Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Seven Oaks Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to maintain sanitary conditions and proper food storage, including heavy food and grease buildup on stoves, ovens, and a deep fryer, dusty walk‑in cooler fans, and a dirty ceiling vent, as well as multiple wet rags stored under a hand‑washing sink. Prepared food was left uncovered in the walk‑in cooler, and an open, undated bag of frozen food was found in a stand‑alone freezer. The DFN acknowledged that these conditions reflected multiple days of buildup and were inconsistent with expected cleaning and storage practices, while the Maintenance Director reported delays in scheduled cleaning of cooler fans and could not recall the last cleaning of ceiling vents. The report notes that these failures could place residents who consume food from the kitchen at risk of food‑borne illness and references applicable Texas food safety regulations on sanitary food handling and required cleaning frequencies.
Surveyors found that two of four stove burners in the facility’s only kitchen were non-functioning and heavily soiled with soot and food debris, and the pilot lights did not ignite when attempted by dietary staff. The DFN reported that the back burners were unreliable and required the Maintenance Director to re-light the pilots, and acknowledged the visible soiling. The Maintenance Director stated he was aware of carbon build-up on the pilot lights that clogged the flutes, reported infrequent cleaning intervals, and could not produce documentation of recent cleaning. The Administrator was aware that the pilots had been re-lit previously but not that two burners had been non-functional over time, despite a facility policy requiring routine preventive maintenance to ensure a safe, functional, sanitary, and comfortable environment.
Three residents did not receive food and beverages according to their documented preferences and requests, including missing milk at supper, being served unwanted breakfast items, and not receiving condiments or bread due to supply shortages. Staff interviews confirmed these failures, and residents reported ongoing issues with food and condiment availability.
A resident with Alzheimer's disease, who was able to communicate her needs, reported missing clothing items to the Housekeeping Supervisor, but no grievance was filed and the resident was not updated on the status of her belongings. The Housekeeping Supervisor did not follow facility policy to report the issue to the Administrator, resulting in the grievance not being tracked or resolved.
PASRR Level I screening was not accurately completed for two residents with MI diagnoses. One resident admitted with bipolar disorder and major depression had a PL1 marked no for MI when it should have been marked yes, and another resident with schizophrenia and later schizoaffective disorder did not have a new PL1 completed after the new psychotic diagnosis was added. Staff interviews confirmed the PL1s were not handled correctly and that the records were not updated to reflect the qualifying diagnoses.
During a breakfast meal, two residents were served oatmeal that was excessively thick and resembled cornbread, making it unappetizing and difficult to eat. Staff interviews confirmed the oatmeal was not prepared or served according to proper standards, and there was no policy in place regarding food palatability.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify meals to accommodate specific dietary requirements or physical abilities.
Two residents did not receive physician-ordered double or large protein portions with their meals, as required by their therapeutic diet orders. Staff and dietary management confirmed that the correct portions were not consistently provided, and both residents reported not regularly receiving the prescribed amounts. The deficiency was observed during meal service and acknowledged by facility leadership.
Surveyors found that the ice scoop and its container in the kitchen had visible pink, black, and brown films, indicating improper cleaning and sanitation. The Director of Food and Nutrition and other staff were unclear about the cleaning schedule, despite facility policy requiring regular cleaning and sanitizing of all food contact equipment. This failure resulted in unsanitary conditions for the ice machine equipment.
Two residents were found to have razors and shaving gel accessible in their rooms without documented assessment or care plan interventions addressing the safety of this practice. Staff interviews revealed a lack of clear policy or consistent understanding regarding the storage of these items, and the facility's policy only stated that articles should be stored in an appropriate place, without further guidance.
A facility failed to notify a resident's family member, who was also the medical power of attorney, about significant medical changes, including doppler study results, gangrene, and the need for a vascular surgeon. The resident had severe arteriosclerosis and near absent blood flow in the right lower extremity. Staff interviews revealed a lack of communication and documentation, with some assuming others had informed the family. The facility's policy required notification of significant changes, but this was not documented, potentially risking the involvement of responsible parties in care plans.
The facility failed to involve residents and their families in care planning, as evidenced by the lack of invitations and documentation for care plan meetings. Residents with varying cognitive abilities were not informed or included in their care decisions, and staff interviews revealed confusion about the responsibility for notifying residents and families. This deficiency highlights a significant lapse in communication and adherence to facility policy.
