Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Richardson Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure call lights were accessible for four residents with significant fall risks, cognitive impairment, mobility issues, and, in one case, COPD requiring PRN O2. Observations found call lights on the floor, behind a headboard, hanging on a headboard, or wrapped and hanging off the wall while residents were in bed, despite care plans requiring call lights to be within reach and used for assistance. One cognitively intact resident reported she typically walked to the nurses’ station if her call bell was not answered promptly. The DON, an LVN, and a CNA all acknowledged that call lights should always be within reach so residents can call for help, and facility policy required staff to ensure call light accessibility at the bedside.
Surveyors found that two cognitively intact residents with COPD and physician orders for oxygen therapy did not have their nasal cannulas stored according to facility policy and professional standards. One resident’s nasal cannula, connected to an oxygen concentrator, was observed lying on the floor under the bed, and another resident’s cannula was left hanging on the concentrator when not in use, despite the resident stating it should be bagged. The DON, an LVN, and a CNA all stated that nasal cannulas are expected to be bagged and dated when not in use to keep them clean, and the facility’s oxygen policy requires delivery devices to be covered in a plastic bag when not in use.
Two male residents with neuromuscular bladder dysfunction and suprapubic catheters were observed with Foley catheter drainage bags that were either hanging from the bed frame or lying on the floor without required privacy covers, despite physician orders, care plan interventions, and facility policy mandating that catheter bags be covered at all times to maintain dignity and privacy. One resident reported his bag was never usually covered and that no one had informed him it should be, while the other acknowledged the bag should not be on the floor but expected it to be changed soon. The DON, an LVN, and a CNA all confirmed that catheter drainage bags should be covered and not touching the floor, consistent with the written catheter care policy.
A cognitively intact male resident with allergic rhinitis and hypertension had an ordered zinc oxide 20% ointment for PRN use on buttock redness, and his care plan noted his desire to keep personal cream at bedside with interventions for education and evaluation of self-administration ability. During observation, the zinc oxide tube was found on his bedside table, and he reported using it on multiple body areas and that staff also used it during care. The DON, an LVN, and a CNA each stated that residents should not have medications in their rooms and that medications should be stored in locked medication carts or areas unless there is an assessment and physician order for self-administration, consistent with the facility’s policy requiring all drugs and biologicals to be stored in locked compartments accessible only to authorized personnel. This resulted in a failure to comply with medication storage requirements for drugs and biologicals.
A resident with diabetes, peripheral vascular disease, and a sacral wound present on admission had physician orders for daily sacral wound care on the day shift, including cleansing, application of betadine and calcium alginate, and a dry dressing. Review of the TAR showed multiple consecutive days with no documented wound care, and the resident’s care plan and MDS lacked any wound-related problems, goals, or interventions. During observation, the wound dressing was soiled, undated, and uninitialed, and the Wound Nurse reported that the treatment had been done on the night shift instead of the ordered day shift. Both the Wound Nurse and the DON stated that dressings must be dated and that failure to do so could result in skipped wound care and possible infection, contrary to facility policy requiring treatments to follow MD orders and be documented on the TAR or in the EHR.
Surveyors found that staff failed to follow the facility’s infection prevention and control policies when a medication aide stored personal items, including a phone, portable fans, and deodorant spray, on a medication cart, and a CNA provided high-contact care to a resident on enhanced barrier precautions without wearing required PPE such as a gown and gloves. Multiple staff, including the DON, ADON, LVNs, and CNAs, acknowledged that personal items are not permitted on medication carts and that appropriate PPE must be used for residents on EBP, consistent with the facility’s written infection control program.
A resident on hospice with Alzheimer’s disease, aphasia, and prior stroke pulled out a G-tube and was sent to the ER for replacement after an MD order and ambulance transport were arranged. Nursing staff notified the hospital ER and the resident’s representative, but did not notify the hospice agency, and the transfer form reflected no hospice contact. A hospice representative later confirmed they were not informed, while the DON stated nurses were expected to notify hospice of changes in condition or hospital transfers and that this requirement was outlined in the facility’s hospice coordination policy.
A resident's vital signs were left exposed on an unattended med cart in the hallway while an MA moved between rooms and administered meds, and the MA acknowledged the information should have been secured. In a separate event, a cognitively intact resident who required a mechanical lift was transferred in the hallway by two CNAs, allowing others to see the lift transfer and the resident's dependence on staff.
Unclean resident rooms and hallways, along with a missing personal item, led to deficiencies. Observations found stained hallway carpets, dirt and stains in multiple resident rooms, and air conditioning units covered with dust and debris, with some broken vents or filters. Staff said they were responsible for cleaning the full room, but the housekeeping supervisor said stains remained because the floors were old. The facility also lost a resident’s stainless-steel bedpan after a room move; the resident had intact cognition, needed bedpan assistance, and said the plastic substitute spilled and pinched her skin.
Inaccurate MDS Coding for Hospice, Oxygen, and AVAPS Use: The facility failed to ensure MDS assessments accurately reflected a resident on hospice, a resident receiving oxygen, and a resident using AVAPS. Records, observations, and staff interviews showed the services were in place and documented in care plans, physician orders, pulmonary notes, and bedside observations, but were not coded on the MDS assessments.
Incomplete Care Plans for Oxygen, CHF, AVAPS, and Enteral Feeding: The facility failed to include key needs in several residents’ care plans. One resident using O2 had no oxygen therapy plan, another with CHF had no CHF care plan, a resident using AVAPS had no ventilator plan, and a resident receiving enteral feeding had no feeding plan and no fall-prevention intervention for the bed to be in the lowest position. Staff interviews and record review confirmed the missing care plan elements.
Unsecured fall protection, smoking supervision, and germicidal wipes: A resident with significant fall risk was observed with a fall mat missing from one side of the bed despite an order for mats on both sides. Several residents who smoked were observed outside without active supervision even though their care plans required supervised smoking, and multiple smoking assessments were not current. In addition, two LPNs left germicidal wipes on top of unattended carts, and staff confirmed the wipes should have been secured inside the carts.
A facility failed to ensure respiratory equipment was stored properly when not in use for three residents receiving oxygen or nebulizer treatments. A nasal cannula for one resident with chronic pulmonary edema was found unbagged after transfer, another resident’s nasal cannula was left on the bed unbagged, and a breathing mask for a resident with CHF was left on top of a nebulizer unbagged. Staff stated the equipment should have been bagged to prevent contamination, and the facility policy required delivery devices to be covered in a plastic bag when not in use.
Missing assessment and consent for bed grab bars: The facility had no evidence of assessment, risk/benefit review, or informed consent for grab/enabler bars on the beds of 4 residents. Care plans referenced side rails or enabler bars for bed mobility and repositioning, but the assessment and miscellaneous records contained no related documentation. During observation, bilateral grab bars were present on the beds of residents with significant mobility and cognitive impairments, including one resident who reported being repositioned by staff every few hours.
Food safety deficiencies were identified in the kitchen when a tea dispenser was left uncovered, an unlabeled Styrofoam container was found in the refrigerator, and the ice machine and ice scoop holder showed visible staining and discoloration. An ice chest on a hall also had stains and a scoop stored inside the ice. The dishwasher rinse temperature was observed far below the manufacturer-required 180 degrees.
Staff failed to follow infection control practices during resident care for three residents. Two CNAs prepared to transfer a cognitively intact resident with muscle weakness without hand hygiene before donning gloves, an LVN administered g-tube medication to a resident on EBP without wearing a gown, and a CNA handled soiled linen during incontinent care and then touched clean items without changing gloves. The residents involved were cognitively intact and had needs including mechanical lift transfers, a feeding tube, and bladder and bowel incontinence.
Incorrect Discharge Documentation: A resident with HF and Type 2 DM was documented as leaving AMA, but record review and staff interviews showed the discharge was actually planned, with the MD approving discharge home and home health arranged. The SW initially described the discharge as AMA, then acknowledged the documentation was incorrect and that the resident had been discharged home with family support.
MDS assessments for two residents were completed but not transmitted on time. One resident had a Quarterly MDS left in process and overdue, and another had a Quarterly MDS left in export-ready status; both residents had significant neurologic, psychiatric, and medical diagnoses. The MDS Nurse said the EHR alert stopped once an assessment was started and did not alert her when assessments were not completed or transmitted, and the Adm confirmed the MDS Nurse was responsible for timely completion and transmission.
Wound Care Not Performed per Protocol: A resident with a right heel wound, severe cognitive impairment, and other diagnoses had a physician order for daily cleansing and dressing changes. During observation, the Wound Nurse used the same gauze to cleanse both the inside of the wound and the outer edge, despite the facility’s wound cleaning procedure requiring cleaning from the center outward and using one gauze per stroke. The DON confirmed the proper method and stated the nurse should have used separate gauze to avoid contamination.
