Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Remo during CMS and state inspections, most recent first.
Surveyors found multiple expired milk products stored in the main kitchen refrigerator, despite facility policies requiring safe food storage and stock rotation using a first-in/first-out method. The cook in charge reported that her usual daily expiration-date check was not completed that day and that the expired items were overlooked by all kitchen staff. Other dietary staff, including another cook and two aides, stated they were unaware of the expired milk but acknowledged that all kitchen staff were responsible for labeling, storing, and checking expiration dates on food items and discarding expired products, as covered in prior in-service training.
Surveyors found that multiple resident rooms were not thoroughly cleaned or sanitized, with air conditioning units and filters covered in black dirt and thick dust, bathroom floors and showers with dark substances, soap scum, and rust-like stains, and carpets and bedside tables visibly stained. Housekeeping staff acknowledged responsibility for cleaning entire rooms, while maintenance was responsible for air filter cleaning, which was done quarterly by a single staff member who could not keep up with the needed frequency. Supervisory staff and the administrator confirmed expectations that rooms be thoroughly cleaned and recognized that unclean rooms and air filters could negatively affect residents and their breathing, contrary to the facility’s policy requiring a safe, clean, comfortable, and homelike environment.
Privacy and Confidentiality Failures: Staff left a sheet with multiple residents' vital signs exposed on an unattended cart in the hallway, and an LPN checked a resident's BS and administered insulin with the room door open so the treatment was visible from the hallway. The facility also lacked documented consent in the EHR for AEM in a shared room, despite signage and staff awareness that consent was needed.
A resident with intact cognition and significant functional dependence was given Seroquel 25 mg at bedtime for bipolar disorder even though no bipolar diagnosis was documented in the EHR. The chart instead showed other diagnoses, including recurrent depressive disorder, and the care plan had no focus on bipolar disorder or Seroquel use. Staff interviews confirmed that a matching diagnosis and consent were expected, while the attending physician stated the resident had MDD, not bipolar disorder.
Failure to care plan multiple residents’ ordered treatments and devices. A resident with dysphagia had an order for a weighted spoon, but it was not initially included in the care plan. Other residents had diagnoses or orders for DM, HTN, an indwelling catheter, an external catheter, a g-tube with suprapubic catheter, and a nephrostomy tube, yet their care plans did not address those needs. Staff interviews confirmed these interventions should have been included so care would be coordinated.
Care plans were not reviewed and revised after quarterly MDS assessments for four residents. The MDS Nurse confirmed the plans were outdated, and the ADON, DON, and Administrator stated care plans were expected to be updated quarterly or with changes in condition. Facility policy required the interdisciplinary team to review and revise the comprehensive care plan after each comprehensive and quarterly MDS assessment.
The facility failed to ensure that residents with feeding tubes had physician orders for key tube-management tasks. A resident with dysphagia, a resident with a feeding tube and GI implant displacement, and a resident with gastrostomy status all had enteral feeding-related orders, but the charts lacked orders for checking g-tube placement and/or residuals. Staff observed administering medication via g-tube and checking residuals, and multiple nurses and leaders stated that orders should have been present for these procedures.
Bed rail use lacked required consent and assessment for multiple residents. Records showed that several residents with significant cognitive, mobility, and medical impairments had bilateral quarter rails or grab/enabler bars on their beds, but the chart often had no signed consent and, for some residents, no documented assessment of appropriateness or safe use. Staff interviews confirmed that beds throughout the facility had grab/assist bars or rails and that assessments and consents should be documented in the EHR, while the DON agreed an assessment and documented consent were needed.
Medication Storage and Labeling Failures: Multiple residents had drugs and biologicals left in rooms or within reach, including barrier creams, cough syrup, eye drops, Tylenol, and an EpiPen stored in a refrigerator despite a do-not-refrigerate instruction. One resident was self-administering cough syrup without a self-medication assessment, another had eye drops without an order, and a tramadol blister pack was not updated after an order change. Staff stated several of these items should not have been accessible to residents because of misuse, overdose, or potency concerns.
Staff did not follow infection control precautions during resident care. A resident with a feeding tube, catheter, and PICC line received incontinent care and transfers without required hand hygiene, gown use, or glove changes, and the PICC access port was left uncovered after IV disconnection. Another resident who was incontinent and cognitively impaired also had perineal care performed in a way that involved touching the genital area after cleaning toward the anus.
A cognitively intact male resident with bilateral nephrostomy tubes had his urine collection bags consistently positioned outside his pants, visible in his room, hallways, and dining area, without any documented refusal or informed choice. Staff, including a CNA, ADON, DON, and Administrator, acknowledged that the bags should not be visible for dignity reasons, yet no care plan addressed nephrostomy management or non-compliance, and no documented discussion occurred with the resident or family about keeping the bags inside his pants. The resident and his family later reported they had never been consulted and that they preferred the bags to be concealed for dignity, contrary to staff assumptions.
A resident with lack of coordination, weakness, severe cognitive impairment, and CHF was observed lying in bed with the call light under the bed and out of reach. An LVN and CNA confirmed it needed to be within reach, and the ADON and DON stated staff were responsible for ensuring call lights were accessible; the facility policy also required call lights to be accessible while the resident was in bed.
A facility failed to ensure MDS assessments accurately reflected two residents’ status. One resident had a tracheostomy documented in the chart and observed during survey, but the MDS did not code it. Another resident had a Purewick/external catheter ordered and in use, but the MDS and care plan did not reflect it. The MDS Nurse acknowledged missing both items, and the DON and Administrator stated the MDS should reflect the resident’s current condition.
A resident admitted with pleural effusion had a Pleurex drain in place, but the baseline care plan did not include assessment, treatment, or care instructions for the drain within 48 hours of admission. Staff interviews showed the LPN drained the device without knowing whether it was covered by an order or care plan, the resident said staff were unfamiliar with the drain, and leadership acknowledged the baseline care plan should have reflected the resident’s immediate needs.
Wound Left Open to Air Despite Order A resident with dementia, DM2 with polyneuropathy, PVD, CKD 3A, and pressure ulcer risk had a right lateral ankle ulcer that was ordered to be cleansed, treated with Xeroform, and covered with a dry dressing. During observation, the wound was found open to air, and the ADON, Treatment Nurse, and DON stated it should have been covered per the MD order to help prevent infection and delay in healing.
