Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Skyline Nursing Center during CMS and state inspections, most recent first.
Staff failed to protect resident dignity and privacy when a resident’s mattress was placed on the floor after a fall without a physician order or care plan direction, and when staff loudly discussed resident needs and incontinence in the dining room and hallway where others could hear. The incidents involved residents with dementia, severe cognitive impairment, schizophrenia, bipolar disorder, and other neurocognitive disorders, and included public comments about toileting, eating refusal, changing a resident, and a resident removing his pants.
Soiled, stained, worn, and missing linens were found on several resident beds, including cracked or torn pillows and beds without pillowcases or a blanket. Staff reported ongoing linen shortages on the unit, use of sheets to dry residents when towels were unavailable, and beds sometimes being left stripped until clean linen arrived. Housekeeping and admin staff also described poor linen inventory control and discarded items not being documented, contributing to insufficient clean linen and damaged items remaining in use.
Failure to Provide Timely ADL Assistance and Grooming Care: A resident was found with a soiled brief after stating incontinence care had not been provided that day, while other residents dependent on staff for personal hygiene were observed with dirty or untrimmed fingernails and an unclean face with eye buildup. Records and staff interviews showed the residents had diagnoses including dementia, hemiplegia, CVA, MS, and impaired mobility, and staff stated CNAs and nurses were responsible for routine hygiene, grooming, and incontinence care.
Late Lunch Meal Service: Meal postings showed lunch at noon, but observations found that hall trays for one hall were repeatedly served late, with the last trays not reaching residents until well after the posted time. A resident and two other residents stated breakfast and lunch trays were often late and that their hall was usually served last; staff, including a CNA, LVN, and the Dietary Manager, confirmed that hall trays could be delayed until 12:45 PM to 1:30 PM and that the hall in question was typically last.
Infection control failures were observed during incontinent care and meal assistance for multiple residents. A CNA changed gloves without hand hygiene during peri-care, another CNA used bare hands to handle and cut resident food and handed food directly to a resident, and a CNA provided incontinent care for a resident on EBP without a gown and changed gloves without hand hygiene. The DON stated staff were expected to use proper PPE, utensils or gloves for food handling, and hand hygiene between glove changes.
Failure to Notify Responsible Party of Fall and New Wound: A resident with dementia, schizophrenia, and high fall risk had a fall with a skin tear above the eye and later had a new sacral pressure wound identified. Records and staff interviews showed the family member/medical POA was not notified of the fall or the new wound, while the federal fiduciary listed in the chart handled only VA finances and was not the resident’s medical decision-maker.
Failure to provide privacy during incontinent care: A CNA closed the door but did not pull the privacy curtain around a resident's bed while giving incontinent care, leaving the roommate with full view of the care. The resident had severe cognitive impairment, was always incontinent, and required substantial assistance with ADLs. The CNA acknowledged forgetting to pull the curtain, and the DON stated staff were expected to close the door and pull curtains during resident care.
Failure to arrange routine dental services for a resident with severe cognitive impairment, dysphagia, and dependence for oral hygiene. The resident had missing and broken teeth, and the chart contained no completed dental care or dental assessments. Social work staff stated they were responsible for scheduling dental appointments but could not locate any dental records for the resident.
A resident with dementia and moderate cognitive impairment, who required supervision or partial/moderate assistance with ADLs, requested help with his bank account in the dining room. The Activity Director, despite knowing only certain staff were authorized to assist with resident finances, allowed a housekeeper to help the resident set up an electronic transfer on his cell phone. Later, a $300 electronic transfer from the resident’s bank account was found to have been sent to a phone number matching the housekeeper’s number, which the resident did not recognize, and a screenshot from the resident’s phone confirmed the transfer.
A CNA failed to perform hand hygiene before donning gloves, between glove changes, and after providing incontinence care to a resident with severe cognitive impairment and multiple medical conditions. The CNA continued to assist the resident and his roommate without following required infection control procedures, contrary to facility policy and training.
Two residents with cognitive impairment were involved in a physical altercation resulting in injury, but the incident was not reported to the state agency as required by facility policy. The DON and Administrator determined not to self-report the event, citing the residents' low BIMS scores and memory care status.