Failure to provide ordered pressure injury prevention care was identified for a resident with diabetes, Alzheimer's disease, seizures, severe cognitive impairment, extensive ADL dependence, and tube feeding. Although the TAR showed foam boots were applied to both heels every shift to prevent pressure ulcers, observation found the resident in bed without the boots in place. The LVN stated the boots were needed because the resident was bedbound, while a CNA said she was unaware of the order and the DON stated staff were responsible for ensuring the boots were in place.
Missing Physician Orders for Catheter Care: A resident with neuromuscular bladder dysfunction and severe cognitive impairment had an indwelling catheter documented on the MDS and catheter care listed in the care plan, but the physician order record lacked orders for catheter care, emptying the bag, infection monitoring, urine assessment, leakage checks, and securing the catheter. Staff and leadership acknowledged the missing orders and stated the catheter-related orders were not re-entered after the resident returned from the hospital.
A resident with a G-tube, severe cognitive impairment, and total dependence for nutrition was observed sleeping without the ordered abdominal binder in place, leaving the tube unprotected. The resident’s care plan and physician order required the binder every shift, and staff interviews confirmed it was expected to be on at all times to prevent the resident from pulling out the G-tube.
Failure to Document Administered Medications on MAR: A resident with heart disease, HTN, and dementia had morning doses of Amlodipine, Carvedilol, and Clonidine administered by an ADON, but the MAR was not updated to reflect the meds were given. An LVN was unsure whether the meds were missed or simply not documented, and the DON confirmed the MAR had not been signed after administration as required by facility policy.
A facility failed to keep medications secured and stored per label instructions. Surveyors found multiple topical medications left in a resident’s room, including one beside toothpaste and a toothbrush, even though the resident had dementia and no self-medication assessment. Surveyors also found a probiotic in a med cart that required refrigeration after opening, and staff confirmed it should have been returned to the refrigerator after administration.
A resident with paraplegia and severe cognitive impairment was found in bed without access to her call light, which was left hanging out of reach after care was provided. Staff interviews and facility policy confirmed that call lights should always be accessible to residents, but this was not ensured, resulting in a failure to accommodate the resident's needs.
A nurse left a computer unattended on a medication cart with a resident's confidential medical information visible, including details about a suprapubic catheter and recent re-admission. The nurse failed to lock or close the screen, resulting in unauthorized exposure of protected health information, contrary to facility policy and staff expectations.
A resident with a g-tube and severe cognitive impairment was found lying flat in bed despite physician orders and care plan instructions to keep the head of the bed elevated during and after enteral feeding. Staff interviews confirmed the required intervention was not consistently implemented, and the facility's policy for proper positioning was not followed.
Two residents requiring respiratory care did not receive services consistent with professional standards: one resident's nebulizer mask was left unbagged after use, and another resident receiving oxygen via tracheostomy did not have an 'Oxygen in Use' sign posted outside the room. Staff interviews confirmed these lapses, and facility policy requires both proper storage of respiratory equipment and appropriate safety signage.
A wound cleanser solution was found left on a resident's bedside table, despite facility policy requiring all medications and biologicals to be securely stored in locked compartments. Staff interviews confirmed the solution should not have been in the room, and the resident did not have any wounds requiring its use. The incident was acknowledged by nursing and administrative staff as a failure to follow proper medication storage procedures.
A resident with multiple disabilities and complex care needs was denied physical therapy services after the facility failed to submit required information to the PASRR program by the deadline. Confusion among staff regarding responsibility for follow-up and lack of documentation led to the lapse in care.
The facility failed to ensure a clean and homelike environment for residents, with surveyors observing unclean conditions in resident rooms and hallways. Stains and debris were found on floors, and air conditioning units had debris-filled vents. The Administrator and Housekeeping Supervisor acknowledged the issues, citing a broken floor cleaning machine as a contributing factor.
A resident with cerebrovascular disease and muscle contracture was fed breakfast by a CNA who stood over her while she lay in bed, contrary to the facility's policy requiring staff to sit at eye level to promote dignity. The resident was cognitively intact and required extensive assistance with eating. The DON confirmed the policy violation, highlighting a dignity concern.
A resident with multiple health conditions and a severely impaired BIMS score was not treated with dignity during meal assistance. An LVN stood over the resident while assisting her with her meal, despite the resident expressing she did not want to eat. Facility policy requires staff to sit at eye level with residents during meal assistance to ensure dignity and comfort, which was not followed in this instance.
The facility failed to maintain an effective infection prevention and control program, with CNAs not changing gloves during incontinent care and an RN improperly handling test strips. These lapses in hand hygiene and equipment handling could lead to cross-contamination and infections.
The facility failed to ensure proper respiratory care for two residents. One resident with COPD used oxygen without a physician's order, while another resident's BiPAP mask was improperly stored, risking infection. Staff interviews confirmed the absence of necessary orders and improper storage practices, contrary to facility policies.
A resident with a gastrostomy tube did not receive proper pharmaceutical services when an LPN failed to flush the g-tube before and after administering medications, as well as between each medication. This was against the physician's orders and facility policy, which required flushing to prevent clogging and ensure proper medication absorption. Interviews with facility staff confirmed the expectation for proper flushing procedures, which were not followed in this instance.
The facility failed to maintain a washing machine in safe operating condition, risking contamination and improper laundering. Sudsy water leaked from the washer, and a trash bag was used to secure the door. A technician jammed the door during dispenser installation, loosening a bolt. The Housekeeping Manager tightened the bolt, and the Maintenance Director replaced a washer seal. The facility's policy requires routine equipment inspections.
A resident with dementia and vision impairments eloped from a facility due to a lack of comprehensive care planning. Despite documented wandering and aggressive behaviors, the care plan was not updated, leading to the resident being found outside unsupervised. Staff interviews revealed a lack of communication and awareness of the resident's behaviors, contributing to the oversight.
A resident with a history of wandering and exit-seeking behavior was found outside the facility, highlighting inadequate supervision and failure to update the care plan. Despite previous incidents, the facility did not reassess the resident's elopement risk or implement necessary interventions. Staff interviews revealed a lack of awareness and communication regarding the resident's behaviors, leading to a risk to the resident's safety.
A resident with dementia and vision impairments eloped from the facility and was found in the parking lot without his wheelchair. Despite the incident, the facility's DON and Administrator did not classify it as an elopement and failed to report it to HHSC as required. The facility's policy mandates the investigation and timely reporting of such incidents, which was not followed in this case.
A resident with dementia and vision impairments eloped from the facility and was found in the parking lot. Despite the incident being documented and observed by staff, the facility's DON and Administrator did not consider it an elopement and failed to investigate or report it as required by policy. This oversight could place residents at risk of neglect.
A resident with a history of blindness in one eye and macular degeneration was inaccurately assessed as having adequate vision in a Quarterly MDS assessment. The current MDS nurse was unaware of the resident's visual impairments due to a lack of review of past documentation and interdisciplinary discussions. The DON acknowledged the oversight, attributing it to a previous MDS nurse working remotely, and emphasized the importance of accurate MDS assessments for resident safety.
The facility failed to maintain a safe and clean environment due to significant structural issues and unclean carpets. Observations showed foundation problems near the secretary's desk, including a downward floor slope, wall separation, and large cracks. The carpets were stained with unknown substances. Interviews with staff revealed ongoing foundation issues with no clear repair timeline, despite multiple ownership changes. The carpets were cleaned daily, but replacement was deferred until foundation repairs were completed.
A resident with a tracheostomy did not receive a timely change of their tracheostomy shield due to a lack of supplies and communication failures within the facility. The respiratory therapist reported the shortage to central supply, but no further action was taken to inform nursing leadership or restock the shields promptly. The resident, who was cognitively intact and cooperative, was left with an outdated shield, posing a risk for infection.
Inaccessible Call Lights for Multiple Residents at Risk for Falls and Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that the call light system was accessible to four residents. For Resident #2, a female with a history of falling, repeated falls, severe cognitive impairment (BIMS 6), and an active care plan identifying her as at risk for falls, the care plan specified that her call light should be within reach and that she required a prompt response to requests for assistance. During observation, she was lying in bed while her call light was found on the floor on the left side of her oxygen concentrator, not within her reach. Resident #3, a female with Alzheimer’s disease, fractures of the left acetabulum and left pubis, severe cognitive impairment (BIMS 5), and lack of coordination, also had an active care plan identifying her as at risk for falls with an intervention to keep the call light within reach and encourage its use, with prompt response to all requests. During observation, she was lying in bed while her call light was hanging on the headboard, out of her reach. Resident #4, a female with Alzheimer’s disease, unsteadiness on her feet, severe cognitive impairment (BIMS 3), and a history of falls, had a care plan noting risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, psychoactive drug use, and unawareness of safety needs, with an intervention to keep the call light within reach and encourage its use. During observation, she was lying in bed while her call light was wrapped and hanging off the wall on the left side of the bed, not accessible to her. Resident #5, a cognitively intact female (BIMS 15) with COPD, lack of coordination, gait and mobility abnormalities, muscle weakness, osteoporosis, and a history of falls, had active physician’s orders for PRN oxygen and weekly oxygen tubing changes, and a care plan identifying her as at risk for falls and for shortness of breath/respiratory distress. Her care plan interventions included ensuring the call light was within reach, encouraging its use, and reminding her to use it to request assistance, as well as providing ordered oxygen and monitoring for respiratory symptoms. During observation, she was lying in bed while her call light was on the floor behind the headboard. She stated she was very independent and would usually go to the nurses’ station if her call bell was not answered in a timely manner. The DON, an LVN, and a CNA each stated in interviews that call lights should always be within reach of residents, secured as needed, and that lack of access could prevent residents from calling for help in an emergency or obtaining timely assistance. The facility’s written policy on call light accessibility and timely response required that staff ensure call lights are within reach of residents and accessible while in bed or other sleeping accommodations.
