations prevented timely access to the emergency narcotic box.
A resident with chronic pain and rheumatoid arthritis missed three doses of hydrocodone/APAP due to the facility running out of the medication. Despite receiving prn morphine, the resident experienced increased pain. The facility had an emergency narcotic box, but it was not accessed due to the lack of a hard copy prescription.
Unsecured Medication Carts and Unattended Medications on Secure Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all drugs and biologicals were stored in locked compartments and kept secured when not in use. During an observation on the secure unit, two medication carts (Medication Carts L and R), both assigned to a single certified medication aide responsible for medication administration on that unit, were found unsecured and unsupervised for four minutes. Medication Cart R was positioned against the wall with its drawers facing the hallway, the lock mechanism extended, and the keys left in place, indicating it was unlocked. Medication Cart L was also against the wall with its second drawer open. On top of Medication Cart L, surveyors observed a medication cup containing a white pill, and another medication cup containing white crushed specks mixed with a brown substance and a wooden spoon, all left unattended. Inside Drawer #1 of both carts were OTC aspirin, vitamins, minerals, and eye drops, and Drawer #2 contained multiple residents’ individual bubble-blister medication packets. At the time, 13 residents resided on the secure unit, with four residents and one visitor present in the hallway approximately 15 feet from the carts. Further observation showed that the certified medication aide responsible for both carts was in the employee break room, approximately 75 feet away from the unlocked carts, during the time they were left unattended. In an interview, the medication aide acknowledged she was in charge of the carts, admitted she had left them unlocked with the keys in the lock on one cart, and stated she had gone to the break room to get a drink of water while medications were set up on top of the cart. She also reported that she had been in-serviced on the requirement to keep the medication cart locked at all times when not in use and recognized that anyone on the secure unit could access the medications. The DON and the Administrator both stated their expectation that nursing staff, including medication aides, follow facility policy requiring medication carts to be locked whenever staff walk away or turn their back, and confirmed that staff are trained during orientation, annually, and as needed on medication administration and securing medications. The facility’s written policy, “Security of Medication Cart,” states that the medication cart shall be secured during medication passes.
Care plans not updated for changed resident needs
Penalty
Summary
The facility failed to review and revise comprehensive care plans for 4 of 18 residents reviewed when resident conditions and orders changed. The report identified that the care plans did not reflect current needs for diet texture and consistency, code status, oxygen use, and immobilizer/splint use after changes were documented in orders, progress notes, observations, and interviews. For one resident with dementia, dysphagia following cerebral infarction, and major depressive disorder, the physician order changed to a low concentrated sweet diet with pureed texture and nectar/mildly thick consistency, but the care plan still reflected an older altered diet order and had not been updated to the new diet. The resident was observed being fed a pureed diet with nectar/mildly thick consistency, and the SLP stated the resident had been on that diet since returning from the hospital and was holding or pocketing food and forgetting to swallow during some meals. For another resident, the record showed a change from Full Code to DNR, including an OOH-DNR form and a physician order for DNR, but the care plan remained coded as Full Code at the time of review. A third resident had a hospice-related oxygen order after a decline in condition, and oxygen at 2 liters per nasal cannula was applied, but the care plan did not include oxygen use or related interventions. A fourth resident returned to the facility after a fall and hospital evaluation with a splint/immobilizer to the left shoulder, upper arm, and elbow, but the care plan did not include the new immobilizer intervention until after surveyor intervention. Interviews with the MDS Nurse, DON, Regional Nurse, and Administrator confirmed that the care plans should have been updated to reflect these changes.