Improper wound care technique during sacral pressure ulcer treatment: A resident with an unstageable sacral PU and severe cognitive impairment received wound care from an LPN who reused the same gauze to dry the wound bed, the surrounding skin, and then the wound bed again. The Treatment Nurse acknowledged the technique was incorrect, and the ADON and DON stated the practice could introduce microorganisms and lead to probable infection. The facility policy required wound care to be performed to decrease infection and cross-contamination.
A facility failed to keep a resident’s bathroom free of an accident hazard when two used insulin syringes were left on top of the sharps container instead of being discarded inside it. The facility also failed to keep another resident’s bed in the lowest position as directed in the care plan for fall prevention; the resident was a fall risk with severe cognitive impairment, muscle weakness, restless leg syndrome, and blindness in one eye, and the bed was observed waist high while she was lying in it.
Improper Storage of Respiratory Equipment: Two residents with respiratory-related orders had masks, a nasal cannula, and a breathing treatment device found not properly bagged when not in use. One resident had COPD with PRN nebulizer treatment and a portable O2 setup, and the other had CHF, atrial flutter, and a CPAP order for sleep apnea. Staff confirmed the equipment should have been bagged or otherwise stored to prevent contamination, and the facility policy required respiratory equipment to be kept clean and sanitary.
Two residents were affected by medication administration failures. An LPN prepared one resident’s meds without first acknowledging each drug in the eMAR, and for another resident with HTN and an order for metoprolol to be held for low BP or HR, the LPN prepared the anti-hypertensive before checking BP at the time of administration. Interviews with the ADON and LPN confirmed the expected process was to acknowledge each medication as it was prepared and to obtain BP in real time before giving anti-hypertensive meds.
Failure to Complete Monthly Pharmacist Drug Regimen Review: A resident with multiple neurologic and medical diagnoses, intact cognition, and extensive ADL dependence was not shown to have a monthly pharmacist drug regimen review of the chart and medications. The pharmacy binder reflected only one mention of the resident for Voltaren gel documentation, while the ADON, DON, and physician could not explain why the pharmacist had not reviewed the resident’s regimen for diagnosis, GDR, or medication continuation/reduction recommendations.
The facility's kitchen was found to have several food safety deficiencies, including unsealed and expired items in the dry storage and freezer areas. Staff members were unaware of these issues despite recent training. The dietician and administrator acknowledged the importance of proper food handling to prevent cross-contamination and illness.
A resident was moved from a private to a semi-private room without receiving the required written notice, violating her rights. Despite being cognitively intact, she was not informed in advance, and staff interviews revealed a lack of clarity and documentation regarding the room change process. The facility's policy mandates a 5-day advance written notice, which was not adhered to, potentially causing distress to the resident.
A facility failed to refer a resident with schizophrenia for a PASARR Level II evaluation, necessary for receiving specialized services. The resident expressed a desire for these services, but staff were unaware of her diagnosis and did not complete the required evaluation. The facility lacked a formal PASARR policy, relying instead on HHSC recommendations.
A resident with a suprapubic catheter did not receive proper care, as a CNA failed to clean the catheter site and tubing during a bath, and the catheter lacked a securement device. Interviews confirmed that these actions were required, and the facility's guidelines specify washing the catheter site and tubing with soap and water.
A facility failed to maintain proper infection control practices when a CNA did not wear appropriate PPE or perform hand hygiene while bathing a resident with a suprapubic catheter. The resident was on enhanced barrier precautions, but the CNA wore gloves with a hole and did not use a gown, nor did they clean the catheter site. Interviews confirmed the failure to follow infection control protocols, highlighting a deficiency in the facility's infection prevention program.
A facility failed to ensure proper management of controlled medications, leading to the loss of 30 Oxycodone tablets. An LVN shared keys to her medication cart with another LVN without counting the medications, violating facility policy. The resident involved did not report any missed doses or increased pain. Both nurses denied taking the medication, and drug tests were negative. The facility's investigation was unable to determine the cause of the missing narcotics.
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident with multiple diagnoses, including dementia. The resident's room was frequently found with trash and feces on the floor, despite the family member's repeated requests for cleaning. The Housekeeping Supervisor confirmed that the room required more frequent cleaning due to the resident's behaviors.
A facility failed to update a care plan for a resident with moderately impaired cognition who wanted to change his own brief. Despite the resident's family and staff being aware of the situation, the care plan did not reflect this preference, leading to the resident getting feces on himself and his surroundings. The facility's policy required care plan reviews for changes in condition, but this was not done.
Expired Milk Products Found in Kitchen Refrigerator
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations when, during an initial kitchen tour, they observed multiple expired milk products stored in the main kitchen refrigerator. Specifically, they found one half-pint of 2% reduced-fat milk and three containers of fat-free skim milk with “best use by” dates that had already passed. The facility’s written Food Storage policy, revised in 2019, requires that food be stored safely, that stock be rotated using a first-in/first-out method, and that food be kept safe, wholesome, and appetizing. The FDA Food Code was also cited regarding proper labeling and protection of food from contamination. During interviews, the cook who was in charge in the absence of the Nutrition Services Director stated she was responsible for cooking and performed daily morning checks for expiration dates but acknowledged that this check did not occur that day and that the expired milk had been overlooked by all kitchen staff. Another cook/assistant cook, a dietary aide with four years of employment, and a nutritional aide employed for one month each reported they were unaware of the expired milk in the refrigerator at the time of the survey. They all indicated that kitchen staff were responsible for labeling, storing, and checking expiration dates on food items and that expired items should be discarded, consistent with prior in-service training on food preparation, storage, and expired food dates. The presence of expired milk in the refrigerator despite these responsibilities and policies constituted the cited deficiency.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment for residents, specifically related to room cleanliness and sanitation. Surveyor observations on multiple resident rooms showed that air conditioning units in numerous rooms had black dirt and dust on the front of the units and between the vents, with air filters covered in thick dust. In several bathrooms, floors had thick dark substances near or behind toilets, disposable gloves left on the floor, and shower floors with thick soap scum, rust-like stains, or thick grayish substances. Some carpeted room floors had large dark or white stains, and bedside tables had visible stains on their lower frames. Housekeeping staff interviews confirmed that they were responsible for cleaning entire rooms, including bathrooms, and that air conditioning units were expected to be cleaned, though one housekeeper stated she did not clean air filters. One housekeeper acknowledged that he was responsible for cleaning a specific hall and that floor technicians were supposed to clean carpets; he reported having pointed out carpet issues to the floor techs, but the carpets had not been cleaned. Another housekeeper stated that rooms not being thoroughly cleaned could negatively impact residents. The floor technician reported he was responsible for cleaning floors and that he typically walked around to check carpets for spots, receiving a list of floors to clean from his supervisor and being notified when stains were reported. The housekeeping supervisor stated housekeeping was responsible for cleaning entire rooms, while maintenance was responsible for cleaning air filters, and he was unsure how often filters were cleaned. The maintenance supervisor stated he alone was responsible for cleaning air filters on a quarterly basis and could not get to them as frequently as needed. The administrator acknowledged that he expected housekeeping to thoroughly clean rooms and that failure to do so would not provide a homelike environment, and that not cleaning air conditioning filters could impact residents’ breathing. The facility’s policy on a safe and homelike environment required providing a safe, clean, comfortable, and homelike environment and ensuring residents could receive care and services safely.