The facility failed to follow professional standards for food service safety, with numerous food items found unlabeled and improperly stored, including thawed raw meat above ready-to-eat foods. Interviews with dietary staff revealed a lack of awareness and adherence to protocols, despite the Dietary Manager's daily walk-throughs and in-services. The facility's policies emphasize proper labeling and discarding of expired items, but these were not consistently followed, leading to the deficiencies.
A facility failed to accurately code a resident's use of anticoagulant medication on their MDS assessment. Despite the resident receiving rivaroxaban daily, the MDS did not reflect this, leading to an inaccurate assessment. The MDS Coordinator admitted to the oversight, and both the DON and Administrator confirmed the error, emphasizing the importance of accurate coding for care planning.
A facility failed to update the PASRR for a resident diagnosed with severe major depression, resulting in missed evaluations and services. The resident, with a history of mental health disorders, was not included in a corporate review list, leading to the oversight. The MDS Coordinator admitted responsibility for the lapse, and the facility's policy lacked guidance on updating PASRRs after new diagnoses.
A medication cart was left unlocked and unattended by an LVN while checking a resident's blood sugar, posing a risk of unauthorized access to medications. The DON and Administrator confirmed the expectation for carts to be locked when unattended, but the facility's policy lacked specific guidance on this requirement.
The facility failed to coordinate hospice care for two residents, lacking updated hospice plans of care and proper medication reconciliation. This deficiency involved a male resident with multiple diagnoses and a female resident with senile degeneration and schizophrenia. The facility did not adhere to its policy and agreement with the hospice company, resulting in a lack of coordination of care.
Unsanitary Kitchen Conditions and Improper Food Storage Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s only kitchen related to failure to store, prepare, distribute, and serve food in accordance with professional standards for food safety. During an observation, surveyors noted food and grease debris buildup on the stove backsplash wall, heavy buildup on the left and right front stove burners, and dirty ovens. The deep fryer, including both fryer baskets, had accumulated food and grease that had not been cleaned after prior use. In the walk‑in cooler, two fans had visible dust, and a ceiling air conditioner vent in the kitchen showed visible dirt and grease buildup. Additionally, nine wet wash rags were stored in an open milk crate beneath the hand‑washing sink. Surveyors also observed improper food storage practices. In the walk‑in cooler, two prepared bowls of pears were left uncovered on a tray. In a stand‑alone freezer, an open and undated food storage bag containing three corn dogs was found. These conditions were documented as failures to properly store prepared and frozen food items. The report states that these failures could place residents who ate food from the kitchen at risk of food‑borne illness. During interviews, the Dietary Food Manager (DFN) acknowledged that the buildup on the stove backsplash, burners, ovens, and deep fryer was not acceptable, indicated that the buildup represented multiple days of accumulation, and stated that she expected staff to clean these areas after each use. She also acknowledged not having noticed the dust and debris on the walk‑in cooler fans and the caked‑on buildup on the ceiling vent, and confirmed that wet rags were stored in an unsanitary manner and that prepared food items should be covered and frozen items properly sealed and dated. The Maintenance Director reported that the walk‑in cooler fans were on a computerized cleaning schedule and that he had not yet completed the most recent scheduled cleaning, and he could not recall the last time the ceiling vents were removed and cleaned. The Administrator reported recent staffing challenges in the kitchen and stated that she rounds in the kitchen daily. The report cites Texas Administrative Code and Texas Department of State Health Services food safety requirements regarding sanitary food storage, preparation, and equipment cleaning frequency as the regulatory standards related to these observations.
Failure to Maintain and Sanitarily Operate Kitchen Stove Burners
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the only kitchen by allowing two of four stove burners to remain non-functioning and heavily soiled. During observation, two burners were found corroded with soot and food debris, and they did not turn on when the Dietary Food Manager (DFN) attempted to use them; the pilot lights were not functioning and there was no gas odor. The DFN reported that the two back burners did not always work and that staff needed to contact the Maintenance Director to re-light the pilot lights, acknowledged the visible food debris and soiling, and stated that not having all burners working did not interfere much with cooking. In a subsequent interview, the Maintenance Director stated he was aware of carbon build-up on the pilot lights that clogged the flutes and confirmed he last lit the pilot lights about a month earlier. He reported that he typically cleaned the pilot lights every 4–5 months and that kitchen staff were expected to clean them daily to prevent build-up, but he could not provide a work log to show when the pilot lights were last cleaned, despite stating he had cleaned them about five months earlier. The Maintenance Director acknowledged that carbon build-up and clogged flutes would cause the burners not to light and could create a fire hazard. The Administrator recalled being told about relighting the pilot lights about a month earlier but was not aware that two burners had been non-functioning due to pilot light corrosion, and acknowledged that the work order system needed review to ensure preventive maintenance in the kitchen was routinely triggered. Facility policy required that preventive maintenance be completed routinely and according to protocol to provide a safe, functional, sanitary, and comfortable environment.