Expired Medication and Lab Supplies Left in Cart and Storage Room
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for the medication storage room and one medication cart. During an observation and interview, Hall 400 medication cart contained 2 opened 0.9% sodium chloride 15 ml vials and 3 unopened 0.9% sodium chloride 15 ml vials that had expired in 04/2025. LVN A stated she was responsible for the cart that day and said the nurse using the cart was responsible for checking for expired medication and items, with the ADON double-checking monthly, but the expired items had been overlooked. During a separate observation and interview, the medication storage room contained 2 individual prefilled 0.9% normal saline vials for injection, 13 red top plastic lab vials, and 5 light green top plastic lab vials, all with expiration dates that had passed. The MDS Nurse stated the facility was no longer using the lab company associated with those vials and said the expired items should have been removed from the medication storage room. She identified the administrative nurses, ADON, MDS Nurse, DON, and the pharmacy consultant as responsible for ensuring the room did not contain expired medication and items. The ADON stated she had reviewed the medication room the day before but the expired items were overlooked. She also stated she had not checked the medication carts that week. The DON and Administrator both stated nurses were responsible for the medication carts and the ADON was responsible for the medication room, with backup checks by leadership and the pharmacy consultant, but the expired medication and items remained in place. The consultant pharmacist’s review noted the carts and medication room were secured, clean, and organized and that expired or discontinued medications were being removed with very few exceptions.
Incomplete Medical Record Documentation for Secured Unit Placement and Oxygen Therapy
Penalty
Summary
The facility failed to ensure that medical records were completely documented for 2 of 7 residents reviewed. One resident with diagnoses including dementia, Alzheimer’s disease, mood disorder, psychosis, and anxiety disorder was observed on the secured unit, and the record showed severe cognitive impairment, hallucinations and delusions, daily wandering, and rejection of care behaviors. Although the care plan identified the resident as at risk for wandering/elopement and placed him on the secured unit, the January 2026 physician orders did not include an order for him to reside on that unit. A second resident with Alzheimer’s disease, lung disorder, and kidney disease was observed with oxygen tubing in place, but the tubing had no date on it. The resident’s MDS indicated severely impaired cognition and no oxygen use during the look-back period. Nursing documentation showed that the resident became non-responsive, had pinpoint and non-reactive pupils, and had vital signs of BP 110/52, pulse 48, respirations 18, and oxygen saturation 95% on room air. Hospice and the RP were notified, and oxygen at 2 liters per nasal cannula was applied. The physician orders for January 2026 did not include an order for oxygen for this resident. During interview, the LVN stated she received a verbal order from the hospice nurse to place the resident on oxygen due to a decline in condition, but the order was not transcribed into the chart until later. The DON stated she expected nurses to transcribe orders, or a resident could not receive the needed care or be inappropriately placed on the secured unit.
Infection Control Failures With Precautions, PPE, and Oxygen Equipment
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for multiple residents. Resident #8 had diagnoses including protein-calorie malnutrition, dysphagia, and gastrostomy tube status, and her care plan and physician orders required enhanced barrier precautions for tube feeding and other high-contact care. During observation of a G-tube dressing change, the LVN performed direct care without wearing a gown, and later stated she forgot to don the gown even though she had been trained on enhanced barrier precautions. Resident #28 was admitted with a cutaneous abscess of the buttock and physician orders included Contact Isolation Precautions for the abscess and MRSA of a wound. On observation, the room had enhanced barrier precaution signage rather than Contact Isolation signage, and the PPE cart at the doorway did not contain needed items such as isolation gowns, a stethoscope and blood pressure cuff, or a digital thermometer. A CNA entered the room without PPE, gave the resident a beverage, used the resident’s cell phone to text a family member, placed the phone on the overbed table, and left without performing hand hygiene. The ADON acknowledged the signage was unacceptable and stated the room should have had a Contact Isolation Precaution sign posted. Resident #39 was admitted with end stage renal disease and had a right chest catheter port for hemodialysis, with physician orders for enhanced barrier precautions due to the indwelling medical device. During observation, the resident was seen leaving her room with a walker and a dressing on her right chest wall, and staff later stated they were unaware she should be on enhanced barrier precautions. The ADON acknowledged there was no signage indicating enhanced barrier precautions at the resident’s door. Resident #35 had diagnoses including Alzheimer’s disease, lung disorder, and kidney disease, and was observed with oxygen tubing and a nasal cannula lying on the floor and not bagged. Later, the oxygen tubing had no date on it or the bag, and staff stated the tubing should have been labeled and bagged when not in use.