The facility failed to maintain food safety and hygiene standards, with bruised tomatoes found in storage, improper hand hygiene, and inadequate hair restraints among dietary staff. Additionally, food temperatures were not checked before serving, posing a risk of contamination and food-borne illness.
The facility failed to ensure a clean and sanitary environment, with unsanitary conditions in shower rooms and delayed linen changes for a resident with severe cognitive impairment and a productive cough. Housekeeping staff used an ineffective odor control solution instead of a sanitizing solution, and the facility's policies did not adequately address cleaning procedures, posing a risk to resident health and safety.
A resident with moderate cognitive impairment and physical limitations was unable to reach or use the call light due to its improper placement and his involuntary hand movements. Despite the facility's policy requiring call lights to be within reach, observations revealed the resident's call light was not accessible, placing him at risk of not being able to contact caregivers.
The facility failed to ensure proper nail care and hygiene for two residents with severe cognitive impairments. One resident, on hospice care, had long and chipped nails, while another diabetic resident had long, discolored, and dirty nails. Staff acknowledged the oversight and the potential risks for infection and injury, highlighting a lapse in adherence to the facility's grooming care policy.
The facility failed to provide adequate pharmaceutical services, as evidenced by unsecure medications on Nurses Cart Hall 100. RN C did not remove medications from broken blister packs and failed to check an expired insulin pen, risking drug diversion and diminished medication effectiveness. The DON confirmed that medications with broken seals should be discarded and insulin pens need to be dated and discarded after their shelf life.
A facility failed to maintain an effective infection control program when a CNA did not change gloves or perform hand hygiene during incontinence care for a resident. Despite initial handwashing and glove use, the CNA handled clean items after touching soiled materials without changing gloves, contrary to facility policy. This breach was acknowledged by the DON, who noted the increased infection risk due to non-compliance with established protocols.
A resident with cognitive impairments was financially exploited by a facility employee who used the resident's debit card for unauthorized transactions, resulting in a loss of approximately $25,000. The employee, an Activities Assistant, was trusted with the card to make purchases for the resident but instead made personal withdrawals and purchases. The facility lacked adequate oversight and systems to prevent such misappropriation, leading to a significant deficiency in protecting resident property.
Dignity and Privacy Failures
Penalty
Summary
The facility failed to ensure residents had a dignified existence, self-determination, communication, and privacy for 4 of 6 residents reviewed. The report identified that Resident #178’s care plan was not followed when his mattress was placed directly on the floor in his room after a fall, even though the mattress placement was not included in the care plan and there was no physician order or direction from the ADON or DON for that action. Resident #178 was observed lying on the mattress on the floor in a room that was visible from the hallway, and he was wearing only an incontinent brief at the time. The report also documented multiple instances of staff discussing resident information loudly in areas where other residents could hear. CNA Q loudly told Resident #21 that it was embarrassing that he had urinated in his pants in the dining room while his clothing was soiled and wet. CNA K loudly stated across the dining room that Resident #178 did not want to eat anymore and discarded his protein shake. CNA Q also loudly announced in the dining room that she was going to change Resident #184. In another observation, ADON M loudly told CNA K that Resident #14 had taken his pants off and was walking down the hall, and CNA K repeated the information to another CNA in front of residents. The residents involved had significant cognitive and neurological diagnoses, including dementia, schizophrenia, bipolar disorder, frontotemporal neurocognitive disorder, and severe cognitive impairment based on BIMS scores. The facility’s resident rights policy stated that residents have a right to dignity, self-determination, and privacy in oral, written, and electronic communications.
