Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sabine Heights Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Unsafe Transfers and Improper Gait Belt Use: Two residents were involved in unsafe transfer practices. One resident with anemia, weakness, poor coordination, and cognitive impairment developed bruising to the arm, chest, and shoulder after being lifted under the arms during a bed-to-wheelchair transfer. Another resident with a R foot fracture and post-stroke weakness was observed being transferred with a gait belt that was too loose and with most of the weight taken under the armpits; the CNA and DON confirmed the belt was not positioned or tightened correctly.
Surveyors found that the facility did not follow professional food service standards when the posted menu in the dining area was not updated to the current week, leaving a resident unaware of upcoming meals, and there was no backup process when the Dietary Manager was absent. In the kitchen prep area, a wall above an uncovered pan of rice was coated with grey dust and debris, and a storage/seasoning rack had visible dust and sticky residue, despite the Dietary Manager and maintenance leadership acknowledging responsibility for cleanliness. Surveyors also observed stewed okra prepared without the tomatoes and onions required by the facility recipe, with the cook instead adding tomato sauce, vinegar, sausage, and seasonings at the direction of the Dietary Manager, contrary to the written recipe.
Failure to Notify MD of Repeated Held BP Medication: A resident with COPD, HTN, and renal disease had carvedilol 25 mg ordered with hold parameters for low BP or HR. The MAR showed the med was held multiple times for readings outside the ordered parameters, but the record contained no documentation that the MD was notified of the repeated holds or the pattern of low BP. The DON and Administrator both acknowledged that physician notification and documentation were expected when parameter-based meds were held repeatedly.
A facility with 150 beds failed to ensure its full-time SW met required qualifications. Record review showed the SW was not licensed by the Texas State Board of Social Worker Examiners, and interviews confirmed she had only researched the Texas licensure process and had not applied yet. The job description required a bachelor's degree and licensure per state requirements or eligibility for licensure.
Mandatory QAPI training was not documented for 9 of 18 sampled staff, including several LVNs and CNAs. The training log and personnel files showed no evidence that these employees completed QAPI training during orientation or annually, and HR, the interim DON, and the Administrator each acknowledged the lack of documentation or awareness of the requirement. The facility’s QAPI plan stated that employees are to receive training to perform their jobs effectively and that the QAPI Coordinator facilitates staff education on QAPI principles and practices.
Failure to Report Alleged Abuse/Neglect Complaint to Administrator: A cognitively intact resident with COPD and asthma reported shortness of breath and said an LVN spoke to her in a mean manner and delayed her breathing treatment. A CNA said the resident complained to her and that she reported it to the SW, but she did not notify the Administrator/abuse coordinator as required. No grievance or incident report was found, and the Administrator and SW said they were unaware of the complaint.
Failure to Complete Significant Change MDS After Hospice Enrollment: A resident with CHF, cardiomyopathy, CVA, and COPD enrolled in hospice, but the facility did not complete the required significant change MDS within the required timeframe. Staff said the assessment was overlooked during a period of MDS/DON staffing transition, and the backup reviewer was not notified of the hospice admission. The resident’s most recent MDS still showed no hospice services, while care plans later reflected terminal prognosis and hospice care.
Care Plan Not Updated for Hospice Significant Change: A resident with COPD, DM2, obesity, SOB, and HTN had a significant change in status when she was admitted to hospice, but her comprehensive care plan was not initiated or completed to reflect the change. The RNC/interim DON, ADON, and Administrator acknowledged the hospice-related update was overlooked during a period of DON and MDS vacancy.
Failure to provide needed grooming assistance: A female resident with dementia, anxiety, diabetes, and HTN required help with personal hygiene, but staff did not remove her unwanted chin hair during a bath. The resident said she liked her facial hair shaved with bathing and had not refused care; the CNA acknowledged the hair should have been removed, and the DON, LVN, and Administrator all stated facial hair should be removed unless the resident refuses.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found a 6.67% medication error rate during med pass observation. An LVN gave a resident the wrong dose of bupropion when the MAR and blister pack did not match, and gave another resident carvedilol despite ordered hold parameters because the HR was below 60. The DON and LVN both acknowledged the errors.
Loose pills were found in drawer 2 of the Hall 300 med cart and the Hall 400 nurse's med cart during observation. An LVN was responsible for the Hall 300 cart, and the ADON was responsible for the Hall 400 cart; both stated the loose pills were overlooked during routine checks. The DON and Administrator said the nurse using the cart was responsible for ensuring no loose pills remained in the cart, with the ADON and DON serving as backup for weekly double-checks.
Missing Enhanced Barrier Precaution Signage: Two residents on EBP for wounds and other high-contact care needs did not have the required precaution signs posted on their room doors during repeated observations. An LVN, the ADON, the interim DON, and the Administrator all acknowledged the signs should have been in place so staff would know what PPE to use and to support infection prevention procedures.
A resident with generalized anxiety disorder and moderate cognitive impairment did not have a care plan addressing her anxiety diagnosis or the use of Buspirone, despite documented symptoms and treatment. Assessments and progress notes indicated ongoing anxiety and medication changes, but the care plan was not updated due to missed communication and lack of follow-through by staff, as confirmed by facility leadership.