Incomplete OOH-DNR Form Left Resident Without a Valid Advance Directive
Penalty
Summary
The facility failed to ensure that the right to formulate an advance directive was provided for one resident reviewed for resident rights. Resident #26, an elderly female admitted with diagnoses including dementia, atrial fibrillation, diastolic heart failure, and convulsions, had a physician order indicating DNR status. Her quarterly MDS showed severely impaired cognition with a BIMS score of 3 out of 15, unclear speech, and only intermittent ability to make herself understood and understand others. Record review showed the resident had a care plan for code status: DNR, and an OOH-DNR form was present in the record. However, the form was incomplete because the second witness signature did not include a date. During observation, the resident was in bed and stated she was doing fine and had no issues. During interview, the SW stated the OOH-DNR should be complete and that the missing date on the second witness signature made the form invalid, meaning the resident would be considered full code. The DON also stated that an incomplete OOH-DNR was not valid and that CPR would have to be initiated against the resident's wishes. The facility policy stated that a DNR order form must be completed and signed by the attending physician and resident or legal surrogate, and the instructions for issuing an OOH-DNR required the form to be signed and dated by two competent adult witnesses. The report also noted that the original or a copy of a fully and properly completed OOH-DNR order is sufficient evidence of the order and must be honored by responding health care professionals.
Incomplete baseline care plan for resident on EBP and hemodialysis
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #39 within 48 hours of admission that included the instructions needed to provide effective and person-centered care. Resident #39 was an [AGE] year-old female admitted with end stage renal disease and had a right chest catheter port for hemodialysis, which was scheduled on Mondays, Wednesdays, and Fridays. A physician order dated 01/06/2026 indicated Enhanced Barrier Precautions (EBP) were to be followed due to indwelling medical devices, and the admission MDS indicated she was receiving hemodialysis and was cognitively intact with a BIMS score of 14 out of 15. Record review of the baseline care plan dated 01/05/2026 showed no indication that Resident #39 was on EBP while a resident, and Section 3A, 1h for isolation or quarantine was left unchecked. Section 3F, 2 indicated only that she required hemodialysis. During observation on 01/19/2026, the resident was seen leaving her room with a walker and had a dressing on her right chest wall, which she identified as her dialysis catheter. During interviews, the Regional Nurse, Regional DON, DON, and Administrator stated that admission nurses completed baseline care plans and that the baseline should have reflected EBP and isolation precautions for the resident.
Improper Storage of Open Frozen Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards in freezer #4 in the kitchen. During observation, an open original cardboard box containing a clear plastic bag of frozen biscuits was found unlabeled and not properly sealed, with the food exposed to the elements. In the same freezer, an open clear plastic bag of frozen tater tots was also found unlabeled and not properly sealed, with the food exposed to the elements. The Dietitian Manager identified the contents of both items during the observation. During interview, the Dietitian Manager stated she was not aware the frozen biscuits had to be resealed once the original cardboard box was opened. She stated the tater tots should have been resealed and labeled with the name of the food item, open date, and expiration or use-by date once opened, and said all kitchen products were expected to be stored correctly and sealed to avoid exposure to the elements. A dietary staff member stated she did not know who left the bags open in the freezer and said used bags of food should be sealed or they could cause freezer burn. The Administrator stated she expected kitchen staff to follow food storage and preparation policies, including closing and sealing all open items and labeling and dating them when opened.
Deficiency in RN Coverage and Licensing
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours, seven days a week, over a period of 140 days. Additionally, the facility did not have a Director of Nursing (DON) licensed in the state of Texas, as required. The DON held a valid RN license in Florida and an active Licensed Vocational Nurse (LVN) license in Texas, but not an RN license in Texas. This discrepancy was discovered through interviews and record reviews, which revealed that the DON assumed her position on September 1, 2023, with a Florida RN license, despite residing in Texas. The facility's failure to maintain proper RN coverage and ensure the DON was appropriately licensed in Texas could place residents at risk of inadequate nursing oversight and care. Interviews with the Board of Nursing (BON) staff and the DON revealed that the DON had attended a college in Florida, which was later identified as being involved in fraudulent activities. The DON claimed to have attended classes in both Texas and Florida, with a waiver in place due to COVID-19, and was unaware of any wrongdoing. The facility's administrator was also unaware of the licensing requirements and the college's involvement in fraud. The administrator believed that the DON's multi-state Florida license allowed her to work in Texas, as both states are part of the Nurse Licensure Compact. However, the BON website indicated that an RN license is required in the state of residency, and the facility's failure to verify this led to the deficiency in staffing requirements.