Improper Storage of Oxygen Nasal Cannulas for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of respiratory care related to the storage and handling of oxygen delivery devices for two residents who used nasal cannulas connected to oxygen concentrators. One resident, a cognitively intact male with COPD, shortness of breath, lack of coordination, and dependence on supplemental oxygen, had active physician orders for continuous oxygen at 2 liters via nasal cannula every shift and weekly tubing changes. His care plan included monitoring for complications related to oxygen use and changing oxygen tubing per facility protocol. During observation, his nasal cannula, connected to the concentrator, was found lying on the floor under his bed while he was in bed. Another cognitively intact female resident with COPD, lack of coordination, gait and mobility abnormalities, and osteoporosis had physician orders for oxygen at 2 liters via nasal cannula as needed for shortness of breath, with weekly tubing changes and labeling of each component with date and initials. Her care plan addressed risk for falls and risk for shortness of breath and respiratory distress, with interventions including observing for respiratory symptoms and providing oxygen as ordered. During observation and interview, her nasal cannula, connected to the concentrator, was seen hanging on the concentrator while she sat on her bed. She reported that she used oxygen at night, removed it in the morning, and had been told the tubing should be bagged; she stated staff usually checked to ensure it was bagged but had not yet done so that day. Interviews with the DON, an LVN, and a CNA confirmed that facility practice and expectations were for nasal cannulas to be stored in a bag and dated when not in use, to keep them clean and prevent infection and airway complications. The facility’s written Oxygen Administration Policy stated that oxygen is to be administered consistent with professional standards of practice and the resident’s care plan, and specifically directed that delivery devices be kept covered in a plastic bag when not in use. Despite these policies and staff knowledge, the observed storage of both residents’ nasal cannulas did not comply with the facility’s policy or the stated standards of practice.
Uncovered Catheter Drainage Bags Compromise Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents with indwelling catheters were treated with respect and dignity by keeping their catheter drainage bags covered, as required by physician orders, care plans, and facility policy. One male resident with neuromuscular dysfunction of the bladder and a suprapubic catheter had an active physician order and a comprehensive care plan intervention directing that his catheter drainage bag be covered with a dignity/privacy cover at all times. During observation, he was found lying in bed with his Foley catheter drainage bag hanging from the bed frame without a privacy cover. He reported that the drainage bag was not usually covered, that it had always been that way, and that no one had told him it should be covered, though he stated it would be nice if it was covered. Another male resident with neuromuscular dysfunction of the bladder and a suprapubic catheter was observed sitting on his bed with his Foley catheter drainage bag lying on the floor and without a privacy cover. He stated he was about to receive a shower and have the bag changed with assistance from a CNA, and acknowledged that the bag should not be on the floor to prevent infection, but that it would be changed that day. Interviews with the DON, an LVN, and a CNA confirmed that facility practice and policy require catheter drainage bags to be covered with privacy bags at all times to maintain residents’ dignity and privacy, and that bags should not be touching the floor. Review of the facility’s catheter care policy further confirmed that privacy bags are to be available and catheter drainage bags covered at all times while in use, demonstrating that the observed uncovered and improperly positioned catheter bags for these two residents were inconsistent with established orders, care plans, and policy.
Improper Storage and Unsecured Access to Topical Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored in locked compartments and controlled in accordance with State and Federal laws and the facility’s own medication storage policy. A cognitively intact male resident with diagnoses including allergic rhinitis and hypertension had a physician’s order for zinc oxide 20% ointment to be applied topically to the buttocks every 24 hours as needed for redness. His comprehensive care plan documented that he expressed a desire to keep personal cream at the bedside for frequent use, with interventions including education on proper use, hand hygiene, and evaluation of his cognitive status and ability to safely self-administer. During observation, a tube of zinc oxide cream was seen on the resident’s bedside table in his room. The resident reported that the zinc oxide was part of his ordered medications, that it was originally ordered for a facial rash, and that he now used it on his groin area, scrotum, belly, and buttocks, and that staff also used it when they cleaned him. The DON stated that no medication should be in a resident’s room and that such medications could be a hazard if not supervised by a qualified nurse. An LVN stated she was not aware the resident had the zinc oxide in his possession and that all medications should be stored in the medication cart unless there was an assessment and a physician’s order for self-administration, noting risks such as allergic reaction and improper administration. A CNA stated residents should not have medications on them and that if she found medications in a room, she would take them to the charge nurse, explaining that unsupervised medications could lead to residents not using them as prescribed or other residents using medications not meant for them. The facility’s written medication storage policy required all drugs and biologicals to be stored in locked compartments with access limited to authorized personnel, which was not followed in this case.
Failure to Accurately Document and Date Wound Care Treatments
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and to document wound care treatments as required by physician orders and facility policy for one resident. The resident was an older female with diabetes and peripheral vascular disease, admitted with a sacral wound that was documented as present on admission. A physician’s order dated 04/21/2026 directed daily topical application of 10% povidone-iodine solution to the sacrum on the day shift, including cleansing with saline or wound cleanser, patting dry, applying betadine and calcium alginate, and covering with a dry dressing. However, review of the Treatment Administration Record (TAR) for April 2026 showed no documented evidence that wound care was provided on 04/17/26, 04/18/26, 04/19/26, 04/20/26, and 04/21/26. In addition, the resident’s active initial care plan dated 04/16/2026 and the MDS contained no problem, goals, or interventions related to the resident’s wound care. On 04/23/26, during an observation and interview with the resident and the Wound Nurse, the sacral wound dressing was found to be soiled with brownish discharge and was not dated or initialed to indicate when the dressing change had been performed. The Wound Nurse reported that the wound care had been done the previous night by the night nurse, who had informed her by text, even though the order specified the 6 a.m. to 2 p.m. shift for treatment. The Wound Nurse stated that dressings should be dated and initialed at the time of the dressing change and that failure to date the dressing could result in wound care not being performed as scheduled and could lead to worsening of the wound and possible infection. The DON similarly stated that wound dressings should always be dated with every dressing change and that not dating the dressing could result in skipped wound care and possible infection or worsening of an existing infection. Facility policy on Wound Treatment Management required that wound treatments be provided in accordance with physician orders and documented on the Treatment Administration Record or in the electronic health record.
Failure to Enforce Infection Control Practices for PPE Use and Medication Cart Cleanliness
Penalty
Summary
The deficiency involves the facility’s failure to maintain its infection prevention and control program as required by its own policy. On Hall 100, a medication aide was observed with personal items, including a personal phone, two portable fans, and deodorant spray, stored on top of the medication cart. During interview, the medication aide stated the phone was for personal use to see who was calling, the fans were to keep her cool while passing medications, and the deodorant spray was for use when the hallway smelled bad. She reported she was unsure of the facility policy on personal items on the medication cart but acknowledged she believed such items should not be on the cart due to infection risk. Multiple staff, including the DON, ADON, and LVNs, later confirmed that personal items are not allowed in or on medication carts and should be stored in designated staff areas because of the risk of infection transmission. A second deficiency was identified when a CNA was observed providing care to a resident on enhanced barrier precautions (EBP), as indicated by signage on the resident’s door, without wearing appropriate PPE. The CNA stated she was new and in training and acknowledged she should have been wearing proper PPE, including gloves and a protective gown, and that failure to do so could transmit infection between residents and to herself. The DON, ADON, LVNs, and another CNA all stated that staff providing care to residents on EBP are required to wear appropriate PPE (gown, gloves, and mask for high-contact care) and that not doing so could result in transmission of infection. Review of the facility’s Infection Prevention and Control Program policy showed that all staff are responsible for following infection control policies, using PPE according to facility policy, and demonstrating competence in infection control practices, which was not followed in these observed instances.