A resident with severe cognitive impairment and behavioral issues was able to elope from the facility due to inadequate supervision, lack of clear monitoring instructions, and absence of physical security measures such as door alarms or wander guards. Staff were not consistently informed or able to perform required 15-minute checks, and documentation of monitoring was incomplete, leading to the resident being found off facility grounds in a hazardous area.
A resident with COPD and hypertension was admitted with a hospital discharge summary specifying new and continued medications, but due to staff failing to verify the correct identity on discharge paperwork, the resident was given the wrong medications for several days. The error was discovered after the resident experienced shortness of breath and was readmitted to the hospital, and a review revealed that the prescribed breathing treatments and other medications were omitted while unprescribed drugs were administered.
A resident with COPD and hypertension was given multiple medications not prescribed to her, including blood thinners and blood pressure drugs, while not receiving her required breathing treatments and anti-inflammatory medications. This occurred after staff used another individual's discharge medication list during admission, leading to the resident's hospitalization for COPD exacerbation. The error was discovered after the family raised concerns and a review confirmed the medication mismatch.
Expired medications, including Ondansetron and Clonidine, were found in a medication cart and had not been removed from use despite being expired for several months. An LVN confirmed the expired drugs were present but had not been administered, and the DON acknowledged the oversight, noting that staff are responsible for checking and removing expired medications according to facility policy.
Therapy staff failed to follow infection control protocols, including proper hand hygiene and equipment disinfection between residents, and worked with an open, uncovered wound. Staff had not received facility-specific infection control training, despite having completed general online modules, resulting in lapses that could contribute to cross-contamination.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not maintain the required RN coverage for eight consecutive hours daily, seven days a week, during the first quarter of 2023. On several occasions, there was no RN on duty, as confirmed by PBJ reports and staff interviews. The facility faced challenges in hiring RNs due to its rural location and relied on telehealth consultations and agency RNs, who often did not show up for work.
The facility failed to monitor and manage psychotropic medications for residents, leading to deficiencies in care. A resident on Seroquel was not monitored for side effects or behaviors, and two residents had PRN orders for Ativan without proper documentation or adherence to the 14-day limit. The nursing staff did not follow procedures for monitoring, and the facility's policies were not effectively implemented.
A facility failed to document medication administration for three residents, leading to potential risks of unmet care needs. The residents, with conditions such as COPD, Alzheimer's, and hypertension, had missing entries in their MARs for various medications. The DON confirmed the expectation for timely documentation, and a nurse admitted to possibly forgetting to document, despite administering the medications.
A resident with a tracheostomy experienced improper care when an LVN accidentally removed both the tracheostomy tube and inner cannula during a procedure, despite being trained to only remove the inner cannula. The DON and ADON intervened to correct the situation, ensuring the resident's respiratory stability. The facility's policy outlined the correct procedure, which was not followed in this instance.
A resident with chronic atrial fibrillation was not administered Rivaroxaban (Xarelto) for 38 days due to the facility's failure to transcribe and implement hospital discharge orders. Despite multiple opportunities, the facility's staff did not ensure the continuation of the prescribed anticoagulant, leading to the resident's hospitalization and subsequent death due to heart failure.
A resident with a history of heart disease and atrial fibrillation was not administered Rivaroxaban for 38 days due to a failure to implement hospital discharge orders. The oversight occurred because the medication was not reconciled upon admission, leading to the resident's deterioration and eventual death. Interviews revealed a lack of communication and documentation among facility staff regarding medication reconciliation.
Unsafe Transfers and Improper Gait Belt Use
Penalty
Summary
The facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents during transfers for two residents reviewed for quality of care. One resident had diagnoses including iron deficiency anemia, muscle weakness, lack of coordination, and muscle wasting and atrophy, and her quarterly MDS reflected moderate cognitive impairment and a need for substantial to maximal assistance for sit-to-stand mobility. Her care plan identified an ADL self-care performance deficit related to impaired balance and chronic bilateral knee pain secondary to osteoarthritis. Record review and interviews showed that this resident developed bruising to the right upper arm, right upper chest, and shoulder area after being transferred from bed to wheelchair. The resident stated she was always assisted by two people and described being held under the arms during the transfer, after which she had bruising under her armpit extending to her bicep, chest, and side. The skin incident report, weekly skin review, and head-to-toe skin check documented bruising in the right upper arm, right upper chest, right shoulder, and right antecubital area. A CNA later stated she had transferred the resident twice that day with another CNA and used a gait belt, but did not know the resident had been hurt. For the second resident, who had a displaced right foot fracture, muscle weakness, lack of coordination, and hemiplegia/hemiparesis following a stroke, observation showed two CNAs transferring the resident to a wheelchair with a gait belt that was too loose and riding up to the armpit. The CNAs held the resident under both armpits and pivoted her into the wheelchair. Both CNAs stated the gait belt was not positioned or tightened appropriately, and the DON confirmed it was loose and served no purpose once the resident stood up. The PT and DON stated the gait belt should be placed at the waist and fit snugly, and the facility record showed the CNAs had completed an in-service on safe lifting and transferring after the bruising incident was identified.