Soiled and Worn Linens Found on Resident Beds
Penalty
Summary
The facility failed to ensure residents had clean, in-good-repair linens and enough linen available on the downstairs secured unit. During observation, four resident beds were found with soiled, stained, worn, or missing linen. One resident bed had soiled and worn linen, another had soiled linen, and two additional beds had soiled, stained, and worn linens. Two pillows were observed cracked, torn, or without pillowcases, and one bed had no blanket. The charge nurse stated that linens should be changed when soiled and that fresh linens are placed on beds during baths, which occur every other day. Staff interviews described ongoing linen shortages and inconsistent replacement of damaged items. The charge nurse reported she had to go to laundry about once per week because there was not enough linen on the unit and said she had reported the shortage to the ADON several times. A CNA reported that staff sometimes did not have enough towels after baths and would use sheets to dry residents. Another CNA stated that when clean linen was not available, beds were stripped and left until linen arrived, and that some pillows on the unit had cracks. Staff also described the linens as dingy, old, hard in texture, and insufficient in quantity. Housekeeping and administrative staff confirmed problems with inventory and replacement practices. The Housekeeping Manager said the facility was expected to maintain three times the amount of linen per resident, but he had not completed a linen inventory since starting and the inventory log was not available for review. The Housekeeping Lead stated linen was being discarded without documentation, contributing to the shortage, and that she had observed the condition of pillows and linens on the unit. The Administrator stated his expectation was that staff replace torn or tattered linen, and the facility laundry services policy required linen to be kept clean, in good repair, and in sufficient quantities for every licensed bed.
Failure to Provide Timely ADL Assistance and Grooming Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary assistance with grooming, hygiene, and incontinence care. The report identified four residents reviewed for ADL care who did not receive the expected care: one resident was found with a soiled brief after stating he had not been changed that day, two residents were observed with unclean or untrimmed fingernails, and one resident was observed with an unclean face and buildup in the eye area. Resident #169 had diagnoses including dementia, muscle wasting and atrophy, hypertension, abnormalities of gait and mobility, anemia, and disseminated intravascular coagulation. His MDS reflected a BIMS score of 13 and dependence on staff for toileting. His care plan stated he required dependent staff participation with toileting hygiene and had bowel and bladder incontinence related to impaired mobility. During observation, he was seen with a soiled brief and stated he had not been changed that day and that changing had not been offered by staff. CNA interviews stated incontinence care was provided every 2 hours or every 2 to 3 hours during rounds and as needed, and the DON stated CNAs and nurses were responsible for checking residents and providing incontinent care. Resident #10 had diagnoses including hypertension, non-Alzheimer's dementia, and hemiplegia or hemiparesis. His MDS showed a BIMS score of 7/15 and substantial to maximal assistance needed with personal hygiene. His care plan stated he required sub/max assistance with personal hygiene. During observation, his fingernails on both hands were approximately 0.4 cm long and dirty, and he stated he wanted them cleaned and trimmed. A CNA observed the nails and stated they looked long, dirty, and needed to be cleaned and trimmed. Resident #15 had diagnoses including CVA, non-Alzheimer's dementia, extrapyramidal and movement disorder, and bipolar disorder, with a BIMS score of 12/15 and dependence with personal hygiene. He was observed lying in bed with an oily face and buildup from his eyes in the inner corner by the nose, and he stated his face was not cleaned that day. Resident #50 had multiple sclerosis and dementia, was dependent on staff for personal hygiene, and was observed with long fingernails that were discolored with dark brown residue under the nails and nail beds. The facility policy stated residents are to be provided necessary care and services to maintain well-being, and the grooming policy stated fingernail care is given to clean and keep nails trimmed.
Late Lunch Meal Service
Penalty
Summary
The facility failed to ensure that lunch meals were served at the posted scheduled time on 04/12/26 and 04/13/26. The meal postings in the main dining room showed lunch at 12:00 PM, but observations showed that residents on 200 hall had not yet received lunch trays at 12:45 PM on 04/12/26, and the last lunch hall tray was not passed until 1:36 PM. On 04/13/26, the last hall tray for 200 hall was still being passed at 12:54 PM. The Dietary Manager stated that dining room trays for lunch start at noon, but hall trays can take from 12:45 PM to 1:30 PM before all residents receive lunch, and that 200 hall was usually the last hall served. Resident #174, who had a BIMS of 14 and was cognitively intact, stated at 12:45 PM on 04/12/26 that lunch trays were late and 200 hall was served last. Residents #37 and #38, both cognitively intact or moderately cognitively impaired based on MDS assessments, stated at 1:38 PM on 04/12/26 that breakfast and lunch trays were late most times and that their hall was last served each day; both preferred to eat in their room. A CNA stated on 04/13/26 that 200 hall lunch trays were last and that it could take from 12:30 PM to 1:00 PM before residents received their meal trays. An LVN stated on 04/14/26 that lunch meal times were posted at noon but hall trays could take up to 1:30 PM to be served, and the Dietary Manager stated the facility did not designate between dining room and hall tray times.