Failure to Accommodate Resident Food Preferences and Choices
Penalty
Summary
The facility failed to accommodate the food preferences and choices of three residents, as evidenced by observations, interviews, and record reviews. One resident, who was cognitively intact and at risk for malnutrition, repeatedly requested milk with her supper meals but was consistently served tea instead. Staff interviews revealed that milk was not provided on certain days, with conflicting explanations regarding whether the facility had run out of milk. The Director of Food and Nutrition and the Administrator both confirmed that the resident should have received milk as requested, and that it was her right to have her beverage of choice at meals. Another resident, also cognitively intact and at risk for malnutrition, had documented preferences and physician orders for bacon and oatmeal for breakfast, and a dislike for sausage and eggs. Despite this, she was served sausage and a biscuit instead of her preferred bacon and toast. The resident reported this issue during both an interview and a resident council meeting, and her tray card indicated her correct preferences, which were not honored by the dietary staff. A third resident, with a history of anxiety, bipolar disorder, and depression, reported not receiving bread, butter, or jelly with her meals, and noted that potatoes were served without butter or cheese. Staff interviews confirmed that the facility had run out of these items and was awaiting a delivery. The Director of Food and Nutrition acknowledged being aware of the shortage but did not inform the Administrator or Dietitian, and did not take steps to procure the missing items in the interim. A group interview with residents corroborated that shortages of condiments and food were a recurring issue. The facility's policy states that residents have the right to reasonable accommodation of their needs and preferences, which was not upheld in these instances.
Failure to File and Resolve Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to honor a resident's right to voice grievances and did not make prompt efforts to resolve a grievance regarding missing personal clothing. A female resident with Alzheimer's disease, but with intact cognition and the ability to communicate her needs, reported missing green pants, white capri pants, and a bright colored blouse to the Housekeeping Supervisor. The resident stated that her items had been missing for several weeks and she had not received any updates on whether the items were found or would be replaced, leading to her frustration. Review of facility records confirmed that no grievance was filed for the missing clothing during the relevant period. The Housekeeping Supervisor acknowledged receiving the report about the missing green pants but did not conduct a full search or report the issue to the Administrator as required by facility policy. The Administrator confirmed that she had not received a grievance regarding the missing clothing and stated that her expectation was for such incidents to be reported so a grievance could be filed and tracked. The facility's grievance policy specifies that the Administrator or designee is responsible for receiving and tracking grievances to their conclusion, but this process was not followed in this instance.
PASRR Level I Screening Not Accurate for Two Residents
Penalty
Summary
The facility failed to ensure the PASRR Level I screening accurately reflected the status of two residents with mental illness diagnoses. For Resident #8, record review showed diagnoses including bipolar disorder, depression, and anxiety, and the resident was admitted to the facility with mental illness diagnoses of bipolar and major depression. A PL1 dated 08/30/22 did not indicate any evidence or indication of MI, ID, or DD, and the PASRR Coordinator stated the PL1 submitted for this resident had been marked No for mental illness when it should have been marked Yes by the admitting facility. For Resident #9, record review showed diagnoses including schizophrenia, depression, and anxiety, and the care plan described a mood problem related to a psychotic disorder with delusions, anxiety, and major depressive disorder. A PL1 and PE dated 06/11/21 and 06/21/21, respectively, did not indicate MI, ID, or DD. A nurse note dated 04/05/22 documented a new diagnosis of psychotic disorder with delusions, but the electronic medical record did not show that a new PASRR Level I screening was completed after that diagnosis was added. During interviews, the MDS nurse stated the prior PL1 for Resident #8 was incorrect and should have been queried because of the bipolar diagnosis, and that another PL1 should have been completed for Resident #9 when the new schizoaffective diagnosis was added. The DON and Administrator stated the MDS nurse was responsible for ensuring PL1s were filled out correctly and sent to LIDDA when needed, and the Regional Compliance Nurse stated the facility used the RAI manual because it did not have a PASRR policy.