Failure to Notify Hospice of Resident’s Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to coordinate care with a hospice agency by not notifying the hospice provider of a resident’s transfer to the hospital. The resident was an elderly female with Alzheimer’s disease, aphasia, stroke history, short- and long-term memory problems, and severely impaired cognitive skills. She had been admitted to hospice services for Alzheimer’s disease. According to progress notes, an LVN documented that the resident pulled out her G-tube, the MD was notified, and an order was obtained to send her to the ER for G-tube replacement. The LVN arranged ambulance transport, and another LVN documented that the resident was transported to a named hospital, was stable, and that report was given to the hospital ER and the resident’s representative was notified. Record review of the eINTERACT Transfer Form showed the hospice company was not contacted about the transfer. During interviews, a hospice representative stated the hospice company was not informed of the resident’s hospital transfer and that they expected the facility to communicate when the resident went to the hospital. The DON stated that all nurses knew hospice agencies were supposed to be notified when a hospice resident had a change in condition or was sent to the hospital, and that the nurse on duty was responsible for this communication. The DON also stated she was not aware that hospice had not been notified and that nurse managers normally checked that all necessary parties were notified, but this was not done. An LVN reported he had told the oncoming LVN to call hospice about the transfer and assumed it would be done. The facility’s policy on Coordination of Hospice Services required immediate contact and communication with hospice staff, the attending practitioner, and the family/resident representative regarding significant changes, clinical complications, or emergent situations, which was not followed in this case.
Confidential Records Left Exposed and Resident Transfer Performed in Hallway
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential for five residents. During observation on 03/11/2026 at 6:41 AM, a small notebook was left on top of an MA's cart parked in the hallway, and the notebook contained Residents #79, #3, and #73's vital signs written on a page. The cart was unattended and facing the hallway while staff and residents passed by. At 6:43 AM and 6:44 AM, MA G continued moving between resident rooms and assisting a resident in a wheelchair while the vital signs remained exposed on the cart. At 6:54 AM, MA G obtained Resident #61's vital signs, wrote them in the same notebook, prepared medications, and entered the resident's room to administer them, while the vital signs for Residents #79, #3, #73, and #61 remained visible on top of the cart. During interview, MA G stated she usually covered her notebook when leaving the cart, but may have gotten busy and forgotten. She said she should have flipped the notebook or placed it under her laptop so the medical information would not be exposed, and acknowledged that vital signs were medical information that should be secured to prevent HIPAA violations. The Infection Nurse stated the residents' vital signs should not be left exposed because they were confidential information and should only be available to individuals involved in the residents' care. She also stated staff could input the vital signs as soon as they were obtained so they would not need to be written down. The facility also failed to provide privacy during Resident #5's transfer. Resident #5 was cognitively intact with a BIMS score of 15, was dependent on staff for bed-to-chair transfer, and required extensive assistance by two staff with a mechanical lift. On 03/10/2026 at 2:37 PM, CNA D and CNA E transferred the resident from wheelchair to bed in the hallway by hooking the sling to the mechanical lift, raising the resident in the hallway, and then pushing the lift toward the resident's room before lowering her to the bed. CNA E said he did not know a resident could not be transferred from the hallway, and CNA D said the transfer was done in the hallway because the room was small. Resident #5 later stated nobody talked to her about being transferred inside the room and said it made sense that the transfer should have been done inside the room because others could see that she was being lifted and dependent on the mechanical lift.
Unclean resident areas and missing personal property
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for 11 of 20 resident rooms and for two carpeted hallway areas that were observed for cleanliness. During observations, the 2100 hallway carpet had dark stains, including one approximately 15-inch circular dark gray stain, and the 2500 hallway carpet had a large dark stain approximately four feet long. Multiple resident rooms had visible dirt, stains, and dust buildup, including dirt in floor corners and door frames, stained floors, stained bathroom floors around toilets and drains, stained whiteboards, dust and stains on bedside furniture, and air conditioning units covered with black dirt and dust; some units also had broken vents or a broken filter hanging out of the unit. Housekeeping staff stated they were responsible for cleaning the entire resident room and that areas not properly cleaned could allow germs to spread or make residents sick. The housekeeping supervisor stated the floors had been scrubbed but the stains did not come out and said the floors were old. The administrator stated she expected resident rooms to be thoroughly cleaned and that leadership rounds included checking for cleanliness. She also stated that not cleaning the rooms thoroughly could have respiratory concerns for residents. The facility also failed to exercise reasonable care for the protection of Resident #15's property from loss. Resident #15, who had diagnoses including depression, bipolar disorder, a chronic abdominal ulcer, and morbid obesity, had a BIMS score of 15 and required toileting assistance with a bedpan. After moving rooms, her stainless-steel bedpan was missing, and she reported that the plastic replacement did not hold urine, spilled on the bed, and pinched her skin. Staff stated a stainless-steel bedpan had been ordered, and the administrator stated the facility kept inventories of resident belongings and investigated missing items, but she was not sure what happened to the missing bedpan and said it may have been taken by visitors or other residents.
Inaccurate MDS Coding for Hospice, Oxygen, and AVAPS Use
Penalty
Summary
The facility failed to ensure that Comprehensive MDS assessments accurately reflected the status of three residents. Resident #2 had a Comprehensive MDS dated 01/21/2026 that did not indicate hospice care, even though the care plan stated the resident had chosen hospice services and a physician order documented hospice for Alzheimer’s disease with late onset. Resident #5 had a Quarterly MDS dated 01/06/2026 that did not indicate oxygen therapy, although the care plan stated oxygen was to be administered as ordered and that the resident had started using oxygen on 08/07/2024. Resident #19 had a Comprehensive MDS dated 02/02/2026 that did not indicate use of a non-invasive mechanical ventilator, despite a physician order for AVAPS settings and pulmonary notes stating the resident was wearing the AVAPS mask. During observation, AVAPS equipment was present at the bedside, and staff interviews confirmed the resident had been using AVAPS since admission and every night. The MDS Nurse stated the AVAPS was not coded because there was no documentation about it, but later reviewed progress notes and acknowledged the resident was using AVAPS and that it should have been coded in the MDS. Interviews with the ADON, DON, and Administrator reflected that hospice, oxygen use, and AVAPS use should have been reflected in the MDS assessments. The facility policy stated that resident assessments are to be accurate and reflective of the resident’s status at the time of assessment, and that qualified health professionals are to correctly document the resident’s medical, functional, and psychosocial problems.
Incomplete Care Plans for Oxygen, CHF, AVAPS, and Enteral Feeding
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for four residents whose assessments and orders showed ongoing needs. Resident #14 had a diagnosis of weakness, severe cognitive impairment with a BIMS score of 06, and was observed using oxygen. Her record included physician orders for oxygen at 2 liters per minute via nasal cannula or mask every shift for shortness of breath, along with multiple progress notes documenting oxygen use, but her comprehensive care plan did not include oxygen therapy. Resident #15 had a diagnosis of congestive heart failure and was cognitively intact with a BIMS score of 15. Her record included a physician order for ipratropium-albuterol inhalation solution three times a day for shortness of breath and congestion, and she was observed in bed with a nebulizer machine on her side table. Her comprehensive care plan did not include congestive heart failure. Resident #19 had a diagnosis of sleep apnea and moderate cognitive impairment with a BIMS score of 12. Her physician order included AVAPS settings, and pulmonary notes documented that she was wearing her AVAPS mask. Staff interviews stated she had been using AVAPS since admission and every night, but her comprehensive care plan did not include a plan for the non-invasive mechanical ventilator. Resident #29 had diagnoses of lack of coordination and malnutrition, with an intact BIMS score. Her physician orders included enteral feeding for evening meals, and she was observed with her bed in a low position and stated she wanted it that way because of a prior fall and knee injury. Her comprehensive care plan did not include enteral feeding, and her fall prevention plan did not include the bed being in the lowest position.
Unsecured fall protection, smoking supervision, and germicidal wipes
Penalty
Summary
The facility failed to ensure Resident #31 had the fall prevention intervention ordered for safety. Resident #31 was admitted with diagnoses including type 2 diabetes, Alzheimer’s disease, convulsions, and epilepsy, and the MDS reflected severely impaired decision-making, fall risk, extensive assistance with ADLs, and feeding tube nutrition. Her treatment record and care plan directed that a fall mat be placed on each side of the bed every shift. During observation, she was found in bed with a fall mat only on the right side of the bed, despite the order for mats on both sides. Staff interviews confirmed that the mats were expected to remain in place and that failure to do so could result in injury if she fell. The facility also failed to properly supervise residents while smoking and failed to complete quarterly smoking assessments for several residents who smoked. Residents #4, #10, #11, #24, #34, #74, #91, and #96 had care plans calling for supervised smoking sessions, with diagnoses and MDS findings including COPD, respiratory failure, schizophrenia, lack of coordination, paralysis, and varying levels of cognitive impairment. During observation, these residents were outside smoking while a staff member assigned to monitor them was sitting nearby looking at his phone and not observing them. Record review showed that smoking assessments for several of these residents were not current, with last completion dates ranging from 2024 to 2025. Interviews with the Social Worker, DON, and Administrator confirmed that smoking supervision and quarterly assessments were expected for residents who smoked. The facility further failed to keep germicidal wipes secured on two nurse carts when the carts were left unattended. During one observation, an LVN entered a resident’s room to administer medication and left a container of germicidal wipes on top of the cart while the cart was unattended in a hallway used by residents. In another observation, an opened container of germicidal wipes was left on top of a cart near the nurse’s station with no staff present. Interviews with LVN B, LVN I, the Infection Control Nurse, the ADON, the DON, and the Administrator confirmed that the wipes should have been stored inside the carts because residents could access them and potentially use them inappropriately.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment was stored properly when not in use for three residents who were receiving oxygen or breathing treatments. Resident #5, a cognitively intact female with chronic pulmonary edema, had an order for oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath. During observation, she was seen using oxygen, and when she was transferred from her wheelchair to bed, her nasal cannula was pulled from the bed railing and was not bagged. CNA D stated the cannula was dirty and should have been bagged by whoever transferred the resident earlier in the day. Resident #6, a male with respiratory failure with hypoxia and moderate cognitive impairment, had an order for oxygen at 2 to 3 LPM via nasal cannula as needed for oxygen saturation less than 90%. During observation, he was out of his room and a nasal cannula was found attached to the oxygen concentrator at the bedside and lying on top of the bed without being bagged. CNA D stated the cannula should have been bagged so it would not get dirty and said she would notify the nurse so it could be replaced. Resident #15, a cognitively intact female with congestive heart failure, had an order for Ipratropium-Albuterol inhalation solution three times daily for shortness of breath/congestion. During observation, a nebulizer machine was on the resident’s side table with the breathing mask attached and lying on top of the nebulizer, not bagged. The resident said someone had removed it after her treatment. LVN A later observed the mask, disconnected it, and discarded it, stating it should have been bagged to prevent cross contamination and possible respiratory infection. Facility leadership stated staff were responsible for bagging nasal cannulas and breathing masks when not in use, and the facility policy also stated delivery devices should be kept covered in a plastic bag when not in use.