Food Service Sanitation and Menu Posting Deficiencies in Kitchen
Penalty
Summary
Surveyors identified that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen. On observation, the posted menu in the dining area reflected an outdated week rather than the current week, and a resident reported that the menu had not been correctly posted for approximately one to two weeks, leaving her unaware of daily and weekly meal offerings. The Dietary Manager stated she was responsible for updating the menu every Monday but had been off on the most recent Monday and had no designated backup to update the menu in her absence. The Administrator confirmed that the posted menu was expected to be current so residents would know what they would eat. Additional observations in the kitchen prep area showed environmental sanitation issues and failure to follow recipes. Surveyors observed a wall above an uncovered pan of rice coated with grey dust and debris, and a storage/seasoning rack coated with dust and yellow/brown sticky residue. The Dietary Manager acknowledged she could not recall the last time the wall or rack had been cleaned and that there was no set cleaning schedule, despite her responsibility for ensuring the kitchen was clean and sanitary and for notifying maintenance to clean high walls. The Maintenance Regional Supervisor stated that maintenance staff were responsible for cleaning high ceiling walls and that the wall and rack should have been free of dust and residue. Surveyors also observed stewed okra being prepared without tomatoes or onions, contrary to the written recipe that required diced tomatoes, okra, chopped onions, sugar, and black pepper. The cook reported she did not follow the recipe because many residents did not like tomatoes and that she added tomato sauce, white vinegar, sausage, and seasonings instead, following direction from the Dietary Manager, who admitted she had instructed the cook to add sausage and acknowledged the recipe was not followed.
Failure to Notify Physician of Repeated Held BP Medication
Penalty
Summary
The facility failed to ensure the physician was consulted regarding a need to alter treatment for Resident #5 when her blood pressure medication was held repeatedly over consecutive days. Resident #5 was an older female resident admitted with diagnoses including COPD, hypertension, and renal disease, and her BIMS score was 15, indicating she was cognitively intact. Her physician had ordered carvedilol 25 mg once daily for hypertension with parameters to hold the medication if SBP was less than 120, DBP was less than 60, or heart rate was less than 60. The MARs for December 2025 and January 2026 showed carvedilol was held on multiple occasions when blood pressure readings were outside those parameters, including several low blood pressure readings across the month. During interview and record review, the DON acknowledged the medication had been documented as held according to the ordered parameters and stated best practice would be for nursing staff to notify the physician when medications with parameters were held on consecutive occasions. The DON also stated the nursing staff should document when the physician was notified, but Resident #5’s electronic record contained no indication that the physician had been notified. Review of the nurse’s notes from 12/05/2025 through 01/05/2026 showed no documentation of physician notification. The Administrator stated his expectation was that the physician be notified when a resident’s medications were held, or at least every few times, and that nursing staff should document notifications.
Unlicensed Social Worker Hired
Penalty
Summary
The facility failed to ensure that the hired Social Worker met the required qualifications for the position in a facility certified for 150 beds. Record review showed the employee file dated 01/07/26 identified the Social Worker as not licensed by the Texas State Board of Social Worker Examiners, although she held a bachelor's degree in social work. The facility hired her as a full-time Social Worker on 10/06/25. The facility's job description for the Social Worker position, dated 10/06/25, listed qualifications as a minimum of a bachelor's degree in social work or human services fields and licensure per state requirements or eligibility for licensure. During interview, the Administrator stated the Social Worker had a Bachelor of Science degree in Psychology and had been preparing to take the licensure exam, but was not licensed. The Social Worker stated she had researched the application process for Texas certification requirements but had not applied yet.
Missing Mandatory QAPI Training for Multiple Staff
Penalty
Summary
Mandatory QAPI training was not provided for 9 of 18 staff sampled for licensure and training, including LVN E, LVN F, LVN G, LVN H, CNA J, CNA K, CNA L, CNA M, and CNA N. Review of the facility’s undated training log showed no evidence of QAPI training for these employees, and record review of their personnel files showed they had not completed QAPI training during orientation or annually. The staff members identified had hire dates ranging from 12/12/25 to 10/29/25, and included both LVNs and CNAs. During interviews on 01/07/26, HR stated she was not aware of the new requirement for QAPI training and said she would check with the interim DON and Administrator. The interim DON said she thought the prior DON should have completed the QAPI training for staff but was unable to locate documentation. The Administrator stated he expected the QAPI training to be included in the computerized training system and acknowledged that if staff did not receive the mandatory training, they might not be fully trained. The facility’s undated QAPI Program Plan stated that employees are provided the necessary training to perform their jobs effectively and that the QAPI Coordinator is responsible for facilitating staff education on QAPI principles and practices.