Unpalatable and Improperly Prepared Oatmeal Served at Breakfast
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature during a breakfast meal. Observations and interviews revealed that oatmeal served to residents had a thick, porous texture resembling cornbread, which was not consistent with expected standards. One resident reported being able to cut the oatmeal with a knife, while another resident stated the oatmeal looked hard and did not eat it. The Director of Food and Nutrition acknowledged the oatmeal was too thick and attributed the issue to preparing it in one pan instead of two and not adding enough liquid. The Director also admitted the oatmeal should not have left the kitchen but was concerned about compliance with mealtimes. Further interviews with the DON, Traveling Certified Dietary Manager, and Administrator confirmed that the oatmeal was not prepared or served according to proper standards, as it should have been smooth and not clumpy or thick. The staff agreed that the oatmeal should not have been served in its condition and that it was important for food to be palatable for residents' health and enjoyment. There was also no policy or procedure in place regarding food palatability, as stated by the Regional Compliance Nurse.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures.
Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were prepared and served according to physician orders for two residents who required modified protein portions. One resident, a male with a history of right leg amputation and at risk for malnutrition, had a physician order for double meat/protein portions at all meals. Despite this, he received only half a serving of the entrée during a lunch observation, and both the resident and staff confirmed that he had not previously received double portions as ordered. The dietary manager and the Director of Food and Nutrition acknowledged the error, noting that the resident should have received four cheese manicottis instead of one, and that the correct meal ticket was not used during tray preparation. Another resident, a male with chronic ulcer, depression, hypertension, and anxiety, also had a physician order for large protein portions with meals. During a lunch service, he did not receive the required large protein portion until after surveyor intervention, at which point an additional serving was provided. The resident reported that he did not normally receive that much food, indicating a pattern of not receiving the ordered diet. Both the dietary manager and the Director of Food and Nutrition confirmed the expectation for double or large protein portions and recognized the importance of following diet orders for nutritional needs. Interviews with the dietitian, medical director, DON, and administrator all confirmed that the expectation was for diet orders to be followed as written, with double or large protein portions provided to these residents. The facility's own policy specified that double servings of entrée/protein portions should be served for residents on large portion diets. The failure to provide the prescribed diet as ordered was observed directly by staff and surveyors, and acknowledged by facility leadership.
Unsanitary Ice Machine Equipment in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation standards for food service equipment, specifically regarding the ice machine and its accessories in the kitchen. During an inspection, the ice scoop was found to have a pink film on it, and the container holding the scoop contained black and brown film. The Director of Food and Nutrition confirmed the presence of these substances and acknowledged that kitchen staff were responsible for cleaning the ice scoop and holder. However, there was uncertainty about the cleaning schedule, with the Director stating the scoop was cleaned daily and the holder monthly. The Director described the condition of the equipment as 'gross' and recognized the potential for infection control issues due to the lack of cleanliness. Further interviews with the DON and the Administrator revealed that both were unaware of the specific cleaning schedule for the ice scoop and container, though they agreed that these items should be kept clean to prevent illness. Review of the facility's policies indicated that all kitchenware and food contact equipment should be cleaned and sanitized before use and after each meal preparation, following CDC and state food code guidelines. The observed failure to adhere to these standards resulted in unsanitary conditions for the ice machine equipment.
Failure to Prevent Accident Hazards Related to Razor Storage
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards for two residents who were reviewed for accidents and hazards. One resident, who had an intact cognitive status and required supervision or assistance with personal hygiene, including shaving, was observed to have an electric razor and shaving gel on his bedside table over multiple days. Staff interviews revealed there was no specific policy or assessment in place regarding the storage of such items at the bedside, and staff believed it was the resident's right to keep them for personal hygiene. The Director of Nursing (DON) and Administrator confirmed there was no assessment process for determining if a resident could safely keep razors or shaving gel at bedside, and stated there were no residents who wandered into other rooms. Another resident, also with intact cognition and some independence in activities of daily living, was observed to have multiple disposable razors on his bathroom sink over several days. Staff interviews indicated uncertainty about whether the resident was care planned to have razors in his room, and some staff expressed concerns about safety for both the resident and others who might enter the room. The DON stated the resident was care planned for razors and was safe to have them, but review of the care plan only indicated staff should shave the resident if requested, with no mention of unattended razors in the room. The Administrator stated razors should not be in resident rooms for safety reasons and that it was the responsibility of all staff to ensure this. The facility's policy on shaving and razors was reviewed and found to be undated, only stating that all articles should be stored in the appropriate place, without further guidance. Observations and interviews confirmed that razors and shaving gel were left accessible in resident rooms without documented assessment or care plan interventions addressing the safety of this practice.