Infection Control Failures During Incontinent Care and Meal Assistance
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for five residents during observed care and meal assistance. The deficiency involved improper glove use, lack of hand hygiene between dirty and clean tasks, bare-hand contact with resident food, and failure to use required PPE during incontinent care for a resident on Enhanced Barrier Precautions. For Resident #164, who had dementia, muscle weakness, and a severely impaired BIMS score, CNA B provided incontinent care while wearing gloves but did not change gloves and perform hand hygiene when moving from soiled care to clean care. During the observation, CNA B also dropped a clean brief on the floor, picked it up, and placed it back on the resident bed. She then continued care with the same gloves, applied skin barrier cream, and later removed the gloves and washed her hands. CNA B stated she should change gloves and perform hand hygiene when going from dirty to clean and should not have picked up the brief from the floor. During lunch observations, CNA K assisted Resident #184, who had frontotemporal neurocognitive disorder and dementia, and Resident #21, who had hemiplegia and hemiparesis following cerebral infarction. CNA K used her bare thumb and pointer finger to hold down each resident's pork chop while cutting it with the resident's fork, then later assisted Resident #184 with feeding while her fingers had visible gravy and meat particles on them. CNA K also picked up a chicken finger with her bare hands and handed it to Resident #157, who had dysphagia, dementia, and delirium. The Administrator and DON stated staff should use utensils or gloves when cutting resident food and should not use bare hands. For Resident #105, who had dementia, hemiplegia or hemiparesis, was always incontinent, and was on Enhanced Barrier Precautions for a wound, CNA N entered the room without PPE, despite signage and PPE being available at the door. CNA N donned gloves and performed incontinent care without a gown, changed gloves without hand hygiene, and completed care before washing her hands at the end. CNA N stated she forgot to wear the gown and acknowledged she should have completed hand hygiene each time she changed gloves. The DON stated staff were expected to gown and glove for high-contact care on Enhanced Barrier Precautions and to perform hand hygiene any time gloves were changed.
Failure to Notify Responsible Party of Fall and New Wound
Penalty
Summary
The facility failed to notify the resident’s responsible party of changes in condition for one resident who had a fall and a newly acquired pressure wound. The resident was admitted with diagnoses including paranoid schizophrenia, senile degeneration of the brain, schizoaffective disorder, and dementia, and his MDS showed a BIMS score of 09, indicating moderate cognitive impairment. His care plan identified impaired cognitive function and high fall risk, with interventions to monitor and report changes in cognition and condition. On 04/12/2026, the resident was found on the floor with blood above his right eye and a skin tear above the eye. The nursing note stated that the resident said he fell off his bed while trying to turn over. The record documented that the physician, DON, federal fiduciary, and hospice were notified. During interviews, the resident’s family member stated she was not called about the fall, and the federal fiduciary stated she was not the person responsible for the resident’s medical care and had not been contacted about the fall. The record also showed a new wound on the sacrum identified on 04/06/2026 as a Kennedy terminal ulcer. Treatment notes documented ongoing wound care for the resident’s left lateral foot diabetic ulcer, and staff interviews indicated uncertainty about who had been notified regarding the new buttocks wound. The family member stated she was not aware of any additional wounds other than the foot wound until she was told by the treatment nurse. Interviews with the BOM, DON, ADON, treatment nurse, and administrator confirmed that the family member was the resident’s medical and financial POA and should have been contacted for changes in condition, while the federal fiduciary handled only VA benefits and finances.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident had the right to personal privacy during incontinent care. Resident #105 was an [AGE] year-old male with diagnoses including hypertension, type 2 diabetes mellitus, cerebrovascular accident, non-Alzheimer's dementia, and hemiplegia or hemiparesis. His annual MDS assessment reflected a BIMS score of 05/15, indicating severely impaired cognition, and he was always incontinent of bowel and bladder. His care plan noted that he required sub/max assistance with ADLs, including oral and personal hygiene. During observation on 04/13/26 at 09:10 AM, CNA N provided incontinent care to Resident #105 after closing the door but without pulling the privacy curtain around the bed. The resident was in the first bed in a room with a roommate present. The roommate was up in a wheelchair, watching TV and moving back and forth to the closet beside the room entrance, and had full view of the care being provided. In interview, CNA N confirmed the curtain was not pulled all the way around the bed and stated it should have been pulled for privacy and dignity, adding that she forgot to do so. The DON later stated staff were expected to close the door and pull curtains when providing resident care and identified the failure to pull the curtain during incontinent care as a violation of the resident's rights to privacy and dignity.