Privacy and Confidentiality Failures
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential and failed to maintain privacy during treatment for nine residents. Surveyors observed an untitled sheet of paper left on top of an unattended nurse's cart in the hallway with multiple residents' temperatures, blood pressures, pulse rates, respiratory rates, and oxygen saturations visible. The cart was facing the hallway while staff and residents passed by. The DON and ADON identified the information as medical information and told LVN I to secure or flip the paper, and LVN I stated she should have secured the paper and closed the laptop before leaving the cart unattended. The facility also failed to maintain privacy while Resident #45 was receiving care. Resident #45 was a cognitively intact male with diabetes mellitus who had an order for Humalog insulin by sliding scale before meals and at bedtime. During observation, LVN I checked the resident's blood sugar, prepared insulin after obtaining a blood sugar of 211, and administered 4 units of insulin in the resident's right upper arm while the room door remained open. The treatment was visible from the hallway. ADON A and the DON stated staff should close the door or pull the privacy curtain when providing care or treatment, and LVN I stated she should have closed the door during the blood sugar check and insulin administration. The facility also failed to ensure proper consent documentation for AEM in Resident #73's shared room. Resident #73 was a cognitively intact female with multiple diagnoses including cerebral infarction, hemiplegia, dysphagia, respiratory failure, diabetes, and memory deficit. The resident's room had signage indicating electronic recording, and the privacy curtain between the beds was drawn. However, the record contained no signed consent in the active EHR section for AEM to be conducted in the shared room by the roommate or the roommate's RP. Interviews with staff showed differing understanding of the consent process, and the SW and DON could not locate a signed consent or documentation that consent had been obtained for the room change.
Psychotropic Medication Used Without Documented Diagnosis
Penalty
Summary
The facility failed to ensure Resident #73 was free from a psychotropic medication used without a corresponding diagnosis documented in the EHR. Resident #73 was admitted with diagnoses including restlessness and agitation, shortness of breath, generalized muscle weakness, cerebral infarction with left-sided hemiplegia and hemiparesis, dysphagia following cerebral infarction, acute respiratory failure, type 2 diabetes mellitus with diabetic neuropathy, recurrent depressive disorder, memory deficit following cerebrovascular disease, speech and language deficits following cerebral infarction, and acute embolism and thrombosis of an unspecified vein. No diagnosis of bipolar disorder was found in the record, yet the order summary listed Seroquel 25 mg at bedtime for bipolar, and the medication was administered nightly across multiple months with only a few missed doses. The resident’s care plan, last updated on 11/06/2025, contained no focus or intervention related to bipolar disorder or the use of Seroquel. The quarterly MDS showed a BIMS score of 13, indicating intact cognition, and documented that the resident used a wheelchair and required extensive assistance with many activities of daily living and transfers. The record also contained a nursing psychoactive medication consent for Seroquel for bipolar disorder, verbally consented to by the resident, but the EHR did not contain a bipolar diagnosis to match the medication order. Staff interviews showed that the LVN, ADON, and DON expected a corresponding diagnosis and consent to be documented when Seroquel was used. The DON stated the resident was being followed by psychiatric services for medication management even though no records showed this in the EHR, and acknowledged that Seroquel prescribed for bipolar disorder without that diagnosis could lead to the medication having a sedative effect. The attending physician stated the resident had major depressive disorder, not bipolar disorder, and said he would review the diagnoses in the EHR and reconcile medications.
Failure to Care Plan Multiple Residents’ Ordered Treatments and Devices
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for multiple residents whose assessments and orders identified ongoing medical needs. For Resident #20, the record showed dysphagia, malnutrition, and an order for a weighted spoon with meals, but the care plan initially did not reflect the weighted spoon intervention. Staff interviews confirmed the resident used a weighted spoon to eat and that it should have been care planned as part of his care. Resident #45 had diagnoses of diabetes mellitus and hypertension, with physician orders for daily insulin glargine and metoprolol for HTN, but the comprehensive care plan did not include care plans for either condition. During observation, the resident’s blood sugar was checked and insulin was administered. Staff later confirmed that diabetes and hypertension should have been care planned because they were part of the resident’s plan of care. Resident #78 had an indwelling urinary catheter and an order for catheter care, but no care plan for the catheter was present. Resident #106 had an order for a Purewick external catheter system used overnight and when in bed, but the care plan did not include the external catheter. Resident #112 had a feeding tube and a suprapubic catheter, with orders for enteral feeding and catheter care, but the care plan did not address either device. Resident #113 had a nephrostomy tube and an order for daily nephrostomy care, but no care plan for the nephrostomy tube was present. Staff interviews, including the MDS nurse, ADONs, DON, and Administrator, confirmed that these needs should have been care planned and that the omissions were oversights.