Failure to Notify Family of Significant Medical Changes
Penalty
Summary
The facility failed to immediately notify the responsible party of a resident when there was a significant change in her medical condition, specifically regarding the results of a doppler study, the presence of gangrene, and the need for a vascular surgeon consultation. The resident, who had a complex medical history including Huntington's disease, heart failure, and vascular dementia, was found to have severe arteriosclerosis and near absent blood flow in her right lower extremity. Despite these critical findings, the resident's family member, who was also her medical power of attorney, was not informed of these developments. Interviews with various staff members, including LVNs and the DON, revealed a lack of communication and documentation regarding the notification of the resident's family member. Some staff members assumed that others had communicated the necessary information, while others were unsure if the family had been informed at all. The DON admitted to not remembering if she had communicated the doppler study results and gangrene diagnosis to the family member, citing a COVID-19 outbreak as a contributing factor to the oversight. The facility's policy required that significant changes in a resident's status be communicated to the family or legal guardian, and that all attempts to notify them be documented. However, the nursing progress notes did not reflect any such communication with the resident's family member. This lack of notification and documentation could potentially place residents at risk of their responsible parties not being involved in their plan of care, as evidenced by the family member's distress upon discovering the resident's condition during a hospital admission.
Failure to Involve Residents and Families in Care Planning
Penalty
Summary
The facility failed to facilitate resident and family participation in the care planning process for four residents, leading to a deficiency in care planning. Resident #15, a cognitively intact individual with multiple health conditions, was not invited to her care plan meetings, and there was no documentation explaining her absence or that of her representative. Similarly, Resident #17, who has severe cognitive impairments, was not involved in care plan meetings, and her responsible party was not notified or invited, as confirmed by the absence of documentation and the responsible party's statement. Resident #21, also cognitively intact, was not invited to care plan meetings, and there was no documentation of her or her representative's attendance. She expressed a desire to be involved in her care, indicating a lack of communication from the facility. Resident #28, another cognitively intact resident, was not invited to care plan meetings, and there was no documentation of her or her representative's participation. She stated she would have attended if she had been informed, highlighting the facility's failure to engage residents in their care planning. Interviews with facility staff revealed confusion and lack of clarity regarding the responsibility for sending care plan meeting invitations. The Activity Director and Social Worker both indicated they were unsure of their roles in notifying residents and families. The Director of Nursing and Administrator acknowledged the importance of involving residents and families in care planning but admitted to lapses in the notification process. The facility's policy required advance notice for care planning conferences, but this was not consistently followed, resulting in residents and families being uninformed and uninvolved in care decisions.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen's walk-in refrigerator, freezer, and dry storage areas. During the inspection, numerous food items were found without proper labeling, including missing preparation, receive, and expiration dates. This included a large bowl of chicken salad, a prepared ham sandwich, various vegetables, cheeses, meats, and other food items. Additionally, some food items were stored improperly, such as thawed raw meat being placed above ready-to-eat foods, which poses a risk of cross-contamination. Interviews with the dietary staff, including the acting Dietary Manager and a cook, revealed a lack of awareness and adherence to proper food labeling and storage protocols. The acting Dietary Manager admitted to not knowing about the unlabeled and expired items and acknowledged that ready-to-eat foods should not be stored below thawing meats. The cook confirmed that all food items should be labeled and dated, and that expired items should be discarded, but was unaware of the expired items present in the kitchen. The Dietary Manager, who has been in the role for four years, stated that she conducts daily walk-throughs and in-services on labeling and dating, but was not aware of the expired and improperly stored food items. The Administrator, overseeing the dietary staff, also confirmed the importance of labeling and discarding expired food to prevent foodborne illnesses. The facility's dietary policies, dated 2012, emphasize the need for proper labeling, dating, and discarding of expired or suspect food items, yet these practices were not consistently followed, leading to the identified deficiencies.