Missing assessment and consent for bed grab bars
Penalty
Summary
The facility failed to assess residents for the appropriateness of grab/assist bars on their beds and failed to review the risks and benefits with the resident or resident representative and obtain informed consent before installation for 4 of 7 resident rooms observed and reviewed. The report states that the facility had no evidence of informed consent for Resident #1, Resident #13, Resident #76, and Resident #91 for grab/enabler bars placed on their beds, and no evidence of assessments for risk of entrapment or ability to safely use the bars. Resident #1 was admitted with multiple diagnoses including metabolic encephalopathy, adult failure to thrive, acute kidney failure, cognitive communication deficit, bipolar II disorder, anxiety disorder, PTSD, dystonia, unspecified dementia, alkalosis, shortness of breath, and COPD. The care plan identified impaired balance, limited mobility, and bed mobility requiring extensive assist by 1 staff, and also noted risk for injury related to a 1/4 side rail to enable assistance with bed mobility/transfers. However, the assessment list and miscellaneous list contained no assessment or consent related to bed rails or grab bars. During observation, bilateral grab bars were present on the bed. Resident #13 had diagnoses including quadriplegia, chronic respiratory failure with hypoxia, COPD, muscle weakness, altered mental status, senile degeneration of brain, unspecified intellectual disabilities, other specified extrapyramidal and movement disorders, and unspecified lack of coordination. The care plan documented total assistance for bed mobility and listed bed rails as an enabler for turning and repositioning in bed, with bilateral 1/4 enabler bars per resident preference. The assessment list and miscellaneous list contained no assessment or consent related to bed rails or grab bars. The resident stated staff repositioned her every few hours, that she had no ability to move her arms or legs, and that the grab bars were sometimes in the way of TV viewing. Resident #76 had diagnoses including anemia, major depressive disorder, obstructive sleep apnea, and alcohol abuse. The care plan identified risk for injury related to a 1/4 side rail to enable assistance with bed mobility/transfers, but the assessment list and miscellaneous list contained no assessment or consent related to bed rails or grab bars. Resident #76’s bed was observed with bilateral grab bars raised. Resident #91 had diagnoses including epilepsy, senile degeneration of brain, extrapyramidal and movement disorder, chronic respiratory failure, unspecified convulsions, schizoaffective disorder bipolar type, generalized muscle weakness, gait and mobility abnormalities, abnormal posture, and other muscle spasm. The care plan identified risk for injury related to a 1/4 side rail and included education for the resident/family on risks regarding use of the side rail device, but the assessment list and miscellaneous list contained no assessment or consent related to bed rails or grab bars. Resident #91’s bed was observed with bilateral grab bars raised while the resident was in bed.
Food Storage, Ice Equipment, and Dishwasher Sanitation Deficiencies
Penalty
Summary
Food safety practices in the facility’s only kitchen were not followed during observation and record review. A tea dispenser in the kitchen was observed with tea in it and no lid on top. A Styrofoam container in the kitchen refrigerator had no date or name on it, and the Nutrition manager stated that any premade food in the refrigerator should have a date on it and that no staff or resident personal food should be in the kitchen refrigerator. The facility policy on date marking for food safety required ready-to-eat, time/temperature control for safety food to be clearly marked with the date or day by which it must be consumed or discarded, and the Head Cook or designee was responsible for checking the refrigerator daily for expiring items. The ice machine in the kitchen was observed with black, greenish, and red stains inside, and the ice scoop holder had black discoloration on the base. An ice chest on the 2500-hall had reddish and light brownish stains inside, contained ice, and had a metal ice scoop sitting in the ice. The Nutrition manager stated the ice machine and ice scoop holder were cleaned weekly, that the ice chest should be brought to the kitchen and run through the dishwasher every morning, and that the scoop should not be stored in the ice chest. During observation, the dishwasher rinse temperature was 110 degrees, which was 70 degrees below the manufacturer-required operating temperature of 180 degrees.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents reviewed for infection control. Resident #5 was cognitively intact, had muscle weakness, and required extensive assistance by two staff with a mechanical lift for bed-to-chair transfer. During an observation, CNA D and CNA E were preparing to transfer the resident from a wheelchair to the bed and both put on gloves from a wall box without performing hand hygiene first. In interviews, both CNAs stated hand hygiene should have been done before the transfer and before putting on gloves. Resident #29 was cognitively intact, had a gastrostomy status and irritable bowel syndrome, and had a feeding tube. The resident’s care plan reflected enhanced barrier precautions related to the g-tube, including the use of gowns and gloves during high-contact resident care, and the physician order also indicated enhanced barrier precautions for the indwelling medical device with gown and gloves required for high-contact resident care activities. During an observation, LVN B prepared and administered medication via the resident’s g-tube without wearing a gown. In interview, LVN B stated she did not think to put on a gown and acknowledged that gowns were needed in addition to gloves when caring for the resident with tubing. Resident #38 was cognitively intact and incontinent of bladder and bowel. The care plan directed staff to provide peri care after each incontinent episode. During an observation of incontinent care, CNA F rolled the resident’s soiled draw sheet, then handled the new draw sheet and new brief without changing gloves after touching the soiled linen. She performed hand hygiene after touching the soiled draw sheet. In interview, CNA F stated she should have changed her gloves before touching the clean draw sheet and brief. The ADON, DON, and Administrator all stated that staff should perform hand hygiene before and after care, change gloves after touching anything soiled, and wear a gown when residents required enhanced barrier precautions.
Incorrect Discharge Documentation
Penalty
Summary
The facility failed to ensure that Resident #105’s transfer or discharge was accurately documented in the medical record. Resident #105 was a [AGE]-year-old male admitted with heart failure and Type 2 Diabetes, and his MDS assessment reflected an intact BIMS score and active diagnoses of heart failure and Type 2 Diabetes. Record review showed a progress note stating the resident left AMA on 02/19/26, and the discharge document also reflected discharge Against Medical Advice on 02/17/26. During interview and record review, the Social Worker initially stated the resident had discharged AMA and that she had forgotten to have him sign the AMA form because she was busy arranging home health. She later stated the discharge was not AMA and that the resident and his family had spoken with her about discharge planning one week prior, with the physician agreeing to the discharge and home health being arranged for a safe discharge home. The Administrator stated the discharge had been incorrectly documented as AMA, and Physician O stated the resident was discharged home with home health care, not AMA, after meeting with the resident and caregiver to discuss discharge and providing medications at discharge.
MDS Assessments Not Timely Transmitted
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete MDS data to the CMS system within the required timeframe for 2 of 11 residents reviewed for MDS transmission. Resident #1 had a Quarterly MDS completed with an ARD of 1/23/2026, but the EHR showed the assessment remained in an "In Process" status and was 34 days overdue; the last transmitted and accepted MDS for this resident was the Annual assessment dated 10/23/2025. Resident #1's record showed diagnoses including metabolic encephalopathy, adult failure to thrive, acute kidney failure, cognitive communication deficit, bipolar II disorder, anxiety disorder, PTSD, dystonia, unspecified dementia, alkalosis, shortness of breath, and COPD. Resident #65 also had a Quarterly MDS completed with a date of 1/15/2026, but the EHR showed it remained in "Export Ready" status and had not been transmitted; the last transmitted Quarterly MDS for this resident was 10/15/2025. Resident #65's record showed diagnoses including anoxic brain damage, unspecified dementia, extrapyramidal and movement disorder, lack of coordination, generalized muscle weakness, impulse disorder, mood disorder due to known physiological condition, chronic pain syndrome, and schizophrenia. During interview, the MDS Nurse stated the EHR alerts when assessments are due, but once an assessment is started the alert turns off and the system is not alerted when assessments are not completed or transmitted, and she was not sure how these two assessments were missed. The Adm stated the MDS Nurse was responsible for completing Annual and Quarterly MDS assessments and that the expectation was for each resident to be accurately assessed and timely transmitted by the due date or before.