Care Plans Not Updated After Quarterly Assessments
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for four residents were timely developed, reviewed, and revised after comprehensive and quarterly assessments. Record review showed that Resident #78’s last comprehensive MDS assessment was completed on 12/22/2025, but the last care plan on file was dated 06/10/2025. Resident #84’s last comprehensive MDS assessment was completed on 02/02/2026, but the last care plan on file was dated 03/11/2025. Resident #104’s last comprehensive MDS assessment was completed on 01/18/2026, but the last care plan on file was dated 05/03/2025. Resident #106’s last comprehensive MDS assessment was completed on 12/22/2025, but the last care plan on file was dated 03/14/2025. During an observation and interview on 02/18/2026, the MDS Nurse stated she was responsible for making and updating resident care plans and said they should be updated quarterly or with a change in condition, fall, or infection. She reviewed the residents in question and confirmed their care plans were not updated, stating their quarterly assessments had been completed and the quarterly care plans should have followed. During later interviews, the ADON, DON, and Administrator each stated that care plans were to be completed at admission and updated quarterly or when needed, and that the care plans should reflect current resident care needs. The facility policy stated that the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Missing Physician Orders for G-Tube Placement and Residual Checks
Penalty
Summary
The facility failed to ensure that residents with feeding tubes had the appropriate physician orders in place for tube management. Resident #1, a cognitively intact male with dysphagia and a feeding tube, had an enteral feeding order for Nutren 1.5 via g-tube, and his care plan included checking g-tube placement and gastric contents, but the physician orders reviewed on 02/18/2026 did not include an order to check g-tube placement. Resident #112, a cognitively intact female with a feeding tube and a diagnosis of displacement of gastrointestinal implants, had an enteral feeding order for Jevity 1.5 via feeding tube, but her record also did not contain an order to check residuals or placement. Resident #112 was observed in bed with formula connected to her g-tube during the morning observation. Resident #42, a male with gastrostomy status and severe cognitive impairment, had a care plan that included checking placement and gastric content, and physician orders for medication administration via g-tube and flushing before and after medication administration. However, his physician orders reviewed on 02/18/2026 did not include an order to check residuals. During observation, an LVN administered medication via the g-tube, disconnected the tube from the formula, attached a syringe, pulled the plunger to check for residual, and then flushed the tube before and after giving the medication. The LVN stated there should be an order for checking residuals so staff would not miss it. During interviews, RN C stated residuals should be checked prior to flushing and administering medications and that there was no order for it in the resident's chart. RN C said this should have been caught earlier and that she was partly at fault for not checking the orders. The ADON and DON both stated there should be orders for everything done for residents with g-tubes, including residual checks, and the DON stated staff knew the procedure but there still should be an order in place. The facility policy on medication administration via enteral tube stated that a physician's order is required and that staff must verify physician orders.
Bed Rail Consent and Assessment Deficiencies
Penalty
Summary
The facility failed to assess residents for the risk of entrapment from bed rails before installation and failed to review the risks and benefits of bed rails before installation for 5 of 8 residents reviewed for grab/assist bars. The report states that the facility also failed to have evidence of informed consent for five residents for grab/enabler bars placed on the bed, and failed to have evidence of assessment for three residents for risk of entrapment and ability to safely use the grab/enabler bars. Resident #1 was an older male with diagnoses including ASHD, mitral valve stenosis, COPD, need for assistance with personal care, gait and mobility abnormalities, generalized muscle weakness, gastrostomy status, tracheostomy status, malignant neoplasm of the hypopharynx, acute respiratory failure with hypoxia, sepsis due to MRSA, and pneumonia due to Pseudomonas. His MDS showed a BIMS score of 13 and that he used a wheelchair, was dependent for all functional self-care abilities, and required partial/moderate assistance with bed mobility and transfers. His care plan had no focus or intervention related to grab bars, bed rails, or alternatives previously attempted. The record contained no signed consent for grab bars or bed rails, although an Assist Rail/Enabler Device Assessment dated 01/20/2026 recommended bilateral quarter bed rails. Observation showed bilateral grab/enabler bars raised on his bed while he was asleep. Resident #5 was a female with diagnoses including cerebral infarction, type 2 DM with diabetic neuropathy, dysphagia following cerebral infarction, generalized muscle weakness, dementia with psychotic disturbance, schizoaffective disorder, major depressive disorder, polyneuropathy, encephalopathy, systolic CHF, dysphagia, need for assistance with personal care, acquired absence of the left leg below knee, gastrostomy status, and NSTEMI. Her MDS showed a BIMS score of 12 and significant dependence for ADLs and transfers. Her care plan identified quarter rails as enablers and included an intervention to complete an assist rail/enabler device assessment, but the record contained no signed consent for grab bars or bed rails and no assessment for appropriateness or safe use. She was observed asleep with bilateral grab/enabler bars raised on her bed. Resident #42 was a male with diagnoses including metabolic encephalopathy, dysphagia, generalized muscle weakness, lack of coordination, need for assistance with personal care, ASHD, and presence of an aortocoronary bypass graft. His MDS showed a BIMS score of 2 and dependence for multiple self-care and mobility tasks. The record showed no signed consent for grab bars or bed rails. Resident #87 had diagnoses including COPD, dysphagia, type 2 DM without complications, and major depressive disorder; his MDS showed he was rarely/never understood, severely impaired, and dependent for all self-care and mobility. His care plan also identified quarter rails as enablers and included an intervention to complete an assist rail/enabler device assessment, but the record contained no signed consent and no assessment for appropriateness or safe use. He was observed asleep with bilateral grab/enabler bars raised on his bed.