Failure to Report Alleged Abuse/Neglect Complaint to Administrator
Penalty
Summary
The facility failed to ensure that an alleged abuse/neglect complaint involving a resident with COPD, asthma, obesity, shortness of breath, hypertension, and type 2 diabetes was reported immediately to the Administrator. Resident #14, who was cognitively intact with a BIMS of 15, told staff that she had shortness of breath and requested a breathing treatment. She reported that an LVN told her she could breathe because she had just been talking on the phone, and she said she did not like how the LVN spoke to her. Resident #14 stated she reported the complaint to a CNA on the day it happened. The CNA said the resident told her she wanted to talk to someone about the LVN talking mean to her and that the resident said she could not breathe but the LVN told her she was breathing fine while on the phone so she could breathe. The CNA said she reported the complaint to the Social Worker immediately, but she did not report it to the Administrator, who was the abuse coordinator, and she did not provide the details of what the resident told her. The CNA also stated she knew the complaint should have been reported to the abuse coordinator within 2 hours of becoming aware of it. The Administrator stated he had not been aware of any grievance or incident involving Resident #14 and said staff should have made him aware immediately. The Social Worker stated she did not recall any grievance from Resident #14 and had not been told about the incident by the CNA. The LVN stated the resident had been sick and had received breathing treatments, denied telling the resident she could breathe because she was on the phone, and said the resident had no signs or symptoms of difficulty breathing. Facility records showed no grievance report, incident report, or nursing note documenting the complaint or incident, and the facility policy stated suspected abuse or neglect should be reported in a timely manner to appropriate agencies.
Failure to Complete Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days after determining that Resident #34 had a significant change in condition related to hospice enrollment. Resident #34 was an older male with diagnoses including heart failure, cardiomyopathy, cerebral infarct, and COPD. His most recent significant change MDS indicated intact cognition with a BIMS score of 13 and did not reflect hospice services. Later record review showed physician orders and care plans documenting that he was admitted to hospice for congestive heart failure, but the required significant change assessment was not completed within the required timeframe. Record review showed an open quarterly MDS, a completed significant change MDS, and a completed entry MDS for Resident #34, but the hospice admission was not captured with a new significant change assessment. During observation, the resident stated he received hospice services but was unsure which one. Staff interviews showed the MDS nurse responsible for assessments was in training, the prior MDS nurse had become PRN, and the backup reviewer did not open a significant change MDS because the facility did not notify her of the hospice admission. The MDS nurse stated the significant change MDS was overlooked when the resident admitted to hospice services. The DON and Administrator both stated the significant change MDS was overlooked during a period when the MDS and DON positions were vacant or in transition. The Senior Director of Reimbursement said she performed only random accuracy checks and did not review every MDS, and she also stated she was not notified of the hospice admission. The report cited the RAI Manual requirement that an SCSA be completed when a terminally ill resident enrolls in hospice, with the ARD within 14 days of the hospice election date, and noted that this assessment was not completed for Resident #34 as required.
Care Plan Not Updated for Hospice Significant Change
Penalty
Summary
The facility failed to ensure Resident #14’s comprehensive care plan was reviewed and revised by the interdisciplinary team after a significant change in condition. Resident #14 was a re-admitted female with diagnoses including COPD, type 2 diabetes, obesity, shortness of breath, and hypertension. Her significant change MDS assessment identified the assessment type as a significant change in status assessment for hospice, and the record showed she was admitted to hospice on 12/04/2025. Record review of the care plan showed a review start date of 12/1/2025 and a target completion date of 12/17/2025, but the care plan was not initiated or completed for the change in condition related to hospice. During interviews, the Regional Nurse Consultant, ADON, and Administrator stated that the MDS nurse, DON, interim DON, and ADON were responsible for updating care plans and acknowledged that Resident #14’s hospice-related significant change should have been added to the care plan but was overlooked due to the DON and MDS vacancy.
Failure to Provide Needed Grooming Assistance
Penalty
Summary
The facility failed to ensure Resident #11 received necessary assistance with personal hygiene and grooming when unwanted facial hair on her chin was not removed during bathing. Resident #11 was a female resident with diagnoses including type 2 diabetes mellitus, dementia, generalized anxiety disorder, and hypertension. Her MDS reflected a BIMS of 14 and indicated she required supervision or assistance with personal hygiene, and her care plan included staff participation with personal hygiene and oral care. Her December 2025 aide flowsheet reflected she did not refuse baths or personal hygiene. During an observation and interview on 01/05/2026 at 1:00 p.m., Resident #11 stated she did not understand why CNA P did not remove her facial hair when she was bathed that morning and said it had been a long time since she was shaved. She stated she likes her chin hair shaved with her bath and had not complained about it. The hair under her chin was observed to be approximately 15 dark curly hairs. During interviews, CNA P said she should have removed the facial hair with the bath, the interim DON said residents should be kept without long facial hair unless they refuse, LVN O said the facial hair should be removed during bath unless the resident refuses, and the Administrator stated his expectation was for facial hair to be removed unless the resident refused. The facility policy stated residents unable to carry out ADLs independently will receive services necessary to maintain good grooming and personal hygiene.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. During observation, interview, and record review, surveyors identified 2 medication errors out of 30 opportunities, resulting in a 6.67 percent error rate involving 2 of 5 residents reviewed during medication pass. The facility’s medication administration policy required medications to be given in accordance with prescriber orders and for the nurse to verify the right resident, right medication, right dosage, right time, and right route before administration. One error involved a resident with paranoid schizophrenia and major depressive disorder who had intact cognition and was ordered bupropion HCL ER 150 mg tablets, 2 tablets by mouth daily for depression. During the medication pass, the LVN prepared and administered 2 bupropion HCL ER 300 mg tablets instead. The LVN later acknowledged the incorrect dose and stated she should have noticed the blister pack contained 300 mg tablets rather than 150 mg tablets. The DON stated the resident had previously been receiving two 150 mg tablets and that nursing should have recognized the pharmacy change and reflected the dosage on the MAR. The second error involved a resident with heart failure and hypertension who had an order for carvedilol 3.125 mg twice daily with instructions to hold for BP less than 110/60 or heart rate less than 60. During the medication pass, the LVN obtained vital signs showing a heart rate of 58, but still administered carvedilol. The LVN acknowledged she overlooked the ordered parameters and made a mistake in giving the medication. The DON stated medications were expected to be administered according to physician orders and parameters.