Failure to Arrange Routine Dental Services
Penalty
Summary
The facility failed to assist Resident #117 in obtaining routine dental care after admission. Resident #117 was a [AGE]-year-old male admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, cognitive communication deficit, and vascular dementia. His quarterly MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and he required substantial to maximal assistance with oral and personal hygiene. During observation, he was noted to have missing and broken teeth, and his record did not show any completed dental care or dental assessments. Record review and staff interviews showed the facility could not locate any dental assessments for Resident #117. The social workers stated they were responsible for scheduling dental appointments and were unaware that he had not seen a dentist. The facility policy stated that Social Services coordinates referrals to outside agencies for services not offered by the facility, including dental services, but no completed dental services or assessments were found for this resident.
Failure to Protect Resident From Misappropriation of Funds by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property by an employee. A male resident with dementia and moderate cognitive impairment, as evidenced by a BIMS score of 12, required supervision or partial/moderate assistance with ADLs and had a care plan for impaired cognitive function related to dementia and memory deficit. The facility’s Abuse Prevention and Prohibition Program policy stated that each resident has the right to be free from misappropriation of property and that the facility has zero tolerance for such conduct. According to interviews and record review, the resident requested assistance with his bank account while in the dining room. The Activity Director reported that the resident asked a housekeeper for help with his bank account, and the Activity Director told the housekeeper she could assist him, despite being aware that only the Activity Director and Activity Assistants were authorized to assist residents with financial matters. The Administrator later confirmed that only the Business Office, Activities employees, and Social Workers were authorized to assist residents with financial matters and that these responsibilities could not be delegated to other employees. Subsequently, an electronic transfer of $300 was made from the resident’s bank account to a cell phone number that matched the housekeeper’s number. The Social Worker learned from the resident that an employee had assisted him with sending money to a family member, but when they reviewed the transaction history, the resident did not recognize the name or phone number associated with the $300 transfer. A screenshot from the resident’s cell phone showed the $300 transfer to the housekeeper’s phone number. The resident reported that someone from activities obtained his debit card and that there were bank charges he did not recognize, which he reported to the Social Worker. The housekeeper admitted to helping set up the electronic transfer on the resident’s phone but denied taking the money or knowing how her number appeared on the transaction.
Failure to Follow Hand Hygiene Protocols During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during incontinence care for one resident. During an observation, a CNA assisted a male resident with severe cognitive impairment and multiple diagnoses, including dementia, neurogenic bladder, and muscle weakness, in changing his wet clothing and providing perineal care. The CNA put on gloves without performing hand hygiene, changed gloves multiple times without sanitizing hands, and continued to assist the resident and his roommate without following proper hand hygiene protocols. The facility's policies required hand hygiene before donning gloves, after glove removal, and when moving from dirty to clean tasks, but these procedures were not followed during the observed care. The resident involved required substantial assistance with personal hygiene due to his cognitive and physical limitations, as documented in his care plan and MDS assessment. Despite these needs and the facility's established policies, the CNA did not perform hand hygiene at any point during the care process, including after removing soiled gloves and before assisting another resident. This lapse in infection control practices was confirmed through interviews with the CNA and the DON, both of whom acknowledged the importance of hand hygiene and the failure to adhere to protocol during the incident.