Medication Storage and Labeling Failures
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional principles and state and federal requirements. During observations, multiple residents had medications or topical products left in their rooms or within reach, including zinc oxide barrier creams on side tables or drawers, cough syrup on a side table with a cup beside it, eye drops on an overbed table, a bottle of Tylenol on a nightstand, and an EpiPen stored inside a refrigerator even though the box instructed not to refrigerate it. The report also noted that a change-of-instruction label was not placed on a resident’s tramadol blister pack after the order changed. Resident #27 was cognitively intact with a BIMS score of 13 and had a diagnosis of neuromuscular dysfunction of the bladder, bowel incontinence, and a care plan for urinary tract infection monitoring. On observation, a tube of zinc oxide was on top of the resident’s side table while the resident was in bed. The resident stated staff used it when changing the brief. The resident did not have an assessment for self-administration of medications. LVN D stated the barrier cream should not be within reach of the resident to prevent misuse. Resident #29 had severe cognitive impairment with a BIMS score of 02 and was incontinent of bladder and bowel. On observation, a tube of skin barrier was on the side table and a box of single-vial eye drops was on the overbed table while the resident was not in the room. Resident #69 had moderate impairment with a BIMS score of 12 and was also incontinent of bowel and bladder; two tubes of barrier creams were observed on the side table while the resident was in bed. Resident #78 was cognitively intact with a BIMS score of 14, had Parkinson’s disease, and had an order for Tussin DM for cough; a bottle of cough syrup and a small cup were observed on the side table, and the resident stated he had been administering the cough medication himself. Resident #84, who had severe cognitive impairment and dementia, had eye drops on the overbed table despite no order for eye drops and no self-medication assessment. The same resident also had an EpiPen in the refrigerator even though the instruction said not to refrigerate, and the resident had no order for epinephrine or care plan for anaphylaxis. Resident #82 had a full bottle of Tylenol on the nightstand, and staff stated the resident should not have it because he could take too much and overdose. Resident #90 had tramadol orders that changed from every 6 hours as needed to every 8 hours for moderate to severe pain, but the blister pack still reflected the old instruction and no change label had been placed. Resident #112 had a tube of skin barrier on the side table while in bed, and CNA F stated it should be stored away from residents when not in use.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for residents reviewed for infection control. For Resident #112, who was cognitively intact and had a feeding tube, catheter, and PICC line, staff did not follow the posted enhanced barrier precautions during care. During incontinent care, CNA F entered the room without washing hands, wore gloves but no gown, leaned on the resident’s catheter while turning and lowering the resident’s pants, did not change gloves after cleaning the resident’s bottom before handling a new brief, and performed care without hand hygiene being observed before or after the task. During a transfer of Resident #112 using a stand-and-pivot technique, CNA F and CNA G did not wash their hands and did not wear gowns or gloves even though the room sign indicated a gown was required during transfer. After the resident was moved to the wheelchair and taken to the therapy room, CNA F later fixed the resident’s linens without a gown or gloves and had direct contact with the bed linens while leaning on the bed. In addition, after LVN D disconnected the resident’s IV, the resident’s PICC access port was left uncovered; LVN D stated she was supposed to cover the port but the facility did not have the green cap used for that purpose. For Resident #42, who had severe cognitive impairment and was incontinent of bowel and bladder, CNA J performed incontinent care while wearing gloves and a gown, but after cleaning the resident’s perineal area she removed her gloves and sanitized her hands, then put on new gloves and continued care. While cleaning the resident’s genital area, she touched the urethral opening after cleaning toward the anus. CNA J stated she should have removed her gloves, sanitized her hands, and put on new gloves before touching the head of the penis after cleaning toward the anus.
Failure to Maintain Dignity and Privacy for Resident With Nephrostomy Bags
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to dignity and privacy related to visible nephrostomy urine collection bags. The resident, an older male with malignant neoplasm of the prostate and bilateral nephrostomy tubes, was cognitively intact with a BIMS score of 13. On observation, he was seen in his room with two nephrostomy bags hanging outside his pants, visible from the hallway, and staff reported that the bags had always been outside his pants since admission, including when he walked in the hallways and went to the dining area. The facility’s own staff, including a CNA and the Administrator, acknowledged that the bags should not be visible to others for dignity reasons. Record review showed there was a physician’s order for daily nephrostomy care but no care plan addressing the nephrostomy tubes or any non-compliance with keeping the bags inside the pants. Progress notes contained no documentation that the resident refused to have the bags covered. The resident stated he never told anyone he wanted the bags exposed and that no one had discussed with him the need to keep them inside his pants. His family member similarly reported that no staff had spoken with them about placing the bags inside the pants and expressed a preference for the bags to be concealed for dignity. The ADON stated she only added a care plan for non-compliance after questions were raised about the exposed bags and admitted she had not discussed bag placement with the resident or family. The DON acknowledged the resident’s right to refuse but did not respond when informed that no such discussion or documentation had occurred. The facility’s resident rights policy states that residents have the right to a dignified existence, which was not upheld in this situation.
Call Light Out of Resident’s Reach
Penalty
Summary
The facility failed to ensure that Resident #86’s call light was positioned within reach and accessible in the resident’s room. Resident #86 was a [AGE]-year-old female admitted on [DATE] with diagnoses of lack of coordination and weakness, and her quarterly MDS dated 02/19/26 reflected a BIMS score indicating severe cognitive impairment and an active diagnosis of congestive heart failure. During an observation on 02/17/26 at 09:11 a.m., the resident was lying in bed and her call light was observed under the bed and out of reach. During the same observation, LVN H and CNA N were shown the call light under the bed and stated it needed to be within reach in case the resident needed help. Later interviews with the ADON and DON confirmed that the resident’s call light needed to be within reach so she could contact staff for assistance, and that staff were responsible for ensuring call lights were within reach. The facility policy on Call Lights: Accessibility and Timely Response stated that call lights should be accessible to residents while in bed or other sleeping accommodations.
MDS Assessments Did Not Reflect Tracheostomy and External Catheter Use
Penalty
Summary
The facility failed to ensure that Quarterly MDS assessments accurately reflected residents’ clinical status for two residents reviewed for assessment accuracy. One resident had a tracheostomy documented in the face sheet, physician orders, and care plan, but the Comprehensive MDS assessment did not indicate that the resident had a tracheostomy. The resident was observed in bed with eyes closed and had a tracheostomy in place during the survey observation. A second resident had a physician order for a Purewick system to be used overnight and when in bed, with instructions to insert the external catheter at bedtime and as needed, but the Quarterly MDS assessment did not indicate that the resident was using an external catheter. The resident’s care plan also did not include a care plan for the external catheter. During observation, the external catheter was seen on top of the resident’s side table while the resident was not in the room. During interviews, the MDS Nurse stated the MDS is used to collect and record pertinent resident data and forms the basis for care plans, and she acknowledged that she missed coding the resident with the tracheostomy and the resident using an external catheter. The ADON and DON stated that if a resident had an external catheter or tracheostomy, the MDS should reflect it, and the Administrator stated the MDS should reflect the resident’s current condition. The Administrator also stated the facility did not have a policy about Accurate Assessment.