Loose Pills Found in Medication Carts
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles when loose pills were found in medication cart drawers on Hall 300 and Hall 400. During observation and interview, 7 whole miscellaneous pills and 6 broken pills were found loose in drawer 2 of the Hall 300 medication cart while an LVN was responsible for the cart. The LVN stated the ADON double-checked medication carts weekly for scattered pills and debris, but the loose pills had been overlooked, and she said she had not yet cleaned the cart during her shift. During a separate observation and interview, 3 whole pills and 1 broken pill were found loose in drawer 2 of the Hall 400 nurse's medication cart while the ADON was responsible for medication administration on that hall. The ADON stated she was the backup person who double-checked medication carts every Friday for cleanliness, loose medication, and expired medication, and that the loose pills had been overlooked. The DON and Administrator both stated that the nurse using the cart was responsible for ensuring no loose pills were left in the cart, and that the ADON and DON were the backup staff who double-checked the carts weekly.
Missing Enhanced Barrier Precaution Signage
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 residents observed for Enhanced Barrier Precautions. Resident #4 was on Enhanced Barrier Precautions for a stage 4 sacrum wound, and Resident #6 was on Enhanced Barrier Precautions for pressure injuries, including a stage 2 right superior hip wound and a stage 3 left hip wound. The facility record also identified Resident #6 as being on Enhanced Barrier Precautions for tube feedings and wounds on the left and right foot during interview. During observations on 01/05/2026, 01/06/2026, and 01/07/2026, there was no Enhanced Barrier Precaution sign on either Resident #4's door or Resident #6's door. The missing signage was noted repeatedly over multiple observations. The facility policy stated that signs are to be posted in the door or wall outside the resident room indicating the type of precautions and PPE required. During interview, the LVN stated the sign should have been on the door so staff would know what needed to be worn during care and to protect staff and visitors. The ADON stated the sign should have been posted so staff would know which protective equipment to use and said she should have noticed it was missing for Resident #4. The interim DON and Administrator both stated that staff were responsible for ensuring the Enhanced Barrier Precaution signs were on the appropriate residents' doors.
Failure to Develop and Implement Comprehensive Care Plan for Anxiety Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident diagnosed with generalized anxiety disorder. Despite the resident's documented diagnosis and the prescription of Buspirone (Buspar) for anxiety, there was no care plan addressing either the anxiety diagnosis or the use of the anti-anxiety medication. Record reviews showed that the resident had a history of Parkinsonism, diabetes, cognitive communication deficit, and generalized anxiety disorder, and was assessed as having moderate cognitive impairment. The resident was alert, coherent, and oriented, and expressed difficulty adjusting to the nursing home environment, with observable anxious behaviors and a willingness to participate in therapy. Multiple assessments and progress notes from licensed professionals, including a Licensed Professional Counselor (LPC) and a Psychiatric Mental Health Nurse Practitioner (PMHNP), documented the resident's ongoing anxiety symptoms and the initiation of Buspirone to manage these symptoms. The medication was later discontinued at the request of a family member. Despite these significant changes in the resident's condition and treatment, the care plan was not updated to reflect the anxiety diagnosis or the medication regimen, as confirmed by interviews with facility leadership and staff. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the care plan omission was due to a lack of communication and oversight. The MDS Coordinator was not informed of the new diagnosis or medication, and the nurse who received the order did not complete the required care plan update. Facility policies required that changes in a resident's condition be reported and care plans updated accordingly, but this process was not followed, resulting in the deficiency.