Failure to Timely Report Resident-on-Resident Abuse and Injury
Penalty
Summary
The facility failed to ensure timely reporting of an alleged incident of neglect involving two residents. One resident, who had a history of Alzheimer's Disease and dementia with moderate cognitive impairment, was found with a swollen and red face, as well as a skin tear to the right elbow. The resident was unable to describe what had happened due to cognitive limitations. Documentation and interviews revealed that the resident was assessed, treated for pain, and sent for further medical evaluation. The incident was determined to have involved physical aggression from another resident, who was also observed with a swollen and bruised hand. Despite the facility's policy requiring immediate reporting of abuse, neglect, or injuries of unknown source to the state survey agency and other authorities, the incident was not reported as required. The DON and Administrator acknowledged that the event was not self-reported to the Texas Health and Human Services Commission. The Administrator stated the decision not to report was based on the belief that the altercation lacked intent to harm, given both residents' low BIMS scores and their placement in the memory care unit.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas, as observed during a survey. Six tomatoes in the walk-in refrigerator were found to be bruised, indicating improper storage and handling of produce. The Dietary Supervisor admitted to checking produce only weekly, which led to the oversight of bruised tomatoes. This failure in monitoring could lead to the use of compromised produce in meal preparation. During the lunch meal preparation and service, multiple instances of improper hand hygiene and inadequate use of hair restraints were observed among the dietary staff. Dietary staff members were seen not washing their hands before donning gloves and after handling food, which is against the facility's hand hygiene policy. Additionally, several staff members, including the Dietary Supervisor, were found with hair and facial hair not fully covered by their restraints, increasing the risk of contamination. Furthermore, the facility did not take the temperature of the second container of zucchini and gravy before serving them to residents, which is a violation of the facility's policy on food temperatures. The Dietary Supervisor and staff admitted to not checking the temperatures of these items, which could result in serving food at unsafe temperatures. These deficiencies collectively pose a risk of food-borne illness and contamination to the residents.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, particularly in the shower rooms across multiple hallways and in the provision of clean linens for a resident. Observations and interviews revealed that the shower rooms on several hallways were not cleaned thoroughly, with visible residues and unsanitary conditions present. Housekeeping staff were using an odor control solution instead of a sanitizing solution, which did not effectively sanitize the surfaces, thereby placing residents at risk of exposure to infectious diseases. The housekeeping supervisor was unaware of the misuse of cleaning solutions and the lack of a proper sanitizing solution in the supply closet. Additionally, the facility failed to provide clean linens for a resident with severe cognitive impairment and a productive cough. The resident was observed with soiled bed linens for an extended period, from 9:27 AM to 11:00 AM, without being changed. The CNA responsible for changing the linens acknowledged the delay and stated that it was unacceptable for the linens to remain soiled for that duration. The facility's policy required linens to be changed promptly when soiled to prevent infection and maintain a homelike environment. The facility's housekeeping policy and deep clean checklist did not adequately address the cleaning of shower rooms, contributing to the oversight in maintaining sanitary conditions. The lack of documentation and adherence to a deep cleaning schedule further exacerbated the issue, as the shower rooms were not cleaned to the facility's standard. The failure to use appropriate cleaning solutions and maintain cleanliness in both the shower rooms and resident linens posed a risk to resident health and safety.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #23, had access to a call light system that accommodated his needs and preferences. Resident #23, a male with moderate cognitive impairment and conditions including stroke, drug-induced subacute dyskinesia, and muscle wasting, was totally dependent on staff for activities of daily living. The resident's comprehensive care plan indicated a high risk for falls and required that his call light be within reach and usable. However, during observations, the call light was found clipped to the bed cover sheet at the level of his left shoulder, out of his reach, and he was unable to use it due to his involuntary hand movements. Interviews with RN A and the Director of Nursing (DON) confirmed that the call light should always be within reach and usable by the resident. RN A acknowledged that Resident #23 required a special call light due to his condition, but even with a flat call light provided, the resident was unable to use it. The Administrator also stated that the call light should be accessible before staff leave the room. The facility's policy on the call system emphasized the need for call cords to be within the resident's reach and for adaptive call bells to be provided as per the resident's needs. This deficiency placed the resident at risk of not being able to contact caregivers when needed.