Facility Fails to Maintain Clean Environment in Secured Unit
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in the secured unit, as observed during a survey. The hall floor was found to be dusty with bits of debris, and there was a significant buildup of grime along the edges of the hallway and sitting area. The dining room floor, which also served as an activity room, was dirty with debris and spilled beverages, and a deteriorated medication patch was found stuck to the floor. Additionally, resident rooms were not properly cleaned, with one room having dirt tracks from a wheelchair and grime buildup around the perimeter, while another room had trash and a heavy layer of dust behind the nightstand, as well as dirt and a dead spider behind the door. Interviews with housekeeping staff revealed that they were trained to clean the halls and resident rooms daily, with two housekeepers assigned to the secure unit each day. However, the Housekeeping Supervisor acknowledged that the secure unit was not clean and did not meet the expected standards. The facility's Operations Policies and Procedures manual, dated 2001, stated that residents should be provided with a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Inaccurate MDS Assessments for Restraint Use
Penalty
Summary
The facility failed to ensure accurate assessments for three residents regarding the use of restraints, specifically Geri-chairs. The MDS assessments for these residents inaccurately indicated the use of physical restraints, which was not the case. Resident #21, a male with dementia and glaucoma, was prescribed a Geri-chair for poor trunk control. Observations and interviews revealed that the Geri-chair was not a restraint as the resident never attempted to get out of it, contrary to what was documented in the MDS assessment. Similarly, Resident #23, a male with dementia and a history of stroke, was also inaccurately assessed as having a restraint. The Geri-chair was used for poor trunk control, and staff interviews confirmed that the resident did not attempt to leave the chair, indicating it was not a restraint. The MDS nurse had been misinformed about the classification of Geri-chairs, leading to the incorrect documentation. Resident #27, a female with dementia, bipolar disorder, and heart disease, was also affected by this documentation error. Her MDS assessment incorrectly noted the use of a restraint, despite staff confirming that the Geri-chair was an enabler, not a restraint. The MDS nurse's misunderstanding of the RAI guidelines contributed to these inaccuracies, which were later identified and acknowledged by the facility's Regional RN and DON.
Failure to Implement Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours, as required by their policy. This deficiency was identified during a survey, where it was found that the resident, a male with a history of prostate cancer, hypertension, and peripheral vascular disease, did not have a baseline care plan initiated prior to the survey intervention. The resident was on continuous oxygen therapy and taking an antidepressant, yet no baseline care plan was in place to guide his care. Interviews with the Director of Nursing (DON) and the Administrator revealed that the responsibility for completing the baseline care plan within 24 hours of admission fell on the floor nurses. However, this was not done for the resident in question. The Administrator acknowledged the importance of baseline care plans in providing staff with essential information to care for new residents effectively. Despite the facility's policy requiring the development of baseline care plans within 48 hours, this was not adhered to, resulting in a lack of guidance for the resident's care needs.
Failure to Implement Comprehensive Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. The resident, who was admitted with diagnoses of diabetes, stroke, and altered mental status, had a physician's order for a low concentrated sweet (LCS) diet with no salt on tray, mechanical soft texture, nectar thick liquids, and chopped meats. However, the care plan did not address the inclusion of a health shake, and there was no documentation of the physician being notified about the need for a change in the plan of care regarding regular health shakes or the resident's refusal of meals or diabetic health shakes. During an observation, the resident refused her lunch meal, and an LVN provided her with a regular chocolate health shake, which was high in sugar, instead of a diabetic health shake. The LVN acknowledged that she should have obtained approval from the physician for the regular health shakes due to their high sugar content. Interviews with the dietary manager and the resident confirmed the resident's diet was LCS, and the resident expressed willingness to try the diabetic shake. The facility's policy required a comprehensive person-centered care plan with measurable objectives and timetables, which was not adhered to in this case.