Failure to Prevent Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A facility failed to provide adequate supervision to prevent an elopement incident involving a male resident with severe cognitive impairment, a history of behavioral issues, and recent aggressive and exit-seeking behaviors. The resident, who was admitted with diagnoses including cognitive communication deficit and generalized anxiety disorder, had a BIMS score indicating severe cognitive impairment and was independently ambulatory. Despite a care plan noting behavioral problems and interventions, the resident's risk for elopement was not initially recognized as high, and monitoring protocols were inconsistently implemented. On the day of the incident, the resident was able to leave the facility through an unlocked door, which had no keycode or alarm, and was found by staff approximately 50 feet off the premises in a hazardous area with tall grass, rocks, and uneven ground. Staff interviews revealed that the 15-minute monitoring checks ordered for the resident were not consistently performed or documented, and several staff members were unaware of the monitoring requirement. The DON did not provide specific instructions on how to monitor the resident or what behaviors to observe, nor was a staff member designated to be responsible for the checks. Additionally, the facility lacked physical security measures such as wander guards or door alarms, and residents could exit the building freely. Further interviews indicated that staff were unable to adequately supervise the resident due to competing responsibilities and lack of clear communication. The monitoring sheets for the resident contained missing or incomplete documentation, and staff reported being unable to perform checks during medication passes or breaks. The facility's elopement policy required identification of at-risk residents and specific interventions, but these were not effectively implemented prior to the incident, resulting in the resident's unsupervised exit from the facility.
Failure to Accurately Reconcile and Administer Discharge Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not accurately reviewing and implementing the hospital discharge medication regimen. Upon admission, the resident, who had a history of hypertension and COPD and required continuous oxygen, was supposed to receive a specific set of medications as outlined in the hospital discharge summary, including new prescriptions for budesonide, prednisone, and levalbuterol, as well as continuation of several home medications. However, the facility administered a different set of medications, which were not those prescribed at discharge, over a period of several days. This error occurred because the hospital discharge paperwork provided to the facility included medication lists for a different individual, and staff failed to verify the correct resident's name and date of birth on the documents. As a result, the resident did not receive the prescribed breathing treatments and other necessary medications, and instead received multiple doses of medications not intended for her. The error was not identified until the resident's family questioned the medication regimen, prompting a review that revealed the discrepancy. During the period the resident was given the incorrect medications, she experienced shortness of breath and anxiety, leading to a decrease in oxygen saturation and subsequent transfer back to the hospital, where she was admitted for an exacerbation of COPD and anxiety. Interviews with staff indicated that the admitting nurse was responsible for reconciling medications with the physician, but the process failed due to lack of verification of the resident's identity on the discharge paperwork and incomplete transcription of orders.
Significant Medication Error Due to Incorrect Admission Reconciliation
Penalty
Summary
A significant medication error occurred when a resident was admitted with a history of hypertension and COPD, requiring continuous oxygen and specific medications as outlined in her hospital discharge summary. Upon admission, the facility failed to accurately reconcile the resident's medications, resulting in the administration of multiple medications that were not prescribed to her, including two blood thinners and blood pressure medications. At the same time, the resident did not receive her prescribed breathing treatments and anti-inflammatory medications, which were essential for her COPD management. The error was traced to the use of incorrect hospital discharge paperwork, which contained another individual's medication list. This paperwork was used to transcribe and order medications for the resident, leading to the administration of the wrong medications and omission of necessary treatments. The family brought the discrepancy to the facility's attention after noticing inconsistencies in the medications being administered. Upon investigation, it was confirmed that the medication list used during admission did not match the resident's actual discharge orders. During the period following admission, the resident experienced shortness of breath and anxiety, with decreasing oxygen saturation levels, ultimately resulting in her transfer back to the hospital for evaluation and treatment of a COPD exacerbation. Interviews with facility staff revealed that the admitting nurse was responsible for reconciling medications with the physician, and the ADON was to ensure accuracy in transcription. However, these processes failed, and the error was not identified until after the resident's condition deteriorated and the family intervened.
Expired Medications Found in Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored in accordance with accepted professional principles on one of three medication carts reviewed. Specifically, expired medications were found in the 300 Hall medication storage cart, including four tablets of Ondansetron 8mg that had expired for 322 days and five tablets of Clonidine 0.1mg that had expired for 414 days. These expired medications were not removed from use and remained accessible in the medication cart. The LVN responsible for the cart confirmed the presence of the expired medications and stated she had not administered them, noting she was new to the facility and had received training on medication storage and checking for expired medications. The Director of Nursing (DON) stated that expired medications should not be present in medication rooms or carts and that nurses are responsible for checking and removing expired medications. The DON acknowledged that the expired medications had been overlooked, possibly due to them not being administered for months. Review of the facility's pharmacy monthly medication review records from July to September did not indicate any expired medications needing removal, and the facility's policy requires staff to remove expired medications from active stock. No evidence was found that the expired medications had been administered to residents.