Deficiencies in Resident Nail Care and Hygiene
Penalty
Summary
The facility failed to provide necessary services for two residents who were unable to perform activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #14, a female with severe cognitive impairment due to dementia, was observed with long and chipped fingernails, indicating a lack of proper nail care. Despite being on hospice care, the responsibility for her nail care was not adequately managed, as noted by RN A, who acknowledged the potential risk for infection and skin integrity issues. Similarly, Resident #31, a male with severe cognitive impairment and diabetes, was found with long, discolored, and dirty fingernails. CNA K admitted to not noticing the condition of the resident's nails, which posed a risk for infection and injury. The Director of Nursing (DON) confirmed that nail care should be performed as needed and observed daily, with specific protocols for diabetic residents. The facility's policy on grooming care was not adhered to, leading to these deficiencies in resident care.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by issues with the medication management on Nurses Cart Hall 100. RN C, who was responsible for this cart, did not remove medications from unsecure containers, which included broken blister packs for controlled medications such as hydrocodone acetaminophen and tramadol. These medications were found with broken seals, yet the pills remained inside the blister packs. RN C admitted to not checking the blister packs during the narcotics count at shift change and was unaware of who might have damaged the blisters. The Director of Nursing (DON) stated that any medication with a broken seal should be discarded to prevent drug diversion and infection control issues. Additionally, the facility failed to ensure that an expired insulin pen for a resident was removed from the cart. The insulin pen had an expired open date, which could lead to diminished effectiveness of the medication. RN C acknowledged not checking the insulin pen for the open date and stated that insulin is only effective for 28 days after opening. The DON confirmed that insulin pens need to be dated upon opening and discarded after their shelf life to maintain effectiveness. The facility's policies on medication storage and handling were not adhered to, as outdated or improperly stored medications were not immediately removed from inventory as required.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA J during incontinence care for Resident #9. On the observed date, CNA J, along with CNA B, entered the resident's room and began providing peri care. Although both staff initially washed their hands and donned gloves, CNA J did not change her gloves or perform hand hygiene after handling soiled materials and before touching clean items. Specifically, after cleaning the resident's anal area and handling a soiled draw sheet, CNA J placed a clean draw sheet and brief under the resident without changing her gloves, which is a breach of infection control protocols. The facility's policy on perineal care and hand hygiene clearly outlines the necessity of changing gloves and performing hand hygiene when transitioning from dirty to clean tasks. Despite this, CNA J failed to adhere to these guidelines, as confirmed by her own admission during an interview. The Director of Nursing (DON) acknowledged that staff are trained to change gloves and sanitize hands when moving from dirty to clean tasks, and recognized that the failure to do so increases the risk of infections. This incident highlights a lapse in following established infection control procedures, potentially placing residents at risk of cross-contamination and infection.
Misappropriation of Resident's Funds by Facility Employee
Penalty
Summary
The facility failed to protect a resident from misappropriation of property by an employee, identified as an Activities Assistant (AA). The Business Office Manager and Administrator discovered that AA had been using the resident's bank debit card for unauthorized transactions over several months, resulting in a loss of approximately $25,000 from the resident's personal bank account. The resident, who had a moderate cognitive impairment and a history of paranoid schizophrenia, had given his debit card and PIN to the AA to purchase cigarettes and food. However, the AA made unauthorized ATM withdrawals and purchases for personal use. The resident's care plan indicated communication problems and cognitive impairments, which may have contributed to his vulnerability. The Activity Director, who was responsible for overseeing the purchases made by the AA, failed to review the receipts, trusting the AA with the resident's bank card. This lack of oversight allowed the AA to exploit the resident's financial resources without detection. The Business Office Manager eventually discovered the unauthorized transactions while reviewing bank statements for Medicaid application purposes. The facility's policy on abuse prevention and prohibition was not effectively enforced, as the AA was able to misuse the resident's debit card for personal gain. The Administrator and Corporate Representative acknowledged that there was no system in place to monitor ATM cash withdrawals or other transactions for personal benefit, which allowed the misappropriation to occur. The facility's failure to protect the resident from financial exploitation highlights a significant deficiency in safeguarding resident property and ensuring staff accountability.
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Illustrative
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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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At Mountain View | 2 mi | ★★★★★ | 6 | 0 |
| The Renaissance At Kessler Park | 3.2 mi | ★★★★★ | 5 | 0 |
| The Laurenwood Nursing And Rehabilitation | 4 mi | ★★★★★ | 8 | 0 |
| The Lennwood Nursing And Rehabilitation | 4.2 mi | ★★★★★ | 4 | 0 |
| Duncanville Healthcare And Rehabilitation Center | 4.3 mi | ★★★★★ | 18 | 0 |
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