Wound Care Not Performed per Protocol
Penalty
Summary
The facility failed to ensure treatment and care were provided according to orders and the facility’s wound cleaning protocol for a resident with a right heel wound. The resident had diagnoses including pressure ulcer of the sacral region, cognitive communication deficit, lack of coordination, and weakness, and the MDS documented a BIMS score of 6 indicating severe cognitive impairment. A physician order dated 03/10/26 directed daily right heel treatment with cleansing using normal saline or wound cleanser, patting dry, and applying Xeroform and bordered gauze. During observation on 03/11/2026, the Wound Nurse cleansed the inside of the heel wound and the outer edge with the same gauze. When asked about the danger of doing so, she stated it would spread infection from the inside of the wound to the outer perimeter of the wound and could delay wound healing or make it worse. The DON stated the Wound Nurse should use a gauze only once, with one gauze to cleanse the inside of the heel wound and one gauze for the outside of the wound to prevent contamination and possible spread of infection. The facility’s wound cleaning procedure stated to clean from the cleanest area to the dirtiest area, cleaning from the center of the wound toward the edges, using one gauze per stroke and discarding gauze after each pass.
Failure to Apply Ordered Heel Protection
Penalty
Summary
Failure to provide the necessary treatment and services to prevent development of pressure injuries was identified for one resident. The resident was admitted with diagnoses including type 2 diabetes, Alzheimer's disease, convulsions, and epilepsy. The MDS indicated the resident was at risk for pressure ulcers/injuries, had severely impaired decision-making skills, required extensive assistance with all ADLs, and received all nutrition via feeding tube. The care plan identified a potential for injury development related to immobility. The resident had an order on the TAR to apply foam boots to both heels every shift to prevent pressure ulcers, and the TAR was signed off as completed every shift. During observation, the resident was in bed sleeping and no foam boots were in place on either heel, although the skin on the heels was intact. The LVN stated the foam boots were necessary to prevent pressure injuries because the resident was bedbound. The CNA stated she did not know the resident had an order for foam boots, and the DON stated the boots needed to be in place to prevent pressure ulcers and that it was the responsibility of all care staff to ensure they were in place during rounds.
Missing Physician Orders for Catheter Care
Penalty
Summary
Resident #14, a female with neuromuscular dysfunction of the bladder and severe cognitive impairment with a BIMS score of 06, had an indwelling catheter documented on the MDS assessment. Her care plan identified alteration of bladder related to a Foley catheter and included catheter care per shift as an intervention. However, the physician order record reviewed for the resident did not include orders for catheter care, when to empty the catheter bag, or monitoring for signs and symptoms of infection, dysuria, hematuria, urine color, leakage, or securing the catheter to prevent pulling. During observation, the resident was in bed awake with a catheter in place and did not respond when asked how long she had the catheter. A CNA stated the resident had the catheter since admission and that she would empty the bag before the end of her shift. An LVN later reviewed the resident’s profile and confirmed there was no order for catheter care, stating he knew the resident had a catheter but did not pay attention to the orders. The ADON and DON stated that residents with catheters should have orders for catheter care, patency checks, and assessment parameters, and that everything done for the resident should have an order. They acknowledged that when the resident returned to the facility after a hospital stay, the catheter-related orders were not re-entered into the MAR/TAR. The Administrator also stated that everything done for residents should have orders, including treatment, medications, diet, and therapy.
Failure to Protect G-Tube With Ordered Abdominal Binder
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding for 1 of 7 residents reviewed for enteral feeding. Resident #31 had diagnoses including Type 2 diabetes, Alzheimer’s disease, convulsions, and epilepsy, and the MDS indicated severely impaired decision-making skills, extensive assistance with all ADLs, and all nutrition provided via a feeding tube. The resident’s physician order dated 03/31/26 directed that an abdominal binder be applied every shift, and the care plan identified tube feeding with dysphagia/swallowing problems and noted the abdominal binder intervention had been initiated and revised previously. During observation on 03/10/26 at 1:50 pm, Resident #31 was found in bed sleeping with no abdominal binder in place and the G-tube was not protected as ordered. Staff interviews reflected that the binder was expected to be in place to prevent the resident from pulling on the G-tube, and the DON stated it needed to be on at all times to prevent the resident from pulling the tube out. The DON also stated that all care staff were responsible for ensuring the abdominal binder was in place during rounds.
Failure to Document Administered Medications on MAR
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when Resident #39’s morning medications were not recorded on the MAR after administration on 03/03/26. Resident #39 was a [AGE]-year-old female admitted to the facility with a diagnosis of heart disease, and her MDS reflected an intact BIMS along with active diagnoses of hypertension and dementia. Physician orders dated 03/11/26 included Amlodipine 5 mg daily, Carvedilol 25 mg twice daily, and Clonidine HCl 0.1 mg twice daily for hypertension. Review of the MAR for 03/03/26 showed the resident was not documented as having received Amlodipine, Carvedilol, and Clonidine during the morning medication pass. During interview, the LVN stated she was unsure whether the medications were missed or given without being checked off in the system. The ADON stated she administered the medications that morning but forgot to update the MAR, and the DON confirmed the ADON had failed to update the MAR after administration. The facility policy stated medications are to be signed on the MAR after administration.
Medication Storage and Refrigeration Deficiencies
Penalty
Summary
The facility failed to keep all drugs and biologicals stored in locked compartments under proper temperature controls and accessible only to authorized personnel. During the survey, medications were found inside Resident #90’s room and a probiotic product that required refrigeration after opening was left in a medication cart instead of being refrigerated. Resident #90 was a [AGE]-year-old female admitted to the facility with dementia and severe cognitive impairment, with a BIMS score of 02. Her care plan reflected impaired cognitive function and included administering medications as ordered, and her assessment notes did not show an assessment for self-administration of medications. On 03/10/2026, surveyors observed four tubes of medication on top of the resident’s drawer while she was not in the room, including hydrocortisone, Neosporin, betamethasone cream, and a pain-relieving cream. One pain-relieving tube was observed on a mug with toothpaste and a toothbrush. Staff interviews confirmed the medications should not have been in the room and that the resident had not been assessed for self-medication. On 03/11/2026, surveyors observed a bottle of probiotics in a medication cart with an open date of 02/23/2026 and instructions on the label to refrigerate after opening. Staff acknowledged the product should have been returned to the refrigerator after administration. The Infection Control Nurse stated the bottle would be discarded because the refrigeration instruction had not been followed and the effectiveness was less. The DON and Administrator both stated medications should not be left in resident rooms and that products requiring refrigeration should be stored in the refrigerator after use.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with paraplegia and severe cognitive impairment had access to a call light within reach, as required by her care plan. On the date of observation, the resident was found in bed with her call light hanging on a wall-mounted lamp bracket, out of her reach. The resident was dependent on staff for personal hygiene, transfers, and bed mobility, and her care plan specifically included an intervention to keep the call light within reach to address her risk for falls and need for assistance. Multiple staff interviews confirmed that the call light was not accessible to the resident, and staff acknowledged that it should have been placed within her reach after care was provided. The facility's policy also required staff to ensure call lights were accessible to residents at all times. The deficiency was identified through observations, interviews, and record review, which demonstrated a failure to reasonably accommodate the resident's needs and preferences as required.
Failure to Secure Electronic Medical Records Exposes Resident Information
Penalty
Summary
A deficiency occurred when a nurse (LVN) left her computer unattended on a medication cart with a resident's confidential medical information visible on the screen. The LVN had been documenting on the computer and left to retrieve an 'Oxygen in Use' sign for another resident, leaving the monitor displaying sensitive details such as the resident's name, recent re-admission, presence of a suprapubic catheter, and current medical status. The LVN acknowledged that she failed to properly close or lock the computer screen, resulting in the exposure of protected health information. The resident involved had a history of neuromuscular dysfunction of the bladder, severe cognitive impairment, and required an indwelling suprapubic catheter. The facility's policy and staff interviews confirmed that all resident information is to be kept confidential and only accessible to authorized personnel. The incident was observed and confirmed by facility leadership, who reiterated the expectation that staff must secure electronic medical records when left unattended to prevent unauthorized access.
Failure to Elevate Head of Bed for Resident with G-Tube
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube (g-tube) was observed lying flat in bed, contrary to physician orders and the resident's care plan, which required the head of the bed to be elevated at 30-45 degrees during and after enteral feeding. The resident, who had severe cognitive impairment and dysphagia, was found with a bottle of feeding formula at the bedside and the bed in a flat position. Staff interviews confirmed that the head of the bed should have been elevated to prevent complications, and that the omission was likely due to staff oversight after providing care. The resident's care plan and physician orders specifically directed that the head of the bed be elevated during feeding and for a period afterward, but this intervention was not consistently implemented. Staff acknowledged the importance of this measure and admitted to not always ensuring the bed was properly positioned after care activities. The facility's policy also required appropriate positioning for residents with g-tubes, but this was not followed in this instance.