Baseline Care Plan Missing Pleurex Drainage Instructions
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for Resident #117 that included the instructions needed to provide effective and person-centered care for pleural effusion and Pleurex drainage. Resident #117 was admitted with a diagnosis of pleural effusion, and the record showed a progress note documenting that LVN D drained 250 ounces of bright red blood from the rocket drain. However, the baseline care plan dated 02/10/2026 contained no evidence of assessment, treatment, or care documentation for the Pleurex drainage placed at the hospital for the pleural effusion. During interview, Resident #117 stated the facility was not familiar with her Pleurex drainage and that her responsible party was going to come show staff how to care for it because he had done so at home. She said she had told someone about draining the Pleurex but had not heard back and did not remember who she told. LVN D stated she drained the Pleurex drainage but did not know whether the order was a physician order or a care plan and did not know who updated the care plan. The ADON stated the Pleurex drainage should be in the comprehensive care plan due in 21 days after admission, while the MDS nurse, Regional Clinical Nurse, and DON stated a baseline care plan should be completed within 48 hours of admission to reflect the resident’s immediate needs.
Wound Left Open to Air Despite Dressing Order
Penalty
Summary
The facility failed to ensure that Resident #12’s right lateral ankle ulcer was covered according to physician orders on 02/19/2026. Resident #12 was an elderly female admitted to the facility with diagnoses including Alzheimer’s disease, dementia, type 2 diabetes with polyneuropathy, peripheral vascular disease, chronic kidney disease stage 3A, and a stage 3 sacral pressure ulcer. Her quarterly MDS assessment dated 01/22/2026 showed a BIMS score of 2 and indicated she was at risk for pressure ulcers. Her care plan reflected that she was at risk for infection, and the physician’s order dated 10/21/2025 directed wound care to the right lateral ankle with cleansing, application of Xeroform, and coverage with a dry dressing. A wound consult dated 02/19/2026 documented a full-thickness wound on the right lateral ankle with a treatment plan for Xeroform gauze and a bordered gauze island dressing three times per week and as needed. During observation at 9:15 a.m. on 02/19/2026, Resident #12 was in bed with the wound open to air. During interviews later that morning, the ADON and Treatment Nurse stated the wound should be closed to avoid infection per the wound orders, and the DON stated the wound should have been covered per doctor’s orders to prevent infection and delay in healing. A CNA stated that if she noticed a wound without a dressing, she must notify the nurse immediately to prevent infection, cross contamination, and bacteria.
Improper wound care technique during sacral pressure ulcer treatment
Penalty
Summary
The facility failed to ensure proper wound care for a resident with an unstageable pressure ulcer to the sacrum. The resident was a [AGE]-year-old male admitted with failure to thrive and had severe cognitive impairment with a BIMS score of 02. His care plan included treatment as ordered and monitoring for effectiveness, and the physician’s order directed staff to cleanse the sacral wound with normal saline or skin cleanser, pat dry, apply calcium alginate with silver to the wound bed, and cover with a dry dressing. During an observation of wound care, the Treatment Nurse cleansed the resident’s sacral pressure ulcer and then patted dry the inside of the wound. She then used the same gauze to dry the surrounding skin of the pressure ulcer and used that same gauze again to pat dry the inside of the wound. The treatment was then completed with calcium alginate with silver and a dry dressing. During interview, the Treatment Nurse stated she was not aware she had reused the gauze in that manner and acknowledged that the proper procedure was to dry from inside to outside and not reuse the same gauze. The ADON stated that using the gauze from the surrounding skin to dry the inside of the wound could lead to probable infection because microorganisms could be introduced into the pressure ulcer. The DON stated there could be probable harm if the gauze used on the surrounding skin was used again on the wound bed, and the Administrator stated improper wound care could lead to infection by transferring what was outside of the pressure ulcer. The facility policy stated wound care should be provided in a manner to decrease potential for infection and cross-contamination and to avoid contaminating other skin surfaces or other surfaces of the wound.
Unsafe Syringe Disposal and Bed Positioning for Fall Risk Resident
Penalty
Summary
The facility failed to ensure Resident #25’s environment was free from accident hazards when two used syringes were observed sitting on top of the sharps container in the resident’s bathroom rather than being inserted into the container. Resident #25 was a male admitted to the facility with a diagnosis of Type 2 diabetes and had physician orders for daily insulin glargine injections. His MDS reflected an intact cognitive response and active diabetes diagnoses. During observation, the used syringes were seen outside the sharps container, and an LVN stated they should have been discarded into the container after the insulin was given. The ADON and DON later stated staff were responsible for ensuring syringes were discarded correctly in the resident’s bathroom sharps container. The facility also failed to ensure Resident #101’s bed was kept in the lowest position as identified in her care plan for fall prevention. Resident #101 was a female with muscle weakness, severe cognitive impairment, restless leg syndrome, and blindness in one eye, and her comprehensive care plan identified her as a fall risk with an intervention to keep the bed in the lowest position. During observation, her bed was waist high while she was lying in it, and an LVN entered and exited the room without lowering the bed. The ADON and DON acknowledged the resident was a fall risk and stated the bed needed to be in the lowest position, but the observation showed it was not.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment was properly stored when not in use for two residents who had respiratory-related orders. Resident #36, an older female with COPD and an intact BIMS, had orders for Ipratropium-Albuterol inhalation every 6 hours as needed for shortness of breath. During observation, her nebulizer mask was found sitting unbagged in her nightstand, and a portable oxygen tank attached to a nasal cannula was observed in a tote bag hanging from her wheelchair, with the nasal cannula not properly stored in a bag. Staff who observed the equipment stated it needed to be properly bagged to avoid infection and noted the resident had just returned from the hospital. Resident #82, an older male with CHF and atrial flutter with an intact BIMS, had an order for CPAP at bedtime for sleep apnea. During observation, his CPAP mask and breathing treatment device were found not properly stored. An LVN stated it was the nurse’s responsibility to ensure the equipment was properly bagged to avoid infection, and the ADON and DON later confirmed that nursing staff were responsible for ensuring breathing masks, nasal cannulas, and breathing treatment devices were bagged when not in use. The facility policy stated that oxygen therapy equipment was to be maintained in a clean and sanitary manner, that masks or cannulas not in use were to be covered loosely to prevent contamination, and that nebulizer equipment was to be stored, cleaned, and dried until next use.