Failure to Maintain Infection Control Practices in Therapy Department
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of improper hand hygiene and equipment disinfection practices among therapy staff. Specifically, a physical therapist was observed wearing the same pair of gloves while touching multiple residents, their wheelchairs, gait belts, and walkers, without changing gloves or performing hand hygiene between contacts. Additionally, both the physical therapist and occupational therapist did not use hand hygiene before assisting residents or between resident contacts, and therapy equipment such as parallel bars was not disinfected between uses by different residents. Further observations revealed that the physical therapist had an open, uncovered cut on his finger while working with residents and used a paper towel to wipe sweat from his forehead and hands, then proceeded to touch residents without performing hand hygiene. Interviews with therapy staff indicated that they were aware of proper infection control practices but had not received facility-specific training or skill check-offs on infection control from the Director of Nursing (DON) or the facility. The DON, who serves as the infection preventionist, confirmed that the rehabilitation department had not been trained on infection control by the facility. Record reviews showed that therapy staff had completed online infection control modules provided by their contracting company, but these were annual refresher courses and not specific to the facility's policies or procedures. The facility's infection control policy requires all personnel to be trained on infection control upon hire and periodically thereafter, with oversight by the Quality Assurance and Performance Improvement Committee. Despite these requirements, the lack of facility-specific training and failure to follow basic infection control practices led to the observed deficiencies.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, during the first quarter of 2023. Specifically, there was no RN coverage on several days, including 10/07/23, 11/11/23, 11/12/23, 11/25/23, 12/03/23, 12/16/23, and 12/17/23. This deficiency was identified through a review of the CMS Payroll-Based Journal (PBJ) reports and confirmed by interviews with the Corporate Nurse, Director of Nursing (DON), and the Administrator. The Corporate Nurse acknowledged the lack of RN coverage on the specified dates, and the DON confirmed she was on approved leave during those times. The Administrator cited difficulties in hiring RNs due to the facility's rural location and noted that agency RNs often failed to show up for work. The facility attempted to mitigate the lack of on-site RN coverage by contracting with a telehealth company for 24-hour RN consultation and ensuring the Corporate Nurse was available by phone. However, the facility's policy, revised in August 2022, clearly stated that an RN should provide services for at least eight consecutive hours every 24 hours, seven days a week. Despite these efforts, the facility did not meet the regulatory requirement for RN coverage, which could potentially impact the level of nursing oversight and care provided to residents.
Failure to Monitor and Manage Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring and management of psychotropic medications for residents, leading to deficiencies in care. Resident #39, a female with diagnoses of psychosis and anxiety, was prescribed Seroquel for psychosis. However, the facility did not document monitoring of side effects or behaviors associated with the antipsychotic medication from March to October 2024. This oversight was acknowledged by LVN A, who admitted that the monitoring was overlooked and not entered into the computer system, despite being educated on the importance of monitoring antipsychotic medications. Additionally, the facility did not adhere to the 14-day limit for PRN orders of psychotropic medications for Residents #55 and #61. Resident #55 had an order for Ativan without a stop date, and there was no documented rationale from the attending physician for extending the PRN order beyond 14 days. Similarly, Resident #61 had an order for Ativan with no stop date and no documentation from the physician or NP justifying the continuation of the medication. The DON and ADON confirmed that the responsibility for monitoring and ensuring compliance with medication orders lay with the nursing staff, but these processes were not followed. The facility's failure to monitor and manage psychotropic medications as required could lead to adverse consequences for the residents. The Administrator and nursing leadership acknowledged the oversight and the potential risks associated with not monitoring psychotropic medications for side effects and behaviors. The facility's policies on psychotropic medication use and monitoring were not effectively implemented, resulting in these deficiencies.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to ensure that medical records for three residents were accurately documented in accordance with professional standards. This deficiency was identified through observation, interviews, and record reviews. Specifically, the facility did not ensure that staff documented the administration of medications on the Medication Administration Records (MARs) for three residents. This lack of documentation could potentially place residents at risk of not receiving the necessary care and services to meet their needs. Resident #15, a female with multiple diagnoses including COPD, GERD, and hypertension, had several instances where her MARs lacked documentation of medication administration. For example, there were missing entries for medications such as Pantoprazole, Atorvastatin, and Remeron on various dates in September and October 2024. During an interview, the Director of Nursing (DON) acknowledged the expectation for nurses to document medication administration at the time of delivery, highlighting the risk of double dosing due to missed documentation. Similarly, Resident #55, a male with dementia and Alzheimer's disease, also had missing documentation for medications like Atorvastatin and Seroquel on several dates. Resident #61, another male with Alzheimer's disease and hypertension, had missing entries for medications such as Donepezil and Metoprolol. The DON confirmed that the night shift nurses were responsible for the missing documentation, and RN C admitted to possibly forgetting to document the administration of medications, although she claimed to have given them.