Failure to Ensure Proper Respiratory Care and Safety Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents requiring such care, as evidenced by two specific incidents involving six residents reviewed for respiratory care. In the first incident, a male resident with a history of respiratory failure and chronic obstructive pulmonary disease was observed with his nebulizer breathing mask left unbagged on his side table after use. The resident was cognitively intact and receiving inhalation treatments as ordered. Staff interviews confirmed that the mask should have been bagged when not in use to prevent respiratory infections, but this was not done. In the second incident, a female resident admitted with respiratory failure and requiring continuous oxygen via tracheostomy did not have an "Oxygen in Use" sign posted outside her room upon admission. Staff acknowledged that the sign was not placed as required, which is necessary to alert staff and visitors to the presence of oxygen in the room. The facility's own policy mandates that such a sign be posted at the entrance when oxygen is in use. Interviews with nursing staff, the ADON, and the Administrator confirmed that the expected practice is to bag breathing masks when not in use and to post "Oxygen in Use" signs for residents receiving oxygen therapy. The facility was unable to provide a policy regarding the storage of breathing masks prior to the survey exit.
Improper Storage of Wound Cleanser Solution
Penalty
Summary
A wound cleanser solution was found left on the bedside table of a resident who was in bed with her eyes closed. The wound cleanser was not supposed to be inside any resident's room, and staff interviews confirmed that the resident did not have any wounds requiring such treatment. The LVN present stated she had not noticed the wound cleanser during her morning rounds and was unsure who had left it there. The Wound Care Nurse also confirmed she had not left the cleanser and questioned its presence, reiterating that it should be stored in the treatment cart after use. Further interviews with the ADON and DON confirmed that the wound cleanser is considered a medication and should not be accessible in resident rooms. Both acknowledged that the solution contained chemicals that could cause adverse reactions and that facility policy requires all drugs and biologicals, including antiseptics and disinfectants, to be stored securely and separately from regular medications. The Administrator also confirmed that medications for wound treatment should be kept in the treatment cart and not left in resident rooms.
Failure to Coordinate PASRR Assessments and Submit Required Documentation
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program to the maximum extent practicable for one resident reviewed for PASRR. Specifically, after receiving a request from the Texas Medicaid & Healthcare Partnership (TMHP) for additional information to support physical therapy services, the facility did not provide the required documentation by the stated deadline. This resulted in a denial of physical therapy services for the resident. The resident involved was a female with multiple complex medical conditions, including quadriplegia, unspecified intellectual disabilities, paranoid personality disorder, cognitive communication deficit, major depressive disorder, and urinary and kidney disorders. She was readmitted from an acute care hospital and required significant assistance with activities of daily living, used a wheelchair for mobility, and had an indwelling catheter. Her Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and dependency on staff for care. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for coordinating PASRR services and responding to TMHP's request. The MDS nurse and Director of Rehabilitation each believed the other was responsible for following up on the information request, and the Social Services director was unaware of the denial letter. The Director of Nursing was not informed of the lapse in services and acknowledged that follow-up should have occurred. No documentation was provided to show that the required information was submitted to TMHP, resulting in the resident not receiving approved physical therapy services.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as evidenced by observations of unclean and unsanitary conditions in four resident rooms and the facility hallways. Specifically, the surveyors observed large dark stains on the carpet and tiles in the hallways, and various stains and debris in the resident rooms. In one room, dirty clothes were found on the bathroom floor, and black stains were noted under the sink and along the corners of the floor. Another room had brown stains under the sink and along the floor corners. Additional rooms had shredded papers, dirt, and stains on the floors, as well as air conditioning units with vents filled with debris and missing filters. Interviews with the facility's Administrator and Housekeeping Supervisor revealed acknowledgment of the cleanliness issues, with the Administrator noting that the floor cleaning machine had been broken and was recently repaired. Both the Administrator and Housekeeping Supervisor recognized the need for a clean environment, as the facility serves as the residents' home. The facility's policy on maintaining a homelike environment emphasizes the importance of providing a clean, sanitary, and orderly setting for residents.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during meal times. Specifically, a certified nursing assistant (CNA) was observed feeding a resident breakfast while the resident was lying in bed. The CNA was standing up and positioned higher than the resident, rather than sitting at eye level as required by the facility's policy on dignity. This practice was identified as a dignity concern, as it did not promote the resident's sense of well-being and self-worth. The resident involved was a 62-year-old female with diagnoses including cerebrovascular disease and muscle contracture, who required extensive assistance with eating. Her Minimum Data Set indicated she was cognitively intact with a BIMS score of 12 and required a one-person physical assist for feeding. The facility's policy, dated February 2021, emphasized the importance of caring for residents in a manner that enhances their self-esteem and satisfaction with life. Despite this, the CNA initially did not adhere to the policy, which was later acknowledged by the Director of Nursing (DON) during an interview.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity during meal assistance. An LVN was observed standing over a resident while assisting her with her meal in the dining room. The resident, who had a severely impaired BIMS score and required partial to moderate assistance with eating, expressed that she did not want to eat. Despite this, the LVN insisted that the resident needed to eat, which led to the resident being taken back to her room without finishing her meal. The resident involved was an elderly female with multiple health conditions, including anemia, hypertension, renal insufficiency, diabetes mellitus, thyroid disorder, malnutrition, and anxiety. Her care plan indicated that she required setup assistance from one staff member for eating and was dependent on staff for meeting her emotional, intellectual, physical, and social needs. The care plan also emphasized the importance of maintaining her current level of ADL function and ensuring she showed signs of enjoyment in activities. Interviews with staff, including the LVN, RN, DON, and ADON, revealed that the facility's policy required staff to sit at eye level with residents while assisting them with meals to ensure dignity and comfort. The DON and other staff members acknowledged that standing over residents could make them feel rushed or forced to eat, which was against the facility's training and policy. The facility's policy and training materials highlighted the importance of feeding residents with attention to safety, comfort, and dignity, explicitly stating that staff should not stand over residents while assisting them with meals.
Infection Control Lapses in Hand Hygiene and Equipment Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hand hygiene and glove use during resident care. On one occasion, a CNA providing incontinent care to a resident did not change gloves after cleaning the resident's bottom before handling a new brief. This oversight was acknowledged by the CNA, who admitted that her gloves were considered soiled after cleaning the resident's bottom and should have been changed before touching clean items. In another instance, a different CNA also failed to perform proper hand hygiene and glove changes while assisting a resident with toileting. The CNA did not wash her hands before putting on gloves and did not change gloves after cleaning the resident's bottom, subsequently handling a clean brief with soiled gloves. This CNA recognized the mistake, noting that the brief was contaminated due to the failure to change gloves. Additionally, an RN brought a whole container of test strips into a resident's room while checking blood sugar levels, which is against the facility's infection control policy. The RN acknowledged that the container should have remained on the cart, as it was intended for use with multiple residents, and bringing it into the room could lead to cross-contamination. The facility's policies emphasize the importance of hand hygiene and proper equipment handling to prevent infections, but these procedures were not followed in these instances.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to ensure that a resident, who required oxygen therapy, had a physician's order for its administration. Resident #49, a female with chronic obstructive pulmonary disease (COPD), was observed using an oxygen concentrator set at 2 liters per minute without a corresponding physician's order. Despite the presence of an order to change the oxygen tubing weekly, there was no documented order for the actual administration of oxygen. Interviews with the LPN and DON confirmed the absence of an order and highlighted the necessity of having a physician's order for oxygen therapy, as it is considered a medication. Another deficiency was identified with Resident #77, who used a BiPAP machine for sleep apnea. The BiPAP mask was observed on the resident's side table without being properly stored in a plastic bag, which is necessary to prevent cross-contamination and infection. The resident was not informed about the need to bag the mask, and staff failed to notice and address the improper storage during their rounds. Interviews with RN B and the ADON revealed that the staff did not consistently ensure the BiPAP mask was bagged when not in use, and there was a lack of education provided to the resident regarding proper storage. The facility's policies on oxygen administration and noninvasive ventilation require a physician's order for oxygen therapy and proper storage of BiPAP masks, respectively. However, these policies were not adhered to, resulting in the deficiencies observed. The lack of a physician's order for oxygen therapy and the improper storage of the BiPAP mask could potentially place residents at risk for respiratory infections and unmet respiratory needs.