Medication Administration Errors During Pass
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for two residents. During a medication pass for Resident #118, LVN I was observed preparing medications by glancing at the eMAR and placing medications into a cup without first clicking the Y next to each medication. The eMAR screen was still white until ADON A instructed her to refresh it, after which the screen turned yellow and LVN I began clicking Y for medications she had already prepared. ADON A and LVN I both stated that the system was intended to have staff acknowledge each medication when it was prepared to avoid confusion and medication errors. The facility also failed to ensure Resident #45’s blood pressure was checked before administration of an anti-hypertensive medication. Resident #45 was a cognitively intact male with a diagnosis of hypertension and an order for Metoprolol Succinate ER 100 mg twice daily, with instructions to hold for SBP <110, DBP <60, or HR <60. During the medication pass, LVN I prepared the resident’s medications, including Metoprolol, and was about to administer them when ADON A instructed her to check the resident’s blood pressure. LVN I stated she had taken the blood pressure about twenty minutes earlier, but there was no observation that it was taken immediately before preparing or administering the anti-hypertensive medication. Interviews confirmed the expected procedure was to click yes when each medication was placed in the cup and to obtain blood pressure in real time before giving anti-hypertensive medication. ADON A stated the blood pressure should be checked at the time of administration for safety, and the Administrator stated the expectation was that blood pressure be taken in real time because it could change from the time it was previously measured. The facility’s medication administration policy, reviewed by surveyors, included identifying the resident, obtaining and recording vital signs, and ensuring the six rights of medication administration.
Failure to Complete Monthly Pharmacist Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review, including review of the medical chart, for Resident #73. Record review showed the resident was admitted with multiple diagnoses, including restlessness and agitation, shortness of breath, cerebral infarction with left-sided hemiplegia and hemiparesis, dysphagia following cerebral infarction, acute respiratory failure, type 2 diabetes mellitus with diabetic neuropathy, recurrent depressive disorders, memory deficit following cerebrovascular disease, and other speech and language deficits following cerebral infarction. The resident’s care plan, last updated on 11/06/2025, did not include a focus or intervention related to bipolar disorder or use of Seroquel. The quarterly MDS showed a BIMS score of 13, indicating intact cognition, and documented that the resident used a wheelchair and required extensive assistance with multiple activities of daily living. Review of the facility’s Pharmacy Review binder for August 2025 through January 2026 showed Resident #73 was mentioned only once, in September 2025, for a recommendation that staff document the amount of Voltaren External gel applied. No other pharmacy review entries for the resident were found or provided. During interview, the ADON stated the licensed pharmacist should review each resident’s medications regularly for gradual dose reductions, diagnosis, and recommendations to continue, reduce, or stop medications, but was unsure of the exact interval. The DON stated the facility contracted a licensed pharmacist to review resident medications and medical charts as required, but was not aware that Resident #73 appeared only once in the binder since admission. The physician stated he had provided care for the resident for 2 to 2 1/2 years and managed medications for major depressive disorder, but could not provide a reason the pharmacy consultant had not reviewed medications for gradual dose reduction, other than the Voltaren documentation recommendation.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. In the dry storage area, several food items were found unsealed, including a box of baking soda, a bag of powdered sugar, and containers of breadcrumbs and sugar. Additionally, expired items were discovered, such as bottles of thickened orange juice and a bag of egg noodles. The freezer also contained unsealed items like chopped collard greens, broccoli florets, and a lemon meringue pie. These practices could potentially lead to cross-contamination and pose a risk of foodborne illnesses to residents. Interviews with staff members revealed a lack of awareness regarding the presence of expired and unsealed items in the kitchen. One staff member, employed for six years, admitted to not knowing about the expired and unsealed food, despite having received recent in-service training on food preparation and storage. Another staff member, with three years of employment, also expressed unawareness of the kitchen's condition and acknowledged the potential for cross-contamination and bacterial growth due to expired and unsealed food. The facility's dietician, who visits weekly, was also unaware of the expired and unsealed items. She emphasized that all staff are responsible for ensuring food safety and that they had been trained on proper food handling procedures. The dietician stated that the expired and unsealed items were discarded, and she believed there was no risk to residents as a result. The facility's administrator was informed of the findings and acknowledged the importance of following proper food storage and preparation protocols to prevent cross-contamination and illness.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide Resident #92 with written notice prior to a room change, violating her right to be informed in advance of such changes. Resident #92, a cognitively intact female with a BIMS score of 14, was moved from a private room to a semi-private room without receiving any written or verbal explanation. The resident expressed that she was abruptly informed of the move without any prior notice or reason, and she did not believe the change was related to insurance issues. Interviews with facility staff, including the Unit Manager, Social Worker, Administrator, and DON, revealed a lack of clarity and communication regarding the room change process. The Unit Manager and Social Worker were unable to confirm if any written notice was provided, and the Administrator admitted uncertainty about whether residents received written documentation for room changes. The DON acknowledged conversations with the resident and her family about transitioning from skilled therapy to private pay but could not confirm if written notice was given. The facility's policy requires a 5-day advance written notice for room changes, but no documentation was found to support compliance with this policy. Interviews with LVNs involved in the resident's care indicated that they were either unaware of the room change or did not see any written notice. The lack of documentation and communication highlights a failure to adhere to the facility's policy, potentially causing distress to the resident by not allowing her to prepare for the move.