Inaccurate MDS Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to ensure that the MDS assessment for a resident accurately reflected the use of anticoagulant medication. Specifically, the quarterly MDS assessment for a resident did not indicate that the resident had received rivaroxaban, an anticoagulant medication, within the 7-day look-back period. This oversight was identified during a review of the resident's medication administration record, which showed that the resident had been receiving rivaroxaban daily without any missed or refused doses. The resident's comprehensive care plan also indicated that the resident was on anticoagulant therapy, with specific interventions to monitor for complications. Interviews with the MDS Coordinator, DON, and Administrator revealed that the omission was a mistake, with the MDS Coordinator acknowledging the error in not coding the anticoagulant medication. The MDS Coordinator stated that she was responsible for ensuring the accuracy of MDS assessments and had missed the medication during her review. Both the DON and Administrator confirmed that the MDS assessment should have been coded to reflect the resident's anticoagulant use, and the failure to do so resulted in an inaccurate assessment. The Administrator noted that such inaccuracies could lead to errors in the resident's care plan.
Failure to Update PASRR for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with mental health disorders received an accurate Preadmission Screening and Resident Review (PASRR) following a new diagnosis of severe major depression. The resident, a male with a history of psychosis, intermittent explosive disorder, and anxiety, was diagnosed with severe major depression on July 17, 2023. Despite this diagnosis, the facility did not update the resident's PASRR Level 1 screening, which initially indicated no evidence of mental illness. This oversight meant that the resident did not receive the necessary PASRR evaluation and potentially missed out on individualized care and specialized services. The MDS Coordinator acknowledged that major depression is considered a mental illness and that a Form 1012 should have been completed to update the PASRR Level 1 screening. However, the resident was not included in a corporate list of residents needing documentation review, resulting in the oversight. The MDS Coordinator admitted responsibility for ensuring PASRR updates and recognized that the failure to complete the necessary form led to the resident not receiving proper evaluation or additional services. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of awareness regarding the resident's long-term mental health issues upon admission. The DON confirmed that the MDS Coordinator was responsible for updating PASRRs, and the Administrator noted that the resident's behaviors, such as calling the police, prompted psychiatric referrals. The facility's policy did not address updating PASRR Level 1 after a new mental illness diagnosis, contributing to the deficiency.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. This deficiency was observed when LVN C left a medication cart unlocked and unattended while checking a resident's blood sugar for insulin administration. The incident occurred when LVN C entered the resident's room, closed the door, and left the cart unsupervised. Upon returning, LVN C acknowledged the mistake and recognized the risk it posed for unauthorized access to medications. Interviews with the Director of Nursing (DON) and the Administrator revealed that the expectation was for nurses to lock medication carts when unattended. Both the DON and the Administrator acknowledged the risk of unauthorized access to medications if carts were left unlocked. The facility's policy on medication storage, revised in July 2012, did not specify when medication carts should be locked, contributing to the oversight.
Failure to Coordinate Hospice Care for Residents
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was identified for two residents who were reviewed for hospice services. The facility did not obtain the most recent updated hospice plans of care for these residents, which could potentially place them at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Resident #34, a male with multiple diagnoses including psychosis, major depression, and chronic kidney disease, was receiving hospice services. His comprehensive care plan indicated the need for cooperation with the hospice team to meet his various needs. However, the facility's records did not reflect the most recent hospice plan of care, which included specific medication orders that were not updated in the facility's order summary report. Discrepancies in medication orders were noted, with some medications being discontinued without proper reconciliation in the facility's records. Similarly, Resident #27, a female with diagnoses including senile degeneration of the brain and schizophrenia, was also receiving hospice services. Her care plan required collaboration with the hospice team, but the facility lacked the updated hospice plan of care in her records. Interviews with hospice and facility staff revealed expectations for updated documentation and medication reconciliation, which were not met. The facility's agreement with the hospice company and its policy required regular updates to the hospice plan of care, which were not adhered to, leading to a lack of coordination of care.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 51 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bonham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clyde W Cosper Texas State Veterans Home | 0.1 mi | ★★★★★ | 20 | 0 |
| North Star Ranch Rehabilitation And Health Care Ce | 1.2 mi | ★★★★★ | 7 | 0 |
| Mullican Care Center | 11.3 mi | ★★★★★ | 1 | 0 |
| Honey Grove Nursing Center | 15.4 mi | ★★★★★ | 10 | 1 |
| Denison Nursing And Rehab | 23.6 mi | ★★★★★ | 3 | 0 |
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