Failure to Properly Administer Medications via G-Tube
Penalty
Summary
The facility failed to ensure that a resident received proper pharmaceutical services, specifically in the administration of medications through a gastrostomy tube (g-tube). The resident, a male with a diagnosis requiring tube feeding for 100% nutrition, was observed on a specific date when an LPN did not flush the g-tube before and after administering medications, as well as between each medication. This was contrary to the physician's orders and the facility's policy, which required flushing to prevent clogging and ensure proper medication absorption. During the medication administration, the LPN prepared and crushed the medications, dissolved them in water, and administered them through the g-tube without the necessary flushing steps. The LPN acknowledged the omission, stating that flushing was necessary to maintain the patency of the g-tube and to prevent clogging. The facility's policy clearly outlined the need for flushing with water between medications, which was not followed in this instance. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the VP of Clinical Operations confirmed the expectation that g-tubes should be flushed before and after medication administration and between each medication. They emphasized that the failure to do so could lead to blockages and compromised medication delivery. The deficiency was identified through observation, interviews, and record reviews, highlighting a lapse in adherence to established procedures for medication administration through a g-tube.
Failure to Maintain Washer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain one of two washing machines in the laundry room in safe operating condition, which could place residents at risk of contamination and improper laundering of items. During an observation and interview, it was noted that sudsy water was leaking from the door of a front-loading washer onto the floor. A trash bag was used to secure the washer door, and lime buildup was observed along the front and side of the washer. The laundry employee mentioned that the trash bag had been used for two days to secure the door, and there was no pending work order for the washer in the maintenance log. Further investigation revealed that a bolt on the washer door latch had to be tightened after a technician jammed the door while installing new chemical dispensers. The Maintenance Director had to force the door open, causing the bolt to loosen. The Housekeeping Manager noticed the loose bolt and tightened it, and by the following day, the washer was no longer leaking, and the trash bag was not in use. The Maintenance Director later stated that a washer seal was replaced, although there was no recommended time for changing these seals, which were replaced as needed. The facility's policy indicated that resident care equipment should be routinely inspected to ensure safe operating conditions according to manufacturer's recommendations.
Failure to Update Care Plan Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for a resident, which led to an incident of elopement. The resident, who had a history of dementia, major depressive disorder, and vision impairments, was moderately cognitively impaired and required assistance with daily activities. Despite these conditions, the resident's care plan did not include goals or interventions for documented wandering, exit-seeking, and elopement behaviors, nor was it updated following an incident of physical aggression. On a specific date, the resident was observed hitting his roommate, which resulted in the roommate being relocated. However, this aggressive behavior was not reflected in the resident's care plan. Additionally, the resident was able to leave the facility unsupervised on another occasion, found in the parking lot by a staff member. The door alarm did not sound, and there was no prior documentation of the resident's wandering or exit-seeking behavior, indicating a lack of proper monitoring and assessment. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's behaviors. The MDS nurse, who was responsible for updating care plans, was not informed of the resident's previous behaviors and had not reviewed past documentation. The Director of Nursing acknowledged that the resident's care plan should have been updated following the incidents, but attributed the oversight to staffing changes and remote work arrangements. This failure to update the care plan and implement necessary interventions placed the resident at risk of inappropriate and unsafe care.
Inadequate Supervision and Care Plan Updates for Resident with Elopement Risk
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a documented history of wandering and exit-seeking behavior. This resident, who was moderately cognitively impaired and had several medical conditions including dementia and vision impairments, was found outside the facility by a staff member. The incident occurred after the resident had previously attempted to leave the facility, but the facility did not reassess his elopement risk or update his care plan to address these behaviors. The resident's care plan did not include interventions for wandering, elopement, or exit-seeking behavior, despite a previous incident where the resident attempted to leave the facility. The facility's staff, including the MDS nurse and DON, were not aware of the resident's previous wandering behaviors, and the incident was not reported in interdisciplinary meetings. The facility's policies required that care plans be updated when new behaviors were exhibited, but this was not done in this case. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's behaviors and the necessary interventions. The facility's DON acknowledged that the resident's care plan should have been updated and that it was her responsibility to ensure accurate assessments and care plans. The facility's failure to reassess the resident's risk and update his care plan led to the resident being able to leave the facility unsupervised, posing a risk to his safety.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an alleged violation involving neglect within the required timeframe to the Health and Human Services Commission (HHSC). Specifically, the facility's Abuse Coordinator did not report an elopement incident involving a resident who was moderately cognitively impaired and had multiple health issues, including dementia and vision impairments. The resident was found outside the facility in the parking lot without his wheelchair, which was considered an elopement. Despite this, the Director of Nursing (DON) and the facility's Administrator did not classify the incident as an elopement and therefore did not report it to the appropriate authorities. The resident involved in the incident had a history of confusion related to urinary tract infections (UTIs) but was not documented as having wandering or exit-seeking behaviors. On the day of the incident, a Speech-Language Pathologist (SLP) found the resident outside the facility and noted that the door alarm did not sound. The facility's policy requires the investigation and reporting of any allegations of abuse, neglect, or mistreatment within the timeframes required by federal regulations. However, the facility did not adhere to this policy, potentially placing residents at risk of continued neglect.
Failure to Investigate Resident Elopement Incident
Penalty
Summary
The facility failed to investigate an alleged incident of neglect involving a resident's elopement. The resident, a male with dementia, major depressive disorder, generalized anxiety disorder, and vision impairments, was found outside the facility in the parking lot. The incident occurred early in the morning, and the resident was discovered by a staff member from the therapy department. Despite the resident's confusion and ambulation without a wheelchair, the facility's Director of Nursing (DON) and Administrator did not consider the incident as elopement and thus did not report or investigate it. The facility's policy requires the identification and investigation of all possible incidents of abuse, neglect, and mistreatment, and mandates reporting within federal timeframes. However, the facility's Abuse Coordinator did not investigate the incident as required. The DON and Administrator both expressed that they did not view the incident as elopement, despite documentation and staff observations indicating otherwise. This oversight could potentially place residents at risk of abuse, neglect, and/or exploitation.
Inaccurate Resident Assessment of Visual Impairments
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment reflective of their status, specifically regarding visual impairments. The resident, a male with a history of blindness in one eye and macular degeneration, was inaccurately assessed as having adequate vision in a Quarterly Minimum Data Set (MDS) assessment. This discrepancy was identified during a review of the resident's records, which included a face sheet and a comprehensive care plan that documented the resident's visual impairments. Interviews with the facility's MDS nurse and Director of Nursing (DON) revealed that the current MDS nurse, who began employment after the assessment was completed, was not aware of the resident's visual impairments due to a lack of review of past documentation and interdisciplinary discussions. The DON acknowledged the oversight and attributed it to a previous MDS nurse working remotely, emphasizing the importance of accurate MDS assessments for resident safety. The facility's policy mandates comprehensive assessments at specified intervals to ensure accurate reflection of residents' clinical conditions.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment, as evidenced by significant structural issues and unclean carpets. Observations revealed foundation problems in the hallway near the secretary's desk, including a downward slope on the floor, separation of walls from the floor, large cracks on the walls and ceiling, and a large open hole in the ceiling. These issues were marked with caution cones and tape. Additionally, the carpets throughout the facility were stained with unknown substances, indicating a lack of cleanliness. Interviews with facility staff, including the Administrator, CEO, DON, and SW, revealed that the foundation issues had been ongoing for an extended period, with no clear timeline for repairs. The Administrator, who had been in the position for two weeks, was unsure when the repairs would be completed. The CEO mentioned that an engineering survey had been conducted, and the facility was working on addressing the issues. The DON and SW confirmed that the foundation damage had been present since their employment began, and the facility had undergone multiple changes in ownership without resolving the problem. The carpets were cleaned daily, but replacement was deferred until the foundation work was completed.
Failure to Provide Timely Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, as evidenced by the failure to change the resident's tracheostomy shield weekly as per physician orders. The resident, who was cognitively intact and required extensive assistance, was observed with a tracheostomy shield dated 12 days prior to the observation, indicating it had not been changed as required. The resident denied refusing care, and there was no documentation of any refusals. The respiratory therapist (RT) responsible for the resident's care reported that the facility was out of tracheostomy shields on the scheduled change date and had informed the central supply staff. However, the central supply staff did not notify nursing leadership or ensure the shields were restocked promptly. The RT did not inform nursing leadership either, assuming the central supply staff would handle the issue. This lack of communication and follow-up resulted in the resident not receiving the necessary tracheostomy shield change. Interviews with facility staff, including the nurse, assistant director of nursing (ADON), and director of nursing (DON), revealed a lack of awareness regarding the shortage of tracheostomy shields and the failure to change the resident's shield. The DON expressed surprise at the shortage and emphasized the importance of being informed about supply issues. The facility's policy on tracheostomy care and refusal of treatment was not followed, as there was no documentation of any refusals or attempts to address the resident's care needs.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,175 citations issued within 25 miles in the last 12 months — including the 24 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Richardson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottonwood Creek Healthcare Community | 0.6 mi | — | 0 | 0 |
| The Plaza At Richardson | 0.6 mi | ★★★★★ | 3 | 0 |
| The Reserve At Richardson | 0.8 mi | ★★★★★ | 19 | 0 |
| Lindan Park Care Center Lp | 2.2 mi | ★★★★★ | 11 | 0 |
| Remington Transitional Care Of Richardson | 2.6 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.