Failure to Refer Resident for PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident for a PASARR Level II evaluation to the State-designated authority, which is necessary for residents with serious mental disorders to receive specialized services. The deficiency was identified during a review of records and interviews, where it was found that a resident with a diagnosis of schizophrenia was not referred for the necessary evaluation. The resident's quarterly MDS Assessment indicated that her cognition was intact, and she expressed a desire to receive PASARR services, which she was not receiving. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's mental health diagnosis and the need for a PASARR Level II evaluation. The LVN responsible for PASARR services was unaware of the resident's schizophrenia diagnosis and admitted that the resident was at risk of not receiving qualified services. The DON, who was responsible for ensuring the accuracy of PL-1 screenings, also did not know why a new PL-1 was not completed for the resident's diagnosis. It was noted that the facility did not have a formal PASARR policy but followed recommendations from HHSC.
Inadequate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter, leading to a deficiency in preventing urinary tract infections. The resident, who was cognitively intact and required partial assistance for bathing, was observed with a suprapubic catheter that had crusty, brown drainage at the site and on the tubing. During a bath, a CNA did not clean the catheter site or tubing, which is a necessary step in catheter care. Additionally, the resident's catheter lacked a securement device, which is essential to prevent the catheter from pulling out and potentially causing complications. Interviews with the CNA, Unit Manager, and DON confirmed that the catheter site and tubing should have been cleaned, and a securement device should have been in place. The facility's in-service guidelines for suprapubic catheter care, revised in October 2010, specify the need to wash around the catheter site and the outer part of the catheter tube with soap and water. The failure to adhere to these guidelines and provide the necessary care could place the resident at risk of cross-contamination and the development of urinary tract infections.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) and inadequate hand hygiene by a certified nursing assistant (CNA) while providing care to a resident. The resident, a male with a history of bone infection, diabetes, and urinary tract infection, required partial assistance with bathing and had a suprapubic catheter. During an observation, the CNA was seen wearing gloves but not a gown, despite the resident being on enhanced barrier precautions. The CNA's clothing came into contact with the bed and the resident, and the CNA did not clean the resident's catheter site or tubing. Additionally, the CNA continued to use gloves with a hole, failing to change them or perform hand hygiene after bathing the resident. Interviews with the CNA, Unit Manager, and Director of Nursing (DON) confirmed that the resident was on enhanced barrier precautions, which required the use of a gown and gloves. The CNA admitted to not following proper procedures, including changing gloves and performing hand hygiene. The Unit Manager and DON reiterated the importance of correct PPE usage and hand hygiene to prevent infection spread. The facility's in-service training on infection control emphasized the need for a comprehensive infection prevention and control program, which was not adhered to in this instance.
Failure to Properly Manage Controlled Medications
Penalty
Summary
The facility failed to ensure proper management of controlled medications, leading to the loss of 30 tablets of Oxycodone belonging to a resident. LVN A shared the keys to her medication cart, which contained a separately locked compartment for controlled medications, with LVN B during their shift. This action was against the facility's policy, which requires a count of controlled medications before handing over keys. At the end of her shift, LVN A discovered that the Oxycodone tablets were missing, and the medications were never located. The resident involved was a female with severe cognitive impairment and multiple medical conditions, including a bacterial infection, surgical aftercare, amputation, peripheral vascular disease, and chronic non-pressure ulcers. She was receiving scheduled pain medications and hospice services. Despite the missing Oxycodone, the resident did not report any missed doses or increased pain during the period in question. Interviews with the involved staff revealed that LVN A and LVN B breached facility policy by sharing keys without counting the medications. Both nurses denied taking the missing medication, and drug tests for both were negative. The facility conducted a thorough investigation, including a full medication audit, but was unable to determine the cause of the missing narcotics. The incident highlighted a significant lapse in the facility's procedures for managing controlled substances.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, leading to unsanitary living conditions. The resident, a male with diagnoses including encephalopathy, hyperlipidemia, type 2 diabetes, and dementia, was observed with a soiled brief on the floor. The resident admitted to changing his own brief and missing the trash can, and had not called staff to clean up. The resident's family member, who visited several times a week, also noted that the room frequently needed cleaning and often had trash on the floor, including broken pieces of a plastic cup and used gauze with feces on it. The family member stated she frequently informed staff about the need for cleaning in the resident's room. The Housekeeping Supervisor confirmed that resident rooms were cleaned once a day or more if needed, and that this particular resident's room was cleaned more frequently due to behaviors of throwing things and issues with feces on the floor. The supervisor stated that CNAs or nurses would inform housekeeping staff if additional cleaning was needed. The facility's policy on resident rights, revised in February 2021, guarantees residents the right to a dignified existence and to be treated with respect, kindness, and dignity. However, the facility failed to uphold this policy for the resident in question.
Failure to Update Care Plan for Resident's Independence in Brief Changing
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for a resident with moderately impaired cognition. The resident, who had diagnoses including encephalopathy, hyperlipidemia, type 2 diabetes, and dementia, expressed a desire to be independent and change his own brief. However, the care plan did not address this preference, leading to the resident changing his own brief and getting feces on himself and his surroundings. Despite the resident's family member and staff being aware of the situation, the care plan was not updated to reflect the resident's needs and preferences. Observations and interviews revealed that the resident often did not call for assistance and waited for staff rounds to be cleaned. The CNA and LVN confirmed that the resident had been attempting to change his own brief for a couple of weeks, and the Director of Nursing acknowledged that the care plan should have included the resident's desire to change his own brief. The facility's policy required changes in the resident's condition to be reported and the care plan to be reviewed, but this was not done, placing the resident at risk for delayed treatment and not maintaining their highest practicable wellbeing.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Richardson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Collinwood Nursing And Rehabilitation | 1.3 mi | ★★★★★ | 2 | 0 |
| Remington Transitional Care Of Richardson | 2.2 mi | ★★★★★ | 1 | 0 |
| Lindan Park Care Center Lp | 3 mi | ★★★★★ | 0 | 0 |
| The Parks At Garland Healthcare And Rehab | 3.3 mi | ★★★★★ | 3 | 0 |
| Legend Oaks Healthcare And Rehabilitation Garland | 3.6 mi | ★★★★★ | 4 | 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.