Improper Tracheostomy Care by LVN
Penalty
Summary
The facility failed to provide proper respiratory care for a resident with a tracheostomy, specifically during tracheostomy care and suctioning. The resident, a female with a diagnosis of acute respiratory failure with hypoxia and a tracheostomy, was dependent on supplemental oxygen. The care plan and physician orders required specific tracheostomy care, including cleaning the inner cannula every shift and changing the tracheostomy dressing and collar every shift. During an observation, LVN A, who had been educated on tracheostomy care, improperly removed both the tracheostomy tube and the inner cannula while performing tracheostomy care for the resident. This error occurred despite LVN A's training, which emphasized only removing the inner cannula during care. The LVN panicked upon realizing the mistake and placed oxygen over the open stoma to maintain the resident's oxygen supply. The DON and ADON intervened to reinsert the tracheostomy tube and a new inner cannula, ensuring the resident's respiratory stability. Interviews with the LVN, DON, ADON, and the Administrator confirmed that the improper removal of the tracheostomy tube was an error, and the facility's policy outlined the correct procedure for tracheostomy care. The incident highlighted a lapse in following the established protocol, which could have led to respiratory distress for the resident. The facility's policy emphasized the importance of proper tracheostomy care to prevent infection and ensure the resident's ability to breathe comfortably.
Failure to Transcribe and Administer Anticoagulant Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, the facility did not transcribe and implement the discharge orders for a resident, which included the anticoagulant Rivaroxaban (Xarelto). This medication was crucial for the resident's condition, as it was prescribed to prevent blood clots due to her chronic atrial fibrillation. The resident did not receive this medication for 38 days, leading to a severe medical condition. The resident, who had a history of chronic respiratory failure, hypertension, peripheral vascular disease, and chronic atrial fibrillation, was discharged from the hospital with orders to continue taking Rivaroxaban. However, the facility failed to transcribe these orders into the resident's medication administration record. Despite multiple opportunities to review and reconcile the resident's medications, the facility's staff, including the attending physician and nurse practitioners, did not ensure the continuation of the prescribed anticoagulant. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's medication reconciliation. The Director of Nursing acknowledged the failure to reconcile the resident's medications upon admission and the absence of documentation verifying the reconciliation process. The attending physician and nurse practitioners also failed to review the hospital records and ensure the resident received the necessary medication, resulting in the resident's hospitalization and subsequent death due to heart failure.
Removal Plan
- A facility audit to be completed by the Director of Nursing/Designee of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR.
- For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented.
- If a trend is established then we will QAPI the trend and in-service staff on root cause to prevent in the future.
- Facility will implement system changes requiring the admitting nurse to put in a progress note indicating that they have reviewed the admission orders with the MD.
- Facility will implement a system requiring the primary care physicians to put in a progress note indicating that they have reviewed and reconciled hospital discharge orders with admission orders within 72 hours of admission.
- PCP's will be made aware of the new system.
- The DON/Administrator and, or designee will notify all facility PCPs of the new system.
- If the physician cannot reconcile the orders then the patient will be sent out to the hospital.
- In-services initiated by DON/Designee with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours.
- DON/ADON will then notify the medical director.
- All other licensed staff will be in-serviced prior to working next shift.
- Ad Hoc QAPI meeting completed with IDT and Medical Director.
- Education was completed with the administrative nursing team by the Regional Nurse Consultant related to completing chart audits of new admissions to assure that orders were transcribed correctly.
- Education to be completed with all nursing staff working either in person or via phone call.
- Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings.
Failure to Administer Anticoagulant Leads to Resident's Deterioration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Rivaroxaban (Xarelto), a medication used to prevent blood clots. The resident, who had a history of chronic respiratory failure, hypertension, heart disease, and atrial fibrillation, was not administered Rivaroxaban for 38 days following her admission. This oversight occurred because the hospital discharge orders, which included Rivaroxaban, were not implemented, and there was no documentation of medication clarification. The resident's medical records indicated that she was not on anticoagulants, and there was no order to discontinue Rivaroxaban. Despite notes from the nurse practitioner (NP) indicating the need to review hospital records to determine if the medication should be restarted, Rivaroxaban was not included in the medication list. The resident eventually developed symptoms of poor peripheral circulation, leading to a hospital admission where she was diagnosed with iliac artery occlusion, a medical emergency. Interviews with facility staff revealed a lack of communication and documentation regarding the reconciliation of the resident's medications upon admission. The Director of Nursing (DON) acknowledged the failure to reconcile medications and the potential consequences of not administering Rivaroxaban. The NP and medical director also recognized the oversight, with the NP admitting to not reviewing the hospital records and the medical director acknowledging the shared responsibility for ensuring appropriate medication orders. This deficiency ultimately contributed to the resident's deterioration and subsequent death.
Removal Plan
- A facility audit to be completed by the Director of Nursing/Designee of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR. For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented.
- In-services initiated by DON/Designee with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts. DON/ADON will then notify the medical director.
- All other licensed staff will be in-serviced prior to working next shift.
- Ad Hoc QAPI meeting completed with IDT and Medical Director.
- Education was completed with the Administrative nursing team by the Regional Nurse Consultant related to completing chart audits of new admissions to assure that orders were transcribed correctly.
- Education to be completed with all nursing staff working either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 135 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Port Arthur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Port Arthur Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 5 | 0 |
| Magnolia Manor | 2.4 mi | ★★★★★ | 2 | 0 |
| Bonne Vie | 3 mi | ★★★★★ | 7 | 0 |
| Oak Grove Nursing Home | 3.8 mi | ★★★★★ | 0 | 0 |
| Oakwood Manor Nursing Home | 13.1 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.