Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at 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 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.
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 1,076 citations issued within 25 miles in the last 12 months — including the 39 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 | — | 7 | 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 | ★★★★★ | 0 | 0 |
| Remington Transitional Care Of Richardson | 2.6 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.