Improper Storage of Flammable Materials Near Resident Area
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards in Hall 200. During an observation, it was noted that a barbeque pit located approximately 10 feet down the sidewalk from Hall 200 had a shelf with two bottles of lighter fluid, each containing about 4 ounces. These bottles were labeled as flammable and were positioned approximately 2 feet from the building wall, making them accessible to residents and visitors. The Maintenance Supervisor acknowledged that flammable chemicals should be stored at least 20 feet away from the building to prevent accidents and fires, and that he was responsible for ensuring this. However, he was unsure who had left the lighter fluid there. The Administrator expressed a desire for chemicals to be stored correctly or offsite to prevent accidents. A review of the facility's Fire Safety and Prevention policy indicated that flammable items should be stored away from resident living areas and in a locked metal cabinet.
Failure in Pain Management Due to Medication Shortage
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident #32, who required routine pain medication. Resident #32, a female with dementia, chronic pain, and rheumatoid arthritis, was admitted to the facility and had a care plan that included administering hydrocodone-APAP to maintain her pain level at 3 or below on a scale of 1-10. However, on October 20, 2024, the resident missed three doses of her routine hydrocodone/APAP medication due to the facility running out of the medication. This resulted in the resident experiencing increased pain levels, which she reported as being between 3-4, affecting her ability to rest comfortably. The facility's medication administration records indicated that the resident received her morning dose of hydrocodone/APAP on October 20, 2024, but missed the subsequent doses at 12:00 p.m., 4:00 p.m., and 8:00 p.m. Instead, she was given morphine sulfate as a prn medication, which helped alleviate her pain to some extent but was not as effective as her routine medication. Interviews with the resident and nursing staff revealed that the resident was aware of the medication shortage and expressed dissatisfaction with the situation, noting that the morphine provided only partial relief. The nursing staff, including LVN B and LVN A, acknowledged the shortage and took steps to address the issue by contacting the pharmacy and the resident's physician for a refill prescription. However, due to procedural limitations, they were unable to access the emergency narcotic box to provide the needed medication promptly. The Director of Nursing and the Administrator were informed of the missed doses and acknowledged the oversight, emphasizing the importance of timely medication ordering to prevent such occurrences.
Resident Missed Multiple Doses of Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically missing three doses of hydrocodone/APAP 10/325mg on a single day. The resident, a female with dementia, chronic pain, and rheumatoid arthritis, was admitted to the facility with a care plan that included the administration of hydrocodone/APAP for pain management. Despite this, the resident did not receive her scheduled doses at 12:00 p.m., 4:00 p.m., and 8:00 p.m., leading to increased pain and discomfort. Interviews and record reviews revealed that the facility ran out of the resident's prescribed medication after the 8:00 a.m. dose. The resident reported experiencing pain and difficulty sleeping due to the lack of medication. Although the resident was given prn morphine, it was not sufficient to manage her pain effectively. The LVN on duty confirmed that the medication was unavailable and that the pharmacy was contacted to deliver the medication, which arrived the following morning. The facility had an emergency narcotic box available, but the LVN was unable to access it due to the lack of a hard copy prescription, which was required to retrieve medication from the box. The DON acknowledged the missed doses and the use of prn morphine as a temporary measure. The ADM was informed of the situation and emphasized the expectation for timely medication ordering to prevent such occurrences.
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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.
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Nursing homes near Jasper
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Timberidge Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 3 | 0 |
| Shady Acres Health And Rehabilitation Center | 15.5 mi | ★★★★★ | 14 | 4 |
| Avalon Place Kirbyville | 17 mi | ★★★★★ | 7 | 1 |
| Dogwood Trails Manor | 25.3 mi | ★★★★★ | 8 | 0 |
| Woodville Health And Rehabilitation Center | 27 mi | ★★★★★ | 2 | 0 |
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